Abdel-Fattah Salem, M.D., F.R.C.O.G. The Bony Pelvis Sex differences in the pelvis Female Iliac blades more vertical Iliac fossa shallower Sacrum broader Sub-pubic arch 80-85: Ischiopubic rami narrower Obturator foramen traiangular Greater sciatic notch wider Greater anteroposterior diameters
Male Iliac crest rugged
Sub-pubic arch 50-60:
Obturator foramen ovoid Ischial spines closer
Cavity longer and more conical
Normal Pelvic Shape in Females The brim is round Sacral promontory is not prominent The angle of inclination is about 55: to the horizontal The cavity is shallow with straight, non-converging walls The sacrum is smoothly curved In the outlet the sacro-scieatic notches are wide and shallow
Normal Pelvic Shape in Females(continued) The sacrum does not project forwards
The ischial spines are not prominent
The pubic arch is wide and domed
The sub-pubic angle is about 90:
The inner tuberous diameter is wide accommodating four knuckles of the average-sized hand with ease
12 Angle of Inclination Uteropelvic axes Anatomy of the female reproductive organs External Genitalia Referred to collectively as the vulva Blood Supply: Internal pudendal artery
Nerve Supply: Pudendal nerve (sensory)
Lymphatic Drainage: via the inguinal nodes
Muscular Canal Extends from cervix to vulva Anterior to Rectum Posterior to bladder Epithelial Lining Rugated, stratified squamous Separated by cervix into; Anterior fornix Posterior fornix Lateral fornix Vagina Vagina (continued) Blood Supply; - Uterine artery - Inferior pudendal artery - Inferior vesical artery - Middle rectal artery
Structures coursing through broad ligament; - Fallopian tubes - Round ligament - Ovarian ligament - Nerves, vessels, lymphatics Fallopian Tubes 8-14 cm muscular tubes extending laterally from uterus Consists of 4 segments; - Interstitial - Isthmic - Ampullary - Infundibular Ends with fimbriae at the ovary Mesosalpinx is a peritoneal fold that attaches the fallopian tubes to the broad ligament Blood supply: Uterine and ovarian arteries Ovaries Consists of 2 parts; - Cortex contains ova - Medulla contains blood vessels
Mesovarium is a peritoneal fold that attaches the ovary to the broad ligament
Blood supply: ovarian arteries (branch of aorta)
Left ovarian vein drains into left renal vein Embryology Gonadal differentiation Ovarian differentiation
Determined by presence of two X chromosomes
Located on short arm of X chromosome
Absence of short arm of X chromosome results in ovarian agenisis Testicular differentiation TDF induces differentiation Determined by presence of cell surface antigen (H-Y)
Gene for H-Y antigen located close to TDF gene In Females In Males Development of the ovary 25 th Day Germ cells originate from; Primitive hind gut 30 th Day Germ cells migrate to; Root of mesentry At birth At puberty Number of follicles; 2 million 300,000 Development of the ovary (continued) The coelomic epithelium proliferates and forms the genital ridges At early stages the primitive gonads consist of mesoderm covered by coelomic epithelium Germ cells migrate from the root of mesentry to the genital ridge Epithelium growing into the genital ridges forms the sex cords Germ cells and most of the sex cords remain in the superficial part to form the ovarian cortex Some of the sex cord cells form the ovarian medulla
Mullerian Duct Also known as paramesonephric duct The 2 mullerian ducts extend caudally until they reach the urogenital sinus at 9 weeks gestation The blind end projects into the posterior wall of the sinus to become the mullerian tubercle Lower ends of ducts fuse in the midline to form the uterus and cervix The thick muscular walls of the uterus and cervix develop from proliferation of the mesenchyme The cephalic ends of the ducts remain separated to form the fallopian tubes
Development of the Vagina Develops from an area of marked growth of the mullerian tubercle also known as vaginal plate The vaginal plate grows in all dimensions greatly increasing the distance between the cervix and the urogenital sinus The upper 4/5 th of the vagina is formed from the Mullerian duct The lower 1/5 th of the vagina is formed from the urogenital sinus
Development of external genitalia The primitive cloaca is divided by a transverse septum into; - anterior urogenital portion - posterior rectal portion
The genital folds and the genital swellings are then formed by the proliferation of mesoderm around the end of the urogenital sinus The bladder and urethra form from the vesicourethral portion of the urogenital sinus External Genitalia Genital tubercle enlarges slightly Clitoris
Genital swelling Scrotum In Females In Males Uterine Anomalies
Absence of Uterus Fusion Anomalies Absence of the Uterus Fusion anomalies of the uterus Incidence; -Overall; not uncommon - Lesser degrees of defects are quite common Minor fusion defects are asymptomatic Possible presenting symptoms; - Repeated abortion - Persistent transverse lie of the fetus in late pregnancy - Uterus didelphysis (double uterus) may lead to obstructed labour - Profound bleeding from rupture of rudimentary horn consequent to implantation of the fetus Agenesis of one Mullerian duct Unicornuate uterus Incomplete fusion of Mullerian duct Double, arcuate or septate uterus Fusion anomalies of the uterus Vaginal Anomalies
Absence of vagina Vaginal Septum - Longitudinal - Transverse
Absence of vagina Generally associated with absence of uterus which presents with 1: amenorrhea
Rarely; uterus maybe present and vagina absent
Secondary sexual characters + primary amenorrhea ANATOMICAL DEFECTS such as; - imperforate hymen - absent vagina Absence of vagina (treatment) Meticulous search for urinary anomalies
Use of dilators in cases of absent uterus
McIndoe and Read operation; the created vagina is then lined by either; - split-skin graft - amnion
The contents of the ovarian pedicle in torsion are:1. Infundibulopelvic ligament with ovarian vessels 2. Ovarian ligament3. Mesoovarium4. Part of fallopian tube5. Utero-ovarian anastomosis