1. Assoc. Prof. Gazi YILDIRIM, M.D.
Introduction to
Obstetrics and Gynecology
Anatomy
Assoc. Prof. Gazi YILDIRIM, M.D.

2. Objectives To learn female reproductive anatomy Pelvic anatomy
Pelvic innervation
Pelvic blood supply
Basic hormon knowledge
Steroid hormon pathways
Female reproductive endocrinology

3. Abdominal Wall
Skin
Subcutaneous fat (superficial fascia), which below the navel can be considered as two layers:
Camper’s fascia; the superficial layer containing fat,
Scarpa’s fascia; fibroelastic membrane.
Muscles, The abdominal muscular wall can be considered a group of 4 paired muscles along with their aponeurosis:
The three lateral muscles (from superficial to deep) are the
External abdominal oblique
Internal abdominal oblique
Transversus abdominis muscle
Medially muscles are the:
Rectus Abdominis
Pyramidalis muscles
Preperitoneal fat
Peritoneum
Parietal peritoneum peritoneum of anterior abdominal wall
Visceral peritoneum peritoneum investing the viscera

5. Anatomy: Perineum Clitoris Urethra Vagina Anus Labia majora and minora
Bartholin’s and Skene’s glands
Hymen
Perineum: area below pelvic floor perforated by urethra, vagina, anus

6. Elements comprising the Pelvis
Bones
Ilium, ischium and pubis fusion
Ligaments
Muscles
Obturator internis muscle
Arcus tendineus levator ani or white line
Levator ani muscles
Urethral and anal sphincter muscles

7. Bony pelvis
Composition: formed by paired hip bones, sacrum, coccyx, and their articulations
Two portions
Greater pelvis
Lesser pelvis
Terminal line ( pelvic inlet): formed by promontory of sacrum, arcuate line, pectin of pubis, pubic tubercle, upper border of pubic symphysis
Pelvic outlet: formed by tip of coccyx, sacrotuberous ligament, ischial tuberosity, ramus of ischium, inferior ramus of pubic symphysis

8. Anatomy: Bones of Pelvis
Sacrum
Coccyx
Innominates (2)
Ilium
Ischium
Pubis

11. Anatomical antero-posterior diameter (true conjugate) = 11cm
Obstetric conjugate = 10.5 cm (-2cm from diagonal conj)
Diagonal conjugate = 12.5 cm

13. Pelvic Floor Muscles Levator Ani Obturator Internus Piriformis
Puborectalis
Pubococcygeus
Ileococcygeus
Obturator Internus
Piriformis
Coccygeus
Levator Plate
Netter F Atlas of Human Anatomy Novartis 1997

14. “Ligaments and Fascia”
Cardinal/Uterosacral Complex
(Delancy level I)
Paracervical Ring
Arcus Tendineus Fascia Pelvis ATFP
Pubocervical “fascia”
Rectovaginal “fascia”

15. Perineal Body Bulbocavernosis (urethrovaginal sphincter)
Superficial Transverse perineus
Pyramidal Fibrous Body
Internal Anal Sphincter
External Anal Sphincter
Perineal Membrane
Cleveland Clinic Foundation
Burnett Novack’s Gynecology 2004

16. Sphincter urethrae externus
Bulbospongiosus
Ischiocavernosus
Transversus perinei profundus
Transversus perinei superficialis

17. Bony structures of a pelvis

18. Perineal muscles Urethra M. ischiocavernosus Vagina
M. bulbospongiosus
M. transversus perinei superficialis
M. sphincter ani externus
Urethra
Vagina

19. Urogenital fascia Urethra Vagina M. transversus perinei profundus
M. transversus perinei superficialis
M. sphincter ani externus

20. Pelvic floor
ATFP

21. Add rectum

22. Rectal connections

23. Vaginal connections

24. Urethra
Bladder
Cervix

25. lig.cardinale

26. Lig. sacrouterina
Lig. cardinale

28. Layers of the Anterior Triangle of the Perineum
Skin
Subcutaneous tissue   .Camper's fascia   .Colles fascia
Superficial space   .Clitoris and its crura   .Ischiocavernous muscle   .Vestibular bulb   .Bulbocavernous muscle   .Greater vestibular gland   .Superficial transverse perineal muscle
Deep space-perineal membrane   .Compressor urethrae   .Urethrovaginal sphincter

29. Ürogenital trigon: Anal trigon: M. Transversus perinei superficialis
M. İschiocavernosus
M. Bulbocavernosus
M. Transversus perinei profundus
Anal trigon:
M. Levator ani
M. Sphincter ani externus

30. FIGURE 7.2. Superficial compartment and perineal membrane.

31. EKSTERNAL ACCESSORY ORGANS (Vulva – Pudendum)
Mons pubis
Labium majus
Labium minus
Clitoris
Bulbus vestibuli
Gl. vestibularis major
Gl. vestibulares minor

32. Labium Majus Pudendi Correspond to the scrotum Includes numerous hairs
Rima pudendi
Commisura labiorum ant.
Commisura labiorum post.
Lig.rotundum
Rima pudendi
Commissura post

33. Labium Minus Pudendi (Nymphae)
Includes sweat glands
Preputium clitoridis
Frenilum clitoridis
Sulcus nympholabialis
Frenulum labiorum pudendi
Fossa navicularis
Fourchette
Sulcus nympholabialis
Frenulum clitoridis
Frenulum labiorum pudendi

34. Clitoris Corresponds to the male penis Corpus, crus, glans
Attach to the side of the pubic arch with Lig. Suspansorium

35. Vestibüle - Introitus (Vestibulum Vaginae)
The Vaginae and ostium urethra externa opens vestibüle
Covered by stratified squamous epithelium
Vestibül

36. Glandula Vestibularis Major (Bartholin’s glands)
Correspond to the male bulbourethral glands
Covered by M.bulbocavernosus
Secrete fluid that moistens and lubricates vestibule

37. Glandula Vestibularis Minor (Skene glands)
Opening either side of the urethra
To get Gonore retansiyon abscess
Skene kanalları

38. FIGURE 7.2. Superficial compartment and perineal membrane.

39. Hymen Feminus
Mucosal fold
Carunculae myrtiformis

40. Anatomy: Pelvic Innervation
Pelvic splanchnic nerves from 2nd to 4th sacral nerves
Pudendal nerve supplies vulva and lower vagina

41. Vulva blood supply comes from a terminal branch of the a
Vulva blood supply comes from a terminal branch of the a.iliaca interna - a.pudenda interna
N. pudendus

43. INTERNAL ACCESSORY ORGANS
Vagina
Uterus
Uterine tubes
Overies

46. Vagina (Kolpos) Fibromuscular tube about 9 cm Fornix vaginae
Columna rugarum
Tunica mucosa
Tunica muscularis
Tunica adventisya
A. vaginalis
V. iliaca interna
Vajina

47. Uterus (Metra - Hystera)
8 x 6 x 4 cm g.
Corpus, isthmus, collum (cervix)
Portio vaginalis uteri

48. Serosal layer (perimetrium)
Muscular layer (myometrium)
Mucosal layer (endometrium)
Excavatio vesicouterina
Excavatio rectouterina (Douglas )

49. Squamocolumnar Junction

50. Tuba Uterina (Fallop Tüpleri-Salpinx)
İnfundibulum (fimbria, fimbriae ovarica) pars ampullaris, isthmica, interstitialis
A.ovarica ve A.uterina

52. Ovaries Medulla (blood and lenf vessels, nerves)
Cortex (germinal epitel, tunica albuginea, hilum ovarii)
Lig. Ovarii Proprium (between overies and uterus)
Lig. Suspensorium Ovarii (infundibulopelvic) (between overies and pelvic side wall)
A.ovarica, plexus pampiniformis

54. Pelvic Vasculature Sakralis Media İnternal iliak (hipogastrik)
İliolumbar
Common Iliac
Lateral Sakral
Superior Gluteal
Inferior Gluteal
Orta Hemoroidal
Pudendal
Uterin
Inferior Vesika
Umbilical
Obturator
Burnett Novack’s Gynecology 2004

55. Anterior Division Posterior Division Uterine Superior gluteal
Branches of the Internal Iliac Artery
Anterior Division
Posterior Division
Uterine
Superior gluteal
Umbilical
Lateral sacral
Uterine vesical
Iliolumbar
Obturator
Internal pudendal
Inferior gluteal
Middle vesical
Middle rectal
Vaginal

57. Collateral Arterial Circulation of the Pelvis
Primary Artery
Collateral Arteries
Aorta
    Ovarian artery
Uterine artery
    Superior rectal artery
(inferior mesenteric artery)
Middle rectal artery
Inferior rectal artery (internal pudendal)
    Lumbar arteries
Iliolumbar artery
    Vertebral arteries
    Middle sacral artery
Lateral sacral artery
External Iliac
    Deep iliac circumflex artery
Superior gluteal artery
    Inferior epigastric artery
Obturator artery
Femoral
    Medial femoral circumflex artery
Inferior gluteal artery
    Lateral femoral circumflex artery

59. Ovarian arteries Ovarian veins:
Originate directly from the aorta, inferior to the renal arteries.
Most frequently identified at the IP ligament.
Ovarian veins:
Left ovarian vein drains into the left renal vein
Right ovarian vein drains directly into the inferior vena cava.

60. Ligaments of the Uterus
Lig.Sacrouterinum (LUNA)
Lig.Latum Uteri
Lig.Rotundum
Cyst of Nuck canal
A.Sampson
Lig. Cardinale most important lig.

61. 8 Avascular Spaces Prevesical (1) Vesicouterine (1) Rectovaginal (1)
Presacral (1)
Paravesical (2)
Pararectal (2)

62. Lymph Drainage
The external genitalia, anus, and anal canal drain to the superficial inguinal nodes
The lower one third of the vagina drains to the sacral nodes and the internal and common iliac nodes
The cervix drains to the external or internal iliac and sacral nodes

63. Lymph Drainage The lower uterus drains to the external iliac nodes
The upper uterus drains into the ovarian lymphatics to the lumbar nodes. The lymphatics of the ovaries drain out of the pelvis to the lumbar nodes

64. Lymph Drainage Cervical Cancer: Uterine Cancer: Ovarian Cancer:
Drains 1st to the parametrial nodes --> obturator nodes --> pelvic nodes --> para-aortic
Uterine Cancer:
Drains 1st to the pelvic nodes or para-aortic.
Ovarian Cancer:
Can metastasize to either the pelvic or para-aortic nodes.

66. Pelvic Innervation Lumbar Pleksus Sacral Pleksus Genitofemoral n.
Obturator n.
Femoral n.
Pudendal n.
Obturator Foramen
Sciatic n.
Hipogastrik Plexus
(Otonomic)
Pelvik Plexus
(Otonomic)
Irvin W Obstetrics/Gynecology 2003

67. Pelvic Autonomics Superior hypogastric plexus (presacral nerve)
Contains no parasympathetics
Hypogastric nerve
Inferior hypogastric plexus
Contains parasympathetic fibers from the pelvic splanchnics
Ganglion impar

68. Pelvik Organların Sinirleri

69. Pelvik Organların Sinirleri

70. Pelvic Vasculature Sakralis Media İnternal iliak (hipogastrik)
İliolumbar
Common Iliac
Lateral Sakral
Superior Gluteal
Inferior Gluteal
Orta Hemoroidal
Pudendal
Uterin
Inferior Vesika
Umbilical
Obturator
Burnett Novack’s Gynecology 2004

71. The End