1. Female Reproductive Anatomy ALEX HAMMANT AND PHIL COPEMAN

2. Defining stuff  Pelvic girdle = bony pelvis  Pelvis = the space bound by the pelvic girdle  Great pelvis = Upper abdominal region of pelvic girdle  Lesser pelvis = Lower region of pelvic girdle (pelvic cavity & perineum)  Pelvic cavity = Region between inlet and pelvic floor  Perineum = Region below the pelvic floor

3. What’s what 2 1 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26

4. Even more what’s what Labia majora Clitoris Labia minora Vaginal orifice Perineal body Important structural support Urethral orifice Greater vestibular gland Drain into vestibule at 5 & 7 o’clock Vestibule 1 2 3 4 5 6 7 8

5. Guess what? Fundus Uterine body & cavity Cervical canal Connects vagina and uterine cavity via the external and internal os External os Vagina Ampulla Infundibulum Isthmus Uterine tubes Open into the abdominal cavity into which ovulation takes place Internal os 1 2 3 4 5 6 7 8 9 10

6.  An 19 year old girl has had pain in the inside of her thigh for the last few days. The same thing happened last month, what could be the problem?  Ovulation/cysts/tumours can impinge the obturator nerve (L2-4) which results in pain in the medial thigh, hip or knee; leading to medial thigh weakness/wasting.

7. Did someone say more labelling? Ovarian artery Form aorta @ ~L2 Ovarian, tubal & fundal lymph drainage is to para- aortic nodes Uterine artery Heads toward lateral cervix/fornix Passes superior to the ureter Vaginal artery Often a branch of the uterine Can arise independently from internal iliac Ureter Passes inferior to uterine artery (water under bridge). Very delicate and must not be ligated, crushed or moved too much Uterine & cervical lymphatics Pass to external, internal iliac & sacral nodes Some go to palpable inguinal nodes via round ligament 1 2 3 4 5

8. Lymph drainage summary table OrganLymph drainage OvariesPara-aortic nodes around L2 level Uterus Fundus and upper body Lower body Cervix Para-aortic nodes External iliac Internal and external iliac and sacral 1 2 3 4

9. Can you describe the alignment of these uterus:cervix:vaginas?  Which is the most common?  Trick question: anteverted anteflexed is the most common alignment! * * * * Retroverted Anteflexed Anteverted Retroflexed Retroverted Retroflexed 1 2 3

10. Surely not more labels?  The broad ligament is made up of the mesometrium, mesosalpinz and mesovarium. Suspensory ligament of ovary Round ligament of the uterus Round ligament of the ovary Broad ligament Large double layered fold of peritoneum 1 2 3 4

11.  A 16 year old girl is bleeding heavily PV, she has been the subject of a ‘backstreet abortion’. Where is she most likely to be bleeding?  The recto-uterine pouch.  What is the name of the other pouch?  Vesico-uterine pouch  How are these pouches formed?  Peritoneum covers the bladder, uterus, cervix and upper rectum

12. What refers where? Pelvic organs covered in peritoneum  Refer pain to T10-L1 (via Sympathetic nerves) Pelvic organs not covered in peritoneum  Refer pain to S2-4 (via Parasympathetic nerves) Pelvic pain line

13. How to anaesthetise? Sensory Neurons run with Sympathetics (T10-T12) Spinal Block @ L3/4 (inject into CSF) & an epidural at the same level (Combined spinal epidural – CES/CSE) Sensory Neurons run with Parasympathetics (S2-4) Caudal epidural (sacral hiatus & canal) Somatic sensory innervation (S2-4 Pudendal nerve) Pudendal Nerve Block Where do you do a pudendal nerve block? Ischial spine!

14.  Where does the pudendal nerve run?  From S2-4 out of the greater sciatic foramen and then back into the pelvis via the lesser sciatic foramen.