Reproductive

Anatomy

1st Batch
Faculty of Medicine
University of Moratuwa
 Anatomy of the Pelvis

Bones of the pelvis

Pelvic bone

The pelvic bone is irregular in shape and has two major parts separated by an oblique line
on the medial surface of the bone

1. The pelvic bone above this line represents the lateral wall of the false pelvis, which is
part of the abdominal cavity.

2. The pelvic bone below this line represents the lateral wall of the true pelvis, which
contains the pelvic cavity.

The pelvic bone actually consists of 3 parts,

1. Ilium
2. Ischium
3. Pubis

At birth, these bones are connected by cartilage in the area of the acetabulum; later, at
between 16 and 18 years of age, they fuse into a single bone
The sacrum

o The sacrum (Latin sacred) is a large, flattened, triangular bone formed by the fusion of
five sacral vertebrae.

Note
• The upper part of the sacrum is massive because it supports the
body weight and transmits it to the hip bones.

• The lower part is free from weight, and, therefore, tapers rapidly

o It forms the posterosuperior part of the bony pelvis, articulating on either side with the
corresponding hip bone at the sacroiliac joint.

Being triangular, the sacrum has,

1. A base or upper surface

2. An apex or lower end

3. Four surfaces— pelvic, dorsal and right and left lateral.

• The pelvic surface is smooth and concave.

• The dorsal surface is irregular and convex
• The lateral surface is irregular and partly articular.

4. The sacrum is divided by rows of foramina into:

• Median portion, traversed by the sacral canal.

• A pair of lateral masses formed by fusion of the transverse processes
posteriorly, and of the costal elements anteriorly.
Orientation of the Pelvis

o In the anatomical position, the pelvis is oriented so that the front edge of the top of the
pubic symphysis and the anterior superior iliac spines lie in the same vertical plane

o As a consequence, the pelvic inlet, which marks the entrance to the pelvic cavity, is tilted
to face anteriorly.

As a result, the bodies of the pubic bones and the pubic arch are positioned in a nearly
horizontal plane facing the ground.

The pelvis – Men vs women

The pelvises of women and men differ in a number of ways, many of which have to do with
the passing of a baby through a woman’s pelvic cavity during childbirth.

1. The pelvic inlet in women is circular compared with the

heart-shaped pelvic inlet in men.

The more circular shape is partly caused by the less

distinct promontory and broader alae in women.

2. The angle formed by the two arms of the pubic arch is

larger in women (80°–85°) than it is in men (50°–60°).

3. The ischial spines generally do not project as far medially

into the pelvic cavity in women as they do in men
 The true pelvis
o The true pelvis is cylindrical and has an inlet, a wall, and an outlet.

o The inlet is open, whereas the pelvic floor closes the outlet and separates the pelvic
cavity, above, from the perineum, below.

Pelvic inlet Pelvic outlet

The pelvic inlet is the circular opening between the The diamond-shaped pelvic outlet is formed by both
abdominal cavity and the pelvic cavity. bone and ligaments.

This is where structures traverse between the 1. It is limited anteriorly in the midline by the pubic
abdomen and pelvic cavity. symphysis.

The promontory of the sacrum protrudes into the inlet, 2. On each side, the inferior margin of the pelvic bone
forming its posterior margin in the midline. projects posterolaterally from the pubic symphysis.

On either side of the promontory, the margin is formed a. This consists of the inferior pubic ramus &
by the alae of the sacrum. the Ramus of the ischium.

The margin of the pelvic inlet then crosses the Sacro- b. This ends at the ischial tuberosity.
iliac joint and continues along the linea terminalis
These elements construct the pubic arch, which forms
(i.e., the arcuate line, the pecten pubis or pectineal the margin of the anterior 1/2 of the pelvic outlet.
line, and the pubic crest)
The sacrotuberous ligament continues this margin
To reach the pubic symphysis. posteriorly from the ischial tuberosity to the coccyx and
sacrum.
Joints of the Pelvis

Pubic symphysis

o This is a secondary cartilaginous joint between the bodies of the right and left pubic
bones & each articular surface is covered with a thin layer of hyaline cartilage.

The fibrocartilaginous disc is reinforced by surrounding ligamentous fibres.

o The fibres are thickest inferiorly where they form the arcuate pubic ligament.

o Anteriorly, the fibres form the anterior pubic ligament

Note

1. The pubic symphysis permits slight movement between

the hip bones, which helps in absorbing shocks.

2. The range of movement is increased during pregnancy

Lumbosacral

o The joints and ligaments between the fifth lumbar vertebra and the base of the sacrum
are similar to those between any two typical vertebrae.

The lumbosacral disc is very thick, and is thickest anteriorly

o The stability of the fifth lumbar vertebra on the sacrum is further increased by:

a. The widely spaced articular processes.

b. Strong iliolumbar ligament which extends from the transverse process of L5 to the
posterior part of the inner lip of the iliac crest

o The body of the fifth lumbar vertebra makes an angle of about 120° opens backwards
with the sacrum.

This is the lumbosacral or Sacro-vertebral angle, and opens backwards

Sacrococcygeal joint

o The sacrococcygeal joint is a secondary cartilaginous joint between the apex of the
sacrum and the base of the coccyx.

The bones are united by,

1. A thin intervertebral disc.

2. Ventral sacrococcygeal ligament corresponding to the anterior longitudinal ligament.

3. Deep dorsal sacrococcygeal ligament corresponding

to the posterior longitudinal ligament.

4. Superficial dorsal sacrococcygeal ligament,

completing the lower part of the sacral canal.

5. Lateral sacrococcygeal ligament corresponding to

the intertransverse ligament and completing the
foramen for the fifth sacral nerve

6. Intercornual ligament, connecting the cornua of the

sacrum and the coccyx.

In old age, the joint is obliterated, and the ligaments are ossified.
Sometimes the joint is synovial, and the coccyx is freely mobile.
The intercoccygeal joints

• Are present only in young subjects.

• Fusion of the segments begins at the age of 20 years and is complete by about 30 years

Sacroiliac joint

• This is a synovial joint of the plane variety.

• The articular surfaces are flat in infants; but in adults show interlocking irregularities
which discourage movements at this joint.

The joint is formed between:

1. Auricular surface of the sacrum, which is covered with fibrocartilage.

2. Auricular surface of the ilium, which is covered with hyaline cartilage
Important ligaments

Sacroiliac ligaments [Support the sacroiliac joint]

It is continuous laterally with the medial edge of the sacrotuberous ligament.

The iliolumbar ligament

o This is a strong, triangular ligament, extending from the thick transverse process of the
fifth lumbar vertebra to the posterior part of the inner lip of the iliac crest.

o It is continuous with the middle and anterior layers of the thoracolumbar fascia and
gives partial origin to the quadratus lumborum.

It is covered anteriorly by the psoas, and posteriorly by the erector spinae.

The sacrotuberous ligament

o This is a long and strong band which forms parts of the boundaries of the pelvic outlet
and of the sciatic foramina.

Its superomedial end or base is wide & It is attached to,

1. The posterior superior and posterior inferior iliac spines

2. The lower transverse tubercles of the sacrum
3. The lateral margin of the lower part of the sacrum and the upper part of the coccyx.

o The inferolateral end is narrow & it is attached to the medial margin of the ischial
tuberosity.

A part of it that extends along the ramus of the ischium is called the falciform process.
Also...
• The ligament is covered by and also gives partial origin to gluteus maximus

• It is pierced by the perforating cutaneous nerve, the fifth sacral and first coccygeal
nerves, and branches of the coccygeal plexus

The sacrospinous ligament

This is a thin, triangular ligament, which lies deep to sacrotuberous ligament, and separates
the greater and lesser sciatic foramina.

1. Its base is attached to the lateral margins of the last piece of the sacrum and to the
coccyx

2. Its apex is attached to the ischial spine.

Its pelvic surface is covered by and also gives origin to the coccygeus.

The sacrotuberous and sacrospinous ligaments bind the sacrum to the ischium.

They oppose upward tilting of the lower end of the sacrum and, therefore, downward
tilting of its upper end under body weight
 Pelvic Fascia
The pelvic fascia is distributed in the extraperitoneal space of the pelvis.

1. It covers the lateral pelvic wall and the pelvic floor called parietal pelvic fascia
2. Surrounds the pelvic viscera called visceral pelvic fascia.

Principles of distribution

1. The fascia is dense and membranous over non expansile structures e.g., lateral
pelvic wall

2. The fascia is loosely arranged over expansile structures, e.g., viscera, and over
mobile structures, e.g., the pelvic floor

3. Usually, the fascia does not extend over bare bones & at the margins of the muscles,
it fuses with the periosteum.

Parietal pelvic fascia

The parietal pelvic fascia consists of,

1. Obturator fascia
2. The fasciae over piriformis
3. Fascia over levator ani (the pelvic diaphragm)
4. The presacral fascia

o It is a well-defined layer of fascia that covers the obturator internus muscle.

o It arches below the obturator vessels and nerve, investing the obturator canal, and is
attached anteriorly to the back of the pubis.

Below the obturator canal,

The fascia is markedly aponeurotic and gives a firm attachment to the iliococcygeal portion of
Obturator fascia
levator ani, usually called the tendinous arch of levator ani (arcus tendineus levatoris ani).

This arch extends from the deep surface of the pubic bone to the ischial spine

Posteriorly, it forms part of the lateral wall of the ischio-anal fossa in the perineum, and

Anteriorly, it merges with the fasciae of the muscles of the deep perineal space, which is
continuous with the ischio-anal fossa.
 The fascia over the inner aspect of piriformis is very thin, and fuses with the periosteum on
the front of the sacrum at the margins of the anterior sacral foramina.

Important
Fascia over
piriformis o It ensheathes the anterior primary rami of the sacral nerves that emerge from these
foramina; the nerves are often described as lying behind the fascia.

o The internal iliac vessels lie in front of the fascia & their branches draw out sheaths of the
fascia and extraperitoneal tissue into the gluteal region, above and below piriformis.

Both surfaces of levator ani have a fascial covering & the combination of the two fascial
layers and the intervening muscle is called the pelvic diaphragm.

Inferior fascia of the pelvic diaphragm

o This thin fascia is continuous with the obturator fascia below the tendinous arch of
levator ani laterally.

o It covers the medial wall of the ischio-anal fossa and blends below with fasciae on the
urethral sphincter and the external anal sphincter.

The superior fascia of the pelvic diaphragm

o This is markedly thicker than the inferior fascia and is attached anteriorly to the
posterior aspect of the body of the pubis, approximately 2 cm above its lower border.
Fascia over
levator ani o It extends laterally across the superior pubic ramus, blending with the obturator fascia
(pelvic and continuing along an irregular line to the spine of the ischium.
diaphragm)
o It is continuous posteriorly with the fascia over piriformis and the anterior
sacrococcygeal ligament.

o Medially, it blends with the visceral pelvic fascia to contribute to the endopelvic fascia.

Tendinous arch of the pelvic fascia/white line of the parietal pelvic fascia

Low on the superomedial aspect of the upper fascia over levator ani, a thick, white band of
condensed connective tissue extends,

o From the lower part of the pubic symphysis

o To the superior margin of the ischial spine.

It provides attachment for the condensations of visceral pelvic fascia [AKA endopelvic fascia]
that provide support to the urethra and bladder, and to the vagina in females
 This forms a hammock-like structure behind the posterior portion of the mesorectal fascia.

Laterally
o It extends to the origin of the fascia over piriformis and the fascia over levator ani
(superior pelvic diaphragmatic fascia), with which it blends.

More inferiorly, it extends between the white line of the parietal pelvic fascia on either side.

Inferiorly
o It extends to the anorectal junction, where it fuses with the posterior aspect of the
mesorectal fascia and the iliococcygeal raphe at the level of the anorectal junction.

Superiorly
Presacral fascia o It can be traced to the origin of the superior hypogastric plexus, where it attaches at about
the sacral promontory and becomes continuous with the retroperitoneal tissues.

Note

The right and left hypogastric nerves and inferior hypogastric plexuses lie on its surface, and
the presacral veins lie immediately posterior to it.

Therefore,
o The presacral fascia provides an important landmark because extension of rectal tumors
through it significantly reduces the possibility of curative resectional surgery.

Dissection in the plane posterior to the fascia may result in bleeding from the presacral
veins as the adventitia of the veins is partly attached to the posterior surface of the fascia.
Visceral Pelvic fascia

• Visceral pelvic fascia is the fascia covering organs of the pelvis and its expansile
unlike the parietal pelvic fascia.

What is the endopelvic fascia?

The urogenital organs in both sexes are connected bilaterally to the pelvic walls by
neurovascular mesenteric condensations lying above the perineal membrane.

The lateral extensions that attach the pelvic organs to the pelvic side walls are referred to
as the endopelvic fascia.

So basically

• The endopelvic fascia is the enveloping connective tissue network for the pelvic
viscera, suspending, supporting and fusing the pelvic organs to the arcus tendineus
fasciae pelvis.

The connections provide a conduit for conducting neurovascular elements from the pelvic
side wall to the organs and attachments that help to retain the pelvic organs in place.

The fascial tissues contain varying amounts of connective tissue and smooth muscle; where
they either are unusually dense or form visible ridges, they are called ‘ligaments’.

(e.g., cardinal ligament, uterosacral ligament).

Note

The mesenteries passing to the bladder in the male, or the bladder and upper vagina and
uterus in the female, are relatively long.

But these lateral connections become shorter towards the pelvic outlet.

Until at the level of the perineal membrane, there is a direct connection between the organs
and the pelvic walls.
 Pelvic muscles
The muscles arising within the pelvis form two groups.

1. Piriformis and obturator internus form part of the walls of the pelvis and are
considered primarily as muscles of the lower limb.

2. Levator ani and ischiococcygeus form the pelvic diaphragm and delineate the lower
limit of the true pelvis

• The fasciae investing the muscles are continuous with visceral pelvic fascia
above, perineal fascia below, and obturator fascia laterally.

Piriformis forms part of the posterolateral wall of the true pelvis.

Origin
• The middle three pieces of its own half of the sacrum.
• Starts from the lateral mass and extending medially between the anterior sacral
foramina.

Thus, the emerging sacral nerves and sacral plexus lie on the muscle

Insertion
Piriformis • It passes out of the pelvis through the greater sciatic foramen above the
sacrospinous ligament to attach to the medial side of superior border of greater
trochanter of femur

Note
The pelvic surface of the muscle and the sacral plexus are covered by pelvic fascia attached
to the sacral periosteum at the margin of the muscle.

Action
• Lateral rotation of the extended hip joint
• Abduction of flexed hip
 The large obturator foramen contains in life a felted mass of fibrous tissue, the obturator
membrane.

In this membrane, there is a gap above that converts the obturator notch into a canal for
the obturator nerve and vessels.

Origin
1. The muscle arises from the whole membrane and from the bony margins of the
foramen.
2. The origin extends posteriorly as high as the pelvic brim and across the flat surface of
the ischium to the margin of the greater sciatic notch.
3. On the ischial tuberosity the origin extends down to the falciform ridge.
Obturator internus
From this wide origin the muscle fibres converge fanwise towards the lesser sciatic notch.

Note
Tendinous fibres develop on the muscle surface where it bears on the lesser sciatic notch
and the bone often shows low ridges and grooves where the tendon takes a right-angled
turn to pass into the buttock.

Insertion
Ends up inserting to the Medial surface of greater trochanter of femur

Action
• Lateral rotation of the extended hip joint
• Abduction of flexed hip
The pelvic floor
o The pelvic floor consists of a gutter-shaped sheet of muscle, the pelvic diaphragm, slung
around the midline viscera (urethra and anal canal and, in the female, the vagina).

This Pelvic diaphragm separates the pelvis from the perineum

The muscles of the pelvic floor are,

1. The levator ani

2. The coccygeus.

Levator Ani

This arises in continuity from,

1. The body of the pubis

2. The tendinous arch over the obturator fascia
3. The spine of the ischium

From their origin the muscle fibres slope downwards and backwards to the midline &
therefore the pelvic floor produces a gutter that slopes downwards and faces forwards.

They are inserted into the coccyx and the postanal plate

o The muscle is subdivided into named portions according to their attachments and the
pelvic viscera to which they are related (pubococcygeus, iliococcygeus and puborectalis).

Note that these parts are often referred to as separate muscles but the boundaries between
each part cannot be distinguished and they perform many similar physiological functions.
 Pubococcygeus originates from the posterior aspect of the body of the pubis & the
tendinous arch of obturator fascia, and then passes back almost horizontally.

Most medial fibres of the first few cm from the Pubis,

• Run directly lateral to the urethra and its sphincter as it passes through the pelvic
floor where it is in close relationship to the upper half of the urethra in both
sexes.

Therefore, it is often referred to as pubourethralis.

[No direct connection with urethra]

In males,

• Some of these fibres lie lateral and inferior to the prostate and are referred to
as puboprostaticus (levator prostate)
Pubococcygeus
part
In females,

• Fibres run further back and attach to the lateral walls of the vagina, where
they are referred to as pubovaginalis.

In both sexes, fibres from this part of pubococcygeus attach to the perineal body.

Also,

• Some fibres, sometimes called puboanalis, decussate and blend with the
longitudinal rectal muscle and fascial elements to contribute to the conjoint
longitudinal coat of the anal canal.

• Behind the rectum, other fibres of pubococcygeus form a tendinous

intersection as part of the levator raphe. [Anococcygeal ligament]

Lies lateral & inferior to pubococcygeus and cannot been seen from inside the
pelvis.

• It originates from the lateral part of the pelvic surface of the body of the pubis.
Puborectalis
• Its fibres pass lateral to those of iliococcygeus and pubococcygeus to decussate
posterior to the rectum at the anorectal junction.

Here it blends with the external anal sphincter

 Anterior fibres are attached to,

• The inner surface of the ischial spine below and anterior to the attachment of
ischiococcygeus

• The tendinous arch as far forwards as the obturator canal.

Iliococcygeus
The most posterior fibres are attached to,

• The tip of the sacrum and coccyx

• To fibres from the contralateral side to form a raphe that is effectively

continuous with the fibroelastic anococcygeal ligament.

Relations of the levator ani

1. The superior or pelvic surface is covered with pelvic fascia which separates it from
the bladder, prostate, rectum and the peritoneum.

2. The inferior or perineal surface is covered with anal fascia and forms the medial
boundary of the ischioanal fossa

3. The anterior borders of the two muscles are separated by a triangular space for the
passage of the urethra and the vagina

4. The posterior border is free and lies against the anterior margin of coccygeus

The Coccygeus muscle [Ischiococcygeus]

o This separate muscle & lies as the most posterosuperior portion of levator ani and arises
as a triangular musculotendinous sheet.

Its apex is attached to the pelvic surface and tip of the ischial spine, and base attached to
the lateral margins of the coccyx and the fifth sacral segment.

o It lies on the pelvic aspect of the sacrospinous ligament and may be fused with it,
particularly if it is mostly tendinous.

Actions of Levator Ani and Coccygeus

1. They close the posterior part of the pelvic outlet.

2. The levators ani fix the perineal body and support the pelvic viscera.
3. During coughing, sneezing, lifting and other muscular efforts, the levators ani and
coccygei counteract or resist increased intra-abdominal pressure and help to maintain
continence of the bladder and the rectum.

4. In micturition, defaecation and parturition, a particular pelvic outlet is open, but

contraction of fibres around other openings resists increased intra-abdominal pressure
and prevents any prolapse through the pelvic floor.

5. The sling formed by the puborectalis muscles pulls the anorectal junction forwards, thus
it prevents untimely descent of the faeces.

6. The coccygeus pulls forwards and supports the coccyx, after it has been pressed
backwards during defaecation, parturition or childbirth.

Now that we know the structures of the pelvic wall, let’s take a look at the
apertures of the pelvic wall

o Each lateral pelvic wall has three major apertures through which structures pass
between the pelvic cavity and other regions:

1. The obturator canal

2. The greater sciatic foramen
3. The lesser sciatic foramen.

Obturator canal

o At the top of the obturator foramen is the obturator canal, which is bordered by the
obturator membrane, obturator internus and its fascia and the superior pubic ramus

The obturator nerve and vessels pass from the pelvic cavity to the thigh through this
canal.

Greater sciatic foramen

o The greater sciatic foramen is a major route of communication between the pelvic cavity
and the lower limb.

o It is formed by the greater sciatic notch in the pelvic bone, the sacrotuberous and the
sacrospinous ligaments, and the spine of the ischium.

The piriformis muscle passes through the greater sciatic foramen, dividing it into two
parts.

1. The superior gluteal nerves and vessels pass through the foramen above the
piriformis.
 2. Passing through the foramen below the piriformis are,
a. The inferior gluteal nerves and vessels
b. The sciatic nerve
c. The pudendal nerve
d. Internal pudendal vessels
e. Posterior femoral cutaneous nerves
f. Nerves to the obturator internus and quadratus femoris muscles.

Lesser sciatic foramen

o This is formed by the lesser sciatic notch of the pelvic bone, the ischial spine, the
sacrospinous ligament, and the sacrotuberous ligament.

o The tendon of the obturator internus muscle passes through this foramen to enter the
gluteal region of the lower limb.

Because the lesser sciatic foramen is positioned below the attachment of the pelvic floor,
it acts as a route of communication between the perineum and the gluteal region.

Mechanism of the Pelvis

The most important mechanical function of the pelvis is to transmit the weight of trunk to
the lower limb.

The weight passes mainly through the alae of sacrum and through the thick part of hip bone
lying between sacroiliac joint and acetabulum.

Theoretically, the weight falling on the lumbosacral joint is divided into two components.

a. One component of the force is expanded in trying to drive the sacrum downwards
and backwards between the iliac bones. [Like breaking a chocolate in half]

This is resisted by the ligaments of pubic symphysis.

b. Second component of the force tries to push the upper end of sacrum downwards
and forwards towards the pelvic cavity.

o This is resisted by the middle segment of the sacroiliac joint, where the
auricular surface of the sacrum is wider posteriorly,

i.e., wedge-shaped and is concave for interlocking with the reciprocal

surface of the ilium.
Also...

Because of the poor wedging and poor locking of the articular surfaces in the anterior and posterior
segments of the sacroiliac joint, the sacrum is forced to rotate under the influence of body weight.

In this rotation, the anterior segment is tilted downwards and the posterior segment upwards.

Therefore,

• The downward tilt of the anterior segment is prevented chiefly by the dorsal and interosseous
sacroiliac ligaments

• The upward tilt of the posterior segment is prevented chiefly by the sacrotuberous and
sacrospinous ligaments.

Additionally,
Blood vessels
• During all these movements, the separation of iliac bones is resisted by sacroiliac and iliolumbar
ligaments, and the ligaments of pubic symphysis.

Arteries

o The major artery of the pelvis and perineum is the internal iliac artery on each side.

o Other vessels that originate in the abdomen and contribute to the supply of pelvic
structures include,

• The median sacral artery

• In women, the ovarian arteries.
 Internal iliac artery

• Originates from the common iliac artery on each side, approximately at the level of the
intervertebral disc between LV and SI and lies anteromedial to the Sacro-iliac joint.

• The vessel courses inferiorly over the pelvic inlet and then divides into anterior and
posterior trunks at the level of the superior border of the greater sciatic foramen.

1. Branches from the posterior trunk contribute to the supply of the lower posterior
abdominal wall, the posterior pelvic wall, and the gluteal region.

2. Branches from the anterior trunk supply the pelvic viscera, the perineum, the gluteal
region, the adductor region of the thigh, and, in the fetus, the placenta.

Posterior trunk [3 branches]

Ascends laterally back out of the pelvic inlet and divides into a lumbar branch and an iliac
branch.

The lumbar branch contributes to the supply of,

Iliolumbar artery
• The posterior abdominal wall psoas and quadratus lumborum muscles
• The cauda equina [via a small spinal branch that passes through the intervertebral
foramen between LV and SI]
• The iliac branch passes laterally into the iliac fossa to supply muscle and bone
Usually two, originate from the posterior division of the internal iliac artery and course
medially and inferiorly along the posterior pelvic wall.

Lateral sacral They give rise to branches that pass into the anterior sacral foramina to supply,
artery
1. Related bone and soft tissues
2. Structures in the vertebral (sacral) canal
3. Skin and muscle posterior to the sacrum
Largest branch of the internal iliac artery and is the terminal continuation of the posterior
trunk.

It courses posteriorly, usually passing between the lumbosacral trunk and anterior ramus of
Superior gluteal S1, to leave the pelvic cavity through the greater sciatic foramen above the piriformis muscle.
artery
Then it enters the gluteal region of the lower limb.

This vessel makes a substantial contribution to the blood supply of muscles and skin in the
gluteal region and also supplies branches to adjacent muscles and bones of the pelvic walls.
 Anterior trunk

Gives origin to the superior vesical artery and then travels forward just inferior to the margin
of the pelvic inlet.

Anteriorly, the vessel leaves the pelvic cavity and ascends on the internal aspect of the
anterior abdominal wall to reach the umbilicus.

Umbilical artery In the fetus, the umbilical artery is large and carries blood from the fetus to the placenta.
[Obliterated in an
adult] • After birth, the vessel closes distally to the origin of the superior vesical artery and
eventually becomes a solid fibrous cord.

• On the anterior abdominal wall, the cord raises a fold of peritoneum termed the medial
umbilical fold.

• The fibrous remnant of the umbilical artery itself is the medial umbilical ligament.

o Normally originates from the root of the umbilical artery and courses medially and
Superior vesical inferiorly to supply the superior aspect of the bladder and distal parts of the ureter.
artery
o In men, it also may give rise to an artery that supplies the ductus deferens.

Inferior vesicle
o Occurs in men and supplies branches to the bladder, ureter, seminal vesicle, and prostate.
artery

In women is the equivalent of the inferior vesical artery in men.

Descending to the vagina, this supplies branches to,

• The vagina
Vaginal artery • Adjacent parts of the bladder and rectum.

Note

The vaginal artery and uterine artery may originate together as a common branch from the
anterior trunk, or the vaginal artery may arise independently
Courses medially to supply the rectum.

The vessel anastomoses with,

Middle rectal
artery • The superior rectal artery, which originates from the inferior mesenteric artery in the
abdomen
• The inferior rectal artery, which originates from the internal pudendal artery in the
perineum.
 Courses anteriorly along the pelvic wall and leaves the pelvic cavity via the obturator canal.

Obturator artery Together with the obturator nerve, above, and obturator vein, below, it enters and supplies
the adductor region of the thigh.

The internal pudendal artery is the main artery of the perineum.

Courses inferiorly from its origin in the anterior trunk and leaves the pelvic cavity through the
greater sciatic foramen inferior to the piriformis muscle.
Internal pudendal
In association with the pudendal nerve on its medial side, the vessel passes laterally to the
artery
ischial spine and then through the lesser sciatic foramen to enter the perineum.

Among the structures it supplies are the erectile tissues of,

• The clitoris
• The penis
This is a large terminal branch of the anterior trunk of the internal iliac artery.

It passes between the anterior rami S1 and S2 or S2 and S3 of the sacral plexus and leaves the
Inferior gluteal
pelvic cavity through the greater sciatic foramen inferior to the piriformis muscle.
artery
It enters and contributes to the blood supply of the gluteal region and anastomoses with a
network of vessels around the hip joint.
The uterine artery is the major blood supply to the uterus and enlarges significantly during
pregnancy. [Supplies ovaries & Vagina too]

In women courses medially and anteriorly in the base of the broad ligament to reach the
cervix.
Uterine artery
Along its course, the vessel crosses the ureter and passes superiorly to the lateral vaginal
fornix.

Once the vessel reaches the cervix, it ascends along the lateral margin of the uterus to reach
the uterine tube, where it curves laterally and anastomoses with the ovarian artery.

Ovarian arteries

In women, the gonadal (ovarian) vessels originate from the abdominal aorta and then
descend to cross the pelvic inlet and supply the ovaries.

They anastomose with terminal parts of the uterine arteries.

On each side, the vessels travel in the suspensory ligament of the ovary (infundibulopelvic
ligament) as they cross the pelvic inlet to the ovary.
Median sacral artery

• Originates from the posterior surface of the aorta just superior to the aortic bifurcation
at vertebral level LIV in the abdomen.

• It descends in the midline, crosses the pelvic inlet, and then courses along the anterior
surface of the sacrum and coccyx.

Veins

• Pelvic veins follow the course of all branches of the internal iliac artery except for the
umbilical artery and the iliolumbar artery.

Internal iliac veins

On each side, the veins drain into internal iliac veins, which leave the pelvic cavity to join
common iliac veins situated just superior and lateral to the pelvic inlet.

Within the pelvic cavity, extensive interconnected venous plexuses are associated with the
surfaces of the viscera (bladder, rectum, prostate, uterus, and vagina).

Together, these plexuses form the pelvic plexus of veins.

The single deep dorsal vein

• Drains erectile tissues of the clitoris and the penis does not follow branches of the internal
pudendal artery into the pelvic cavity.

• Instead, this vein passes directly into the pelvic cavity through a gap formed between the
arcuate pubic ligament and the anterior margin of the perineal membrane.

The vein joins the prostatic plexus of veins in men and the vesical (bladder) plexus of veins
in women.

The median sacral veins

• Coalesce to form a single vein that joins either the left common iliac vein or the
junction of the two common iliac veins to form the inferior vena cava.

The ovarian veins

• Follow the course of the corresponding arteries; on the left, they join the left renal
vein, and, on the right, they join the inferior vena cava in the abdomen
 Lymphatics of the Pelvis

Int./Ext. Iliac Common iliac Lateral aortic

Lumbar trunk Cisterna Chyli
nodes nodes nodes

Nerves of the pelvis

Somatic plexuses

• Sacral and coccygeal plexuses

• The sacral and coccygeal plexuses are situated on the posterolateral wall of the pelvic
cavity and generally occur in the plane between the muscles and blood vessels.

They are formed by the ventral rami of S1 to Co, with a significant contribution from L4
and L5, which enter the pelvis from the lumbar plexus.

What do they do?

1. Somatic plexuses mainly contribute to the innervation of the lower limb and muscles
of the pelvis and perineum.

2. Cutaneous branches supply skin over the medial side of the foot, the posterior
aspect of the lower limb, and most of the perineum

Sacral Plexus

• The plexus is formed in relation to the anterior surface of the piriformis muscle,
which is part of the posterolateral pelvic wall.

• The sacral plexus on each side is formed by the anterior rami of S1 to S4, and the
lumbosacral trunk (L4 and L5).

1. Sacral contributions to the plexus pass out of the anterior sacral foramina and
course laterally and inferiorly on the pelvic wall.

2. The lumbosacral trunk, consisting of part of the anterior ramus of L4 and all of
the anterior ramus of L5, courses into the pelvic cavity by passing immediately
anterior to the sacro-iliac joint.

Note

• Gray rami communicantes from ganglia of the sympathetic trunk connect with each of the anterior
Ventral
rami & dorsal
and carry divisions sympathetic fibers destined for the periphery to the somatic nerves.
postganglionic

• In addition, special visceral nerves (pelvic splanchnic nerves) originating from S2 to S4 deliver
preganglionic parasympathetic fibers to the pelvic part of the prevertebral plexus
• Each anterior ramus has ventral and dorsal divisions that combine with similar divisions
from other levels to form terminal nerves.

The anterior ramus of S4 has only a ventral division.

Branches of the sacral plexus include,

1. The sciatic nerve

2. Gluteal nerves [Inferior & Superior]
3. The pudendal nerve
 Courses of pelvic nerves

Originate from the sacral plexus leave the pelvic cavity by passing through the greater sciatic
foramen inferior to the piriformis muscle and enter the gluteal region of the lower limb.
Most nerves
[E.g., Superior & inferior gluteal nerves]

Do not leave the pelvic cavity and course directly into the muscles in the pelvic cavity.
Few nerves
[E.g., Nerve to the piriformis, Levator ani nerves]

1. Leave the pelvic cavity through the greater sciatic foramen

2. Loop around the ischial spine and sacrospinous ligament.
3. Then pass medially through the lesser sciatic foramen to supply structures in the perineum
2 nerves
and lateral pelvic wall.

[E.g., Nerve to the obturator internus and pudendal nerve]

Coccygeal plexus

• The small coccygeal plexus has a minor contribution from S4 and is formed mainly by the
anterior rami of S5 and Co, which originate inferiorly to the pelvic floor.

They penetrate the coccygeus muscle to enter the pelvic cavity and join with the anterior
ramus of S4 to form a single trunk, from which small anococcygeal nerves

What do they innervate?

• They penetrate the muscle and the overlying sacrospinous and sacrotuberous
ligaments and pass superficially to innervate skin in the anal triangle of the
perineum.
Visceral [Autonomic plexuses]
Paravertebral sympathetic chain

• The paravertebral part of the visceral nervous system is represented in the pelvis by
the inferior ends of the sympathetic trunks.

Each trunk enters the pelvic cavity from the abdomen by passing over the ala of the
sacrum medially to the lumbosacral trunks and posteriorly to the iliac vessels.

• The trunks course inferiorly along the anterior surface of the sacrum, where they are
positioned medially to the anterior sacral foramina. [4 ganglia occur along each
trunk]

• Anteriorly to the coccyx, the two trunks join to form a single small terminal ganglion
(the ganglion impar).

What do these trunks do?

• They deliver postganglionic sympathetic fibers to the anterior rami of sacral nerves
for distribution to the periphery, mainly to parts of the lower limb and perineum.

• This is accomplished by gray rami communicantes, which connect the trunks to the
sacral anterior rami.

Note

In addition to gray rami communicantes, other branches (the sacral splanchnic

nerves) join and contribute to the pelvic part of the prevertebral plexus.

Pelvic extensions of the prevertebral plexus

• The pelvic parts of the prevertebral plexus carry sympathetic, parasympathetic, and
visceral afferent.

• The prevertebral plexus enters the pelvis as two hypogastric nerves, one on each
side, that cross the pelvic inlet medially to the internal iliac vessels

The hypogastric nerves are formed by the separation of the fibers in the superior
hypogastric plexus, into right and left bundles.

Note

The superior hypogastric plexus is situated anterior to vertebra LV

between the promontory of the sacrum and the bifurcation of the aorta.
Explain the Formation of the inferior hypogastric plexus

o When the hypogastric nerves are joined by pelvic splanchnic nerves carrying
preganglionic parasympathetic fibers from S2 to S4, the pelvic plexuses (inferior
hypogastric plexuses) are formed.

o The inferior hypogastric plexuses, one on each side, course in an inferior direction
around the pelvic walls, medially to major vessels and somatic nerves.

They give origin to the following subsidiary plexuses, which innervate the pelvic viscera:

• Rectal plexus
• Uterovaginal plexus
• Prostatic plexus
• Vesical plexus.

Terminal branches of the inferior hypogastric plexuses penetrate and pass through the
deep perineal pouch and innervate erectile tissues of the penis and the clitoris in the
perineum.
Anatomy of the Female Reproductive system
Anatomy of internal female reproductive organs

The ovaries

What is it?

• The ovary is ovoid in shape, smaller than the testis & is about 3 cm long, 2 cm wide and 1 cm
thick, being smaller before menarche and postmenopausally.

In the erect position, the ovary lies almost vertically.

Where is it?
Each ovary lies in the ovarian fossa on the lateral pelvic wall, which is bounded:

1. Anteriorly by the obliterated umbilical artery.

2. Posteriorly by the ureter and the internal iliac artery

It is overlaid by the coils of sigmoid colon and ileum that occupy the rectouterine pouch of
Douglas.
Orientation & Position [Variable]

• In nulliparous women, its long axis is nearly vertical, so that the ovary is usually described as
having an upper pole and a lower pole.

• However, in multiparous women, the long axis becomes horizontal, so that the upper pole
points laterally and the lower pole medially

External features

• In young girls, before the onset of ovulation, the ovaries have smooth surfaces which are
greyish pink in colour.

• After puberty, the surface becomes uneven and the colour changes from pink to grey.

Each ovary has,

• 2 poles or extremities—the upper or tubal pole, and the lower or uterine pole
• 2 borders— the anterior or mesovarian border, and the posterior or free border.
• 2 surfaces—lateral and medial.

Its upper pole [The tubal extremity]

Visceral relations

• It is tilted laterally and is overlapped by the fimbriated end of the uterine tube and the
external iliac vein.

Peritoneal relations

• Suspensory ligament of the ovary are attached to the upper pole of the ovary

How is the suspensory ligament formed?

The lateral part of the broad ligament of uterus, extending from the
infundibulum of the uterine tube and the upper pole of the ovary to the
external iliac vessels, forms a distinct fold known as suspensory ligament of
the ovary or infundibulopelvic ligament.

It contains the ovarian vessels and nerves

Lower pole [Uterine extremity]

It is narrower than the upper pole and is related to the pelvic floor.

It is connected, by the ligament of the ovary, to the lateral angle of the uterus, posteroinferior to the
attachment of the uterine tube.

The ligament lies between the two layers of the broad ligament of the uterus and contains some
smooth muscle fibres
The anterior border [Mesovarian border]

• It is straight and is related to the uterine tube and the obliterated umbilical artery.

• This is attached to the posterior leaf of the broad ligament by a double fold of peritoneum,
the mesovarium and forms the hilus of the ovary

The peritoneum does not invest the rest of the surface of the ovary, which is covered with
cuboidal epithelium and faces the peritoneal cavity.

The mesovarium transmits the vessels and nerves to and from the ovary

Posterior or free border

• It is convex and is related to the uterine tube and the ureter.

The lateral surface

• This lies in the angle between the internal and external iliac vessels, in the ovarian fossa
which is lined by parietal peritoneum.

• This peritoneum separates it from the obturator nerve laterally and the ureter posteriorly.

A diseased ovary may therefore cause referred pain along the cutaneous
distribution of this nerve on the inner side of the thigh

The medial surface

This is mainly related to the uterine tube & the peritoneal recess between the mesosalpinx and this
surface is known as the ovarian bursa.

As you can see now

Only the lower pole and lateral surfaces are not related to uterine tube, remaining
two borders, upper pole and medial surface are related to the tube.

Can we palpate the ovaries?

• Yes!

• The ovary in its normal position can just be reached through the vagina by the
tip of the examining finger.

The location and line of the ovary change during pregnancy and usually never
return to their original state.
 Blood supply of the ovaries

The ovarian artery arises from the abdominal aorta just below the renal artery.

• It descends over the posterior abdominal wall and enters the suspensory ligament of the
ovary.

• It sends branches to the ovary through the mesovarium, and continues medially through
Arterial supply the broad ligament of the uterus to anastomose with the uterine artery

In addition to ovary, the ovarian artery also supplies the uterine tube, the side of uterus and
the ureter.

The uterine artery gives the ovarian branch of the ascending branch of the uterine artery,
which anastomoses with the ovarian artery.
The veins emerge at the hilus and form a pampiniform plexus around the artery.

The plexus condenses into a single ovarian vein near the pelvic inlet, which ascends on the
Venous drainage posterior abdominal wall and drains into,

1. The inferior vena cava on the right side

2. The left renal vein on the left side.
Anatomy of the Uterus

What is it?

Uterus is a child-bearing organ in females, situated in the pelvis between bladder and rectum.

What does it do in brief?

It is the organ which protects and provides nutrition to a fertilized ovum, enabling it to grow into a
fully formed fetus.

At the time of childbirth or parturition, contractions of muscle in the wall of the organ result in
expulsion of the fetus from the uterus.
Size and shape

• The uterus is pyriform in shape, is about 7.5 cm long, 5 cm broad, and 2.5 cm thick & weighs 30
to 40 grams.

Position & orientation

• Normally, the long axis of the uterus forms an angle of about 90° with the long axis of the
vagina. [this angle is open forwards]

1. The forward tilting of the uterus relative to the vagina is called anteversion
2. The backward tilting of the uterus relative to vagina is known as retroversion.

The uterus is also usually slightly flexed at the level of internal os of cervix & this is referred to as
anteflexion.

The uterus comprises:

1. Fundus
2. Cervix.
3. Body with two surfaces & two lateral borders

The Fundus

o This is formed by the free upper end of the uterus & lies above the openings of the uterine
tubes.

o It is convex like a dome & is covered with peritoneum and is directed forward when the
bladder is empty.
The body
1. The anterior or vesical surface is flat and related to the urinary bladder.

o It is covered with peritoneum and forms the posterior or superior wall of the
uterovesical pouch.

2. The posterior or intestinal surface is convex and is related to coils of the terminal ileum and to
the sigmoid colon.

o It is covered with peritoneum and forms the anterior wall of the rectouterine pouch

Note

• In sagittal section, the cavity of the body of the uterus is seen as a mere slit because
the uterus is compressed anteroposteriorly.

• In coronal section, the cavity is seen to be triangular in shape, the apex being directed
downwards.

At the apex, the cavity becomes continuous with the canal of the cervix & the junction
between the two is called the internal os.

Lateral Borders of the body [Each is round and convex]

o It provides attachment to the broad ligament of the uterus which connects it to the lateral pelvic
wall.

The uterine tube opens into the uterus at the upper end of this border.

It also provides attachment to,

1. The round ligament of the uterus, anteroinferior to the tube

2. The ligament of the ovary posteroinferior to the tube.

Note

The uterine artery ascends along the lateral border of the uterus
between the two layers of the broad ligament.

The cervix
o The cervix is the lower, cylindrical part of the uterus, & is less mobile than the body.

It is about 2.5 cm long and is slightly wider in the middle than at either end.
o The lower part of the cervix projects into the vagina which divides it into supravaginal and
vaginal parts.
The supravaginal part of the cervix is related:

a. Anteriorly to the bladder.

b. Posteriorly to the rectouterine pouch, containing coils of intestine and to the rectum
c. On each side, to the ureter and to the uterine artery, embedded in parametrium.

The fibrofatty tissue between the two layers of the broad ligament and
below it, is called the parametrium.

It is most abundant near the cervix and vagina

• The vaginal part of the cervix projects into the anterior wall of the vagina & the spaces
between it and the vaginal wall are called the vaginal fornices.

The cervical canal opens into the vagina by an opening called the external os.

a. In a nulliparous woman, the external os is small and circular

b. In multiparous women, the external os is bounded by anterior and posterior lips, both of
which are in contact with the anterior & posterior wall of the vagina.

The cervical canal

o This fusiform in shape & it communicates,

1. Above with the cavity of the body of the uterus, through the internal os
2. Below with the vaginal cavity through the external os.

The canal is flattened from before backwards so that it comes to have anterior and posterior walls.

o These walls show mucosal folds which resemble the branches of a tree called the arbor vitae
uteri.

o The folds in the anterior and posterior walls interlock with each other and close the canal.
Folds & ligaments of the uterus
The uterus is connected to a number of ‘ligaments’,

1. Some are true ligaments, in that they have a fibrous composition and provide support to the
uterus

2. Some provide no support to the uterus; and others are simply folds of peritoneum.

Peritoneal folds

The parietal peritoneum is reflected over the upper genital tract to produce,

1. Anterior (uterovesical) fold

2. Posterior (rectovaginal) fold
3. Lateral peritoneal folds [commonly called the broad ligaments]

Uterovesical and rectovaginal folds

The anterior uterovesical, fold consists of peritoneum reflected on to the bladder from the uterus at
the junction of its cervix and body.

The posterior rectovaginal fold extends lower than the anterior fold and consists of peritoneum
reflected from the posterior vaginal fornix on to the front of the rectum.

Thereby they the deep recto-uterine pouch (pouch of Douglas).

The recto-uterine pouch is bounded,

a. Anteriorly by the uterus, supravaginal cervix and posterior vaginal fornix
b. Posteriorly, by the rectum
c. Laterally, by the uterosacral ligaments.

Broad ligament of the Uterus

The lateral folds, or broad ligaments, extend on each side from the uterus to the lateral pelvic walls,
where they become continuous with the peritoneum covering those walls.

o Upper border is free & the anterior and posterior layers of peritoneum forming the ligament
become continuous here.

o The lower border is continuous with the peritoneum over the bladder, rectum and side wall
of the pelvis

So basically, when the bladder is full, the ligament has anterior and posterior surfaces, and upper,
lower, medial and lateral borders.

Between layers of the broad ligament is the parametrium

The broad ligament is divided into,

1. An upper mesosalpinx
2. A posterior mesovarium
3. An inferior mesometrium

Mesosalpinx

This is attached,

o Above to the uterine tube

o Postero-inferiorly to the mesovarium.
o Superior and laterally to the suspensory ligament of the ovary
o Medially to the ovarian ligament.

The fimbria of the tubal infundibulum projects from its free lateral end.

Between the ovary and uterine tube, the mesosalpinx contains,

a. Vascular anastomoses between the uterine and ovarian vessels

b. The epoophoron and the paroophoron.

The Mesovarium

o This projects from the posterior aspect of the broad ligament, of which it is the smaller part
& it is attached to the hilum of the ovary and carries vessels and nerves to the ovary.

Mesometrium

o This is the largest part of the broad ligament and extends from the pelvic floor to the
ovarian ligament and uterine body.

The uterine artery passes between its two peritoneal layers typically 1.5 cm lateral to the cervix.

o It crosses the ureter shortly after its origin from the internal iliac artery and gives off a
branch that passes superiorly to the uterine tube.

Here, branches into ovarian and tubal branches & anastomoses with the ovarian and tubal
branches of the ovarian artery.

Between the pyramid formed by the infundibulum of the tube, the upper pole of the ovary, and the
lateral pelvic wall,

o The mesometrium contains the ovarian vessels and nerves lying within the fibrous
suspensory ligament of the ovary (infundibulopelvic ligament).

o This ligament continues laterally over the external iliac vessels as a distinct fold.

The mesometrium also encloses the proximal part of the round ligament of the uterus, as well as
smooth muscle and loose connective tissue.
 The uterus and vagina are supported by the close interaction of,

1. The true ligaments of the uterus

2. Muscles of the pelvic floor, including the levatores ani and coccygei
3. The perineal membrane
4. The perineal body.

True ligaments of the uterus

This consist of,

1. The round ligament
2. The uterosacral ligament
3. The transverse cervical ligament
4. The pubocervical ligaments.

Round ligament

Each round ligament is a narrow smooth muscle band 10–12 cm long & its course through the pelvis
is as follows,

o It extends from the lateral cornu of the uterus through the broad ligament to enter the deep
inguinal ring lateral to the inferior epigastric artery.

o Then it passes through the deep inguinal ring, traverses the inguinal canal & merges with the
areolar tissue of the labium majus after breaking up into thin filaments

Near the uterus, the round ligament contains a considerable amount of smooth muscle, but this
gradually diminishes, and the terminal portion is purely fibrous.

The round ligament also contains,

1. Blood vessels
2. Nerves
3. Lymphatics [drain the uterine region around the entry of the uterine tube to the superficial
inguinal nodes.]

In the fetus,

• A projection of peritoneum (processus vaginalis) is carried with the round ligament for a short
distance into the inguinal canal.

This
The is generally
uterosacral, obliterated
transverse in adults,
cervical althoughligaments
and pubocervical it is sometimes patent even in old age.

• o processus
A patent These are condensations of inguinal
vaginalis in the the visceral or endopelvic
canal in femalesconnective tissue that
is often referred connect
to as the of
the canal
Nuck. pelvic viscera to the side wall of the pelvis.

o They radiate like the spokes of a wheel around the hub of the cervix, providing it with
It may be asymptomatic, or it may give rise to an inguinal hernia or hydrocele of the canal of Nuck.
considerable support.

In the canal, the ligament receives the same coverings as the spermatic cord, although they are thinner
and blend with the ligament itself, which may not reach the mons pubis.

The round and ovarian ligaments both develop from the gubernaculum and are continuous.
 They pass back from the cervix and uterine body on both sides of the rectum and are attached to
the anterior aspect of the sacrum.
Uterosacral
ligaments
They can be palpated laterally on rectal examination and can be felt as thick bands of tissue
passing downwards on both sides of the posterior fornix on vaginal examination.
These extend from the side of the cervix and lateral fornix of the vagina and are attached
Transverse cervical extensively on the pelvic wall.
ligaments
[Cardinal The lower parts of the ureters and pelvic blood vessels traverse the transverse cervical
ligaments] ligaments.

Fibres pass forwards from the anterior aspect of the cervix and upper vagina to diverge around the
urethra and are attached to the posterior aspect of the pubic bones.

Pubocervical
ligaments

The transverse cervical and uterosacral ligaments are almost vertically orientated in the
standing position and maintain the near-horizontal axis of the upper vagina
 Blood supply of the uterus

Supplied by the uterine artery, a branch of the internal iliac.

It passes medially across the pelvic floor in the base of the broad ligament, above the ureter, to
reach the side of the supravaginal part of the cervix.

Giving a branch to the cervix and vagina, the vessel turns upwards between the layers of the broad
Arterial supply ligament to run in a tortuous manner alongside the uterus as far as the cornu.

All while giving off branches which penetrate the uterine walls and anastomose across the midline
with corresponding branches of the opposite uterine artery.

At the junction of uterus and uterine tube the artery turns laterally and ends by anastomosing with
the tubal branch of the ovarian artery, which supplies the uterine tube.
They course below the artery at the lower edge of the broad ligament where they form a wide plexus
across the pelvic floor.
Venous drainage
This communicates with the vesical and rectal plexuses and drains to the internal iliac veins. The
tubal veins join the ovarian veins.

Nerve supply

The uterus is richly supplied by both sympathetic and parasympathetic nerves, through the inferior
hypogastric and ovarian plexuses.

1. Sympathetic nerves from T12, L1 segments of spinal cord produce uterine contraction and
vasoconstriction.

2. The parasympathetic nerves (S2–4) produce uterine inhibition and vasodilatation.

However, these effects are complicated by the pronounced effects of hormones on the
genital tract.

The uterine nerves terminate in the myometrium and endometrium, and usually accompany the
vessels
As with most hollow viscera,

• Distension causes pain, but both the cervix and body are relatively insensitive to cutting and
burning

Note

• Presacral neurectomy (cutting the hypogastric nerves from the superior hypogastric plexus)
does not abolish labour pain, although it may improve dysmenorrhoea.

The abolition of uterine sensation requires the division of all nerves, or transection of the
cord, above T10 level.
 Anatomy of the Uterine tubes
What are they?

o They are tortuous ducts which convey oocyte from the ovary to the uterus.

o Spermatozoa introduced into the vagina pass up into the uterus, and from there into the uterine
tubes & fertilization usually takes place in the lateral part of the tube [Ampulla]

Where are they and what are their features?

o These are situated in the free upper margin of the broad ligament of uterus & each uterine tube
is about 10 cm long.

The part of the broad ligament between the attachment of the mesovarium and the uterine tube
is known as the mesosalpinx.

o At the lateral end, the uterine tube opens into the peritoneal cavity through its abdominal
ostium, which is about 3 mm in diameter.

o The medial opening of the tube (the uterine os) is located at the superior angle of the uterine
cavity.

Subdivisions

The lateral end of the uterine tube is shaped like a funnel and is, therefore, called the infundibulum.
Infundibulum
It bears a number of finger-like processes called fimbriae and is, therefore, called the fimbriated end.
The part of the uterine tube medial to the infundibulum is called the ampulla.

It is thin-walled, dilated and tortuous, and forms approximately the lateral two-thirds or 6 to 7 cm of
Ampulla
the tube.

It arches over the upper pole of the ovary &is about 4 mm in diameter
This succeeds the ampulla & it is narrow, rounded and cord-like.
Isthmus
It forms approximately the medial one-third or 2 to 3 cm of the tube.
This is about 1 cm long and lies within the wall of the uterus.
Uterine/Intramural
/interstitial part of
It opens at the superior angle of the uterine cavity by a narrow uterine ostium, which is about 1 mm
the tube
in diameter.

Blood Supply

1. The tubal branch of the uterine artery supplies approximately the medial two-thirds
2. The tubal branch of the ovarian artery supplies the lateral one-third of the tube.

The veins run parallel with the arteries and drain into the pampiniform plexus of the ovary and
into the uterine veins
Nerve Supply
o The uterine tubes are supplied by both the sympathetic and parasympathetic nerves running
along the uterine and ovarian arteries.

1. The sympathetic nerves from T10 to L2 segments are derived from the hypogastric plexuses.

a. They contain both visceral afferent and efferent fibres.

b. The latter are vasomotors and perhaps stimulate tubal peristalsis. [However,
peristalsis is mainly under hormonal control]

2. Parasympathetic nerves are derived from,

a. The vagus for the lateral half of the tube and from

b. Pelvic splanchnic nerves from S2–4 segments of spinal cord for the medial half.

They inhibit peristalsis and produce vasodilatation.

The vagina

What is it?
o The vagina is a fibromuscular canal, forming the female copulatory organ.[‘vagina’ means a
sheath.]

Extent and Situation The vagina extends from the vulva to the uterus, and is situated behind the
bladder and the urethra, and in front of the rectum and anal canal.

Direction
o In the erect posture, the vagina is directed upwards and backwards.

o Long axis of uterus and cervix forms an angle of 90° with long axis of vagina.

Size and Shape

o The anterior wall of the vagina is about 8 cm long and the posterior wall about 10 cm long.

o The diameter of the vagina gradually increases from below upwards [The upper end or vault
is roughly 5 cm twice the size of the lower end (2.5 cm)]

However, it is quite distensible and allows passage of the head of the foetus during delivery
 Also.....

o The lumen is circular at the upper end because of the protrusion of the cervix into it.

o Below the cervix, the anterior and posterior walls are in contact with each other, so that the
lumen is a transverse slit in the middle part and is H-shaped in the lower part.

Note

o In the virgin, the lower end of the vagina is partially closed by a thin annular
fold of mucous membrane called the hymen.

o In Non-virgins, the hymen is represented by rounded elevations around the

vaginal orifice, the caruncular hymenales.

Fornices of Vagina
o The interior of the upper end of the vagina or vaginal vault is in the form of a circular groove that
surrounds the protruding cervix.

o The groove becomes progressively deeper from before backwards and is arbitrarily divided into
four parts called the vaginal fornices.

Special features of the fornices

1. The anterior fornix lies in front of the cervix and is the shallowest.
2. The posterior fornix lies behind the cervix and is the deepest.
3. The lateral fornices lie one on each side of the cervix

Relations of the vagina

Upper half is related to the base of the bladder

Anterior Wall
Lower half to the urethra
Upper one-fourth is separated from the rectum by the rectouterine pouch.

Posterior Wall Middle two-fourths are separated from the rectum by loose connective tissue

Lower one-fourth is separated from the anal canal by the perineal body and the muscles attached to
it.
Upper one-third is related to the transverse cervical ligament of pelvic fascia in which are embedded
a network of vaginal veins, and the ureter gets crossed by the uterine artery

Lateral Walls Middle one-third is related to the pubococcygeus part of the levator ani.

Lower one-third pierces the perineal membrane, below which it is related to the bulb of the
vestibule, the bulbospongiosus and the duct of greater vestibular gland of Bartholin.
Blood supply

Derived from the internal iliac arteries by two median longitudinal vessels, the azygos
arteries of the vagina, which descend anterior and posterior to the vagina.

They also supply the vestibular bulb, fundus of the bladder, and adjacent part of the
Arteries
rectum.

The uterine, internal pudendal and middle rectal branches of the internal iliac artery may
contribute to the blood supply of the vagina
The vaginal veins, one on each side, arise from lateral plexuses that connect with uterine,
vesical and rectal plexuses and drain to the internal iliac veins.
Veins
The uterine and vaginal plexuses may provide collateral venous drainage to the lower limb

Innervation

• The lower vagina is supplied by the pudendal nerve (S2, S3 and S4).

• The upper vagina is supplied by the pelvic splanchnic nerves (S2, S3 and, sometimes, S4)
The External genitalia of a female [Vulva]
o The female external genitalia or vulva include the mons pubis, labia majora, labia minora,
clitoris, vestibule, vestibular bulb and the greater vestibular glands

Mons Pubis
o The mons pubis is the rounded, hair-bearing area of skin and adipose tissue over the pubic
symphysis and adjacent pubic bone.
Note

o Before puberty, the mons pubis is relatively flat and hairless, and the
labia minora are poorly formed.

o Through adolescence and into adult life, the mons becomes prominent
with coarse hair and atrophies slightly after menopause.

Labia majora
o The labia majora are two prominent, longitudinal folds of skin that extend back from the
mons pubis to the perineum.

They form the lateral boundaries of the vulva.

o Each labium has an external, pigmented surface covered with hairs and a smooth, pink
internal surface with large sebaceous follicles.

Between these surfaces there is loose connective and adipose tissue, intermixed with smooth
muscle (resembling the scrotal dartos muscle), vessels, nerves and glands.

The subcutaneous layer consists of,

o A superficial fatty layer similar to Camper’s fascia

o Deep membranous layer – Colles’ fascia – continuous with Scarpa’s fascia of the anterior
abdominal wall.

The labia join anteriorly to form the anterior commissure.

o Posteriorly, they do not join, but instead merge into neighbouring skin ending near and
almost parallel to each other.

o The connecting skin between them posteriorly forms a ridge, the posterior commissure,
which overlies the perineal body and is the posterior limit of the vulva.

The distance between the posterior vulva and the anus is 2.5–3 cm and is termed the
‘gynaecological’ perineum.

The uterine round ligament may end in the adipose tissue and skin in
the anterior part of the labium.

A patent processus vaginalis may also reach a labium.

Labia minora
o The labia minora are two small cutaneous folds, devoid of fat, that lie between the labia
majora.

o Sebaceous follicles are numerous on the medial surfaces.

Course
o They extend from the clitoris obliquely down, laterally and back, flanking the vaginal orifice.

Anteriorly, each labium minus bifurcates.

o The upper layer of each side passes above the clitoris to form the hood or prepuce, while the
lower layer passes below the clitoris to form the frenulum of the clitoris.

Vestibule

The vestibule is the cavity that lies between the labia minora & it contains the following structures,

1. Vaginal orifice
2. External urethral orifice
3. Openings of the two greater vestibular (Bartholin’s) glands
4. Openings of numerous mucous, lesser vestibular glands.

There is a shallow vestibular fossa between the vaginal orifice and the frenulum of the labia
minora.
Urethral orifice

The urethra opens into the vestibule about 2.5 cm below the clitoris and above the vaginal opening
via a short, sagittal cleft with slightly raised margins: the urethral meatus.

The meatus is very distensible and varies in shape; the aperture may be rounded, slit-like,
crescentic or stellate.

The ducts of the para-urethral glands (Skene’s glands) open on each side of the lateral margins of
the urethra. [Secreted mucus during sexual activity]
Bulbs of the vestibule

The bulbs of the vestibule lie on each side of the vestibule & they are two elongated masses of
erectile tissue, 3 cm long, which flank the vaginal orifice.

o Their anterior ends taper and are joined by a commissure, and also to the clitoris by two
slender bands of erectile tissue.

o Their posterior ends are expanded and are in contact with the greater vestibular glands.

o Their deep surfaces contact the inferior aspect of the perineal membrane.

o Superficially, each is covered posteriorly by bulbospongiosus

Greater vestibular glands (Bartholin’s glands)

o The greater vestibular glands are homologues of the male bulbourethral glands & they
secrete a clear or whitish mucus for lubrication during sexual arousal

o They are two small, oval, reddish-yellow bodies that flank the vaginal orifice, in contact with,
and often overlapped by, the posterior end of the vestibular bulb.
 Clitoris
o The clitoris is an erectile structure, partially enclosed by the anterior bifurcated ends of the
labia minora.
It has a root, a body and a glans.

The body

o This can be palpated through the skin.

o It contains two corpora cavernosa, composed of erectile tissue and enclosed in dense
fibrous tissue, and separated medially by an incomplete fibrous pectiniform septum.

Also...

o The fibrous tissue forms a suspensory ligament that is attached superiorly to the pubic
symphysis.

o Each corpus cavernosum is attached to its ischiopubic ramus by a crus that extends from the
root of the clitoris.

The glans clitoris

This is a small, round tubercle of spongy erectile tissue at the end of the body, connected to the
bulbs of the vestibule by thin bands of erectile tissue.

It is exposed between the anterior ends of the labia minora & epithelium has high cutaneous
sensitivity, important in sexual responses

Blood supply of the Vulva

Derived from,

1. The superficial and deep external pudendal branches of the femoral artery
superiorly
2. The internal pudendal artery inferiorly on each side
Arterial supply
This blood supply to the labial fat must be carefully preserved during vaginal surgery

e.g., in creating a Martius fat pad flap to repair a vesico-vaginal fistula where blood
supply has already been compromised by radiation or fibrosis
• Vulval skin is via external pudendal veins to the long saphenous vein.

• Clitoris is via,
Venous drainage
1. Deep dorsal veins to the internal pudendal vein
2. Superficial dorsal veins to the superficial external pudendal and then to
the great saphenous veins.
Innervation of the Vulva

Innervation The main nerve supply of the vulva is the pudendal nerve (S2, 3 and 4) through its,

1. Inferior rectal branch

2. Perineal branches
3. The dorsal nerve of the clitoris.

The sensory innervation of the anterior and posterior parts of the labium majus differs.

1. The anterior third of the labium majus is supplied by the ilioinguinal nerve (L1)

2. The posterior two-thirds are supplied by the pudendal nerve through the posterior labial
branches of the perineal nerve (S3)

3. The lateral aspect is also innervated by the perineal branch of the posterior cutaneous nerve
of the thigh (S2).
 Anatomy of the Male Reproductive System

The Vas/Ductus Deferens

• It enters the abdomen at the deep inguinal ring and passes along the side wall and floor of
the pelvis to reach the back of the bladder.

Course
Remember ➔ In its course no other structure intervenes between it and the peritoneum.

1. First it hooks around the interfoveolar ligament and inferior epigastric artery at the deep
inguinal ring.

2. Then it crosses the external iliac artery and vein, obliterated umbilical artery and the
obturator nerve, artery and vein, lying on the obturator fascia

3. It curves medially and forwards, crosses above the ureter and approaches its opposite
fellow.

4. The two ducts now turn downwards side by side and each dilates in fusiform manner. [This
dilatation is the ampulla, the storehouse of spermatozoa.]

The ampullae lie parallel and medial to the seminal vesicles

• At their lower ends each loses its thick muscle wall and joins with the outlet
of the seminal vesicle to form the ejaculatory duct.

Each ejaculatory duct passes obliquely through the prostate to open on the
verumontanum

• The artery to the ductus deferens arises from one of the terminal branches of the
Arterial supply
superior vesical artery.

• Veins from the ductus join the vesical venous plexus which opens into the internal iliac
Venous Drainage
vein
Seminal vesicles
• This is a thin-walled, elongated sac, like a lobulated, blind-ending tube much folded on itself.

• This is a paired structure and is applied to the base of the bladder above the prostate & each
lies lateral to the ampulla of the vas deferens of its own side

• At the lower end of the ampulla behind the prostate the seminal vesicle duct joins the vas to
form the ejaculatory duct.

Fascial & peritoneal relations

The rectovesical fascia lies behind them and their tops are just covered
by the peritoneum of the rectovesical pouch.
The prostate gland

What is it?

o The prostate is a partly glandular, partly fibromuscular organ of the male reproductive system
& its main function is to add certain secretions to seminal fluid.

Its female homologue is the small group of paraurethral glands.

 Where is it?

It lies in the lesser pelvis beneath the bladder, above the urogenital diaphragm and behind the lower
part of pubic symphysis, in front of the rectal ampulla and is penetrated by the proximal part of the
urethra.

Shape size & weight

It resembles an inverted cone and is normally broader than it is

long, approximately 4 X 3 X 2 cm & it weighs about 8g

Gross features
o The prostate has a base and an apex, and anterior, posterior and inferolateral surfaces.

This is the lowest part, and the prostatic urethra emerges from the front of the apex to become the
membranous urethra which is surrounded by the sphincter urethrae
The blunt apex
It is separated from the anal canal by the perineal body

This is the upper surface, fused with the neck of the bladder and perforated by the urethra which
The base
traverses the whole length of the gland.

is at the back of the retropubic space and is connected to the bodies of the pubic bones by the
puboprostatic ligaments.

• A pair of medial puboprostatic and a pair of lateral puboprostatic ligaments extend from the
Anterior surface
false capsule to the back of pubic bone.

• The medial pair lies near the apex while lateral pair is close to the base. [These four
ligaments support the gland]

The inferolateral These related to the side walls of the pelvis and are clasped by the pubourethralis parts of levator
surfaces ani.

The posterior
This is in front of the lower rectum but separated from it by the rectovesical fascia.
surface
 Zones of the Prostrate and glandular tissue
The prostate is now considered to consist of

1. Peripheral zone
2. Central zone
3. Transition zone

These account for approximately 70%, 20% and 5% of the glandular substance, respectively.

This is wedge-shaped and forms the base of the gland with its apex at the verumontanum
It surrounds the ejaculatory ducts as they course through the gland.
The central zone
The central zone is rarely involved in any disease process.
Surrounds the central zone from behind and below but does not reach up to the base
The peripheral It extends downwards to form the lower part of the gland.
zone
The peripheral zone is almost exclusively the site of origin for carcinoma of the prostate.
Lies around the distal part of the periprostatic urethra, just proximal to the apex of the central zone.

The ducts of this zone open on the verumontanum, just above where the ducts of the peripheral
The transition
zone open into the prostatic sinuses.
zone
Benign prostatic hyperplasia affects the transition zone which may increase markedly in size,
compressing the peripheral zone.

There is very little glandular tissue anterior to the prostatic urethra, the anterior part
of the prostate being mainly fibromuscular.
 Structures within the Prostate

pierce the posterior surface just below the bladder and pass obliquely through the gland for about 2
The ejaculatory cm to open into the prostatic urethra about halfway down.
duct
The prostate’s own ducts also open into this part of the urethra
3–4 cm in length, passes through the substance of the prostate closer to the anterior than the
posterior surface of the gland.

A midline ridge, the urethral crest, projects into the lumen from the posterior wall throughout most
of the length of the prostatic urethra.
The prostatic
urethra The shallow depression on either side of the crest is termed the prostatic sinus.

The proximal part of the prostatic urethra, also termed the pre-prostatic part, is surrounded by a
cylinder of smooth muscle, an extension of the circular muscle at the bladder neck.

This muscle contracts to prevent seminal regurgitation into the bladder during ejaculation.
The verumontanum or seminal colliculus is the rounded eminence of the urethral crest within the
posterior wall of the mid prostatic urethra.
The prostatic
utricle
The prostatic utricle opens into it in the midline and the two ejaculatory ducts open just distal to
the utricle..
 Capsule of the prostate

A thin strong layer of connective tissue at the periphery of the gland forms the ‘true capsule’ of the
True capsule
prostate.
It lies outside the true capsule and is derived from the endopelvic fascia.

Anteriorly, it is continuous with the puboprostatic ligaments.

False capsule
On each side, the prostatic venous plexus is embedded in between false and true capsules.

Posteriorly, it is avascular, and is formed by the rectovesical fascia of Denonvilliers

Blood supply

Supplied by branches from,

• Inferior vesical
Arterial supply • Middle rectal
• Internal pudendal arteries.

Form a rich plexus around the sides and base of the gland.

The plexus communicates with the vesical plexus and with, internal pudendal vein, and drains into the
vesical and internal iliac veins.
Venous drainage
Also...
• Valveless communications exist between the prostatic and vertebral venous plexuses through
which prostatic carcinoma can spread to the vertebral column and to the skull

Nerve supply

• The prostatic plexus of nerves is derived from the lower part of the inferior hypogastric
plexus.

• Also, the gland impulses are relayed to the lower three lumbar and upper sacral segments.
Anatomy of Male external genital organs
External genital organs are two in number:

1. Penis
2. Scrotum, containing testes and epididymis

Penis
The penis is the male organ of copulation. It is made up of:
(a) A root or attached portion
(b) a body or free portion

Root of the penis

The root of the penis is situated in the superficial perineal pouch & it is composed of three masses of
erectile tissue namely the two crura and one bulb.

(a) Each crus (Latin leg) is firmly attached to the margins of the pubic arch and is covered by
the ischiocavernosus.

(b) The bulb is attached to the perineal membrane in between the two crura & it is covered
by the bulbospongiosus.

a. Its deep surface is pierced (above its centre) by the urethra, which traverses its
substance to reach the corpus spongiosum.

b. This part of the urethra within the bulb shows a dilatation in its floor, called the
intrabulbar fossa
Body of the Penis
o This is the free portion of the penis, which is completely enveloped by skin & it is continuous
with the root in front of the lower part of the pubic symphysis.

o The penis has a ventral surface that faces backwards and downwards, and a dorsal surface
that faces forwards and upwards.

It is composed of three elongated masses of erectile tissue, namely,

1. Right and left corpora cavernosa
2. Median corpus spongiosum
Corpora cavernosa (Latin hollow)

• They are the forward continuations of the crura and are in close apposition with each other
throughout their length.

Note ➔ do not reach the end of the penis.

• Each of them terminates under cover of the glans penis

in a blunt conical extremity.

• The corpora cavernosa are not distinct, separate structures but are divided in the midline by
a fibrous septum that is continuous with the deep circular fibres of the tunica albuginea.

The septum is complete and thick proximally, but incomplete distally, permitting communication
and exchange of blood flow between the corporal bodies.

Corpus spongiosum
This is the forward continuation of the bulb of the penis & it’s terminal part is expanded to form a
conical enlargement, called the glans penis.

Throughout its whole length, it is traversed by the urethra.

Like the corpora, it is also surrounded by a fibrous sheath.

The base of the glans (Latin acron) penis has a projecting margin, the corona (Latin crown) glandis,
which overhangs an obliquely grooved constriction, known as the neck of the penis.

Within the glans, the urethra shows a dilatation (in its roof) called the navicular fossa.
More about skin of the body of the Penis

o The skin covering the penis is very thin and dark in colour & It is loosely connected with the
fascial sheath of the organ.

o At the neck, it is folded to form the prepuce (Latin before penis) or foreskin which covers the
glans to a varying extent and can be retracted backwards to expose the glans.

The potential space between the glans and the prepuce is known as the preputial sac.

o On the undersurface of the glans, there is a median fold of skin called the frenulum (Latin
bridle).

o On the corona glandis and on the neck of the penis, there are numerous small preputial or
sebaceous glands which secrete a sebaceous material called the smegma.
 Fascia of the Penis

• Consists of very loosely arranged areolar tissue, completely devoid of fat & it may contain a few
muscle fibres.
Superficial
fascia • It is continuous with the membranous layer of superficial fascia [Scarpa] of the abdomen above and
[Dartos fascia] of the perineum [Colle] below.

It contains the superficial dorsal vein of the penis.

• This is a strong, deep, fascial layer that is immediately superficial to the tunica albuginea.

• It is continuous with the deep fascia of the muscles covering the crura and bulb of the penis, the
ischiocavernosus and bulbospongiosus.
Deep fascia
[Buck’s fascia]
So basically, it surrounds all three masses of erectile tissue but does not extend into the glans.

• Deep to it, there are the deep dorsal vein, the dorsal arteries and dorsal nerves of the penis.
[Neurovascular bundle]

The supports of the body of penis

a. The fundiform ligament which extends downwards from the linea alba and splits to enclose the
penis. It lies superficial to the suspensory ligament

b. The suspensory ligament lies deep to the fundiform ligament & it extends from the pubic
symphysis and blends below with the fascia on each side of the penis.
Blood supply of the Penis
Arterial The supply to deep structures of the penis is derived from a continuation of the internal pudendal artery,
supply after it gives off the perineal branch.

Three branches of the internal pudendal artery flow to the penis.

1. The artery of the bulb (bulbourethral artery) passes through the deep penile (Buck) fascia to enter
and supply the bulb of the penis and penile (spongy) urethra

2. The dorsal artery travels along the dorsum of the penis between the dorsal nerve and deep dorsal
vein and gives off circumflex branches that accompany the circumflex veins.

The terminal branches are in the glans penis

3. The deep penile (cavernosal) artery is usually a single artery that arises on each side and enters the
corpus cavernosum at the crus and runs the length of the penile shaft.

This gives off the helicine arteries, which are an integral component of the erectile process.

The venous Superficial veins are contained in the dartos fascia on the dorsolateral surface of the penis and coalesce at
drainage the base to form a single superficial dorsal vein.

This usually drains into the great saphenous veins via the superficial external pudendal veins.

The deep dorsal and the circumflex veins, lie within and beneath the deep penile (Buck) fascia.

• The circumflex veins course laterally around the cavernosa, passing beneath the dorsal arteries and
nerves and drain into the deep dorsal vein.

• Emissary veins begin within the erectile tissue of the corpora cavernosa and course through the
tunica albuginea and drain into the circumflex or deep dorsal veins.

Where exactly is the deep dorsal vein & what is it’s course?

• The deep dorsal vein lies in the midline groove between the 2 corpora cavernosa and is formed from
5-8 veins emerging from the glans penis, forming the retrocoronal plexus.

• It passes underneath the symphysis pubis at the level of the suspensory ligament, leaving the shaft of
the penis at the crus and draining into the prostatic plexus.
Nerve supply
The nerves to the penis are derived from the pudendal and cavernous nerves.

1. The pudendal nerves supply somatic motor and sensory innervation to the penis.

2. The cavernous nerves are a combination of sympathetic, parasympathetic and visceral

afferent fibers and provide the nerve supply to the erectile tissue.

a. The cavernous nerves run in the crus and corpora of the penis, primarily
dorsomedial to the deep penile arteries.
The Scrotum

The scrotum (Latin bag) is a cutaneous bag in the superficial perineal pouch, containing the right and
left testes, the epididymis and the lower parts of the spermatic cords.

Externally, the scrotum is divided into right and left parts by a ridge or raphe which is continued,

1. Forwards onto the undersurface of the penis

2. Backwards along the middle of the perineum to the anus

The left half of the scrotum hangs a little lower than the right, in correspondence with the greater
length of the left spermatic cord.
The scrotum is made up of the following layers from outside inwards

1. Skin, continuation of abdominal skin.

2. Dartos muscle which replaces the superficial Dartos fascia & is continuous with the
superficial perineal (Colle) fascia.

The dartos muscle is prolonged into a median vertical septum between the two halves of the
scrotum]

3. The external spermatic fascia from external oblique muscle.

4. The cremasteric (Greek to hang) muscle and fascia from internal oblique muscle.

5. The internal spermatic fascia from fascia transversalis.

Scrotal skin is thin, pigmented, devoid of fat, hair-bearing, and rich in sebaceous and sweat glands.

It is also richly innervated by sensory nerves that respond to stimulation of the skin and hairs, and to
changes in temperature.

The appearance of the scrotal skin may vary from smooth to rugated, depending on the degree of
contraction of the underlying dartos muscle
 Blood supply of the Scrotum

The arterial It is well supplied with blood from both the internal and external iliac arteries and has rich interconnected
supply anastomoses.

• Anterior scrotum is supplied by the anterior scrotal artery, a branch of the deep external pudendal
artery (from external iliac).

• Posterior scrotum is supplied by the posterior scrotal artery, a branch of the internal pudendal
artery (from internal iliac)
The venous The veins accompany the arteries, eventually draining into the external pudendal vein and subsequently
drainage the great saphenous vein.

Nerve supply

• The scrotum is innervated anteriorly by the ilioinguinal and genitofemoral nerves

• The posterior portion of the scrotum is innervated by the perineal branches of the pudendal
nerves
The Testis

• The testis is the male gonad & it is homologous with the ovary of the female.

• It is suspended in the scrotum by the spermatic cord. It lies obliquely, so that its upper pole
is tilted forwards and laterally.

The left testis is slightly lower than the right

Note

When the Cremasteric muscle contracts the

testis will be pulled upwards.

Shape and Size

• The testis is oval in shape and is compressed from side to-side.

• It is 3.75 cm long, 2.5 cm broad from before backwards, and 1.8 cm thick from side-to-side.
• Adult testis weighs about 10 to 15 g.

External Features
1. Two poles or ends—upper and lower.
2. Two borders—anterior and posterior
3. Two surfaces—medial and lateral

Poles

• The upper and lower poles are convex, and smooth & the upper pole provides attachment to
the spermatic cord.
Borders

• The anterior border is convex and smooth and is fully covered by the tunica vaginalis.

• The posterior border is straight and is only partially covered by the tunica vaginalis & the
epididymis lies along the lateral part of the posterior border.

• The medial surface of the epididymis is separated from the testis by an extension of the
cavity of the tunica vaginalis. [This extension is called the sinus of epididymis]

Coverings of the Testis

• As we all know by now the testis is covered by layers of the scrotum.

• In addition, it is also covered by three coats from outside inwards, these are,

1. The tunica (Latin cover) vaginalis

2. The tunica albuginea
3. The tunica vasculosa

The tunica vaginalis (Latin sheath)

• Represents the lower persistent portion of the processus vaginalis.

• It is invaginated by the testis from behind and, therefore, has a parietal layer and a visceral
layer with a cavity in between.

It covers the whole testis, except for its posterior border.

The tunica albuginea (Latin white)

• This is a dense, white fibrous coat covering the testis all around.

• It is covered by the visceral layer of the tunica vaginalis, except posteriorly where the
testicular vessels and nerves enter the gland.

• The posterior border of the tunica albuginea is thickened to form an incomplete vertical
septum, called the mediastinum testis, which is wider above than below.

The tunica vasculosa

• This is the innermost, vascular coat of the testis lining its lobules

The spermatic cord

What are the coverings of the spermatic chord?

• The external spermatic fascia – derived from the ext. oblique aponeurosis and
attached to the margins of the superficial inguinal ring

• Cremasteric fascia - derived from the internal oblique muscle

• Internal spermatic fascia – derived from the fascia transversalis and attached
to the margins of the deep inguinal rings

Contents of the spermatic cord

1. Ductus deferens
2. Artery to the ductus deferens (from the inferior vesical artery)
3. Testicular artery (from the abdominal aorta)
4. Cremasteric artery and vein (small vessels associated with the cremasteric fascia)
5. Pampiniform plexus of veins (testicular veins)
6. Genital branch of the genitofemoral nerve (innervation to the cremasteric muscle)
7. Sympathetic and visceral afferent nerve fibers
8. Lymphatics
9. Remnants of the processus vaginalis.
 Blood supply of the testis

To the testis is the testicular artery which arises from the aorta on either side at level of the second lumbar
vertebra.
The arterial
supply
It descends along the posterior abdominal wall towards the deep ring and then passes through the
inguinal canal within the spermatic cord to reach the testis.
Drains through the pampiniform plexus of veins to form a testicular vein which drains differently on the
two sides.
The venous
drainage
• On the left it is to the renal vein at the L2 level.
• On the right it is to the Inferior vena cava at the L2 level.

• They pass through the renal and aortic plexuses.

The epididymis

This is an organ made up of highly coiled tube that acts as reservoir of spermatozoa.

1. Parts Its upper end is called the head which is enlarged and is connected to the upper pole of the
testis by efferent ductules.

2. The middle part is called the body.

3. The lower part is called the tail.

• The head is made up of highly coiled efferent ductules

• The body and tail are made up of a single duct, the duct of the epididymis which is highly coiled on itself.

• At the lower end of the tail, this duct becomes continuous with the ductus deferens (Latin conducing
away).
 Anatomy of the Perineum

what is it?

• The perineum is an approximately diamond-shaped region that lies below levator ani,
between the inner aspects of the thighs and anterior to the sacrum and coccyx.

• It is usually described as if from the position of an individual lying supine with the hip joints
in abduction and partial flexion.

Note

The surface projection of the perineum and the form of the skin covering it vary
considerably, depending on the position of the thighs.

The deep tissues themselves occupy relatively fixed positions.

The perineum is bounded,

1. Anteriorly by the pubic symphysis and its arcuate ligament

2. Posteriorly by the coccyx
3. Anterolaterally by the ischiopubic rami and the ischial tuberosities
4. Posterolaterally by the sacrotuberous ligaments.

Deep & superficial limits

1. The deep limit of the perineum is the inferior surface of the pelvic diaphragm

2. The superficial limit is the skin that is continuous with that over the medial aspect of the
thighs and the lower abdominal wall.
An arbitrary line joining the ischial tuberosities (the inter-ischial line) divides the perineum into an
anterior urogenital triangle and a posterior anal triangle.

1. The urogenital triangle faces downwards and forwards

2. The anal triangle faces downwards and backwards at an approximate angle of 120° from the
plane of the urogenital triangle.

Recap

• The male urogenital triangle contains the bulb and attachments of the penis

• The female urogenital triangle contains the mons pubis, the labia majora, the
labia minora, the clitoris and the vaginal and urethral orifices
 The Anal triangle

The structure of this is similar in males and females, the main difference reflecting the wider
transverse dimension of the triangle in females that is associated with giving birth.

The anal triangle contains the anal canal and its sphincters, and the ischio-anal fossa with its
contained nerves and vessels.

It is lined with superficial and deep fascia.

The superficial fascia of the region is thin and is continuous with the superficial/subcutaneous fascia
of,
1. The skin of the perineum
Superficial fascia
2. Thighs
3. Buttocks.

The deep fascia lines the inferior surface of levator ani and is continuous at its lateral origin with the
fascia over obturator internus below the attachment of levator ani.
Deep fascia
It lines the deep portion of the ischio-anal fossa and its lateral walls.
Ischio-anal fossa

• The ischio-anal fossa is an approximately horseshoe-shaped region filling the majority of the
anal triangle.

Individually on each side, it can be described as a wedge-shaped space lateral to the anal canal

Important

Although often referred to as a space, it is filled with loose adipose tissue and
occasional blood vessels and nerves.

The fat in the lower part of the fossa adjacent to the skin is in small lobules,
while the fat in the upper reaches of the fossa is in large lobules.

• The ‘arms’ of the horseshoe are triangular in cross-section because levator ani slopes
medially from its lateral pelvic origin towards the anorectal junction.

The anal canal and its sphincters lie in the center of the horseshoe.
Boundaries

• The apex of the wedge is where the medial and lateral walls meet (where levator ani is
attached to its tendinous origin over the obturator fascia).

• The base of each fossa lies on the skin over the anal region of the perineum.

At the base,

• The anterior boundary is the posterior border of the perineal body and
muscles of the urogenital diaphragm.

• The posterior boundary is the sacrotuberous ligament overlapped by

the lower border of gluteus maximus.

Walls

• The external sphincter of the anal canal and the sloping levator ani muscles form the medial
wall covered by the deep fascia over levator ani.

• The anterolateral wall is formed by the ischial tuberosity below with obturator internus
(covered by its fascia) above.

• Posterolaterally, the wall is formed by the lower border of gluteus maximus and the
sacrotuberous ligament.

Do the two fossa communicate with each other? Explain.

• There is an anterior recess to the ischio-anal fossa that lies cranial to the perineal membrane
and transverse perineal muscles.
 • It extends anteriorly as far as the posterior surface of the pubis, below the attachment of
levator ani.

The recesses of the two sides do not communicate across the midline.

• Posteriorly, the two fossae communicate with one another, low down through the fibrofatty
tissue of the retro-sphincteric space within the anococcygeal ligament.

This provides the previously mentioned horseshoe-shaped path for communication between the
two fossa

Therefore, Infections, tumors and fluid collections within the fossa,

• May enlarge relatively freely to the side of the anal canal

• May spread with little resistance to the contralateral side and deep to the perineal
membrane.

Anococcygeal ligament and iliococcygeal raphe

The anococcygeal ligament is a musculotendinous structure running between the middle portion of the
external anal sphincter and the coccyx.

The iliococcygeal raphe (the decussation of the posterior fibres of iliococcygeus) lies just above the
anococcygeal ligament and is separated from the rectum by presacral fascia.

These structures are often referred to as the postanal plate.

Division of the anococcygeal raphe may cause descent of the anal canal and a lowering of the posterior
part of the anal triangle but does not demonstrably interfere with the process of defecation.
 The pudendal canal (of Alcock)

Remember

The inferior rectal vessels and nerves cross the fossa from the pudendal canal and often branch within it.

• This is a connective tissue tunnel in the lower lateral wall of the ischio-anal fossa, overlying
obturator internus and the medial side of the ischial tuberosity.

• The canal is formed by a splitting of the obturator fascia above the falciform process of the
sacrotuberous ligament.

It contains,

• The pudendal nerve

• Internal pudendal vessels

which it conducts from the lesser sciatic notch to the deep perineal pouch above the
perineal membrane

Course of Pudendal nerve & internal pudendal vessels

• The pudendal nerve and internal pudendal vessels leave the pelvis through the greater sciatic
foramen, passing beneath the lower border of piriformis to reach the buttock.

Their course in the buttock is short & they turn and enter the lesser sciatic foramen,

• The vessels pass over the tip of the spine of the ischium
• The nerve passes more medially over the sacrospinous ligament.

Running transversely across ischio-anal fossa from the pudendal canal towards the anal canal are
the inferior rectal branches of the pudendal nerve & internal pudendal vessels.

• Their course is not straight across the base of the fossa, but arches convexly upwards through
the fat towards the apex and then downwards to the anal canal.

Therefore, Incisions to drain ischioanal abscesses usually do not interfere with them.
Additionally,

• Accompanied by the vessels, the nerve breaks up into several branches which supply the
external sphincter, mucous membrane of the lower anal canal and perianal skin.

• At the front of the fossa the posterior scrotal (labial) nerves and vessels (from the
pudendals) pass superficially into the urogenital region.

Remember

The inferior rectal vessels and nerves cross the fossa from the pudendal
canal and often branch within it.

Clinical point

The ischio-anal fossa is an important surgical plane during resections of the anal canal and
anorectal junction for malignancy.

It provides an easy, relatively bloodless, plane of dissection that encompasses all of the
muscular structures of the anal canal and leads to the inferior surface of levator ani.

Now the dissections can be carried out through Levator Ani

Perineal body

• This is a midline fibromuscular mass to which a number of muscles gain attachment, and
within which they decussate.

Important points

• It is attached to the posterior border of the perineal membrane.

• It lies between the anal canal and the vagina or bulb of the penis.
• The rectovaginal septum blends into it above.
The muscles running into it include,

1. The external anal sphincter

2. Pubovaginalis (puboprostaticus) part of levator ani
3. Bulbospongiosus
4. Superficial and deep transverse perineal muscles.
 Urogenital triangle

• The urogenital triangle is bounded posteriorly by the inter-ischial line, which usually overlies the
posterior border of the transverse perineal muscles.

• Anteriorly and laterally, it is bounded deeply by the pubic symphysis and ischiopubic rami.

• The urogenital triangle extends superficially to encompass the scrotum and the root of the
In males
penis.

It extends to the lower limit of the labia and mons pubis.

Note
• The female urogenital triangle includes muscles, fasciae, erectile structures and spaces similar
In females
to those in the male.

However, there are some differences in size and disposition caused by the presence of the vagina
and female external genitalia

The perineal membrane & deep perineal pouch

The perineal membrane

Definition
• The perineal membrane is a thick fascial, triangular structure attached to the bony
framework of the pubic arch.

It is oriented in the horizontal plane and has a free posterior margin.

Anteriorly, there is a small gap between the membrane and the inferior pubic ligament (a ligament
associated with the pubic symphysis).
In the male, the perineal membrane is crossed by several structures:

1. The urethra, which traverses it 2–3 cm behind the inferior border of the pubic symphysis

2. The vessels and nerves to the bulb of the penis.

3. The ducts of the bulbourethral glands, posterolateral to the urethral orifice

4. The deep dorsal vessels and dorsal nerves of the penis, behind the pubic arch in the midline

5. Posterior scrotal vessels and nerves, anterior to the transverse perinei.

In the female, the perineal membrane is divided almost into two halves by the vagina and urethra,
such that it forms a triangle on each side of these structures.

1. The lateral margins of the vagina are attached to the perineal membrane at the level of the
hymenal ring, and levator ani lies on its cranial surface.

2. The vagina also passes through a hiatus in the perineal membrane just posterior to the
urethral hiatus

3. The ducts of Bartholin’s glands are at this level in the posterior lateral introitus.

4. The deep dorsal vessels and dorsal nerves of the clitoris lie within its fibres.

The deep perineal pouch

o The perineal membrane is related above to a thin space called the deep perineal pouch which
contains a layer of skeletal muscle and various neurovascular elements.

This pouch is open above and is not separated from more superior structures by a distinct layer of
fascia.

Muscles of the deep perineal pouch

In both men and women,

• Anteriorly, a group of muscle fibers surround the urethra and collectively form the external
urethral sphincter.

Deep transverse perineal muscle

• A deep transverse perineal muscle on each side parallels the free margin of the perineal
membrane and joins with its partner at the midline.

These muscles are thought to stabilize the position of the perineal body, which is a midline
structure along the posterior edge of the perineal membrane.
In women.

1. The sphincter urethrovaginalis, which surrounds the urethra and extends caudally to
surround the vaginal wall. [Surrounds both tubes as a unit]

2. The compressor urethrae, on each side, which originate from the ischiopubic rami, come
along the pubic arch and meet anterior to the urethra.

Together with the external urethral sphincter, the sphincter urethrovaginalis and compressor
urethrae facilitate closing of the urethra.

In men,

• These lateral extensions are not well developed & the sphincter in this area primarily
encircles the membranous urethra, forming a robust constrictor at this level.
Fascia of the Urogenital triangle

Superficial perineal fascia

• The tissue commonly referred to as the superficial fascia of the perineum (Colles’ fascia)
forms a clear, surgically recognizable, plane beneath the skin of the anterior perineum).

• It is firmly attached posteriorly to the fascia over the superficial transverse perineal muscles
and the posterior limit of the perineal membrane.

• Laterally, it is attached to the margins of the ischiopubic rami as far back as the ischial
tuberosities.

From here, it runs more superficially to the skin of the urogenital triangle, lining the skin of the
external genitalia.

• In the male, it is also continuous with the fascial layer in the skin of the scrotum that
contains the dartos muscle.

• In females, the fascia follows the same limits but is much less extensive in the labia majora.

This layer runs anteriorly and superiorly into the skin of the lower abdominal wall where it is
continuous with the membranous fascia (Scarpa’s fascia).

Deep perineal fascia (investing fascia of the superficial perineal muscles)

• The tissue commonly referred to as the deep perineal fascia is a layer of fascia that overlies
the superficial muscles of the perineum,

1. Bulbospongiosus
2. Ischiocavernosus
3. Superficial transverse perineal muscles

It is firmly attached to,

1. The borders of the muscles at attachments to the ischiopubic rami

2. Posterior margin of the perineal membrane and perineal body.
3. Anteriorly, it fuses with the suspensory ligament of the penis or clitoris, and the fasciae of
external oblique and the rectus sheath.
 Subcutaneous perineal pouch

The subcutaneous perineal pouch lies between the deep perineal fascia and the superficial perineal
fascia.

Under normal circumstances, these two layers are only separated by relatively thin subcutaneous
connective tissue.

However, this pouch is capable of expanding considerably in the presence of fluid accumulation.

Blood, urine or fluid collecting in the subcutaneous pouch following trauma or surgery on the
urogenital triangle will spread throughout the tissues of the triangle.

This includes the scrotum or labia majora

Note

Cannot pass posteriorly into the anal triangle or laterally into the medial thigh because
of the firm tethering of the posterior attachments of the subcutaneous fascia.

Since the superficial perineal fascia is in continuity with the fascia of the anterior abdominal wall,

Fluid, blood or pus may also track freely between the subcutaneous tissues of the anterior
abdominal wall and the subcutaneous perineal pouch

Superficial perineal pouch

The superficial perineal pouch lies below the perineal membrane and is limited superficially by the
deep perineal fascia (investing fascia of the superficial perineal muscles).

It contains,

1. The corpora cavernosa

2. Corpus spongiosum
3. Ischiocavernosus
4. Bulbospongiosus
5. Superficial transverse perineal muscles
6. Branches of the pudendal vessels and nerves.

• In the female, it is crossed by the urethra and vagina and contains the clitoris.
• In the male, it contains the urethra as it runs in the root of the penis.

It is a fully confined space

Injuries to the contents of the space (such as bleeding into the urethra in the penile root) do not communicate
with the deep or subcutaneous pouches unless the fascial coverings are also lacerated or breached.
 Muscles of the superficial perineal pouch

The superficial transverse perineal muscles are narrow strips of muscle that run,
Superficial
transverse perineal
• Transversely across the superficial perineal space anterior to the anus
muscles
• From the medial and anterior aspects of the ischial tuberosities to the perineal body.
Bulbospongiosus differs between the sexes.

In the male

It lies in the midline, anterior to the perineal body & consists of two symmetrical parts united by a
median fibrous raphe.

Origin
1. The perineal body, in which they decussate
2. To the transverse superficial perinei
3. To the external anal sphincter

Then they diverge like the sides of a feather from the median raphe.

Insertion

• A thin layer of posterior fibres joins the posterior portion of the perineal membrane.

• The majority of the middle fibres encircle the bulb of the penis and adjacent corpus spongiosum
and attach to an aponeurosis on the dorsal surfaces.

• The anterior fibres spread out over the sides of the corpora cavernosa, ending partly in them,
Bulbospongiosus anterior to ischiocavernosus, and partly in a tendinous expansion that covers the dorsal vessels of
the penis.

In the female

Origin

Bulbospongiosus also attaches to the perineal body, but the muscle on each side is separate and covers
the superficial parts of the vestibular bulbs and greater vestibular glands.

Insertion

Fibres run anteriorly on either side of the vagina to attach to the corpora cavernosa clitoridis, and a
few fibres cross over the dorsum of the body of the clitoris.

Actions

In the male,

1. It helps to empty the urethra of urine after the bladder has emptied.

2. It may assist in the final stage of erection as the middle fibres compress the erectile tissue of the
 bulb and the anterior fibres contribute by compressing the deep dorsal vein of the penis.

3. It contracts six or seven times during ejaculation, assisting in the expulsion of semen.

In the female

1. It acts to constrict the vaginal orifice and express the secretions of the greater vestibular glands.

2. Anterior fibres contribute to erection of the clitoris by compressing its deep dorsal vein.
In the male, Ischiocavernosus covers the crus penis.

Origin

It is attached by tendinous and muscular slips to the medial aspect of the ischial tuberosity posteriorly,
and to the ischial ramus on both sides of the crus.

Insertion

These fibres end in an aponeurosis that is attached to the sides and undersurface of the crus penis.

In the female, ischiocavernosus is related to the crus of the clitoris but is otherwise similar to the
corresponding muscle in the male
Ischiocavernosus
Actions

In the male,

1. Compresses the crus penis in males and may help to maintain penile erection.

• They form a triangle on each side of the midline with bulbospongiosus medially and superficial
transverse perineal muscles posteriorly, attached to the perineal membrane.

• When contracted, the two ischiocavernosi act together to stabilize the erect penis.

In the female,

1. Ischiocavernosus may help to promote increased pressure in the clitoris.

 Blood supply of the perineum
Arterial Supply
The internal pudendal artery enters the perineum around the posterior aspect of the ischial spine and runs
on the lateral wall of the ischio-anal fossa in the pudendal (Alcock’s) canal.

Along with the pudendal veins and the pudendal nerve.

As the artery approaches the margin of the ischial ramus, it proceeds above or below the perineal
membrane, along the medial margin of the inferior pubic ramus, en route to its target structures.

In the male,

This artery distal to the perineal artery gives a branch to the bulb of the penis before it divides into the
cavernous (deep, cavernosal) and dorsal arteries of the penis.

Given its distribution, the internal pudendal artery distal to its perineal branch has been named the artery
of the penis.

So basically,
Internal
pudendal 1. The artery to the bulb supplies the corpus spongiosum
artery (in the
perineum) 2. The cavernous artery of the penis supplies the corpus cavernosum on each side.

3. The dorsal artery runs on the dorsal aspect of the penis and supplies,

• Circumflex branches to the corpora cavernosa

• Corpus spongiosum

These branches end by anastomosing in the coronal sulcus and supplying the glans
penis and its overlying skin.

In the female,

1. A similar branch of the pudendal artery is distributed to the erectile tissue of the corpus
spongiosum and vagina.

2. The cavernous artery supplies the corpora cavernosa of the clitoris; the dorsal artery supplies the
glans and prepuce of the clitoris.
• The inferior rectal artery arises just after the internal pudendal artery enters the pudendal canal on the
lateral wall of the ischio-anal fossa.

• It runs anteromedially through the adipose tissue of the ischio-anal fossa to reach the deep portion of
Inferior rectal
the external anal sphincter, and often branches before reaching the sphincter.
artery
• In dissections of anal canal, particularly during perineal excisions of the anorectum, the inferior rectal
vessels are encountered in the ischio-anal fossa & must be secured before division.

Otherwise, they tend to retract laterally to the canal, where they can cause troublesome bleeding.
Perineal artery The perineal artery is a branch of the internal pudendal artery that arises near the anterior end of the
 pudendal canal and runs through the perineal membrane.

In the male,

It approaches the scrotum in the superficial perineal space, between bulbospongiosus and
ischiocavernosus.

A small transverse branch passes medially, inferior to the superficial transverse perineal muscle, to
anastomose with,
• The contralateral artery
• The posterior scrotal
• Inferior rectal arteries.

It supplies,

1. The transverse perinei

2. The perineal body
3. The bulb of the penis.

In the female, the perineal artery runs an almost identical course to that in the male and gives off the
posterior labial arteries
Veinous drainage
The internal pudendal veins are venae comitantes of the internal pudendal artery and unite as a single
vessel.
Internal
pudendal veins
Perineal tributaries receive veins from the penile bulb and the scrotum (males), or clitoris and labia
(females), & the inferior rectal veins join towards the posterior end of the pudendal canal

Innervation of the Perineum

The pudendal nerve gives rise to,

1. The inferior rectal nerve

2. Perineal nerve
3. The dorsal nerves of the penis or clitoris.

The course of its branches parallels the pudendal vessels.

Note

• The pudendal nerve occupies a very constant position over the ischial spine
and is readily found.

• It may also be palpated over the ischial spine through the lateral wall of the
rectum.
 The inferior rectal nerve runs through the medial wall of the pudendal canal with the inferior rectal
vessels.

It crosses the ischio-anal fossa to supply the external anal sphincter, the lining of the lower part of
the anal canal and the circumanal skin.

It frequently breaks into terminal branches before reaching the lateral border of the sphincter.
Inferior rectal
nerve
The inferior rectal nerve occasionally arises directly from the sacral plexus and crosses the
sacrospinous ligament or reconnects with the pudendal nerve.

Also...
• In females, the inferior rectal nerve may supply sensory branches to the lower part of the
vagina.
The perineal nerve is the inferior and larger terminal branch of the pudendal nerve in the pudendal
canal.

It runs forwards below the internal pudendal artery and accompanies the perineal artery, dividing
into posterior scrotal or labial and muscular branches.

The posterior scrotal or labial nerves are usually double.

Perineal nerve
They have medial and lateral branches that run over the perineal membrane and pass forwards in
the lateral part of the urogenital triangle.

They take this path along with the scrotal or labial branches of the perineal artery.

They supply,

• The skin of the scrotum or labia majora, overlapping the distribution of the perineal branch
 of the posterior femoral cutaneous and inferior rectal nerves.
• In females, the posterior labial branches also supply sensory fibres to the skin of the lower
vagina.
• In males, a nerve to the bulb of the urethra leaves the nerve to the bulbospongiosus,
pierces this muscle to supply the corpus spongiosum penis, and ends in the urethral
mucosa.
The dorsal nerve of the penis or clitoris runs anteriorly above the internal pudendal artery along the
ischiopubic ramus, deep to the perineal membrane.
Dorsal nerve of the
It supplies the corpus cavernosum and accompanies the dorsal artery of the penis or clitoris
penis or clitoris
between the layers of the suspensory ligament.

In males, the dorsal nerve of the penis runs on the dorsum of the penis to end in the glans
 Anatomy & Development of the female
breast

What is it?

• The breast is found in both sexes but is rudimentary in the male.

• It is well developed in the female after puberty & it forms an important accessory organ of
the female reproductive system to provide the newborn with of milk.

• Its shape may be hemispherical, conical, pyriform, pendulous or flat.

Situation

• The breast lies in the superficial fascia of the pectoral region & it is divided into four
quadrants. [upper medial, upper lateral, lower medial and lower lateral]

• A small extension of the upper lateral quadrant, called the axillary tail of Spence, passes
through an opening in the deep fascia and lies in the axilla.

The opening is called foramen of Langer.

The breast lies on the deep fascia (pectoral fascia) covering the pectoralis major & it must be notes
that,
1. 2/3 of it rests the pectoralis major
2. 1/3 of it rests on the serratus anterior
3. Its lower medial edge overlaps the upper part of the rectus sheath [Basically the ext.
obliques]
The breast is separated from the pectoral fascia by loose areolar tissue, called the retromammary
space.

Because of the presence of this loose tissue, the normal breast can be moved freely over the
pectoralis major.

Surface markings of the extent of the Base

1. Vertically, it extends from the second to the sixth ribs.
2. Horizontally, it extends from the lateral border of the sternum to the midaxillary line

Structure of the Breast

The structure of the breast may be conveniently studied by dividing it into,

1. The skin
2. The parenchyma [known as the mammary gland.]
3. The stroma

Nipples

• This is a conical projection that is present just below the center of the breast & it is pierced
by 15 to 20 lactiferous ducts

• It contains circular and longitudinal smooth muscle fibres which can make the nipple stiff or
flatten it, respectively.

The skin surrounding the base of the nipple

• This is pigmented and forms a circular area called the areola.

• This region is rich in modified sebaceous glands, particularly at its outer margin become
enlarged during pregnancy and lactation to form raised tubercles of Montgomery.

o Oily secretions of these glands lubricate the nipple and areola and prevent them from
cracking during lactation.

o Apart from sebaceous glands, the areola also contains some sweat glands, and accessory
mammary glands.

The skin of the areola and nipple is devoid of hair, and there is no fat subjacent to it, instead
below the areola lies the lactiferous sinus where stored milk is seen.
 Parenchyma (The Mammary Gland)

• Mammary gland is a compound tubulo-alveolar gland which secretes milk & it lies in
superficial fascia, there is no capsule.

It is basically a modified sweat gland

• Each lobe is a cluster of alveoli and is drained by a lactiferous duct & the lactiferous ducts
converge towards the nipple and open on it.

• Near its termination, each duct has a dilatation called a lactiferous sinus

Stroma

It forms the supporting framework of the gland & is partly fibrous and partly fatty.

• The fibrous stroma forms septa, known as the suspensory ligaments of Cooper, which
anchor the skin and gland to the pectoral fascia.

• The fatty stroma forms the main bulk of the gland & is distributed all over the breast, except
beneath the areola and nipple.

Blood Supply
It is supplied by branches of the following arteries

1. Internal thoracic artery, a branch of the subclavian artery, through its perforating
branches.

2. The lateral thoracic, superior thoracic and acromiothoracic (thoracoacromial)

Arterial supply
branches of the axillary artery.

3. Lateral branches of the posterior intercostal arteries.

The arteries converge on the breast and are distributed from the anterior surface [The
posterior surface is relatively avascular]
They first converge towards the base of the nipple where they form an anastomotic venous
circle, from where veins run in superficial and deep sets.
Veinous drainage
1. The superficial veins drain into the internal thoracic vein and into the superficial veins
of the lower part of the neck.
2. The deep veins drain into the axillary and posterior intercostal veins
Lymphatic Drainage
Lymphatic drainage of the breast assumes great importance to the surgeon because carcinoma of
the breast spreads mostly along lymphatics to the regional lymph nodes.

1. The superficial lymphatics drain the skin over the breast except for the nipple and areola.

The lymphatics pass radially to the surrounding lymph nodes (axillary, anterior thoracic,
supraclavicular and cephalic).

2. The deep lymphatics drain the parenchyma of the breast & they also drain the nipple and areola.
So basically, the Lymph from the breast drains into the following lymph nodes ,

1. The axillary lymph nodes, chiefly the anterior (or pectoral) group.

• The posterior, lateral, central and apical groups of nodes also receive lymph from the
breast either directly or indirectly.

2. The anterior thoracic (parasternal) nodes which lie along the internal mammary (thoracic)
vessels

Development of the breast

1. The breast develops from an ectodermal thickening, called the mammary ridge, milk line, or line
of Schultz.

This ridge extends from the axilla to the groin.

• It appears during the fourth week of intrauterine life, but in human beings, it disappears
over most of its extent persisting only in the pectoral region.

• The gland is ectodermal, and the stroma mesodermal in origin.

2. The persisting part of the mammary ridge is converted into a mammary pit & secondary buds
(15–20) grow down from the floor of the pit.

• These buds divide and subdivide to form the lobes of the gland.
• The entire system is first solid but is later canalized.

At birth or later, the nipple is everted at the site of the original pit.

Growth of the mammary glands, at puberty, is caused by oestrogens

Apart from oestrogens, development of secretory alveoli is stimulated by

progesterone and by the prolactin hormone of the hypophysis cerebri.

Developmental anomalies of the breast are:

a. Amastia (absence of the breast)

b. Athelia (absence of nipple)
c. Polymastia (supernumerary breasts)
d. Polythelia (supernumerary nipples),
e. Gynaecomastia (development of breasts in a male) which occurs in Klinefelter’s syndrome.
 Reproductive Embryology

Sex differentiation
• The key to sexual dimorphism is the Y chromosome, which contains the testis-determining
gene called the SRY (sex-determining region on Y) gene on its short arm (Ypl 1).

• The protein product of this gene is a transcription factor initiating a cascade of downstream
genes that determine the fate of rudimentary sexual organs.

The SRY protein is the testis-determining factor,

1. Under its influence, male development occurs
2. In its absence, female development is established.

Gonads
• Although the sex of the embryo is determined genetically during fertilization, the gonads
don’t acquire male or female morphological characteristics until 7th week of development.

Gonads appear initially as a pair of longitudinal ridges, the genital or gonadal ridges.

• They are formed by proliferation of the epithelium and a condensation of underlying

mesenchyme.

Germ cells do not appear in the genital ridges until the sixth week of development.
 • PGC originate in the epiblast, migrate through the primitive streak, and by the 3rd week
reside among endoderm cells in the wall of the yolk sac close to the allantois.

• In the 4th week, they migrate by ameboid movement along the dorsal mesentery of the
hindgut, arriving at the primitive gonads at the beginning of the 5th week.

• They invade the genital ridges in the sixth week & if they fail to reach the ridges, the gonads
do not develop.

Hence, the primordial germ cells have an inductive influence on development of the gonad
into ovary or testis.

o Shortly before and during arrival of primordial germ cells, the epithelium of the genital ridge
proliferates, forming a number of irregularly primitive sex cords.

o In both male and female embryos, these cords are connected to surface epithelium, and it is
impossible to differentiate between the male and female gonad.

Hence, the gonad is known as the indifferent gonad.

Testis
o If the embryo is genetically male, the primordial germ cells carry an XY sex chromosome
complex.

Under influence of the “SRY” gene on the Y chromosome, which encodes the testis-determining
factor,

o The primitive sex cords continue to proliferate and penetrate deep into the medulla to form
the testis or medullary cords.

o Toward the hilum of the gland, the cords break up into a network of tiny cell strands that
later give rise to tubules of the rete testis.
During further development,

• A dense layer of fibrous connective tissue, the tunica albuginea, separates the testis cords
from the surface epithelium.

• In the 4th month, the testis cords become horseshoe-shaped, and their extremities are
continuous with those of the rete testis.

• Testis cords are now composed of primitive germ cells and sustentacular cells of Sertoli
derived from the surface epithelium of the gland.

Interstitial cells of Leydig, derived from the original mesenchyme of the gonadal ridge, lie between
the testis cords.

• They begin development shortly after onset of differentiation of these cords.

• By the 8th week of gestation, Leydig cells begin production of testosterone, and the testis is
able to influence sexual differentiation of the genital ducts and external genitalia.

Testis cords remain solid until puberty, when they acquire a lumen, thus forming the seminiferous
tubules.

• Once the seminiferous tubules are canalized, they join the rete testis tubules, which in turn
enter the ductuli efferentes.

• These efferents ductules are the remaining parts of the excretory tubules of the
mesonephric system.

They link the rete testis and the mesonephric or Wolffian duct, which becomes the ductus
deferens

Ovary

In female embryos with an XX sex chromosome complement and no Y chromosome,

primitive sex cords dissociate into irregular cell clusters.

These clusters, containing groups of primitive germ cells, occupy the medullary part of the
ovary.

Later, they disappear and are replaced by a vascular stroma that forms the ovarian
medulla.
The surface epithelium of the female gonad, unlike that of the male, continues to
proliferate.

In the seventh week, it gives rise to a second generation of cords, cortical cords, which
penetrate the underlying mesenchyme but remain close to the surface.

In the third month, these cords split into isolated cell clusters & the cells in these clusters
continue to proliferate and begin to surround each oogonium.

This forms a layer of epithelial cells called follicular cells & together, the oogonia and
follicular cells constitute a primordial follicle.

In summary for male and female embryos

1. In embryos with an XX sex chromosome configuration, medullary cords of the gonad

regress, and a secondary generation of cortical cords develops.

2. In embryos with an XY sex chromosome complex, medullary cords develop into

testis cords, and secondary cortical cords fail to develop
Genital ducts

Indifferent Stage Initially, both male and female embryos have two pairs of genital ducts:

1. Mesonephric (Wolffian) ducts

2. Paramesonephric (Müllerian) ducts.
Indifferent stage
Paramesonephric duct arises as a longitudinal invagination of the epithelium on the antero-lateral
surface of the urogenital ridge.

• Cranially, the duct opens into the abdominal cavity with a funnel-like structure.

• Caudally, it first runs lateral to the mesonephric duct, then crosses it ventrally to grow
caudomedially.

• In the midline, it comes in close contact with the paramesonephric duct from the opposite
side.

The caudal tip of the combined ducts projects into the posterior wall of the urogenital sinus, where it
causes a small swelling, the sinus tubercle

Meanwhile,

• The mesonephric ducts open into the urogenital sinus on either side of the sinus tubercle.

Genital Ducts in the Male

Genital ducts in the male are stimulated to develop by testosterone and are derived from parts of
the mesonephric kidney system.

• Some of the original excretory tubules, the epigenital tubules, establish contact with cords of
the rete testis and form the efferent ductules of the testis.

• Excretory tubules along the caudal pole of the testis, the paragenital tubules, do not join the
cords of the rete testis.

Their vestiges are collectively known as the paradidymis.

Except for the most cranial portion, the appendix epididymis, the mesonephric ducts persist and
form the main genital ducts.

Immediately below the entrance of the efferent ductules, the mesonephric ducts elongate and
become highly convoluted, forming the (ductus) epididymis.

From the tail of the epididymis to the outbudding of the seminal vesicle, the mesonephric ducts
obtain a thick muscular coat and form the ductus deferens.

The region of the ducts beyond the seminal vesicles is the ejaculatory duct.

Under the influence of anti-Müllerian hormone (AMH; also called Müllerian inhibiting
substance [MIS]) produced by Sertoli cells,

• Paramesonephric ducts in the male degenerate except for a small portion at

their cranial ends, the appendix testis.
Genital Ducts in the Female
In the presence of estrogen and the absence of,
1. Testosterone
2. AMH (MIS)

Paramesonephric ducts develop into the main genital ducts of the female.

Initially, three parts can be recognized in each duct:

(1) Cranial vertical portion that opens into the abdominal cavity
(2) Horizontal part that crosses the mesonephric duct
(3) Caudal vertical part that fuses with its partner from the opposite side

With descent of the ovary, the first two parts develop into the uterine tube and the caudal parts
fuse to form the uterine canal.

o When the second part of the paramesonephric ducts moves medio-caudally, the urogenital
ridges gradually come to lie in a transverse plane.

After the ducts fuse in the midline, a broad transverse pelvic fold is established.

• This fold, which extends from the lateral sides of the fused paramesonephric ducts toward
the wall of the pelvis, is the broad ligament of the uterus.

• The uterine tube lies in its upper border, and the ovary lies on its posterior surface

The uterus and broad ligaments divide the pelvic cavity into the utero-rectal pouch and the
uterovesical pouch.

The fused paramesonephric ducts give rise to,

(1) The corpus [Body] of the uterus
(2) Cervix of the uterus
(3) Upper portion of the vagina.

In the absence of testosterone, mesonephric ducts in the

female degenerate.

Also....
• The uterus is surrounded by a layer of mesenchyme that forms both its muscular coat, the
myometrium, and its peritoneal covering, the perimetrium.
 Formation of the vagina

o Shortly after the solid tip of the paramesonephric ducts contacts the urogenital sinus, two
solid evaginations grow out from the pelvic part of the sinus.

These evaginations, the sinovaginal bulbs, proliferate and form a solid vaginal plate.

o Proliferation continues at the cranial end of the plate, increasing the distance between the
uterus and the urogenital sinus.

By the fifth month, the vaginal outgrowth is entirely canalized.

The wing-like expansions of the vagina around the end of the uterus, the vaginal fornices, are of
paramesonephric origin.

• Thus, the vagina has a dual origin, as the upper portion derived from the uterine canal
[Paramesonephric duct] & the lower portion derived from the urogenital sinus.

o The lumen of the vagina remains separated from that of the urogenital sinus by a thin tissue
plate, the hymen, which consists of the epithelial lining of the sinus and a thin layer of
vaginal cells.

It usually develops a small opening during perinatal life.

Also...

The female may retain some remnants of the cranial and caudal excretory tubules in the mesovarium,
where they form the epoophoron and paroophoron, respectively.

The mesonephric duct disappears except for a small cranial portion found in the epoophoron and
occasionally a small caudal portion that may be found in the wall of the uterus or vagina.
External Genitalia

Indifferent Stage
In the 3rd week of development, mesenchyme cells originating in the region of the primitive streak
migrate around the cloacal membrane to form a pair of slightly elevated cloacal folds.

• Cranial to the cloacal membrane, the folds unite to form the genital tubercle.
• Caudally, the folds are subdivided into urethral folds anteriorly and anal folds posteriorly.

In the meantime,

• Another pair of elevations, the genital swellings, becomes visible on each side of the urethral
folds.

These swellings later form the scrotal swellings in the male & the labia majora in the female

• At the end of the sixth week, it is impossible to distinguish between the two sexes.

External Genitalia in the Male

o Development this is under the influence of androgens secreted by the fetal testes and is
characterized by rapid elongation of the genital tubercle, which is now called the phallus.
During this elongation,

• The phallus pulls the urethral folds forward so that they form the lateral walls of the urethral
groove.

• This groove extends along the caudal aspect of the elongated phallus but does not reach the
most distal part, the glans.

• The epithelial lining of the groove, which originates in the endoderm, forms the urethral
plate.

At the end of the third month, the two urethral folds close over the urethral plate, forming the
penile urethra.

This canal does not extend to the tip of the phallus.

This most distal portion of the urethra is formed during the fourth month,

o When ectodermal cells from the tip of the glans penetrate inward and form a short epithelial
cord.

This cord later obtains a lumen, thus forming the external urethral meatus.

The genital swellings, known in the male as the scrotal swellings,

• With further development, they move caudally, and each swelling then makes up half of the
scrotum.

The two are separated by the scrotal septum

External Genitalia in the Female

Estrogens stimulate development of the external genitalia of the female.

• The genital tubercle elongates only slightly and forms the clitoris & urethral folds do not
fuse, as in the male, but develop into the labia minora.

• Genital swellings enlarge and form the labia majora.

• The urogenital groove is open and forms the vestibule.

Although the genital tubercle does not elongate extensively in the female, it is larger than in
the male during the early stages of development.

In fact, using tubercle length as a criterion (as monitored by ultrasound) has resulted in
mistakes in Identification of the sexes during the third and fourth months of gestation.

Descent of the Testes

 o The testes develop retroperitoneally in the abdominal region and must move caudally and
pass through the abdominal wall to reach the scrotum.

o Passage through the abdominal wall is via the inguinal canal, which is about 4 cm long and
lies just superiorly to the medial half of the inguinal ligament.

o Entry to the canal is by the deep (internal) inguinal ring, and exit is by the superficial
(external ) ring near the pubic tubercle.

Toward the end of the second month,

• The urogenital mesentery attaches the testis and mesonephros to the posterior abdominal wall
& with degeneration of the mesonephros, the attachment serves as a mesentery for the gonad.

• Caudally, it becomes ligamentous and is known as the caudal genital ligament.

Also extending from the caudal pole of the testis is a mesenchymal condensation rich in
extracellular matrices, the gubernaculum.

o Prior to descent of the testis, this band of mesenchyme terminates in the inguinal region
between the differentiating internal and external abdominal oblique muscles.

o Later, as the testis begins to descend toward the internal inguinal ring, an extra-abdominal
portion of the gubernaculum forms and grows from the inguinal region toward the scrotal
swellings.

o When the testis passes through the inguinal canal, this extra-abdominal portion contacts the
scrotal floor (the gubernaculum forms in females also, but in normal cases, it remains
rudimentary).

Factors controlling descent of the testis are not entirely clear.

o It appears, however, that outgrowth of the extra-abdominal portion of the gubernaculum

produces intra-abdominal migration.

o This happens due to an increase in intra-abdominal pressure due to organ growth produces
passage through the inguinal canal.

o Here onwards, regression of the extra-abdominal portion of the gubernaculum completes

movement of the testis into the scrotum.

o Normally, the testes reach the inguinal region by approximately 12 weeks’ gestation, migrate
through the inguinal canal by 28 weeks, and reach the scrotum by 33

The process is influenced by hormones, including,

(1) Androgens like DHT
(2) MIS
 o During descent, blood supply to the testis from the aorta is retained, and testicular vessels
extend from their original lumbar position to the testis in the scrotum.

o Independently from descent of the testis, the peritoneum of the abdominal cavity forms an
evagination on each side of the midline into the ventral abdominal wall.

o This evagination, the processus vaginalis, follows the course of the gubernaculum testis into the
scrotal swellings.

o Hence, the processus vaginalis, accompanied by the muscular and fascial layers of the body wall,
evaginates into the scrotal swelling, forming the inguinal canal.

o The testis descends through the inguinal ring and over the rim of the pubic bone and is present
in the scrotum at birth.

The testis is then covered by a reflected fold of the processus vaginalis.

(1) The peritoneal layer covering the testis is the visceral layer of the tunica vaginalis
(2) The remainder of the peritoneal sac forms the parietal layer of the tunica vaginalis.

In addition to being covered by peritoneal layers derived from the processus vaginalis,
The narrow canal connecting the lumen of the vaginal process with the peritoneal cavity is
• The testis becomes ensheathedobliterated
in layersatderived
birth orfrom
shortly
thethereafter.
anterior abdominal wall through which it
passes.

(1) The transversalis fascia forms the internal spermatic fascia

(2) The internal abdominal oblique muscle gives rise to the cremasteric fascia and muscle
(3) The external abdominal oblique muscle forms the external spermatic fascia

The transversus abdominis muscle does not contribute a layer because it arches over this region &
does not cover the path of migration.

Descent of the Ovaries

Descent of the gonads is considerably less in the female than in the male, and the ovaries finally
settle just below the rim of the true pelvis.

(1) The cranial genital ligament forms the suspensory ligament of the ovary.

(2) The caudal genital ligament forms the ligament of the ovary proper and the round ligament
of the uterus.

The latter extends into the labia majora.

 Male Reproductive System
Testis-Male Gonad

• Tunica vaginalis

o Double layer of mesothelium (parietal and visceral)

o Mesothelial cells secrete serous fluid

o Covers the testis except posteriorly

o Collection of fluid within tunica vaginalis is called Hydrocele

• Tunica albuginea(capsule)

o Dense fibrous tissue with fibroblast and myofibroblast

o Thickened posteriorly to form the mediastinum testis

o Incomplete fibrous septa arise from the

mediastinum testis and divide the testis
into lobules

• Deepest layer (Tunica vasculosa)

o Lines the inner surface of lobules

o Loose connective tissue

o Blood vessels

o Lymphatics Seminiferous
tubules
Seminiferous tubules
• Tubules within testicular lobules
• Tightly packed, highly convoluted
• Lining the tubes are, Germ cells (various stage of spermatogenesis, which are collectively
referred to as the spermatogenic series & non germ cells: Sertoli cells (support and nourish
spermatozoa)
 • Between tubules (interstitial space)
-Leydig cells
-Very vascular
• Seminiferous tubules converge upon the mediastinum testis which consist of
plexus of channels known as Rete testis

Ductuli efferentes
• The rete testis drains into the head of the epididymis via some 15-20 convoluted
ducts, the ductuli efferentes.
• The ductuli are lined by a single layer of epithelial cells,
-tall columnar and ciliated
- short and non-ciliated
• A thin band of circularly arranged smooth muscle surrounds each ductulus and aids
propulsion of the spermatozoa towards the epididymis
Epididymis

• The epididymis is a long extremely convoluted duct extending down the posterior aspect of the testis
to the lower pole where the ductus deferens.

• The epididymis is a tube of smooth muscle lined by a pseudostratified columnar epithelium with
stereocilia.

Ductus deferens
• The ductus (or vas) deferens, conducts spermatozoa from the epididymis to the ejaculatory
ducts.
• It is a thick-walled muscular tube consisting of inner and outer
longitudinal layers and a thick intermediate circular layer.
• The ductus deferens is lined by a pseudostratified columnar epithelium.
• Epithelium and lamina propria are highly folded
Seminal vesicle
• Each seminal vesicle is a complex glandular diverticulum of the associated ductus
deferens.

• Between them the seminal vesicles secrete up to 50 - 70% of the total

volume of seminal fluid, most of the rest being secreted by the prostate
gland.

• The epithelial lining is usually of a pseudostratified tall columnar type.

• The prominent muscular wall is arranged into inner circular and outer
longitudinal layers and is supplied by the sympathetic nervous system;
during ejaculation, muscle contraction forces secretions from the seminal
vesicles into the urethra via the ampullae

• Irregular, honeycomb shaped lumen at low magnification.

 Prostate

• The prostate consists of branched tubulo acinar glands, embedded in a

fibromuscular stroma.

• Epithelium - tall columnar secretory cells.

• Secretions may accumulate in some glands form special concretions (corpora

amylacea) which increase in number with age & may become calcified

5
 Female Reproductive System

Ovaries – female gonads

Outer epithelial covering

(germinal epithelium)

• continuation of peritoneum
• Lined by cuboidal to columnar cells

Ovarian stroma

Stroma is divided,
1. Outer cortex
2. Inner medulla

• Outer cortex contains follicles and corpus luteum,

• superficial cortex contains a fibrous covering (tunica albuginea).

• Inner medulla is highly vascular and contains hilus cells (=Leydig cells) and helicine /spiral
arteries

7
 Overview of follicle maturation in the Ovarian cycle

1. Primordial follicle
• Contains the primary oocyte (large nucleus, small cytoplasm)
• Surrounded by a single layer of flattened follicular cells

2. Primary follicle
• Primary oocyte enlarges
• Follicular cells proliferate to form cuboidal shaped granulosa cells (zona granulosa)
• Zona pellucida – glycoprotein and proteoglycan rich acellular layer
between granulosa cells and primary oocyte
• Surrounding stromal cells (fibroblasts) organize to form a cellular
layer around zona granulosa called theca folliculi

3. Secondary follicle
• Contains the primary oocyte
• Fluid filled spaces develop in the zona granulosa,
they coalesce and form the follicular antrum
• Cumulus oophorus – thickened area in the
zona granulosa where the primary follicle
lies
• Theca folliculi divide into theca externa
(containing spindle cells) and theca interna (round
cells)

4. Graffian follicle
• Initially contains the primary follicle
• Just before ovulation, primary oocyte completes
the 1st meiotic division and forms the secondary
oocyte
• Follicular antrum enlarges
• Zona granulosa forms an even layer around the
periphery of the follicle (cumulus oophorus
diminish)
• Corona radiata – a thick cellular layer around zona
granulosa, attach to ZG by thin bridges of cells
• During ovulation, secondary oocyte, zona pellucida,
corona radiate are released from the ovary

8
 5. Corpus luteum
• Contains granulosa and theca lutein cells
• Granulosa cell are large polygonal cells with round
nuclei and abundant cytoplasm, SER, mitochondria,
lipid droplets and lipofuscin (yellow colour)
• Theca externa – dark staining
• Theca interna – pale staining due to the presence of lipid droplets

9
 Fallopian tube

• Mucosa contains branched longitudinal folds which is most prominent in

ampulla, the usual site of fertilization.

• The muscular wall has 2 layers, an inner circular & an outer longitudinal.

• Epithelium - single layer of tall columnar epithelial cells.

• 3 types of cells line the mucosa

- Ciliated tall (showing irregular cell margin)
- Non-ciliated secretory cells (prominent in ampulla)
- Intercalated cells

• Non-ciliated cells secrete substances to take ova forward with the aid of cilia
• The secretion has a role in the nutrition & protection of the ovum.
• The ratio of affiliated to non-ciliated cells & the height of the cells
undergo cyclical variations under influence of ovarian hormones.
• Serosa – vascular, covered by mesothelium, cont. with the broad ligament

10
 Uterus

Basic organization –

1. Perimetrium
2. Myometrium
3. Endometrium

(1) Endometrium - Epithelium lining tall, columnar cells with microvilli or cilia
Form numerous simple tubular glands supported by endometrial stroma

Histological layers

1. Stratum compactum stratum functionalis – undergo cyclical changes

2. Stratum spongiosum functional layers are shed off during menstrual phase
3. Stratum basalis ➔ No shedding during menstrual cycle

Changes occur in the endometrium during menstrual cycle

Proliferative phase Secretory phase Menstrual phase

-columnar cells (cilia or microvilli) Tall columnar cells Functional layers shed
-glands-initially simples tubular, straight, sparse Coiled tubular glands off due to the absence
But proliferation is started (saw tooth appearance) of implantation
Lined by tall columnar cells Tall columnar cells Stratum functionalis
undergo ischaemia
due to spasm of spiral
arteries
-gradually stroma become thicker, very cellular Stroma reaches to the
maximum thickness, highly
vascular
-Blood vessels less More blood vessels

-Mitotic figures can be seen

-Endometrial surface epithelial cells acquire • Glycogen vacuoles(basal)

microvilli, cilia, cell organelle • Saw tooth appearance
In cross section of glands

11
12
11
Uterine cervix

Endocervix –lined by simple columnar epithelium

Ectocervix – lined stratified squamous epithelium

• The cells of ectocervix o\en have clear cytoplasm due to their high glycogen content.

• The junction between the ecto & endo cervical epithelium is quite abrupt & is
normally located at the external is, the point where the endo cervical canal
opens into the vagina.

• Endocervix contents endo cervical glands which are lined by the columnar
mucus secreting cells.

• During menstrual cycle, the endo cervical epithelium undergo cyclical

changes in secretory activity.

Cervical canal

• Lined by tall columnar mucous secreting cells

• Leukocytes are more between junction of endocervix and ectocervix (external os) - at
squamocolumnar junction
Vagina

In the relaxed state, the vaginal wall collapses to obliterate the lumen, & the vaginal
epithelium thrown up into folds.

(1) Epithelium – stratified squamous, non-keratinized

Superficial cells of epithelium form glycogen
During menstrual cycle, this epithelium undergoes cyclical changes in glycogen level.

Glycogen → (anaerobic respiration) → lactic acid (inhibit growth of microorganisms)

(2) Lamina propria -no glands, contain elastin fibres, has rich plexus of veins.

(3) smooth muscle layer – inner circular and outer longitudinal muscle layers ( ill defined)

(4) Adventitia – fuse with that of rectum posterior and bladder anteriorly.