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Anatomy of female external genital tract, urethra, urinary bladder

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Anatomy of female external genital tract, urethra, urinary bladder

  2. 2. The anatomy of female genital tract is divided into :  EXTERNAL GENITALIA  INTERNAL GENITALIA  ACCESSORY REPRODUCTIVE ORGANS
  3. 3. EXTERNAL GENITALIA (vulva ; pudendum) The vulva includes the structures visible externally from the symphysis pubis to the perineal body. Bounded Anteriorly : by mons pubis Laterally : by thighs Posteriorly : by perineum
  4. 4. VULVA includes • Mons pubis • Labia majora • Labia minora • Clitoris • Hymen • Vestibule • Urethral opening • Greater vestibular or Bartholin’s glands • Minor vestibular glands • Paraurethral glands
  5. 5. MONS PUBIS • Triangular mound of subcutaneous adipose connective tissue that covers the pubic bone. • Growth of curly hair on the mons pubis after puberty forms the escutcheon. • Hair is distributed in a triangle, whose base covers the upper margin of symphysis pubis and tip ends at the clitoris.
  6. 6. LABIA MAJORA • They are 7 to 8 cm in length, 2 to 3 cm in depth, and 1 to 1.5 cm in thickness. • They are continuous directly with the mons pubis superiorly. • Posteriorly, taper and merge into the area overlying the perineal body to form the posterior commissure. Posterior commissure
  7. 7. • The outer surface of the labia majora is covered with hair. • Inner surface has abundant apocrine and eccrine sweat and sebaceous glands and is hairless. • The labia majora are covered by squamous epithelium. • Beneath the skin, dense connective tissue and adipose tissue are present which are supplied with a rich venous plexus. • Nearly void of muscular elements. • Homologous with the scrotum in males.
  8. 8. • It contains the termination of round ligament of uterus at its distal third and the obliterated processus vaginalis (canal of nuck). • The round ligament can give rise to leiomyomas in this region. • Obliterated processus vaginalis can be seen as dilated embryonic remanant in adults. • During pregnancy, this vasculature commonly develops varicosities, especially in parous women, from increased venous pressure created by advancing uterine weight. • May form haematoma if ruptured during childbirth.
  9. 9. LABIA MINORA • Each is a thin fold of tissue, lying medial to each labia majora. • Length : 2-10 cm Width : 1-5 cm • Extend superiorly, where each divides into two lamellae. The lower pair fuses to form the frenulum of the clitoris, and the upper pair merges to form the prepuce. • Inferiorly, extend to approach the midline as low ridges of tissue that fuse to form the fourchette (lacerated during childbirth).
  10. 10. • Structurally, the labia minora are composed of connective tissue with many vessels, elastin fibers, and some smooth muscle fibers. • They are supplied with a variety of nerve endings. • There are many sebaceous glands, but lack hair follicles.
  11. 11. The lateral portion of the inner surface is covered by stratified squamous epithelium to a demarcating line— The Hart line. Medial to this line, each labium is covered by squamous epithelium that is nonkeratinized.
  12. 12. • Cutaneous structures lie on a connective tissue stratum, that is loosely organised and thus permits mobility of skin during coitus. • This loose attachment allows skin to be easily dissected off the underlying fascia during skinning vulvectomy in that area. • Homologous to the ventral aspect of penis.
  13. 13. CLITORIS • This principal female erogenous organ is located beneath the prepuce and above the urethra. • It projects downward between the branched extremities of the labia minora, and the free end points downward and inward toward the vaginal opening. • The clitoris rarely exceeds 2 cm in length and is composed of a glans, a corpus or body, and two crura.
  14. 14. • The glans is usually less than 0.5 cm in diameter, is composed of spindle-shaped cells, and is covered by stratified squamous epithelium that is richly innervated. • The clitoral body contains two corpora cavernosa. Extending from the clitoral body, each corpora cavernosa diverges laterally to form the long, narrow crura. These lie along the inferior surface of the ischiopubic rami and deep to the ischiocavernosus muscles. • Attached to the undersurface of pubic symphysis by suspensory ligament.
  15. 15. • Homologous to penis in males. • Clitoromegaly : Length > 3.5 cm and Width > 1 cm. Occurs in virilism (due to excess androgens). • Injury causes profuse bleeding and intense pain. • BLOOD SUPPLY From branches of Internal Pudendal Artery Clitoral body : Deep Artery of the clitoris Glans & prepuce : Dorsal artery of clitoris
  16. 16. VESTIBULE • In adult women, it is an almond-shaped area that is enclosed by o Hart line laterally, • External surface of the hymen medially, • Clitoral frenulum anteriorly, • Fourchette posteriorly.
  17. 17. • The vestibule usually is perforated by six openings: the urethra, the vagina, two Bartholin gland ducts, and at times, two ducts of the largest paraurethral glands—the Skene glands. • The posterior portion of the vestibule between the fourchette and the vaginal opening is called the fossa navicularis. It is usually observed only in nulliparous women.
  18. 18. • URETHRAL OPENING Situated in front of vaginal opening, 1-1.5 cm below the pubic arch. The paraurethral glands open either on the posterior wall of the urethral orifice or directly into the vestibule.
  19. 19. VAGINAL OPENING & HYMEN • Lies at the posterior end of vestibule. • The vaginal opening is rimmed distally by the hymen or its remnants. • It is composed mainly of elastic and collagenous connective tissue, and both outer and inner surfaces are covered by stratified squamous epithelium.
  20. 20. • In pregnant women, the epithelium of the hymen is thick, and the tissue is rich in glycogen. • Changes produced in the hymen by childbirth are usually readily recognizable. • Over time, the hymen consists of several nodules of various sizes, also termed hymenal caruncles.
  21. 21. VESTIBULAR GLANDS BARTHOLIN’S GLANDS • Termed greater vestibular glands, are the major glands. • Measure 0.5 to 1 cm in diameter, yellowish white in colour. • Lie inferior to the vestibular bulbs and deep to the inferior end of the bulbo cavernosus muscle on either side of the vaginal opening.
  22. 22. • Their ducts are 1.5 to 2 cm long and open distal to the hymenal ring at 5 and 7 o’clock on the vestibule at the junction of the anterior two third and posterior one third. • The duct is lined by columnar epithelium and stratified squamous epithelium near its opening. • Compound racemose variety. • Homologous to bulbo urethral gland of male.
  23. 23. • During sexual excitement it secretes abundant alkaline mucus which helps in lubrication. • Following trauma or infection, either duct may swell and obstruct to form a cyst or abscess.
  24. 24. • MINOR VESTIBULAR GLANDS Shallow glands lined by simple mucin secreting epithelium and open along the Hart line.
  25. 25. PARAURETHRAL GLANDS • Collective arborization of glands whose ducts open predominantly along the entire inferior aspect of the urethra. • The two largest are called Skene glands, and their ducts typically lie distally near the urethral meatus. • Inflammation and duct obstruction of any of the paraurethral glands can lead to urethral diverticulum formation. • Homologous to prostate in males.
  26. 26. VESTIBULAR BULBS • These are almond-shaped aggregations of veins, 3 to 4 cm long, 1 to 2 cm wide, and 0.5 to 1 cm thick. • Lie beneath the bulbocavernosus muscle on either side of the vestibule in front of the bartholin’s glands. • Homologous to the single bulb of the penis and corpus spongiosum in the male. • Likely to be injured during childbirth and may even rupture to create vulvar hematoma.
  27. 27. BLOOD SUPPLY • ARTERIES Branches of INTERNAL PUDENDAL ARTERY  Labial Transverse perineal Artery to the vestibular bulb Dorsal arteries to clitoris Branches of FEMORAL ARTERY Superficial & Deep external pudendal
  28. 28. • VEINS Internal pudendal vein Vesical or Vaginal venous plexus Long saphaneous vein Varicosities may develop during pregnancy and may rupture spontaneously causing visible bleeding or hematoma.
  29. 29. NERVE SUPPLY Bilateral spinal somatic nerves • Anterio-superior part – by Cutaneous branches from ilioinguinal & genital br. Of Genitofemoral Nerve (L1 & L2 ) • Posterio-inferior part – by Pudendal branch from posterior cutaneous nerve of thigh (S123) Between these two vulva supplied by Labial & Perineal branch of Pudendal Nerve (S234).
  30. 30. LYMPHATICS OF VULVA • Labia Majora (Anterior half) Lymphatics intercommunicate with the opposite side in the region of mons veneris → Superficial inguinal nodes • Labia majora (Posterior half) Drains into Superficial inguinal → Deep inguinal → External iliac
  31. 31. • Labia Minora and Prepuce of Clitoris intercommunicate with lymphatics of opposite side in vestibule → Superficial inguinal nodes. • Glans of clitoris Drain directly into deep inguinal and external iliac nodes. • Bartholin’s glands Drain into superficial inguinal and anorectal nodes.
  32. 32. URINARY BLADDER • Hollow muscular organ. • Capacity : 450 ml ; can retain 3-4 liters of urine. • Ovoid shape when distended. • Tetrahedral in shape when empty and has : (a) a base or fundus (directed backwards) (b) a neck (lowest and most fixed part) (c) three surfaces : superior, right, left inferolateral (d) four borders : two lateral , one anterior, one posterior
  33. 33. • A full bladder is ovoid in shape and has : (a) an apex (directed upwards towards umbilicus) (b) a neck (directed downwards) (c) two surfaces – anterior and posterior
  34. 34. RELATIONS • APEX : connected to umbilicus by median umbilical ligament (obliterated urachus). • BASE : related to uterine cervix and vagina. • NECK : lies 3-4cm behind the lower part of pubic symphysis, pierced by the internal urethral orifice, related to pelvic fascia surrounding upper part of urethra.
  35. 35. • SUPERIOR SURFACE : peritoneum covers greater part except for a small area near posterior border related to supravaginal portion of cervix. • INFEROLATERAL SURFACES : devoid of peritoneum, related to pubovesical ligament, levator ani, obturator internus.
  36. 36. • TRIGONE - Small triangular area over lower part of base of bladder. - Its apex is directed downwards and forwards. - The internal urethral orifice opens here. - Ureters open at its postero-lateral angles.
  37. 37. STRUCTURES From outside inwards : • Outer visceral layer of the pelvic fascia • Detrusor muscle • Mucous coat is lined by transitional epithelium with no glands. • There is no submucous coat.
  38. 38. BLOOD SUPPLY • ARTERIAL Superior and inferior vesical arteries • VENOUS Drain into vesical and vaginal plexus → internal iliac veins • LYMPHATICS External and internal iliac lymph nodes
  39. 39. URETHRA • Extends from bladder neck to the external urethral meatus. • 4 cm in length and 6 mm in diameter. • Bladder forms an angle with the posterior wall of urethra called POSTERIOR URETHROVESICAL ANGLE (100°). • Runs downwards and forwards in close proximity with anterior vaginal wall. • About 1 cm from the lower end, pierces the Triangular ligament, opening into vestibule 2.5 cm below the clitoris.
  40. 40. RELATIONS • POSTERIORLY : anterior vaginal wall. • ANTERIORLY : posterior aspect of pubic symphysis. Lower one third is attached to pubic rami by fibrous tissue on each side - PUBOURETHRAL LIGAMENT (prevents hypermobility of bladder neck and urethra). • LATERALLY : passes through triangular ligament , surrounded by Compressor urethrae.
  41. 41. • GLANDS The Paraurethral glands open into the lumen. The largest, Skene’s glands open either on the posterior wall just inside the external urethral meatus or into the vestibule.
  42. 42. SPHINCTERS • LISSOSPHINCTER It is an intricate decussation of the involuntary muscles forming anterior and posterior slings forming involuntary internal sphincter at the urethro-vesical junction. • SPHINCTER URETHRA (in the urogenital diaphragm) Allows voluntary arrest of urine flow. • ACCESSORY EXTERNAL SPHINCTER Bulbocavernosus, ischiocavernosus.
  43. 43. FUNCTIONALLY Urethra is divided into 3 parts • Proximal urethra -Weakest part. - Inner longitudinal muscle of detrusor fades out in this part. - Fails to withstand the rise of intra vesical or intra abdominal pressure.
  44. 44. • MIDURETHRA - Strongest part. - Support by intrinsic striated muscle : Rhabdosphincter urethrae, slow twitch fibres For urethral closure at rest. - Extrinsic muscle: Levator ani First twitch fibres, for support to urethra on stress.
  45. 45. • Distal urethra Passive conduit Surrounded by collagen tissue.
  46. 46. STRUCTURES • Mucous membrane is lined by transitional epithelium except at external urethral meatus -- stratified squamous epithelium. • Submucous coat is vascular. • Muscle coat is composed of involuntary muscles and the fibres are arranged in the form of crossed spirals.
  47. 47. BLOOD SUPPLY • ARTERIAL Proximal part by inferior vesical branch. Distal part by a branch of internal pudendal artery. • VENOUS Drain into vesical plexus and internal pudendal veins. • LYMPHATICS Drain into hypogastric glands → external iliac lymph nodes.
  48. 48. SUPPORT TO BLADDER NECK AND URETHRA • INTRINSIC FACTORS : (i) Intrinsic rhabdosphincter urethrae (ii) Urethral submucosal venous plexus (iii) Urethral smooth muscles (iv) Sympathetic activity (v) Estrogen to increase collagen tissue
  49. 49. • EXTRINSIC FACTORS : (i) Contraction of pubococcygeus (ii) Pubourethral ligaments (iii) Exercise
  51. 51. APPLIED ANATOMY • Because of shortness and close proximity of urethra to vagina and anus, infection is likely and commonly spreads upwards to involve the bladder. • Because of close proximity to vagina, urethra may get injured during childbirth. • Paraurethral glands are sites of infection and development of adenoma or malignant changes can occur. • Urinary incontinence.

Hinweis der Redaktion

  • Apocrine glands---- hidradenitis/hidradenoma
  • Inflammation and duct obstruction of any of the paraurethral glands can lead to urethral diverticulum formation.
  • During childbirth, the vestibular bulbs may be injured and may even rupture to create a vulvar hematoma.
  • Varicosities during pregnancy may rupture spontaneously causing visible bleeding or hematoma formation.
  • As the bladder fills the inferolateral surfaces form anterior surface of distended bladder, which is covered by peritoneum only in its upper part. Lower part comes into direct contact with anterior abdominal wall with no intervening peritoneum. Can be approached surgically without entering peritoneal cavity.