Hauptseite Williams Obstetrics
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03 April 2021 (12:34)
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'ÿ(ÿ)ÿ*"ÿ+!ÿ,-2443'-ÿ,3-. ÿ 8%ÿ()ÿG8HC$ÿÿB5ÿ(:ÿIÿÿÿJ !ÿÿ%ÿÿ7 ÿ79 ÿÿ9 6Aÿ& Kÿ99ÿ#:'ÿ9ÿ:ÿ)ÿ5 ÿ;40/=1?2;ÿ,3-.ÿÿ<7$"5 ÿ,.?;.0;2>ÿ 6L&Lÿ5ÿ*$$ÿMÿ7 ÿHÿÿÿ !ÿ:ÿ"ÿ&9 8: ÿC$!:ÿÿÿ# # 'ÿ9ÿ:ÿ)ÿ5 ÿ;.4/,;1,,,.ÿ,3-,ÿÿ<7$"5 ÿ,;,-222?>ÿ 6%ÿ8ÿ5ÿÿÿÿE'8'ÿÿ :ÿ:"ÿ ÿ$ ÿ 'ÿ9 &ÿNLÿ6 8#"ÿ,-ÿ,3-. ÿ 6ÿ+ÿÿÿ)9ÿÿÿÿ%:ÿÿ$$ÿ#ÿÿ: ÿ!Kÿ"% ÿÿ ÿÿÿ"!Lÿÿ!9!ÿ$!!'ÿ(ÿ)ÿ6#ÿ(#ÿ,,ÿ,3-4ÿ<#$"ÿ9ÿ #>ÿ 6& ÿÿE# ÿÿE'8'ÿÿ!ÿ 'ÿ(%" ÿÿ& &'!'ÿ(!! ÿ)$ÿ;3ÿ,3-4ÿ Hÿ ÿÿ)ÿ7ÿ)ÿ ÿ+ÿ)7ÿÿÿ7 ÿ9 ÿ!# ÿ&9ÿ# ÿ9#ÿ"9ÿÿ9 9 9 'ÿ*"ÿ+!ÿ--?/21-3;4ÿ,3--ÿÿ<7$"5 ÿ,,3-2?4->ÿ H LÿIÿE8ÿ#ÿ"9ÿODPÿÿÿ'ÿ)(5(ÿ;3;/,1--.ÿ,3-3ÿÿ<7$"5 ÿ,33.?-==>ÿ #ÿI)ÿ5ÿÿ%ÿFÿÿÿ9ÿ !ÿ%$ÿL#:ÿÿ#ÿ::' 9ÿ:ÿ)ÿ5 ÿ;.4/,;1,-42ÿ,3-,ÿÿ<7$"5 ÿ,;,-2222>ÿ 36137 mebooksfree.com 012213425 789 ÿÿ8ÿÿ89 ÿÿÿ8ÿ ÿÿ8 ÿ9ÿÿ 88ÿ!"#ÿ9##ÿ #!8!8$ %ÿÿ&9ÿ' #ÿ()*(+)ÿ(*),ÿ 78"ÿ-ÿ./#89ÿ0ÿ.8 ÿ1ÿÿ8ÿ188ÿ8 ÿ 2ÿ/# 9ÿÿ!8 ÿ ÿÿ39ÿ!8 9!8ÿ9ÿ8ÿ 88899$ÿ%ÿÿ&9ÿ' #ÿ(*4546(,4ÿ(*)*ÿÿ7/1 ÿ(*+89(9,:ÿ ;/ÿ<ÿ7 ==ÿÿ#9ÿÿ8#8ÿ29$ÿ> 2ÿ;ÿ? 9ÿ18ÿ9ÿ(*)@ÿ ÿ 1#'82ÿ !=ÿAÿ1#'82Bÿ'8ÿ< /#8 ÿ=9ÿ..$ ÿ %ÿ=9ÿ93 $ÿ ;/ÿCÿ8 99ÿ9ÿ ÿ %##99ÿ3 ÿÿ>8 8ÿ1 #8ÿ.8 3#8 mebooksfree.com 36136 4/11/2018 Williams Obstetrics, 25e > CHAPTER 2: Maternal Anatomy As the mechanism of labour is essentially a process of accommodation between the foetus and the passage through which it must pass, it is apparent that obstetrics lacked a scientific foundation until the anatomy of the bony pelvis and of the so parts connected with it was clearly understood. —J. Whitridge Williams (1903) ANTERIOR ABDOMINAL WALL Skin, Subcutaneous Layer, and Fascia The anterior abdominal wall confines abdominal viscera, stretches to accommodate the expanding uterus, and provides surgical access to the internal reproductive organs. Thus, a comprehensive knowledge of its layered structure is required to surgically enter the peritoneal cavity. Langer lines describe the orientation of dermal fibers within the skin. In the anterior abdominal wall, they are arranged transversely. As a result, vertical skin incisions sustain greater lateral tension and thus, in general, develop wider scars. In contrast, low transverse incisions, such as the Pfannenstiel, follow Langer lines and lead to superior cosmetic results. The subcutaneous layer can be separated into a superficial, predominantly fatty layer—Camper fascia, and a deeper membranous layer—Scarpa fascia. Camper fascia continues onto the perineum to provide fatty substance to the mons pubis and labia majora and then to blend with the fat of the ischioanal fossa. Scarpa fascia continues inferiorly onto the perineum as Colles fascia, described in Perineum. Beneath the subcutaneous layer, the anterior abdominal wall muscles consist of the midline rectus abdominis and pyramidalis muscles as well as the external oblique, internal oblique, and transversus abdominis muscles, which extend across the entire wall (Fig. 2-1). The fibrous aponeuroses of these three latter muscles form the primary fascia of the anterior abdominal wall. These fuse in the midline at the linea alba, which normally measures 10 to 15 mm wide below the umbilicus (Beer, 2009). An abnormally wide separation may reflect diastasis recti or hernia. FIGURE 2-1 Anterior abdominal wall anatomy. (Modified with permission from Corton MM: Anatomy. In Ho man BL, Schorge JO, Bradshaw KD, et al (eds): Williams Gynecology, 3rd ed. New York, McGraw-Hill Education, 2016.) mebooksfree.com 1/32 4/11/2018 These three aponeuroses also invest the rectus abdominis muscle as the rectus sheath. The construction of this sheath varies above and below a boundary, termed the arcuate line (see Fig. 2-1). Cephalad to this border, the aponeuroses invest the rectus abdominis bellies on both dorsal and ventral surfaces. Caudal to this line, mebooksfree.com 2/32 4/11/2018 all aponeuroses lie ventral or superficial to the rectus abdominis muscle, and only the thin transversalis fascia and peritoneum lie beneath the rectus (Loukas, 2008). This transition of rectus sheath composition can be seen best in the upper third of a midline vertical abdominal incision. The paired small triangular pyramidalis muscles originate from the pubic crest and insert into the linea alba. These muscles lie atop the rectus abdominis muscle but beneath the anterior rectus sheath. Blood Supply The superficial epigastric, superficial circumflex iliac, and superficial external pudendal arteries arise from the femoral artery just below the inguinal ligament within the femoral triangle (see Fig. 2-1). These vessels supply the skin and subcutaneous layers of the anterior abdominal wall and mons pubis. Of these three, the superficial epigastric vessels are surgically important to the obstetrician and course diagonally from their origin toward the umbilicus. With a low transverse skin incision, these vessels can usually be identified at a depth halfway between the skin and the anterior rectus sheath. They lie above Scarpa fascia and several centimeters from the midline. Ideally, these vessels are identified and surgically occluded. In contrast, the inferior “deep” epigastric vessels are branches of the external iliac vessels and supply anterior abdominal wall muscles and fascia. Of surgical relevance, the inferior epigastric vessels initially course lateral to, then posterior to the rectus abdominis muscles, which they supply. Above the arcuate line, these vessels course ventral to the posterior rectus sheath and lie between this sheath and the posterior surface of the rectus muscles. Near the umbilicus, the inferior epigastric vessels anastomose with the superior epigastric artery and vein, which are branches of the internal thoracic vessels. Clinically, when a Maylard incision is used for cesarean delivery, the inferior epigastric vessels may be lacerated lateral to the rectus belly during muscle transection. Preventively, identification and surgical occlusion are preferable. These vessels rarely may rupture following abdominal trauma and create a rectus sheath hematoma (Tolcher, 2010; Wai, 2015). On each side of the lower anterior abdominal wall, Hesselbach triangle is the region bounded laterally by the inferior epigastric vessels, inferiorly by the inguinal ligament, and medially by the lateral border of the rectus abdominis muscle. Hernias that protrude through the abdominal wall in Hesselbach triangle are termed direct inguinal hernias. In contrast, indirect inguinal hernias do so through the deep inguinal ring, which lies lateral to this triangle, and then may exit out the superficial inguinal ring. Innervation The entire anterior abdominal wall is innervated by intercostal nerves (T7–11), the subcostal nerve (T12), and the iliohypogastric and the ilioinguinal nerves (L1). Of these, the intercostal and subcostal nerves are anterior rami of the thoracic spinal nerves and run along the lateral and then anterior abdominal wall between the transversus abdominis and internal oblique muscles (Fig. 2-2). This space, termed the transversus abdominis plane, can be used for postcesarean analgesia blockade (Chap. 25, Postpartum Analgesia) (Fusco, 2015; Tawfik, 2017). Others report rectus sheath or ilioinguinal-iliohypogastric nerve blocks to decrease postoperative pain (Mei, 2011; Wolfson, 2012). FIGURE 2-2 Intercostal and subcostal nerves are the anterior rami of spinal nerves. In this figure, an intercostal nerve extends ventrally between the transversus abdominis and internal oblique muscles. During this path, the nerve gives rise to lateral and anterior cutaneous branches, which innervate the anterior abdominal wall. As shown by the inserted needle, the transversus abdominis plane (TAP) block takes advantage of this anatomy. (Modified with permission from Hawkins JL: Anesthesia for the pregnant woman. In Yeomans ER, Ho man BL, Gilstrap LC III, et al: Cunningham and Gilstraps’s Operative Obstetrics, 3rd ed. New York, McGraw Hill Education, 2017.) mebooksfree.com 3/32 4/11/2018 Near the rectus abdominis lateral borders, anterior branches of the intercostal and subcostal nerves pierce the posterior sheath, rectus muscle, and then anterior sheath to reach the skin. Thus, these nerve branches may be severed during a Pfannenstiel incision creation during the step in which the overlying anterior rectus sheath is separated from the rectus abdominis muscle. In contrast, the iliohypogastric and ilioinguinal nerves originate from the anterior ramus of the first lumbar spinal nerve. They emerge lateral to the psoas muscle and travel retroperitoneally across the quadratus lumborum inferomedially toward the iliac crest. Near this crest, both nerves pierce the transversus abdominis muscle and course ventromedially. At a site 2 to 3 cm medial to the anterior superior iliac spine, the nerves then pierce the internal oblique muscle and course superficial to it toward the midline (Whiteside, 2003). The iliohypogastric nerve perforates the external oblique aponeurosis near the lateral rectus border to provide sensation to the skin over the suprapubic area (see Fig. 2-1). The ilioinguinal nerve in its course medially travels through the inguinal canal and exits through the superficial inguinal ring, which forms by splitting of external abdominal oblique aponeurosis fibers. This nerve supplies the skin of the mons pubis, upper labia majora, and medial upper thigh. The ilioinguinal and iliohypogastric nerves can be severed during a low transverse incision or entrapped during closure, especially if incisions extend beyond the lateral borders of the rectus abdominis muscle (Rahn, 2010). These nerves carry sensory information only, and injury leads to loss of sensation within the areas supplied. Rarely, chronic pain may develop (Whiteside, 2005). The T10 dermatome approximates the level of the umbilicus. Analgesia to this level is suitable for labor and vaginal birth. Regional analgesia for cesarean delivery or for puerperal sterilization ideally extends to T4. EXTERNAL GENERATIVE ORGANS Vulva Mons Pubis, Labia, and Clitoris The pudenda—commonly designated the vulva—includes all structures visible externally from the symphysis pubis to the perineal body. This includes the mons pubis, labia majora and minora, clitoris, hymen, vestibule, urethral opening, greater vestibular or Bartholin glands, minor vestibular glands, and paraurethral glands (Fig. 2-3). The vulva receives innervations and vascular support from the pudendal nerve (Pudendal Nerve). FIGURE 2-3 Vulvar structures and subcutaneous layer of the anterior perineal triangle. Note the continuity of Colles and Scarpa fasciae. Inset: Vestibule boundaries and openings onto vestibule. (Reproduced with permission from Corton MM: Anatomy. In Ho man BL, Schorge JO, Bradshaw KD, et al (eds): Williams Gynecology, 3rd ed. New mebooksfree.com 4/32 4/11/2018 York, McGraw-Hill Education, 2016.) The mons pubis is a fat-filled cushion overlying the symphysis pubis. A er puberty, the mons pubis skin is covered by curly hair that forms the triangular escutcheon, whose base aligns with the upper margin of the symphysis pubis. In men and some hirsute women, the escutcheon extends farther onto the anterior abdominal wall toward the umbilicus. Labia majora usually are 7 to 8 cm long, 2 to 3 cm wide, and 1 to 1.5 cm thick. They are continuous directly with the mons pubis superiorly, and the round ligaments terminate at their upper borders. Hair covers the labia majora, and apocrine, eccrine, and sebaceous glands are abundant. Beneath the skin, a dense connective tissue layer is nearly void of muscular elements but is rich in elastic fibers and fat. This fat mass provides bulk to the labia majora and is supplied with a rich venous mebooksfree.com 5/32 4/11/2018 plexus. During pregnancy, this vasculature may develop varicosities, especially in multiparas, from increased venous pressure created by the enlarging uterus. They appear as engorged tortuous veins or as small grapelike clusters, but they are typically asymptomatic and require no treatment. Each labium minus is a thin tissue fold that lies medial to each labium majus. The labia minora extend superiorly, where each divides into two lamellae. From each side, the lower lamellae fuse to form the frenulum of the clitoris, and the upper lamellae merge to form the prepuce (see Fig. 2-3). Inferiorly, the labia minora extend to approach the midline as low ridges of tissue that join to form the fourchette. The labia minora dimensions vary greatly among individuals, with lengths from 2 to 10 cm and widths from 1 to 5 cm (Lloyd, 2005). Structurally, the labia minora are composed of connective tissue with numerous vessels, elastin fibers, and very few smooth muscle fibers. They are supplied with many nerve endings and are extremely sensitive (Ginger, 2011a; Schober, 2015). The epithelia of the labia minora di er with location. Thinly keratinized stratified squamous epithelium covers the outer surface of each labium. On their inner surface, the lateral portion is covered by this same epithelium up to a demarcating line, termed Hart line. Medial to this line, each labium is covered by squamous epithelium that is nonkeratinized. The labia minora lack hair follicles, eccrine glands, and apocrine glands. However, sebaceous glands are numerous (Wilkinson, 2011). The clitoris is the principal female erogenous organ. It is located beneath the prepuce, above the frenulum and urethra, and projects 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 (Verkauf, 1992). The glans is usually less than 0.5 cm in diameter, is covered by stratified squamous epithelium, and is richly innervated. The clitoral body contains two corpora cavernosa. Extending from the clitoral body, each corpus cavernosum diverges laterally to form a long, narrow crus. Each crus lies along the inferior surface of its respective ischiopubic ramus and deep to the ischiocavernosus muscle. The clitoral blood supply stems from branches of the internal pudendal artery. Specifically, the deep artery of the clitoris supplies the clitoral body, whereas the dorsal artery of the clitoris supplies the glans and prepuce. Vestibule In adult women, the vestibule is an almond-shaped area that is enclosed by Hart line laterally, the external surface of the hymen medially, the clitoral frenulum anteriorly, and the fourchette posteriorly (see Fig. 2-3). The vestibule is usually perforated by six openings: the urethra, the vagina, two Bartholin gland ducts, and 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 nulliparas. The bilateral Bartholin glands, also termed greater vestibular glands, measure 0.5 to 1 cm in diameter. On their respective side, each lies inferior to the vestibular bulb and deep to the inferior end of the bulbospongiosus muscle (former bulbocavernosus muscle). A duct extends medially from each gland, measures 1.5 to 2 cm long, and opens distal to the hymeneal ring—one at 5 and the other at 7 o’clock on the vestibule. Following trauma or infection, either duct may swell and obstruct to form a cyst or, if infected, an abscess. In contrast, the minor vestibular glands are shallow glands lined by simple mucin-secreting epithelium and open along Hart line. The paraurethral glands are a collective arborization of glands whose numerous small ducts open predominantly along the entire inferior aspect of the urethra. The two largest are called Skene glands, and their ducts typically lie distally and near the urethral meatus. Clinically, inflammation and duct obstruction of any of the paraurethral glands can lead to urethral diverticulum formation. The urethral opening or meatus is in the midline of the vestibule, 1 to 1.5 cm below the pubic arch, and a short distance above the vaginal opening. Vagina and Hymen In adult women, the hymen is a membrane of varying thickness that surrounds the vaginal opening more or less completely. It is composed mainly of elastic and collagenous connective tissue, and both outer and inner surfaces are covered by nonkeratinized stratified squamous epithelium. The aperture of the intact hymen ranges in diameter from pinpoint to one that admits one or even two fingertips. As a rule, the hymen is torn at several sites during first coitus. However, identical tears may form by other penetration, for example, by tampons used during menstruation. The edges of the torn tissue soon reepithelialize. In pregnant women, the hymeneal epithelium is thick and rich in glycogen. Changes produced in the hymen by childbirth are usually readily recognizable. For example, over time, the hymen transforms into several nodules of various sizes, termed hymeneal or myrtiform caruncles. Proximal to the hymen, the vagina is a musculomembranous tube that extends to the uterus and is interposed lengthwise between the bladder and the rectum (Fig. 2-4). Anteriorly, the vagina is separated from the bladder and urethra by connective tissue—the vesicovaginal septum. Posteriorly, between the lower portion of the vagina and the rectum, similar tissues together form the rectovaginal septum. The upper fourth of the vagina is separated from the rectum by the rectouterine pouch, also called the cul-de-sac or pouch of Douglas. FIGURE 2-4 Vagina and surrounding anatomy. (Reproduced with permission from Corton MM: Anatomy. In Ho man BL, Schorge JO, Bradshaw KD, et al (eds): Williams Gynecology, 3rd ed. New York, McGraw-Hill Education, 2016.) mebooksfree.com 6/32 4/11/2018 Normally, the anterior and posterior walls of the vaginal lumen lie in contact, with only a slight space intervening at the lateral margins. Vaginal length varies considerably, but commonly, the anterior wall measures 6 to 8 cm, whereas the posterior vaginal wall is 7 to 10 cm. The upper end of the vaginal vault is subdivided by the cervix into anterior, posterior, and two lateral fornices. Clinically, the internal pelvic organs usually can be palpated through the thin walls of these fornices. The vaginal lining is composed of nonkeratinized stratified squamous epithelium and underlying lamina propria. In premenopausal women, this lining is thrown into numerous thin transverse ridges, known as rugae, which line the anterior and posterior vaginal walls along their length. Deep to this, a muscular layer contains smooth muscle, collagen, and elastin. Beneath this muscularis lies an adventitial layer consisting of collagen and elastin (Weber, 1997). The vagina lacks glands. Instead, it is lubricated by a transudate that originates from the vaginal subepithelial capillary plexus and crosses the permeable epithelium (Kim, 2011). Due to increased vascularity during pregnancy, vaginal secretions are notably increased. At times, this may be confused with amnionic fluid leakage, and clinical di erentiation of these two is described in Chapter 22 (Identification of Labor). mebooksfree.com 7/32 4/11/2018 A er birth-related epithelial trauma and healing, fragments of stratified epithelium occasionally are embedded beneath the vaginal surface. Similar to its native tissue, this buried epithelium continues to shed degenerated cells and keratin. As a result, epidermal inclusion cysts, which are filled with keratin debris, may form. These are a common vaginal cyst. The vagina has an abundant vascular supply. The proximal portion is supplied by the cervical branch of the uterine artery and by the vaginal artery. The latter may variably arise from the uterine or inferior vesical artery or directly from the internal iliac artery. The middle rectal artery contributes supply to the posterior vaginal wall, whereas the distal walls receive contributions from the internal pudendal artery. At each level, vessels supplying each side of the vagina course medially across the anterior or posterior vaginal wall and form midline anastomoses. An extensive venous plexus also surrounds the vagina and follows the course of the arteries. Lymphatics from the lower third, along with those of the vulva, drain primarily into the inguinal lymph nodes. Those from the middle third drain into the internal iliac nodes, and those from the upper third drain into the external, internal, and common iliac nodes. Perineum This diamond-shaped area between the thighs has boundaries that mirror those of the bony pelvic outlet: the pubic symphysis anteriorly, ischiopubic rami and ischial tuberosities anterolaterally, sacrotuberous ligaments posterolaterally, and coccyx posteriorly. An arbitrary line joining the ischial tuberosities divides the perineum into an anterior triangle, also called the urogenital triangle, and a posterior triangle, termed the anal triangle. The perineal body is a fibromuscular pyramidal mass found in the midline at the junction between these anterior and posterior triangles (Fig. 2-5). Also called the central tendon of the perineum, the perineal body sonographically measures 8 mm tall and 14 mm wide and thick (Santoro, 2016). It serves as the junction for several structures and provides significant perineal support (Shafik, 2007). Superficially, the bulbospongiosus, superficial transverse perineal, and external anal sphincter muscles converge on the perineal body. More deeply, the perineal membrane, portions of the pubococcygeus muscle, and internal anal sphincter contribute (Larson, 2010). The perineal body is incised by an episiotomy incision and is torn with second-, third-, and fourth-degree lacerations. FIGURE 2-5 Superficial space of the anterior perineal triangle and posterior perineal triangle. Structures on the le side of the image can be seen a er removal of Colles fascia. Those on the right side are noted a er removal of the superficial muscles of the anterior triangle. (Modified with permission from Corton MM: Anatomy. In Ho man BL, Schorge JO, Bradshaw KD, et al (eds): Williams Gynecology, 3rd ed. New York, McGraw-Hill Education, 2016.) mebooksfree.com 8/32 4/11/2018 Superficial Space of the Anterior Triangle This triangle is bounded by the pubic rami superiorly, the ischial tuberosities laterally, and the superficial transverse perineal muscles posteriorly. It is divided into superficial and deep spaces by the perineal membrane. This membranous partition is a dense fibrous sheet that was previously known as the inferior fascia of the urogenital diaphragm. The perineal membrane attaches laterally to the ischiopubic rami, medially to the distal third of the urethra and vagina, posteriorly to the perineal body, and anteriorly to the arcuate ligament of the pubis (see Fig. 2-5). The superficial space of the anterior triangle is bounded deeply by the perineal membrane and superficially by Colles fascia. As noted earlier, Colles fascia is the continuation of Scarpa fascia onto the perineum. On the perineum, Colles fascia securely attaches laterally to the pubic rami and fascia lata of the thigh, inferiorly to the superficial transverse perineal muscle and inferior border of the perineal membrane, and medially to the urethra, clitoris, and vagina. As such, the superficial space of the anterior triangle is a relatively closed compartment. This superficial pouch contains several important structures, which include the Bartholin glands, vestibular bulbs, clitoral body and crura, branches of the pudendal vessels and nerve, and the ischiocavernosus, bulbospongiosus, and superficial transverse perineal muscles. Of these muscles, the ischiocavernosus muscles each attach on their respective side to the medial aspect of the ischial tuberosity inferiorly and the ischiopubic ramus laterally. Anteriorly, each attaches to a clitoral crus and may help maintain clitoral erection by compressing the crus to obstruct venous drainage. The bilateral bulbospongiosus muscles overlie the vestibular bulbs and Bartholin glands. They attach to the body of the clitoris anteriorly and the perineal body posteriorly. The muscles constrict the vaginal lumen and aid release of secretions from the Bartholin glands. They also may contribute to clitoral erection by compressing the deep dorsal vein of the clitoris. The bulbospongiosus and ischiocavernosus muscles also pull the clitoris downward. Last, the superficial transverse perineal muscles are narrow strips that attach to the ischial tuberosities laterally and the perineal body medially. They may be attenuated or even absent, but when present, they contribute to the perineal body (Corton, 2016). mebooksfree.com 9/32 4/11/2018 The vestibular bulbs are almond-shaped aggregations of veins that lie beneath the bulbospongiosus muscle on either side of the vestibule. They measure 3 to 4 cm long, 1 to 2 cm wide, and 0.5 to 1 cm thick. The bulbs terminate inferiorly at approximately the middle of the vaginal opening and extend upward toward the clitoris. Their anterior extensions merge in the midline, below the clitoral body. During childbirth, veins in the vestibular bulbs may be lacerated or even rupture to create a vulvar hematoma enclosed within the superficial space of the anterior triangle (Fig. 41-11). Deep Space of the Anterior Triangle This space lies deep to the perineal membrane and extends up into the pelvis (Mirilas, 2004). In contrast to the superficial perineal space, the deep space is continuous superiorly with the pelvic cavity (Corton, 2005). It contains portions of urethra and vagina, certain portions of internal pudendal artery branches, and muscles of the striated urogenital sphincter complex (Fig. 2-6). FIGURE 2-6 Deep space of anterior triangle of the perineum. Structures on the right side of the image can be seen a er removal of the perineal membrane. Also shown are structures that attach to the perineal body: bulbospongiosus, superficial transverse perineal, external anal sphincter, and puboperinealis muscles as well as perineal membrane. (Reproduced with permission from Corton MM: Anatomy. In Ho man BL, Schorge JO, Bradshaw KD, et al (eds): Williams Gynecology, 3rd ed. New York, McGraw-Hill Education, 2016.) Urethra The female urethra measures 3 to 4 cm and originates within the bladder trigone (Ovaries). The distal two thirds of the urethra are fused with the anterior vaginal wall. The epithelial lining of the urethra changes from transitional epithelium proximally to nonkeratinized stratified squamous epithelium distally. The walls of the urethra consist of two layers of smooth muscle, an inner longitudinal and an outer circular. This is in turn surrounded by a circular layer of skeletal muscle referred to mebooksfree.com 10/32 4/11/2018 as the sphincter urethrae or rhabdosphincter (see Fig. 2-6). Approximately at the junction of the middle and lower third of the urethra, and just above or deep to the perineal membrane, two strap skeletal muscles called the urethrovaginal sphincter and compressor urethrae are found. Together with the sphincter urethrae, these constitute the striated urogenital sphincter complex. This complex supplies constant tonus and provides emergency reflex contraction to sustain continence. Distal to the level of the perineal membrane, the walls of the urethra consist of fibrous tissue, serving as the nozzle that directs the urine stream. Here, the urethra has a prominent submucosal layer that is lined by hormonally sensitive stratified squamous epithelium. Within the submucosal layer on the dorsal (vaginal) surface of the urethra lie the paraurethral glands, described earlier (Vagina and Hymen). The urethra receives its blood supply from branches of the inferior vesical, vaginal, or internal pudendal arteries. Although still controversial, the pudendal nerve is believed to innervate the most distal part of the striated urogenital sphincter complex. Somatic e erent branches from S2–S4 that course along the inferior hypogastric plexus variably innervate the sphincter urethrae. Pelvic Diaphragm Found deep to the anterior and posterior triangles, this broad muscular sling provides substantial support to the pelvic viscera. The pelvic diaphragm is composed of the levator ani and the coccygeus muscles. The levator ani, in turn, contains the pubococcygeus, puborectalis, and iliococcygeus muscles. The pubococcygeus muscle is also termed the pubovisceral muscle and is subdivided based on points of insertion and function. These include the pubovaginalis, puboperinealis, and puboanalis muscles, which insert into the vagina, perineal body, and anus, respectively (Kearney, 2004). Vaginal birth conveys significant risk for damage to the levator ani or to its innervation (DeLancey, 2003; Weidner, 2006). Evidence supports that levator ani avulsion may predispose women to greater risk of pelvic organ prolapse (Dietz, 2008; Schwertner-Tiepelmann, 2012). For this reason, current research e orts are aimed at minimizing these injuries. Posterior Triangle This triangle contains the ischioanal fossae, anal canal, and anal sphincter complex, which consists of the internal anal sphincter, external anal sphincter, and puborectalis muscle. Branches of the pudendal nerve and internal pudendal vessels are also found within this triangle. Ischioanal Fossae Also known as ischiorectal fossae, these two fat-filled wedge-shaped spaces are found on either side of the anal canal and comprise the bulk of the posterior triangle (Fig. 2-7). Each fossa has skin as its superficial base, whereas its deep apex is formed by the junction of the levator ani and obturator internus muscles. Other borders include: laterally, the obturator internus muscle fascia and ischial tuberosity; inferomedially, the anal canal and sphincter complex; superomedially, the inferior fascia of the downwardly sloping levator ani; posteriorly, the gluteus maximus muscle and sacrotuberous ligament; and anteriorly, the inferior border of the anterior triangle. FIGURE 2-7 Anal canal and ischioanal fossa. (Reproduced with permission from Corton MM: Anatomy. In Ho man BL, Schorge JO, Bradshaw KD, et al (eds): Williams Gynecology, 3rd ed. New York, McGraw-Hill Education, 2016.) mebooksfree.com 11/32 4/11/2018 The fat found within each fossa provides support to surrounding organs yet allows rectal distention during defecation and vaginal stretching during delivery. Clinically, injury to vessels in the posterior triangle can lead to hematoma formation in the ischioanal fossa, and the potential for large accumulation in these easily distensible spaces. Moreover, the two fossae communicate dorsally, behind the anal canal. This can be especially important because an episiotomy infection or hematoma may extend from one fossa into the other. Anal Canal This distal continuation of the rectum begins at the level of levator ani attachment to the rectum and ends at the anal skin. Along this 4- to 5-cm length, the mucosa consists of columnar epithelium in the uppermost portion. However, at the pectinate line, also termed dentate line, simple stratified squamous epithelium begins and continues to the anal verge. At the verge, keratin and skin adnexa join the squamous epithelium. The anal canal has several tissue layers (see Fig. 2-7). Inner layers include the anal mucosa, the internal anal sphincter, and an intersphincteric space that contains continuation of the rectum’s longitudinal smooth muscle layer. An outer layer contains the puborectalis muscle as its cephalad component and the external anal sphincter caudally. Within the anal canal, three highly vascularized submucosal arteriovenous plexuses, termed anal cushions, aid complete closure of the canal and fecal continence when apposed. Increasing uterine size, excessive straining, and hard stool create increased pressure that ultimately leads to degeneration and subsequent laxity of the cushion’s supportive connective tissue base. These cushions then protrude into and downward through the anal canal. This leads to venous engorgement within the cushions—now termed hemorrhoids. Venous stasis results in inflammation, erosion of the cushion’s epithelium, and then bleeding. mebooksfree.com 12/32 4/11/2018 External hemorrhoids are those that arise distal to the pectinate line. They are covered by stratified squamous epithelium and receive sensory innervation from the inferior rectal nerve. Accordingly, pain and a palpable mass are typical complaints. Following resolution, a hemorrhoidal tag may remain and is composed of redundant anal skin and fibrotic tissue. In contrast, internal hemorrhoids are those that form above the pectinate line and are covered by insensitive anorectal mucosa. These may prolapse or bleed but rarely become painful unless they undergo thrombosis or necrosis. Anal Sphincter Complex Two sphincters surround the anal canal to provide fecal continence—the external and internal anal sphincters. Both lie near the vagina and may be torn during vaginal delivery. The internal anal sphincter (IAS) is a distal continuation of the rectal circular smooth muscle layer. It receives predominantly parasympathetic fibers, which pass through the pelvic splanchnic nerves. Along its length, this sphincter is supplied by the superior, middle, and inferior rectal arteries. The IAS contributes the bulk of anal canal resting pressure for fecal continence and relaxes prior to defecation. The IAS measures 3 to 4 cm in length, and at its distal margin, it overlaps the external sphincter for 1 to 2 cm (DeLancey, 1997). The distal site at which this overlap ends, called the intersphincteric groove, is palpable on digital examination. In contrast, the external anal sphincter (EAS) is a striated muscle ring that anteriorly attaches to the perineal body and posteriorly connects to the coccyx via the anococcygeal ligament. The EAS maintains a constant resting contraction to aid continence, provides additional squeeze pressure when continence is threatened, yet relaxes for defecation. The external sphincter receives blood supply from the inferior rectal artery, which is a branch of the internal pudendal artery. Somatic motor fibers from the inferior rectal branch of the pudendal nerve supply innervation. Clinically, the IAS and EAS may be involved in third- and fourth-degree lacerations during vaginal delivery, and reunion of these rings is integral to defect repair (Chap. 27, Laceration and Episiotomy Repairs). Pudendal Nerve This is formed from the anterior rami of S2–4 spinal nerves. It courses between the piriformis and coccygeus muscles and exits through the greater sciatic foramen at a location posterior to the sacrospinous ligament and just medial to the ischial spine (Barber, 2002; Maldonado, 2015). Thus, when injecting local anesthetic for a pudendal nerve block, the ischial spine serves an identifiable landmark (Chap. 25, Central Nervous System Toxicity). The pudendal nerve then runs beneath the sacrospinous ligament and above the sacrotuberous ligament as it reenters the lesser sciatic foramen to course along the obturator internus muscle. Atop this muscle, the nerve lies within the pudendal canal, also known as Alcock canal, which is formed by splitting of the obturator internus investing fascia (Shafik, 1999). In general, the pudendal nerve is relatively fixed as it courses behind the sacrospinous ligament and within the pudendal canal. Accordingly, it may be at risk of stretch injury during downward displacement of the pelvic floor during childbirth (Lien, 2005). The pudendal nerve leaves this canal to enter the perineum and divides into three terminal branches (Fig. 2-8). The first of these, the dorsal nerve of the clitoris, runs between the ischiocavernosus muscle and perineal membrane to supply the clitoral glans (Ginger, 2011b). Second, the perineal nerve runs superficial to the perineal membrane (Montoya, 2011). It divides into posterior labial branches and muscular branches, which serve the labial skin and the anterior perineal triangle muscles, respectively. Last, the inferior rectal branch runs through the ischioanal fossa to supply the external anal sphincter, the anal mucosa, and the perianal skin (Mahakkanukrauh, 2005). The major blood supply to the perineum is via the internal pudendal artery, and its branches mirror the divisions of the pudendal nerve. FIGURE 2-8 Pudendal nerve and vessels. (Reproduced with permission from Corton MM: Anatomy. In Ho man BL, Schorge JO, Bradshaw KD, et al (eds): Williams Gynecology, 3rd ed. New York, McGraw-Hill Education, 2016.) mebooksfree.com 13/32 4/11/2018 INTERNAL GENERATIVE ORGANS Uterus The nonpregnant uterus lies in the pelvic cavity between the bladder anteriorly and the rectum posteriorly. Almost the entire posterior wall of the uterus is covered by serosa, that is, visceral peritoneum (Fig. 2-9). The lower portion of this peritoneum forms the anterior boundary of the rectouterine cul-de-sac, or pouch of Douglas. Only the upper portion of the anterior uterine wall is covered by visceral peritoneum. At the caudal border of this portion, the peritoneum reflects forward onto the bladder dome to create the vesicouterine pouch. As a result, the lower portion of the anterior uterine wall is separated from the posterior wall of the bladder only by a well-defined loose connective tissue layer—the vesicouterine space. Clinically, during cesarean delivery, the peritoneum of the vesicouterine pouch is sharply incised, and the vesicouterine space is entered. Dissection caudally within this space li s the bladder safely o the lower uterine segment for hysterotomy and delivery (Chap. 30, Hysterotomy). mebooksfree.com 14/32 4/11/2018 FIGURE 2-9 Anterior (A), right lateral (B), and posterior (C) views of the uterus of an adult woman. a = oviduct; b = round ligament; c = ovarian ligament; Ur = ureter. The uterus is pear shaped and consists of two major but unequal parts. The upper, larger portion is the body or corpus, whereas the lower smaller cervix projects into the vagina. The isthmus is the union site of these two. It is of special obstetrical significance because it forms the lower uterine segment during pregnancy. At each superolateral margin of the body is a uterine cornu, from which a fallopian tube emerges. This area also contains the origins of the round and ovarian ligaments. Between the points of fallopian tube insertion is the convex upper uterine segment termed the fundus. The bulk of the uterine body, but not the cervix, is muscle. The inner surfaces of the anterior and posterior walls lie almost in contact, and the cavity between these walls forms a mere slit. The nulligravid uterus measures 6 to 8 cm in length compared with 9 to 10 cm in multiparas. The uterus averages 60 g and typically weighs more in parous women (Langlois, 1970; Sheikhazadi, 2010). Pregnancy stimulates remarkable uterine growth due to muscle fiber hypertrophy. The uterine fundus, a previously flattened convexity between tubal insertions, now becomes dome shaped. Moreover, the round ligaments appear to insert at the junction of the middle and upper thirds of the organ. The fallopian tubes elongate, but the ovaries grossly appear unchanged. Cervix This portion of the uterus is cylindrical and has small apertures at each end—the internal and external cervical ora. The endocervical canal runs through the cervix and connects these ora. The cervix is divided into upper and lower portions by the vagina’s attachment to its outer surface. The upper portion—the portio supravaginalis—begins at the internal os, which corresponds to the level at which the peritoneum is reflected up onto the bladder (Fig. 2-10). The lower cervical portion protrudes into the vagina as the portio vaginalis. FIGURE 2-10 Uterus, adnexa, and associated anatomy. (Reproduced with permission from Corton MM: Anatomy. In Ho man BL, Schorge JO, Bradshaw KD, et al (eds): Williams Gynecology, 3rd ed. New York, McGraw-Hill Education, 2016.) mebooksfree.com 15/32 4/11/2018 Before childbirth, the external cervical os is a small, regular, oval opening. A er labor, especially vaginal childbirth, the orifice is converted into a transverse slit that is divided such that there are the so-called anterior and posterior cervical lips. If torn deeply during labor or delivery, the cervix may heal in such a manner that it appears irregular, nodular, or stellate (Fig. 36-1). The cervical surface that radially surrounds the external os is called the ectocervix and is lined predominantly by nonkeratinized stratified squamous epithelium. In contrast, the endocervical canal is covered by a single layer of mucin-secreting columnar epithelium, which creates deep cle like infoldings or “glands.” Commonly during pregnancy, the endocervical epithelium moves out and onto the ectocervix in a physiological process termed eversion (Chap. 4, Cervix). mebooksfree.com 16/32 4/11/2018 The cervical stroma is composed mainly of collagen, elastin, and proteoglycans, but very little smooth muscle. As described in Chapter 21 (Cervical Ripening), changes in the amount, composition, and orientation of these components lead to cervical ripening prior to labor onset. In early pregnancy, increased vascularity within the cervix stroma beneath the epithelium creates an ectocervical blue tint that is characteristic of Chadwick sign. Cervical edema leads to so ening—Goodell sign, whereas isthmic so ening is Hegar sign. Myometrium and Endometrium Most of the uterus is composed of myometrium, which contains smooth muscle bundles united by connective tissue with many elastic fibers. Interlacing myometrial fibers surround myometrial vessels and contract to compress these. This anatomy allows hemostasis at the placental site during the third stage of labor. The number of myometrial muscle fibers varies by location (Schwalm, 1966). Levels progressively diminish caudally such that, in the cervix, muscle makes up only 10 percent of the tissue mass. The uterine body’s inner wall has relatively more muscle than its outer layers. And, in the anterior and posterior walls, the muscle content is greater than in the lateral walls. During pregnancy, the upper myometrium undergoes marked hypertrophy, but cervical muscle content does not change significantly. The uterine cavity is lined with endometrium, which is composed of an overlying epithelium, invaginating glands, and a supportive, vascular stroma. As discussed in Chapter 5 (Estrogen and Progesterone Action), the endometrium varies greatly throughout the menstrual cycle. This layer is divided into a functionalis layer, which is sloughed with menses, and a basalis layer, which serves to regenerate the functionalis layer following each menses. During pregnancy, the endometrium is termed decidua and undergoes dramatic hormonally driven alterations. Ligaments Several ligaments extend from the uterine surface toward the pelvic sidewalls and include the round, broad, cardinal, and uterosacral ligaments (Figs. 2-10 and 2-11). Despite their appellation, the round and broad ligaments provide no substantial uterine support, which contrasts with the cardinal and uterosacral ligaments. FIGURE 2-11 Pelvic viscera and their connective tissue support. (Reproduced with permission from Corton MM: Anatomy. In Ho man BL, Schorge JO, Bradshaw KD, et al (eds): Williams Gynecology, 3rd ed. New York, McGraw-Hill Education, 2016.) mebooksfree.com 17/32 4/11/2018 The round ligament originates somewhat below and anterior to the origin of the fallopian tubes. Clinically, this orientation can aid fallopian tube identification during puerperal sterilization. This is important if pelvic adhesions limit tubal mobility and thus, hinder fimbria visualization and tubal confirmation prior to ligation. Each round ligament extends laterally and down into the inguinal canal, through which it passes, to terminate in the upper portion of the ipsilateral labium majus. Sampson artery, a branch of the uterine artery, runs within this ligament. In nonpregnant women, the round ligament varies from 3 to 5 mm in diameter and is mebooksfree.com 18/32 4/11/2018 composed of smooth muscle bundles separated by fibrous tissue septa (Mahran, 1965). During pregnancy, these ligaments undergo considerable hypertrophy and increase appreciably in both length and diameter. The broad ligaments are two winglike structures that extend from the lateral uterine margins to the pelvic sidewalls. Each broad ligament consists of a double-layer drape of peritoneum. The anterior and posterior layers of this drape are termed the anterior and posterior leaves, respectively. In forming the broad ligament, this peritoneum folds over structures extending from each cornu. Peritoneum that folds over the fallopian tube is termed the mesosalpinx, that around the round ligament is the mesoteres, and that over the ovarian ligament is the mesovarium. Peritoneum that extends beneath the fimbriated end of the fallopian tube toward the pelvic wall forms the suspensory ligament or the infundibulopelvic ligament of the ovary. This contains nerves and the ovarian vessels, and during pregnancy, these vessels, especially the venous plexuses, are dramatically enlarged. Specifically, the diameter of the ovarian vascular pedicle increases from 0.9 cm to reach 2.6 cm at term (Hodgkinson, 1953). The cardinal ligament—also called the transverse cervical ligament or Mackenrodt ligament—anchors medially to the uterus and upper vagina. The cardinal ligament is the thick base of the broad ligament. As such, during cesarean hysterectomy, sturdy clamps and suture are required for its transection and ligation. Each uterosacral ligament originates with a posterolateral attachment to the supravaginal portion of the cervix and inserts into the fascia over the sacrum, with some variations (Ramanah, 2012; Umek, 2004). These ligaments are composed of connective tissue, small bundles of vessels and nerves, and some smooth muscle. Covered by peritoneum, these ligaments form the lateral boundaries of the pouch of Douglas. The term parametrium is used to describe the connective tissues adjacent and lateral to the uterus within the broad ligament. Paracervical tissues are those adjacent to the cervix, whereas paracolpium is that tissue lateral to the vaginal walls. Pelvic Blood Supply During pregnancy, there is marked hypertrophy of the uterine vasculature, which is supplied principally from the uterine and ovarian arteries (see Fig. 2-10). The uterine artery, a main branch of the internal iliac artery—previously called the hypogastric artery—enters the base of the broad ligament. The uterine artery courses medially to the lateral side of the uterus. Approximately 2 cm lateral to the cervix, the uterine artery crosses over the ureter. This proximity is of great surgical significance, as the ureter may be injured or ligated during hysterectomy when the uterine vessels are clamped and ligated. Once the uterine artery has reached the supravaginal portion of the cervix, it divides. The smaller cervicovaginal artery supplies blood to the lower cervix and upper vagina. The main uterine artery branch turns abruptly upward and travels cephalad along the lateral margin of the uterus. Along its path, this main artery provides a branch of considerable size to the upper cervix and then numerous other medial branches serially penetrate the body of the uterus to form the arcuate arteries. As indicated by the name, each branch arches across the organ by coursing within the myometrium just beneath the serosal surface. Arcuate vessels from each side anastomose at the uterine midline. Radial artery branches originate at right angles from the arcuate arteries and travel inward through the myometrium, enter the endometrium/decidua, and branch there to become either basal arteries or coiled spiral arteries. The spiral arteries supply the functionalis layer. Also called the straight arteries, the basal arteries extend only into the basalis layer. As the uterine artery courses cephalad, it gives rise to Sampson artery of the round ligament. Just before the main uterine artery vessel reaches the fallopian tube, it divides into three terminal branches. The ovarian branch of the uterine artery forms an anastomosis with the terminal branch of the ovarian artery; the tubal branch makes its way through the mesosalpinx and supplies part of the fallopian tube; and the fundal branch penetrates the uppermost uterus. In addition to the uterine artery, the uterus receives blood supply from the ovarian artery (see Fig. 2-10). This artery is a direct branch of the aorta and enters the broad ligament through the infundibulopelvic ligament. At the ovarian hilum, it divides into smaller branches that enter the ovary. As the ovarian artery runs along the hilum, it also sends several branches through the mesosalpinx to supply the fallopian tubes. Its main stem, however, traverses the entire length of the broad ligament toward the uterine cornu. Here, it forms an anastomosis with the ovarian branch of the uterine artery. This dual uterine blood supply creates a vascular reserve to prevent uterine ischemia if ligation of the uterine or internal iliac artery is performed to control postpartum hemorrhage. Uterine veins accompany their respective arteries. As such, the arcuate veins unite to form the uterine vein, which empties into the internal iliac vein and then the common iliac vein. Some of the blood from the upper uterus, the ovary, and the upper part of the broad ligament is collected by several veins. Within the broad ligament, these veins form the large pampiniform plexus that terminates in the ovarian vein. From here, the right ovarian vein empties into the vena cava, whereas the le ovarian vein empties into the le renal vein. Blood supply to the pelvis is predominantly provided by branches of the internal iliac artery (Fig. 2-12). These branches are organized into anterior and posterior divisions, and subsequent branches are highly variable between individuals. The anterior division provides blood supply to the pelvic organs and perineum and includes the inferior gluteal, internal pudendal, middle rectal, vaginal, uterine, and obturator arteries, as well as the umbilical artery and its continuation as the superior vesical artery. The posterior division branches extend to the buttock and thigh and include the superior gluteal, lateral sacral, and iliolumbar arteries. For this reason, during internal iliac artery ligation, many advocate ligation distal to the posterior division to avoid compromised blood flow to the areas supplied by this division (Bleich, 2007). FIGURE 2-12 Pelvic arteries. (Reproduced with permission from Corton MM: Anatomy. In Ho man BL, Schorge JO, Bradshaw KD, et al (eds): Williams Gynecology, 3rd ed. New York, McGraw-Hill Education, 2016.) mebooksfree.com 19/32 4/11/2018 Pelvic Lymphatics mebooksfree.com 20/32 4/11/2018 The lymphatics from the uterine corpus are distributed to two groups of nodes. One set of vessels drains into the internal iliac nodes. The other set, a er joining lymphatics from the ovarian region, terminates in the paraaortic lymph nodes. Lymphatics from the cervix terminate mainly in the internal iliac nodes, which are situated near the bifurcation of the common iliac vessels. Pelvic Innervation As a brief review, the peripheral nervous system is divided into a somatic division, which innervates skeletal muscle, and an autonomic division, which innervates smooth muscle, cardiac muscle, and glands. Pelvic visceral innervation is predominantly autonomic, which is further divided into sympathetic and parasympathetic components. Sympathetic innervation to pelvic viscera begins with the superior hypogastric plexus, also termed the presacral nerve (Fig. 2-13). Beginning below the aortic bifurcation and extending downward retroperitoneally, this plexus is formed by sympathetic fibers arising from spinal levels T10 through L2. At the level of the sacral promontory, this superior hypogastric plexus divides into a right and a le hypogastric nerve, which run downward along the pelvis sidewalls (Ripperda, 2015). FIGURE 2-13 Pelvic innervation. (Reproduced with permission from Corton MM: Anatomy. In Ho man BL, Schorge JO, Bradshaw KD, et al (eds): Williams Gynecology, 3rd ed. New York, McGraw-Hill Education, 2016.) mebooksfree.com 21/32 4/11/2018 In contrast, parasympathetic innervation to the pelvic viscera derives from neurons at spinal levels S2 through S4. Their axons exit as part of the anterior rami of the spinal nerves for those levels. These combine on each side to form the pelvic splanchnic nerves, also termed nervi erigentes. mebooksfree.com 22/32 4/11/2018 Blending of the two hypogastric nerves (sympathetic) and the two pelvic splanchnic nerves (parasympathetic) gives rise to the inferior hypogastric plexus, also termed the pelvic plexus. This retroperitoneal plaque of nerves lies at the S4 and S5 level (Spackman, 2007). From here, fibers of this plexus accompany internal iliac artery branches to their respective pelvic viscera. Thus, the inferior hypogastric plexus divides into three plexuses. The vesical plexus innervates the bladder, and the middle rectal plexus travels to the rectum. The uterovaginal plexus, also termed Frankenhäuser plexus, reaches the proximal fallopian tubes, uterus, and upper vagina. Extensions of the inferior hypogastric plexus also reach the perineum along the vagina and urethra to innervate the clitoris and vestibular bulbs (Montoya, 2011). Of these, the uterovaginal plexus is composed of variably sized ganglia, but particularly of a large ganglionic plate that is situated on either side of the cervix, proximate to the uterosacral and cardinal ligaments (Ramanah, 2012). For the uterus, most of its a erent sensory fibers ascend through the inferior hypogastric plexus and enter the spinal cord via T10 through T12 and L1 spinal nerves. These transmit the painful stimuli of contractions to the central nervous system. For the cervix and upper part of the birth canal, sensory nerves pass through the pelvic splanchnic nerves to the second, third, and fourth sacral nerves. Last, those from the lower portion of the birth canal pass primarily through the pudendal nerve. Anesthetic blocks used during delivery target these levels of innervation. Ovaries Along the pelvic sidewall, each ovary usually rests in the ovarian fossa of Waldeyer, which is a slight depression between the external and internal iliac vessels. During childbearing years, ovaries variably measure 2.5 to 5 cm in length, 1.5 to 3 cm in width, and 0.6 to 1.5 cm in thickness. The ovarian ligament, also called the uteroovarian ligament, originates from the upper posterolateral portion of the uterus, just beneath the tubal insertion level, and extends to the uterine pole of the ovary (see Fig. 2-10). Measuring a few centimeters long and 3 to 4 mm in diameter, this ligament is made up of muscle and connective tissue and is covered by peritoneum—the mesovarium. Blood supply reaches the ovary through this double-layered mesovarium to enter the ovarian hilum. The ovary consists of an outer cortex and inner medulla. In young women, the cortex is smooth, has a dull white surface, and is lined by single layer of cuboidal epithelium, the germinal epithelium of Waldeyer. This epithelium is supported by a connective tissue condensation, the tunica albuginea. Beneath this, the ovarian cortex contains oocytes and developing follicles. The medulla is composed of loose connective tissue, numerous arteries and veins, and a small amount of smooth muscle fibers. The ovaries are supplied with both sympathetic and parasympathetic nerves. The sympathetic nerves are derived primarily from the ovarian plexus that accompanies the ovarian vessels and originates in the renal plexus. Others are derived from the plexus that surrounds the ovarian branch of the uterine artery. Parasympathetic input is from the vagus nerve. Sensory a erents follow the ovarian artery and enter at T10 spinal cord level. Fallopian Tubes Also called oviducts, these serpentine tubes extend laterally 8 to 14 cm from the uterine cornua. They are anatomically classified along their length as an interstitial portion, isthmus, ampulla, and infundibulum (Fig. 2-14). Most proximal, the interstitial portion is embodied within the uterine muscular wall. Next, the narrow 2- to 3-mm wide isthmus widens gradually into the 5- to 8-mm wide ampulla. Last, the infundibulum is the funnel-shaped fimbriated distal extremity of the tube, which opens into the abdominal cavity. These latter three extrauterine portions are covered by the mesosalpinx at the superior margin of the broad ligament. FIGURE 2-14 The fallopian tube of an adult woman with cross-sectioned illustrations of the gross structure in several portions: (A) isthmus, (B) ampulla, and (C) infundibulum. Below these are photographs of corresponding histological sections. (Used with permission from Dr. Kelley S. Carrick.) mebooksfree.com 23/32 4/11/2018 In cross section, the extrauterine fallopian tube contains a mesosalpinx, myosalpinx, and endosalpinx. The outer of these, the mesosalpinx, is a single-cell mesothelial layer functioning as visceral peritoneum. In the myosalpinx, smooth muscle is arranged in an inner circular and an outer longitudinal layer. The tubal musculature undergoes rhythmic contractions constantly, the rate of which varies with cyclical ovarian hormonal changes. The tubal mucosa or endosalpinx is a single layer of columnar epithelium composed of ciliated, secretory, and intercalary cells resting on a sparse lamina propria. Clinically, its close proximity to the underlying myosalpinx contributes to easy invasion by ectopic trophoblast. The tubal mucosa is arranged in longitudinal folds that become progressively more complex toward the fimbria. In the ampulla, the lumen is occupied almost completely by the arborescent mucosa. The current produced by the tuba