16 SECTION II • Anatomy

With the exception of the ovarian, superior hemorrhoidal, and
middle sacral arteries the hypogastric divisions of the common
iliac arteries supply the pelvic viscera. The uterine artery arises
from the anterior division of the hypogastric artery close to or
in common with the middle hemorrhoidal or vaginal artery. It
courses slightly forward and medialward on the superior fascia of
the levator ani muscle to the lower margin of the broad ligament.
It arches over the ureter approximately 2 cm from the uterus. At
the level of the isthmus, it gives off a descending cervical branch,
which surrounds the cervix and anastomoses with the branches
of the vaginal artery. The main uterine vessels follow a tortuous
course upward along the lateral margin of the uterus, giving off
spiral branches to the anterior and posterior surfaces of the uterus.
The uterine artery terminates in a tubal branch within the meso-
salpinx and an ovarian ramus, which anastomoses with the ovarian
artery in the mesovarium.

9 CERVIX, UTERUS, AND ADNEXA

The uterus is a pear-­shaped, thick-­walled, hollow, muscular organ
situated between the bladder and rectum. The fundus is the dome-­
shaped portion above the entrance level of the Fallopian tubes. The
body, or corpus, lies below this and is separated from the cervix by
a slight constriction, termed the isthmus. The cavity of the uterine
body is a flattened potential space that is triangular in shape. The
uterine tubes open into its basal angles in the fundus. The uterine
cavity is continuous with the cervical canal at the internal os. The
uterine wall is composed of an outer serosal layer (peritoneum); a
firm, thick, intermediate coat of smooth muscle (myometrium); and
an inner mucosal lining (endometrium).
The superior surface of the uterus is convex and generally
directed forward. The anterior surface is flat and looks downward
and forward, resting on the bladder. Its peritoneal covering is
reflected at the level of the isthmus to the upper aspect of the blad-
der, creating the vesicouterine pouch. The posterior surface of the
uterus is convex and lies in relation to the pelvic colon and rectum.
The peritoneum of the posterior wall covers the body and upper cer-
vix and then extends over the posterior fornix of the vagina to the
rectum to form the rectouterine pouch or cul-­de-­sac of Douglas.
Laterally the visceral peritoneum becomes the anterior and poste-
rior leaves of the broad ligament.
The cervix is cylindric, slightly expanded in its middle, and
approximately 2.5 cm in length. Its canal is spindle-­shaped and
opens into the vagina through the external os. On the anterior and
posterior walls, the endocervical mucosa is raised in a series of
palmate folds. The cervical wall is more fibrous than the corpus.
The oblique line of attachment of the vagina to the cervix divides
the latter into supra-­and infravaginal segments. Approximately
one-­third of the anterior surface and one-­half of the posterior
surface of the cervix constitute the vaginal portion. The cervix
is directed downward and backward to rest against the posterior
vaginal wall. Only the upper half of its posterior surface is covered
by the peritoneum. The external os of the cervix lies at about the
level of the upper border of the symphysis pubis in the plane of the
ischial spine.
The peritoneum covers the fundus and corpus uteri on both
its anterior and posterior aspects, reflecting at the cervicouterine
junction to cover the vesicouterine excavation in the front and the
rectouterine excavation (cul-­de-­sac, pouch of Douglas) in the back,
whence it spreads over the bladder and rectum, respectively. At its
lowest part the peritoneum covers the cardinal ligament, which
stretches laterally across the pelvic floor to the lateral pelvic walls.
The peritoneal layers that sheathe the fundus and uterine body
unite on both sides of the uterus to form the broad ligament, which
separates the vesicouterine and rectouterine pouches. The upper
borders of the broad ligaments are folds of the peritoneum coming
into existence when the anterior sheath turns to become the posterior
sheath. These folds enclose the Fallopian tubes. The broad ligaments
expand downward from the lower edges of the tubes, assuming the
function of a mesentery to the tubes, the mesosalpinx, in which the
vessels to and from the tube take their course. In the mesosalpinx are
also found the vestigial remnants of the mesonephric ducts.
The extreme lateral parts of the Fallopian tube—the fimbriated
infundibulum and ampulla—are not enclosed by the broad liga-
ment, but the latter forms in this region a band, the infundibulo-
pelvic ligament, which attaches the posterior surface of this end of
the tube to the lateral wall of the pelvis. Another peritoneal fold, the
suspensory ligament of the ovary, crosses the iliac vessels and runs
medially to the free ends of the tubes. It contains the ovarian vessels
and provides an attachment to the lateral pole of the ovary. This fold
is not to be confused with the ligament of the ovary, a cord within
the broad ligament, running from the lateral angle of the uterus just
below the uterine end of the tube downward to the lower or uter-
ine margin of the ovary. The ovary is not enwrapped by the broad
ligament. Only its lateral surface lies on the parietal pelvic perito-
neum, where the external iliac vessels, obliterated umbilical artery,
and ureter pattern a shallow depression called the ovarian fossa. The
anterior border of the ovary is attached to the posterior layer of the
broad ligament by a short fold through which the blood vessels pass
to reach the hilus of the ovary. For this reason, the fold has been
named the mesovarium.
 10 • Ovaries 17

Posterior view
Uterine (Fallopian) tube
Suspensory (infundibulopelvic) Mesosalpinx
ligament of ovary Isthmus Ampulla Infundibulum
Epoöphoron
Ligament of ovary

Vesicular appendix Fundus of uterus

(hydatid of Morgagni)
Fimbriae

Corpus luteum Abdominal

ostium
Ovary

Body of uterus Suspensory ligament of ovary

Ovary

Mesometrium (broad ligament) Mesovarium

Ureter
Ligament of ovary (uteroovarian)
Uterosacral ligament Rectouterine pouch (of Douglas)

Frontal section
Uterine (Fallopian) tube

la
pul
Am
Fundus of uterus
Tubal
ostium
Uterine Isthmus
Body of uterus part
Infun-
dibulum
Folds of
uterine tube
Fimbriae
Isthmus of uterus Ligament Suspensory ligament of ovary
of ovary (contains ovarian vessels)
Endometrium Vesicular appendix (hydatid of Morgagni)
Internal os Epoöphoron
Myometrium
Follicle (graafian)
Mesometrium
(broad ligament) Corpus albicans of ovary
Corpus luteum
Uterine vessels
Cervix of uterus
Cardinal (transverse cervical or Mackenrodt) ligament
Vaginal fornix
External os Cervical canal with palmate folds
Vagina
Fallopian tubes
Section I Section II Section III Intramural portion Isthmus
Ampulla

Fimbria
Isthmus Ampulla
Appendix vesiculosa
Figure 9.1 Uterus, ovaries, and uterine (Fallopian) tubes

OVARIES
The ovaries develop from a thickening of cells, which form ridges
medial to the Müllerian and Wolffian bodies, during the sixth week
of gestation. Primary oocytes, arising in the posterior wall of the
primitive gut, migrate into these embryonic gonads, providing the
countless thousands of ova that crowd the ovary at birth.
By the third month of gestation, the ovaries descend toward the
pelvis. The pull of the gubernaculum—an abdominal fold that grows
more slowly than the rest of the fetus—exerts a downward traction
10
on the gonadal ridges. Later, these folds fuse in their mid-­portion
with the part of each Müllerian duct that develops into the uter-
ine fundus. The lateral half and medial portion of the folds become
the round ligaments and the suspensory ligaments of the ovary,
respectively.
The infant ovary is a sausage-­ shaped structure, with a pale
and smooth surface. A gradual thickening and shortening occurs
throughout the first decade of life. The major gain in size and weight