Uterus and Vagina

-Dr. A. U. Ugwu
• The uterus
• The uterus is a pear-shaped organ.
• It’s about 7.5 cm in length.
• Parts of Uterus;
• fundus, body and cervix.
• The body of the uterus narrows to a waist
termed the isthmus, continuing into the
cervix.
• The isthmus is 1.5 mm wide.
• The anatomical internal os marks junction of
the isthmus with the uterine body.
• The cavity of the uterine body is triangular in coronal
section.
• This cavity communicates via the internal os with the
cervical canal which, in turn, opens into the vagina by
the external os.
• In the other words, opening into the uterus is called the
internal os.
• While the opening into the vagina is called the external
os.
• The nulliparous external os is circular but after
childbirth it becomes a transverse slit with an anterior
and a posterior lip.
• The non-pregnant cervix has the firm consistency of the
nose.
• While the pregnant cervix has the soft consistency of
the lips.
• In fetal life the cervix is considerably larger than the
body.
• In childhood (the infantile uterus), the cervix is still
twice the size of the body.
• During puberty, the uterus enlarges to its adult size and
proportion.
• Positions of the Uterus
• Anteflexion- when the adult uterus is bent forward on
itself at about the level of the internal os to form an
angle of 170°.
• Anteversion -The axis of the cervix forms an
angle of 90° with the axis of the vagina.
• The uterus thus lies in an almost horizontal
plane.
• In retroversion of the uterus, the axis of the
cervix is directed upwards and backwards.
• Normally on vaginal examination the
lowermost part of the cervix to be felt is its
anterior lip; in retroversion either the external
os or the posterior lip becomes the presenting
part.
• In retroflexion, the axis of the body of the uterus
passes upwards and backwards in relation to the
axis of the cervix.
• Frequently these two conditions co-exist.
• They may be mobile and symptomless
• Mobile retroversion is found in a quarter of the
female population and may be regarded as a
normal variant.
• Less commonly, they are fixed – this can result;
adhesions, previous pelvic infection,
endometriosis or the pressure of a tumour in
front of the uterus.
• Relations
• Anteriorly—
• The body is related to the uterovesical pouch
of peritoneum.
• The supravaginal cervix is related directly to
bladder.
• The infravaginal cervix has the anterior fornix
immediately in front of it.
• Posteriorly—lies the rectouterine pouch of
Douglas, with coils of intestine within it.
• Laterally—the broad ligament and its contents.
• The ureter lies 12 mm lateral to the supravaginal cervix.
• Contents of broad ligaments;
• -Fallopian tubes
• -Ovaries
• -Ovarian arteries
• -Uterine arteries
• -Round Ligaments
• -Suspensory (infundibulopelvic) Ligament
• -Ovarian Ligaments.
• Broad ligaments is a double-layered peritoneum that attaches
the lateral side of the uterus to the lateral pelvic sidewalls.
• Made up of 3 parts; Mesometrium, Mesosalpinx, and
Mesovarium.
• Structure
• The body of the uterus is covered with peritoneum except
at two sites;
• - anteriorly on to the bladder at the uterine isthmus, and
• - laterally at the broad ligaments.
• Anteriorly, the peritoneum is only loosely adherent to the
supravaginal cervix; this allows for bladder distension.
• The muscle wall
• This is called myometrium
• The muscle is thick and made up of involuntary muscle
fibres.
• The mucosa of the body of the uterus is the endometrium.
 . Menstrual cycle may be briefly summarized thus:
• - First 4 days—desquamation of its superficial two-
thirds of the endometrium with bleeding;
• - Subsequent 2–3 days — rapid reconstitution of
the raw mucosal surface by growth from the
remaining epithelial cells in the depths of the
glands.
• - At the 14th day the endometrium has reformed;
this is the end of the proliferative phase
• - From the 14th day until the menstrual flow
commences is the secretory phase.
• Only very slight desquamation and bleeding takes
place in the mucosa of the cervical canal.
• Blood supply
• The uterine artery (from the internal iliac) runs
in the base of the broad ligament and crosses
above and at right angles to the ureter.
• Uterine artery reaches the uterus at the level of
the internal os.
• The artery then ascends in a tortuous manner
alongside the uterus, supplying the corpus, and
then anastomoses with the ovarian artery.
• The uterine artery also gives off a descending
branch to the cervix and branches to the upper
vagina.
• The veins - accompany the arteries and drain
into the internal iliac veins.
• They also communicate via the pelvic plexus
with the veins of the vagina and bladder.
• Lymph drainage
• 1. The fundus - The lymphatucs from the
fundus drain alongside the ovarian vessels to
the aortic nodes.
• A few lymphatics pass along the round
ligament to the inguinal nodes.
• 2. The body drains to nodes lying alongside
the external iliac vessels.
• 3. The cervix drains in three directions—
• - laterally, to the external iliac nodes
• - Posterolaterally, to internal iliac nodes, and
• - posteriorly, to the sacral nodes.
• Clinical features
• The most important single practical
relationship in this region is that of the ureter
to the supravaginal cervix.
• At this point, the ureter lies just above the
level of the lateral fornix, below the uterine
vessels as these pass across within the broad
ligament .
• - In performing a hysterectomy, the ureter
may be accidentally divided in clamping the
uterine vessels,
• This is more common when the pelvic anatomy has
been distorted by a previous operation, a mass of
fibroids, infection or malignant infiltration.
• The ureter is readily infiltrated by lateral extension
of a carcinoma of the uterus; bilateral
hydronephrosis with uraemia is a frequent mode of
termination of this disease.
• - The close relationship of ureter to the lateral fornix
is best appreciated by realizing that a ureteric stone
at this site can be palpated on vaginal examination.
• -Uterine artery pulsation can also be palpated at
this site.
• -Uterine Prolapse-
• cuses: Pregnancy, childbirth,, Post menopausal
hormonal changes, obesity, sever coughing, &
straining on the toilet.
• - Endometriosis
• - Placenta previa
• - Cervical cancer
• Fibriod/Leiomyoma uteri
• Pelvic inflammatory disease(PID)
• The Fallopian/uterine tubes
• These are about 10 cm long.
• They open into the cornu of the uterus.
• Each comprises four parts.
• 1. The infundibulum — Its mouth is fimbriated and
overlies the ovary, to which one long fimbria actually
adheres (fimbria ovarica).
• 2. The ampulla—wide, thin-walled and tortuous.
• 3. The isthmus—narrow, straight and thick-walled.
• 4. The interstitial part—which pierces the uterine wall.
• Structure
• Apart from the interstitial part, the tube is clothed in
peritoneum.
• The ova are propelled to the uterus along this
tube, partly by peristalsis and partly by cilial
action.
• Clinical features
• 1. Note that the genital canal in the female is
the only direct communication into the
peritoneum from the exterior and is a
potential pathway for infection (for example,
in gonorrhoea).
• 2. Ectopic pregnancy - The fertilized ovum may
implant ectopically, i.e. in a site other than the
endometrium of the corpus uteri.
• When this occurs in the Fallopian tube it is called,
according to the exact site, fimbrial, ampullary,
isthmic or interstitial, of which the ampullary is the
commonest and interstitial the rarest.
• As the ectopic embryo enlarges, it may;
• 1. Abort into the peritoneal cavity (where rarely it
continues to grow as a secondary abdominal
pregnancy), or
• 2. Ruptures the tube.
• This second fate is particularly likely to occur
in the narrow and relatively non-distensible
isthmus;
• Rupture is usually into the peritoneal cavity
but may rarely occur into the broad ligament.
• The vagina
• The vagina is a musculomembranous tube.
• The vagina serves as a;
• - canal for menstrual fluid.
• - Forms the inferior part of the birth canal.
• - Receives the penis and ejaculate during
sexual intercourse.
• - Communicates superiorly with the cervical
canal, and inferiorly with the vestibule.
• The anterior vaginal wall is about 7.5 cm in
length, while the posterior is about 9 cm long.
• The upper part of vagina surrounds the cervix
of the uterus.
• The vagina passes downwards and forwards
through the pelvic floor to open into the
vestibule.
• The vagina has continuous gutter on its upper
part, called vagina fornix.
• For purpose of description, vagina fornix is
divided into the anterior, posterior and lateral
fornices.
• Hymen
• The hymen is a thin membrane that surrounds the opening to the vagina.
• Though hymens can range in shape and size, most are shaped like a half-
moon.
• This shape allows menstrual blood to leave the vagina.
• When someone first has intercourse or inserts something into the vagina,
the hymen may tear.
• This can also happen during vigorous exercise.
• Certain hymen shapes and types can interfere with menstrual flow,
wearing tampons, or having intercourse.
• These include:
• Imperforate hymen - completely covers the opening to the vagina,
blocking menstrual flow.
• Microperforate hymen - is a very thin membrane that almost completely
covers the vaginal opening.
• Septate hymen - this includes an extra band of tissue that creates two
openings. It’s treated with minor surgery.
• Relations
• Anteriorly — the base of the bladder and the
urethra.
• Posteriorly — from below upwards, the anal
canal, the rectum and then the peritoneum of
the pouch of Douglas which covers the upper
quarter of the posterior vaginal wall.
• Laterally— levator ani, pelvic fascia and the
ureters, which lie immediately above the
lateral fornices.
• Blood supply
• Arterial supply is from the internal iliac artery via its
vaginal, uterine, internal pudendal and middle rectal
branches.
• Vaginal vein drain into the internal iliac vein.
• Lymphatic drainage
• Upper third to the external and internal iliac nodes.
• Middle third to the internal iliac nodes.
• Lower third to the superficial inguinal nodes
• Nerve supply:
• The nerve supply of the upper vagina is provided by the
sympathetic and parasympathetic areas of the pelvic plexus.
• The lower vagina is supplied by the pudendal nerve.
• Clinicals
• 1. Distension Of Vagina
• In nulliparous women the vaginal wall is rugose, but it
becomes smoother after childbirth.
• The rugae of the anterior wall are situated transversely;
this allows for;
• - filling of the bladder.
• - accommodates the erect penis during intercourse.
• In contrast, the rugae on the posterior wall run
longitudinally;
• This allows for sideways stretching to;
• - accommodate a rectum distended with stool
• - the passage of the fetal head, and
• - palpation of sacral promontery durin pelvic examination.
• 3. Vaginal Fistulae
• Because of the close relationship of the vagina
to adjacent pelvic organs, obstetrical trauma
during long and difficult labor may result in
weaknesses, necrosis, or tears in the vaginal
wall and sometimes beyond.
• These may form or subsequently develop into
open communications (fistulas) between the
vaginal lumen and that of the adjacent
bladder, urethra, rectum, or perineum
• Vaginitis
• Vaginitis is an inflammation of the vagina resulting from an
infection.
• It can cause uncomfortable symptoms, such as:
• discharge
• itching
• burning sensation
• There are different types of vaginitis, depending on the cause.
• The most common types include:
• 1. Bacterial vaginosis (BV).
• 2. Yeast infection. A vaginal yeast infection happens when there’s
an overgrowth of a type of yeast called Candida albicans in the
vagina.
• 3. Trichomoniasis - is an STI caused by a parasite called
Trichomonas vaginalis.
• Vaginismus
• Vaginismus causes involuntary contractions of
the vaginal muscles. The muscle contractions
make penetration painful, if not impossible.
• STIs
• Common STIs include:
• chlamydia
• genital herpes
• gonorrhea
• genital warts
• Vaginal atrophy
• Vaginal atrophy causes the tissues of the
vagina to shrink and thin, which can narrow
the canal and reduce its elasticity. It’s more
common during menopause.
• Vaginal prolapse

• Vaginal cancer
• Two-thirds of vaginal cancers are caused by
the human papillomavirus (HPV).
THANK YOU