APPLIED ANATOMY AND PHYSIOLOGY

FEMALE EXTERNAL GENITALIA

The external genital organs of the female are known collectively as the vulva and
included the following:

Mons pubis or mons veneris

 It is a pad of subcutaneous adipose connective tissue lying over the symphysis

pubis.
 It is covered with pubic hair from the time of puberty.

The labia majora (greater lips)

 These are two folds of fat and areola tissue, covered with skin and pubic hair
on the outer surface.
 The inner surfaces of the labia majora are hairless.
 The labia majora are covered with squamous epithelium and contain
sebaceous glands, sweat glands and hair follicles.
 The adipose tissue is richly supplied with venous plexus which may produce
hematoma, if injured during child birth.
 The labia majora arises from the mons veneris and merged into the perineum
behind.

The labia minora (lesser lip)

 These are two thin folds of skin lying between the labia majora.
 Anteriorly, they divide to enclose the clitoris, posterioly, they fuse, forming
the fourchette, it is usually lacerated during childbirth.
 The labia minora do not contain hair follicles.
 The folds contain connective tissue, numerous sabeceous glands, erectile
muscle fibres and numerous vessels and nerve endings.

The clitoris

 It is a small cylindrical, erectile body, measuring about 2.5cm, situated in the

most anterior part of the vulva.

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 It is a rudimentary organ corresponding to the male penis, but differs basically

in being entirely separate from the urethra.
 It is attached to the undersurface of the symphysis pubis by the suspensory
ligament.
 It is extremely sensitive and highly vascular and plays a role in the orgasm of
sexual intercourse.

The vestibule

It is a triangular space bounded anteriorly by the clitoris, posteriorly by the fourchette

and on either side by the labia minora. There are four openings into the vestibule.

i. The urethral opening: it is situated in the midline just in front of the

vaginal orifice, about 2.5cm posterior to the clitoris. The skene’s glands
open on either side of the urethral orifice.
ii. The vaginal orifice or introitus: it occupies the posterior 2/3 of the
vestibule and is of varying size and shape. In vergins and nulliparae, the
opening is closed by the labia minora, but in parous women, it may be
exposed. It is completely closed by a septum of mucus membrane, called
hymen which is usually ruptured at the consummation of marriage.
During child birth, it is extremely lacerated and is known as carunculae
mythiforms.
iii. Opening of batholins gland: there are two bartholins glands (greater
vestibular glands), one on each side. They open on either side of the
vaginal orifice and lie in the posterior part of the labia majora. They are
pear shaped and yellowish white in colour. During sexual excitement, it
secretes abundant alkaline mucous which helps in lubrication. Each gland
has aduct about 2cm and opens into the vestibule outside the hymen.

Blood supply: This comes from the internal and external pudendal arteries. The
blood drains through the corresponding veins

Lymphatic drainage: is into the inguinal and internal iliac lymph nodes.

Nerve supply: This is from the branches of pudendal nerve, anterior part is supplied
by the genitofemoral nerve and posterior inferior part by the pudendal branches from

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the posterior cutaneous nerve of the thigh. The vulva is supplied by the labial and
perineal branches of the pudendal nerve.

INTERNAL GENITAL ORGANS

The internal reproductive organs include: vagina, the uterus, two uterine tubes and
two ovaries. In the non-pregnant state, the internal reproductive organs are siuated
within the true pelvis

VAGINA

Vagina is a fibromusculo-membranous sheath connecting the uterine cavity with the

exterior at the vulva.

Function

 It is a passage, which allows the escape of menstrual flow and uterine

secretions.
 It receives the penis and the ejected sperm during sexual intercourse and
 Provides exit for the fetus during delivery.

The canal is directed upward and backward forming an angle of 45 degree. The
diameter of the canal is about 2.5cm being wider in the upper part and narrowest at
the introitus. It has enough power of distensibility as evident during child birth.

Vaginal walls

Vagina has an anterior, posterior and two lateral walls. The length of the anterior wall
is about 7cm and that of the posterior wall is about 10cm.

Relation:

i. Anterior: in front lies the bladder and urethra, which are closely connected
to the anterior vaginal wall.
ii. Posterior: the pouch of douglas, the rectum and the perineal body each
occupy approximately 1/3 of the vaginal wall.
iii.
iv. Lateral: beside the upper 2/3 aare the pelvic fascia and the ureters, while
beside the lower third are the muscles of the pelvic floor.

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v. Superior: above the vagina lies the uterus.

vi. Inferior: below the vagina lies the external genitalia.

Structures

 The posterior wall is 10cm long while the anterior is only 7cm because the
cervix projects at right angle into the upper part.
 The upper part of the vagina is known as the vault.
 Where the cervix projects into it, the vault forms a circular recess, which is
described as its four fornices.
 The posterior fornix is the largest of these because the vagina is attached to the
uterus at a higher level behind than in front.
 The anterior fornix lies in front of the cervix and the lateral fornices lie on
either side.
 The vaginal walls are pink in appearance and thrown into small folds known
as rugae.
 These allow the vaginal walls to stretch during intercourse and child birth.

Layers

 The lining of the vagina is made of squamous epithelium.

 Beneath the epithelium lies a layer of vascular connective tissue.
 The muscle layer has a weak inner coat of circular fiber and a stronger outer
coat of longitudinal fibers.
 Pelvic fascia surrounds the vagina, forming a layer of connective tissue.

Content

 There are no glands in the vagina.

 It is moistened by mucus from the cervix and the transudate, which seeps out
from the blood vessels of the vaginal wall.
 The vaginal fluid is strongly acidic (PH 4.5) due to the presence of lactic acid
formed by the action of Doderlein’s bacilli on glycogen found in the squamous
epithelium of the lining.
 These bacilli are the normal inhabitants of the vagina. The acid deters the
growth of pathogens.

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Blood supply: This comes from the branches of the internal iliac artery and includes
the vaginal artery and a descending branch of the uterine artery. The blood drains
through the corresponding veins.

Lymphatic drainage: This is via the inguinal, the internal iliac and the sacral glands.

Nerve supply: Sympathetic and parasympathetic nerves from the plexus (Lee
Frankenhauser plexus) supply the vagina. The pudendal nerve supplies the lower part.

THE NON-GRAVID (PREGNANT) UTERUS

Position:

 It is situated in the cavity of the true pelvis, behind the bladder and in front of
the rectum.
 It leaned forward which is termed as anteversion, and it ends forward on
itself, which is termed as anteflexion.
 In standing position, a woman’s uterus is in horizontal position with the
fundus resting on the bladder.

Shape: It is a hollow, muscular pear-shape organ

Size: It is a 7.5cm long, 5cm wide and 2.5cm deep.

Relations:

The structures surrounding the uterus are as follows-

 Anterior: the uterovesicalpouch and the bladder.

 Posterior: the the rectouterine pouch of douglass and the rectum.
 Laterally: the broad ligaments, the uterine tubes and the ovaries.
 Superiorly: the intestines.
 Inferiorly: the vagina.

Supports:

The uterus is supported by the pelvic floor and maintained in position by several
ligaments.

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 The transverse cervical ligaments extend from the sides of the cervix to the
side walls of the pelvis, they are known as the cardinal ligaments
 The uterosacral ligaments pass backward from the cervix to the sacrum.The
pubo cervical ligaments pass forward from the cervix under the bladder to the
pubic bones.
 The broad ligaments formed from the folds of peritoneum, which are draped
over the uterine tubes, they hang down like a curtain and spread from the side
walls of the uterus to the sidewalls of the pelvis.
 The round ligaments arise from the cornua of the uterus in front and from
below the insertion of each fallopian tube, and pass between the folds of the
broad ligament through the inguinal canal and are inserted into each labium
majus.
 The ovarian ligaments also begin at the cornua of the uterus but behind the
tubes and pass down between the folds of the broad ligament to the ovaries.

Gross structure:

 The body or corpus: make up the upper two-third of the uterus, it : lies
between the openings of the two tubes and the isthmus
 The fundus: the doomed upper wall between the insertions of the uterine
tubes.
 The cornua: the upper outer angles of the uterus where the fallopian tubes join
 The cavity: a potential space between the posterior and the anterior walls. It is
triangular in shape, the base of the triangle being uppermost.
 The isthmus: it is a narrow area between the cavity and the cervix, which is
7mm long. It enlarges during pregnancy to form the lower uterine segment.
 The cervix: forms the lower third of the uterus, it protrudes into the vagina.

Microscopic structure:

The uterus has three layers of which the middle muscle layer is the thickest. The
layers from inside outwards are the endometrium, myometrium and the primetrium.

 Endometrium: this forms a lining of ciliated epithelium (mucus membrane),

it is constantly changing in thickness through the menstrual cycle. The basal

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layer does not alter but provides a foundation from which the upper layer
regenerates. The basal layer contains stroma cells, endometrial glands, vessels
and nerves. The endometrium changes to deciduas during pregnancy.
 Myometrium: It consists of thick bundles of smooth muscle fibers held by
connective tissues and are arranged in various directions. It is thick in the
upper part of the uterus and it’s sparser in the isthmus and cervix. Its fibers run
in all directions and interface to surround the blood vessels and lymphatic,
which pass to and from the endometrium. During pregnancy however, three
distinct layers can be identified- outer longitudinal, middle interlacing and
inner circular. In the cervix, the muscle fibers are embedded in collagen fibers
which enable it to stretch in labour.
 Perimetrium: it is a double serous membrane, an extension to the peritoneum,
which is draped over the uterus covering all but a narrow strip on both side
and the anterior wall of the supravaginal cervix from where it is deflected up
over the bladder.

Blood supply: via the uterine artery and ovarian artery, the blood drains through the
corresponding veins.

Lymphatic drainage: Lymph from the uterine body drains to the internal iliac
glands.

Nerve supply: This is mainly from the autonomic nervous system, the sympathetic
and parasympathetic system.

Functions:

 The uterus serves to shelter the fetus during pregnancy,

 It prepares for this possibility each month.
 At the termination of pregnancy, it expels the uterine content.

THE CERVIX

Although the cervix is part of the uterus, its structure and function differ from the
main body of the uterus and it is therefore described separately.

Structure

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 It forms the lower third of the uterus and it is the area bellow the isthmus
which includes the internal and external os.
 It enters the vagina at right angles and it’s sometimes called the neck of the
uterus.

Shape: The cervical canal is fusiform and the cervix as a whole tends to be barrel-
shaped

Size:

 In adult life the cervix is 2.5cm long and, as stated, forms one third of the total
length of uterus.
 During intra uterine life, however, it forms the greater part of the uterus and
then in the last weeks of pregnancy there is an accelerated growth of the
uterine body brought about by the high levels of maternal oestrogenic
hormones.
 When the ovarian hormones are activated at puberty, there is a further
acceleration of uterine body growth, until it is approximately twice the length
of the cervix.

Gross structure

 The supravaginal cervix: is that portion of the cervix which lies outside and
above the vagina. Superiorly, it meets the border of the uterus at the isthmus.
 The infravaginal cervix: is that portion which projects into the vagina.
 The internal os: opens into the cavity of the uterus. Although not a sphincter in
the true sense of the word, it dilates during labor. Incompetence of the cervix
at this level results in spontaneous abortion in the mid trimester of pregnancy.
 The external os: opens into the vagina at the lower end of the cervical canal.
On pelvic examination, it is found at the level of the upper boarder off the
symphysis pubis. In the multiparous woman, it is recognized on vaginal
examination by being circular in shape, smooth and with a dimple in the
center. After the 36th week of pregnancy, the ‘dimple’ will admit a finger tip.
In the multigravida, it is a transverse, slit-like aperture with an irregular edge
and will easily admit a finger tip even in early pregnancy. It is known as a
“multip’s os”.

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 The cervical canal- lies between the internal and external os.

Microscopic structure

There are three layers of tissue

 Endometrium: is the inner layer, it contains many racemose glands, some of

which are ciliated to facilitate the passage of spermatozoa. The tissue is
arranged in folds ‘arbor vitas’ the os allows the dilatation of the cervix to
occur without trauma. In the multigravid patient, the arbor vitae become
flattened out with successive pregnancies. The cervical endometrium is more
glandular than that in the main body of the uterus and it is not shed during
menstruation. Nevertheless, it is affected by oestrogenic hormones and at the
time of ovulation, there is an increase in the glandular secretion, which also
becomes less viscous.
 Muscle: involuntary muscle fibres are mingled with dense collagenous tissue
which gives the cervix a fibrous nature. Longitudinal muscle fibres from the
uterus pass into the cervix. Although the amount of muscle fibre in the uterine
body is increased considerably during pregnancy, histological studies show
that there is a negligible increase in the cervix.
 Peritoneum: covers that part of the cervix which lies above the vagina. It is
loosely applied in the area where it reflects up and over the bladder.

Blood supply: through the uterine ateries, and venous drainage is through the
uterine veins.

Lymphatic drainage: it’s into the internal iliac and sacral glands.

Nerve supply: sympathetic and para-sympathetic nerves from the lee-

Frankenhausers plexus provide the nerve supply.

Supports:

 Transverse cervical ligaments: extend from the cervix to the lateral walls of
the pelvis.
 Pubocervical ligaments: run forward, from the cervix to the pubic bone.

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 Uterosacral ligaments: extends from the cervix and pass backwards to the
sacrum.

Functions:

 It helps prevent infection entering the uterus

 It dilates and withdraws during labour to enable vaginal delivery of the fetus
and placenta.
 Following delivery, the cervix returns almost to its non pregnant state

Relations:

 Anteriorly: uterovesical pouch of peritoneum and the bladder

 Posteriorly: the pouch of douglas and the rectum
 Laterally: the broad ligament and the ureters

THE FALLOPIAN (UTERINE) TUBES

Position:

Each tube extends from the cornua of the uterus, travels towards the sidewalls of the
pelvis, then turns downwards and backwards before reaching it. The tubes lie within
the broad ligament.

Shape:

 They are tubular as their name implies.

 The lumen of each tube communicates with the cavity of the uterus at its
proximal end and the peritoneal cavity at its distal end.

Size: The length of each tube is approximately 10cm. the diameters vary in each part
of the tube.

 Interstitial portion 1mm

 Isthmus 2.5mm
 Ampulla and infundibulum each 6mm

Gross structure:

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 The interstitial portion: lies within the wall of the uterus and its 1.25cm in
length its lumen is 1mm wide.
 The isthmus: it is also 2.5cm in length, it is the narrowest portion of the tube
and acts as a reservoir for spermatozoa because the temperature is lower there
than in the rest of the tube.
 The ampulla: is the widened out area of the tube where fertilization normally
occurs. It is 5cm in length.
 The infundibulum or fimbriated end: is the funnel-shaped terminal and distal
portion of the tube which turns backwards and downwards and ends in
fingerlike projections (fimbriea) which surrounds the orifice of the tube.

Microscopic structure:

 Ciliated epithelium: forms the lining of the tube, the epithelium is arranged in
folds called plicae, Which slow down the passage of the fertilized ovum,
allowing it to develop in preparation for its embedding in the uterus.
 Connective tissue lies beneath the epithelium. The muscle is arranged in two
layers:
i. An inner layer of involuntary circular muscles fibres.
ii. An outer layer of involuntary longitudinal fibres which continue into
the body of the uterus. It is largely their peristaltic action which
propels the ovum towards the uterus. Contractions of the longitudinal
fibres bring the fimbria nearer to the ovary at the time of ovulation.
- Perimetrium: hangs over the tube but it is absent on their inferior surface.

Supports:

This is provided by the infundibulopelvic ligaments. This are formed from the folds of
the broad ligament and run from the infundibulum of the tube to the side walls of the
pelvis.

Functions:

 The uterine tubes propels the ovum towards the uterus,

 Receive the spermatozoa as they travel upward and
 Provide a site for fertilization.

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Relations:

Anteriorly, posterioly and superiorly: the peritoneal cavity and the intestines.

Inferiorly: the broad ligament and the ovaries

Laterally: infundibulopelvic ligament and the ovaries

Medially: the uterus.

Blood supply: via uterine and ovarian arteries, venous return is by corresponding
veins.

Lymphatic drainage: is into the lumber glands.

Nerve supply: is from the ovarian plexus

OVARIES

The ovaries are components of female reproductive system and endocrine system

Function: the ovaries produce oocytes and the hormones, estrogen and progesterone

Position: the ovaries are attached to the back of the board ligaments within the
peritoneal cavity

Relations:

 Anteriorly: to the ovaries are the board ligaments

 Posteriorly: to the ovaries are the intestines
 Laterally: to the ovaries are the infundibulopelvis ligaments and the side walls
of the pelvis
 Superiorly: to the ovaries lie the uterus tubes
 Medially: to the ovaries lie the ovarian ligaments and uterus

Supports:

The ovary is attached to the board ligament but is supported from above by the
ovarian ligament medially and infundibulopelvis ligament laterally

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Structure: The ovary is composed of a medulla and cortex, covered with the
germinal epithelium.

 The medulla is the supporting frameworl, which is made of fibrous tissue; the
ovarian blood vessels, lymphatics and nerves travel through it. The hilum
where these vessels enter lies just where the ovary is attached to the board
ligament and this area is called the mesovarium
 The cortex is the functioning part of the ovary. It contains the ovarian follicles
in different stages of developing, surrounded by stroma. The outer layer is
formed of fibrous tissue known as the tunical albuginea. Over this lies the
germinal epithelium, which is a modification of the peritoneum.

Blood supply: is via the ovarian arteries and drains through the ovarian veins

Lymphatic drainage: is into the lumbar glands

Nerve supply: is from the ovarian plexus

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