1-reproductive Anatomy

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LEARNING OBJECTIVES 1. Significance of Reproductive Anatomy 2. Male reproductive anatomy 3. The components, types and functions of the female pelvis, muscles of the pelvic diaphragm 4. The vulva and perineal region 5 Vagina and its relations 6. The uterus, parts, supports, physiology of the endometrium and reproductive functions 7. The fallopian tube: structure and role in sperm ans ovum transport. 8. The ovary; structure and control and role in fertility 9. Blood supply of the pelvic organs: Colatteral circulation 10. Lymphatic drainage 11. CNS and autonomic nerve supplies 12. Conclusion

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INTRODUCTION Significance of reproductive anatomy. * Understanding of the severity of any pathology. * Surgical intervention * Complications of operation and Appropriate management * Fertility potential * Obstetrics-progress of pregnancy 3

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OTHER IMPORTANT LANDMARKS 1. INGUINAL LIGAMENT

2. INGUINAL CANAL

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FEMORAL TRIANGLE

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FETAL SKULL

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MALE GENITAL ORGANS Prostate- shaped like chestnut Scrotum- dartos muscle testes Testis: left lower than the right within the scrotum capsule- tunica albuginea Blood supply-testicular a nerve supply- T10 sympathetic fibres via renal and aortic plexus. 200-300 lobules(contain seminiferous- each 62 cm long- Epididymis Vas deferens 45 cm ( same as thoracic duct, spinal cord, femur, from incisor to cardia of stomach) Seminal vesicle 5 cm long on each side of peritoneal portion of urinary bladder 10 Penile organ- glans, body( corpus spongiosus and cavernosus.

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PELVIC BONE

Types * Gynaecoid * Android * Anthropoid * Platypelloid

Geneder differences Long A-P diameter Oval pelvic inlet Sacral concavity Wide pubic arch Light ischial spines

Parts * Inominate Ilium Pubis Ischium * Sacrum * Coccyx Joints Lumbo-sacral Pubic symphysis Sacroiliac Sacrococcygeal Coccygeal

Significance: Weight bear Obstetric Outcome Pudendal block

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EXTERNAL GENITALIA Mons pubis Urogenital triangle labia majora labia minora Clitoris -glans, body and two crura Vestibule vagina---HYMEN urethra ostia of bartholin glands Hymen Annular, Semilunar or crescentic, Septate

Perineum Floor- skin Room-pelvic diaphragm(Levator ani and coccygeous muscles

Urogenital triangle superficial fascia Colles fascia superficial perineal pouch Deep perineal pouch

Anal triangle anal canal lateral ischio rectal fossa Sphincter ani muscle Pudendal neurovascular bundle 15

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COMPONENTS OF LEVATOR ANI MUSCLE Muscle Origin Insertion Pubovaginalis

Pubic bone

Puborectalis

Pubic bone

Function

Perineal body

Constriction of the vagina Posterior rectum Sphincter of anal canal Anococcygeal Constriction

Pubococcygeus Tendon of of obturator fascia ligament Iliococcygeus ” " Other muscles Coccygeus Ischial spine Lower border of sacrum and coccyx Obturator internus Piriformis

anal canal "

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SUPPORTS OF THE UTERUS * Levatore Ani muscle *Cardinal ligament(ligament of mackenrodts or transverse ligament) *Uterosacral ligament LIGAMENTS Sacrotuberous ligament- from dorsal surface of sacrum and coccyx, and from the posterior and inferior iliac spine and down to the medial surface of ischiotuberosity Sacrospinous ligament- From lateral margin of coccyx to lowermost of sacrum and attaches to ischial spine. *Greater and lesser sciatic foramina 22

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BLOOD SUPPLY OF THE PELVIS Ovarian arteries superior rectal artery Middle sacral artery Common iliac artery External iliac artery Internal iliac arteries Posterior trunk Iliolumbar artery Lateral sacral artery Superior gluteal artery

Rich Collateral Circulation: OvarianUterine-vaginal

Anterior trunk Umbilical artery Obturator artery Uterine artery Vaginal artery Middle rectal artery Internal pudendal artery Inferior gluteal artery

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Lymphatic drainage of the pelvis * External iliac lymph nodes Bladder Isthmus of the uterus deep inguinal lymph nodes superficial inguinal lymph nodes * Internal iliac lymph nodes * Sacral group of lymph nodes * Lower paraortic nodes Medial superficial lymph nodes Inferior perineal structures inferior anal canal lower vaginal and distal urethra 26

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NERVES OF LESSER PELVIS Lumbosacral trunk( L4, L5) Sacral plexus( L4, L5, S1,S2, S3, S4 Sciatic nerve( L4,L5, S1, S2, S3) --Common peroneal and tibial nerves Pudendal (S2, S3, S4) passes through greater and lesser sciatic foramina to the pudendal canal Coccygeal plexus(S4, S5) Lumbar plexus Iliohypogastric nerve( L1, T12) Ilioinguinal (L1) Genitofemoral(L1, L2) Femoral ( L2, L3, L4) 28

THE AUTONOMIC NERVOUS SYSTEM * Sympathetic pathway paravertebral ganglia sympathetic trunk prevertebral ganglia pelvic organs * Parasympathetic system preganglionic fibres from S2, S3, and S4 (Nervi erigentes). Postganglionic fibres supply urinary bladder, descending colon, the rectum and reproductive organs

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Anterior abdominal wall • Layers: skin subcutaneous tissue (fat) fascia and muscle peritoneum • Nerve supply • Blood supply and lymphatic drainage 30

Landmarks • Umbilicus is obvious - unreliable in anatomical terms • Xiphoid process and symphysis pubis • Costal margin • Anterior superior iliac spine

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Skin • Scars • Striae - secondary to stretching • Natural folds and creases - important for surgical scars • Lower intercostal (T6-11), subcostal (T12), ilio-hypogastric and ilioinguinal (L1) 32

Superficial fascia • Varies in thickness with amount of adipose tissue • Below umbilicus is in two layers: superficial fatty and deep membranous

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Rectus sheath • Anterior layer of the rectus sheath is the aponeurosis of the external and anterior half of aponeurosis of internal oblique muscles • Posterior layer is formed of posterior half of the internal oblique and the whole aponeurosis of transversus abdominis • Linea alba 34

Inguinal canal • Superficial inguinal ring • Deep inguinal ring • Anterior wall • Posterior wall • Floor

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Hernias 1 • Inguinal hernias more common in men • Persistent processus vaginalis (layer of peritoneum. • Acquired or direct appears at superficial ring and does not pass towards scrotum (or labia) • Femoral is inferior to medial part of inguinal ligament 36

Hernias 2 • Umbilical hernia is usually congenital • In adults through linea alba near umbilicus • Incisional 37

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Muscles • External oblique, internal oblique and transversus abdominis • Conjoint tendon • Rectus abdominis - three tendinous intersections, enclosed by rectus sheath

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Muscles 2 • Pyramidalis lies between anterior layer of sheath and rectus abdominis attaches to pubis and linea alba • Muscles supplied by lower six thoracic spinal nerves (through intercostal and subcostal) and first lumbar (iliohypogastric and ilio-inguinal) 41

Fascia transversalis • Layer of fascia between muscles of abdominal and pelvic walls and peritoneum • Thicker above ingiunal ligament

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Blood vessels and lymphatics • Laterally - lower posterior intercostals • Medial - superior and inferior epigastric • Intercostal veins • Superior and inferior epigastric veins • Lymph nodes - four quadrants (inguinal and axillary)

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The Abdominal incision: Integrity and aesthetic nature of scar

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Breast anatomy • Exists in both sexes • Rudimentary in adult male • In female, varies with age and functional state • In lateral plane, base extends from 2nd to 6th rib • At level of 4th costal cartilage, extend from sternum to mid axillary line

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Breast • Superolateral extension upwards and laterally - axillary tail • Deep relation to pectoralis major, • Separated by deep fascia and submammary space

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Breast • Nipple is surrounded by areola • Traversed by 15-20 lactiferous ducts • Contains numerous non-striated muscle fibres • Areola has sebaceous glands (Montgomery)

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Structure of breast • Consists of: a) fat b) glandular tissue • Glandular tissue is arranged in 15-20 radial lobes • Suspensory ligaments of Cooper • Duct of each lobe opens onto nipple 49

Changes in pregnancy • Initial increase in duct tissue • Followed by proliferation of secretory tissue • Initially, colostrum is produced • After delivery, secretory tissue produces milk

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Breast milk • 88% water • 7% lactose • 4% fat • 1% protein • Ca, NA, K, Cl, phospate, antibodies (IgA)

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Breast blood supply • Arterial blood supply from thoracic brances of axillary artery (lateral) and mammary branches of internal thoracic (medial) • Veins form anastamotic circle at base of nipple thence axillary and internal thoracic veins 52

Lymphatics • Mainly to axillary lymph nodes • Five groups: lateral (axillary vein) posterior (subscapular) medial (pectoral) • Drain into central group, thence apical group • Medial tissue drains to anterior end of intercostal spaces

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Additional lymphatic connections • Contra-lateral breast and axilla • Nodes below clavicle • Nodes above clavicle • Parietal peritoneum • Pleura

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Pituitary and Hypothalamus

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Significance anatomy and physiology of the 1.Pituitary The structure, location and relations 2.

Components * Neurohypophysis * Adenohypophysis i Follicle Stimulating hormone (FSH) ii Lutuinising Hormone ( LH) iii Prolactin (PRL) iv Growth Hormone (GH) v Thyroid Stimulating Hormone ( TSH) vi Adreno-corticoid Stimulating Hormone (ACTH) 3. Endocrine control of pituitary function 4. Clinical significance of the pituitary * Hyperprolactinaemia and infertility * Hypopituitarism * Pituitary necrosis- Shehan Syndrome

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Ovulation, Menstrauation and Conception 1. Physiology of menstrual cycle-: Involves a complex interaction between the hypothalamus , pituitary, ovaries and the endometrium. * Proliferative phase *Secretory phase 2. Ovarian control of the menstrual cycle * Follicular phase- oestrogen priming * Ovulation * Luteal phase- progestational 3 Normal menstrual cycle Onset- Menarche 10-16 years of age Cyclicity : 22-35 days Duration of Menstruation : 3-7 days Total amount of blood loss: 80 ml 4. Management of menstruation 5 Disorders of menstruation: amenorrhoea Oligomenorrhoea Polymenorrhoea Menorrhagia Metrorrhagia 6. Fertilisation and Implantation 58

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