Uterus and Adnexal Diseases

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19 Uterus and Adnexal Diseases

Anatomy of the Uterus, Adnexa, and Vagina

image

Uterus and Adnexa

Uterus

• Derived from fusion of paired embryonic paramesonephric (müllerian) ducts: basis for divided, asymmetrical, or bifid (didelphic) uteruses
• Endometrium: highly vascular and glandular uterine lining; thickness or state varies with menstrual cycle
• Myometrium: dense, fibrous connective tissue and smooth muscle, derived from embryonic splanchnic mesoderm
• Mesometrium: peritoneal covering of the uterus, continuous with peritoneum of broad, transverse (cardinal), uterosacral, and suspensory (infundibulopelvic) ligaments
• Fundus: dome superior to uterine tube orifices
• Body: superior 2/3
• Cervix: inferior 1/3; inferior aspect opens into vagina
• Isthmus: surface narrowing marking transition from body to cervix
• Uterine ostia: internal orifices of uterine tubes
• Uterine cavity: typically conical, apex down when not gravid
• Internal os: superior opening of cervical canal
• External os: inferior opening of cervical canal

Position of the Uterus and Pouches

• Typical, nongravid position: body anteflexed, lies against bladder
• Cervix between rectum and inferior bladder
• Nongravid uterus is thus anteverted relative to the vaginal canal and anteflexed on its own axis.
• Rectouterine pouch (of Douglas): posterior, pre-rectal peritoneal recess
• Vesicouterine pouch: anterior peritoneal recess between bladder and uterine fundus; also uterovesical

Uterine (Fallopian) Tubes (Ducts)

• Fimbriae: fringe around infundibular orifice
• Infundibulum: initial, funnel-like section proximal to fimbriae
• Ampulla: middle, wide portion proximal to infundibulum
• Isthmus: narrower portion approaching uterine wall
• Uterine portion: tube within uterine wall

Ovaries

• Normally almond-shaped and -sized
• Lie laterally and posterior to the broad ligament, attached near its upper borders via a peritoneal mesovarium
• Attached to body of uterus via ovarian ligaments running within broad ligament
• Contain follicles embedded in germinal epithelium and stroma

image Primary, secondary and mature (Graafian) ovarian follicles
image Corpus luteum (postovulatory follicle of current cycle)
image Corpus albicans (scar of degenerated corpus luteum)

• Granulosa cells surround an oocyte in its follicle.
• Theca interna and externa cells enclose the mass of granulosa cells and ovum.
• Interna layer differentiates into theca lutein cells of corpus luteum, which secrete estradiol.
• Vascularized stroma surrounds follicles.
• Thin surface epithelium (tunica albuginea) of fusiform cells in connective tissue
• Originally smooth surface epithelium becomes progressively scarred by ovulation.

Vagina

• Fibromuscular tube extending from cervix to vestibule between labia minora
• Vestibule includes vaginal and urethral orifices and greater vestibular gland openings.
• Fornices: (anterior, posterior, lateral) recesses in the superior vagina, surrounding the cervix
• Lower portion typically collapsed, with H-shaped cross-section, anterior and posterior walls in contact
• Urethra runs just superficial to middle of inferior anterior vaginal wall.

Vessels

image

Pelvic Arteries in the Female (right side)

Arterial Supply

• Uterus and adnexa supplied bilaterally (on left and right sides) by three major anastomotic arteries, superior to inferior

image Ovarian arteries: paired, from abdominal aorta, branches originate inferomedial to renal arteries, descend to pelvis in peritonealized suspensory (infundibulopelvic) ligaments of ovaries along with nerves and veins
image Uterine arteries (from internal iliacs): paired, travel medially from pelvic wall, within cardinal ligaments, at about the level of the cervix
image Vaginal (from internal iliacs): travel medially from pelvic walls, at level of inferior vesical or internal pudendal artery branches

• Uterine arteries cross over ureters, close to cervix: risk of ureter damage or ligation in surgery; “water” (urine) “under the bridge” (uterine artery)
• Vagina supplied by named vaginal and internal pudendal branches of internal iliacs

Venous Drainage

• Uterus and adnexa drained by major veins that travel parallel to corresponding arteries
• Uterine, ovarian, and vaginal veins interconnect in an extensive bilateral uterine plexus running within proximal broad ligaments.

Ovarian Veins

• Right ovary drains to right inferior vena cava and left ovary to left renal vein.
• Veins ascend in pelvis and abdomen, traveling with nerves and arteries within suspensory ligaments.

Uterine Veins

• Drain on right and left into internal iliac veins
• Travel laterally to pelvic wall, within cardinal ligaments, at about the level of the cervix

Vaginal Veins

• Drain on right and left into internal iliac veins
• Travel laterally to pelvic wall, at level of inferior vesical or internal pudendal vein tributaries
image

Lymph Vessels and Nodes of Pelvis and Genitalia

Lymphatic Drainage

• Uterine lymphatics drain in multiple directions.
• Ovarian, uterine fundus, and body lymphatics drain upward along ovarian vessels to nodes around lumbar aorta and vena cava.
• Vessels from around the uterine tube junctions drain along the round ligament into superficial inguinal nodes.
• Body and some of the cervix also drain to external iliac nodes along vessels within the broad ligament.
• Cervical lymphatic vessels also drain to external and internal iliac and sacral nodes.

Clinical Correlates

image image

Dysfunctional Uterine Bleeding

Pelvis and Acute Abdomen

• Diseases of uterus and adnexa can manifest as acute abdomen, with pain localized inferiorly.
image

Uterine Fibroids (Leiomyomas)

Uterine Fibromas

• Leiomyomas: firm, benign tumors of myometrial smooth muscle, a.k.a. fibroids
• Most common benign tumor in women
• Prevalence: 30% of all women; 40%-50% of women >50 years
• Risk factors: early menarche, nulliparity; 4-10× increase in African-American women
• Growth stimulated by estrogen, contraceptives, epidermal growth factor
image

Differential Diagnosis of Ovarian Cysts

Ovarian Cysts

• Typically arise from ovarian components: follicular cysts, luteal cysts, ovarian capsule
• Ovarian cysts usually small, asymptomatic, often benign (>90%)
• Diagnosis may be difficult, with many conditions manifesting as lower abdominopelvic masses.
image

Endometriosis

Endometriosis

• Benign foci of endometrial tissue progressively developing in pelvis—ovary, rectouterine pouch, uterine ligaments, tubes—or elsewhere in peritoneum
• Prevalence of endometriosis: ~5%-10% of women; ~30%-50% of infertile patients
• Causes are multifactorial: genetic, menstrual backflow with spread of cells through tubes, vascular or lymphatic dissemination, or metaplasia of peritoneal epithelium.
• Risk factors: cervical or vaginal outflow obstruction, structural abnormalities

Cancer

Uterine Endometrial Carcinoma

• Most common female reproductive tract malignancy
• Risk factors: obesity and increased estrogen synthesis, estrogen replacement therapy without progestin, breast or colon cancer, early menarche or late menopause, diabetes, chronic anovulation

Cervical Carcinoma

• Squamous carcinomas: ~85%-90% of cases
• Adenocarcinomas: ~10%-15% of cases
• About 12,000 cases and ~4000 deaths in 2005 in U.S.
• Risk factors: early sexual activity, multiple partners, human papillomavirus infection, smoking, African-American ethnicity
• Peak age range: 40-60 years

Ovarian Tumors and Cancer

• Origins of tumor tissues

image Surface epithelium/stroma: 65%-70%; 85%-90% of all malignancies
image Germ cell: 15%-10%
image Sex-cord stroma: 5%-10%

• Risk factors: age, high-fat diet, family history, early menarche and late menopause, white ethnicity, high socioeconomic status
• Age of occurrence or discovery

image Benign tumors, 20-29 years
image Malignant tumors, 50% occur in women >50 years

image

Ovarian Tumors

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19 Uterus and Adnexal Diseases

Anatomy of the Uterus, Adnexa, and Vagina

image

Uterus and Adnexa

Uterus

• Derived from fusion of paired embryonic paramesonephric (müllerian) ducts: basis for divided, asymmetrical, or bifid (didelphic) uteruses
• Endometrium: highly vascular and glandular uterine lining; thickness or state varies with menstrual cycle
• Myometrium: dense, fibrous connective tissue and smooth muscle, derived from embryonic splanchnic mesoderm
• Mesometrium: peritoneal covering of the uterus, continuous with peritoneum of broad, transverse (cardinal), uterosacral, and suspensory (infundibulopelvic) ligaments
• Fundus: dome superior to uterine tube orifices
• Body: superior 2/3
• Cervix: inferior 1/3; inferior aspect opens into vagina
• Isthmus: surface narrowing marking transition from body to cervix
• Uterine ostia: internal orifices of uterine tubes
• Uterine cavity: typically conical, apex down when not gravid
• Internal os: superior opening of cervical canal
• External os: inferior opening of cervical canal

Position of the Uterus and Pouches

• Typical, nongravid position: body anteflexed, lies against bladder
• Cervix between rectum and inferior bladder
• Nongravid uterus is thus anteverted relative to the vaginal canal and anteflexed on its own axis.
• Rectouterine pouch (of Douglas): posterior, pre-rectal peritoneal recess
• Vesicouterine pouch: anterior peritoneal recess between bladder and uterine fundus; also uterovesical

Uterine (Fallopian) Tubes (Ducts)

• Fimbriae: fringe around infundibular orifice
• Infundibulum: initial, funnel-like section proximal to fimbriae
• Ampulla: middle, wide portion proximal to infundibulum
• Isthmus: narrower portion approaching uterine wall
• Uterine portion: tube within uterine wall

Ovaries

• Normally almond-shaped and -sized
• Lie laterally and posterior to the broad ligament, attached near its upper borders via a peritoneal mesovarium
• Attached to body of uterus via ovarian ligaments running within broad ligament
• Contain follicles embedded in germinal epithelium and stroma

image Primary, secondary and mature (Graafian) ovarian follicles
image Corpus luteum (postovulatory follicle of current cycle)
image Corpus albicans (scar of degenerated corpus luteum)

• Granulosa cells surround an oocyte in its follicle.
• Theca interna and externa cells enclose the mass of granulosa cells and ovum.
• Interna layer differentiates into theca lutein cells of corpus luteum, which secrete estradiol.
• Vascularized stroma surrounds follicles.
• Thin surface epithelium (tunica albuginea) of fusiform cells in connective tissue
• Originally smooth surface epithelium becomes progressively scarred by ovulation.

Vagina

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