Uterus, Ovary, Cervix, Vagina, Vulval Cancer😍

Cervix to Uterus Ratio by Age

• At birth: 1:1.

• Before puberty: 2:1 (cervix longer than uterus/corpus).

• At puberty: 1:2.

• Reproductive age: 1:3 or 1:4.

• Menopause: 1:1 (organ atrophy).

• Reproduce at 14 yrs

• Puberty at 12 years

Fallopian Tube & Ovary

In an Is land

• Infundibulum

• Ampulla

• Isthmus

• Interstitium

Fallopian Tube Anatomy

• Length: 10 cm.

Parts of Fallopian Tube

• Medial to Lateral:
1. Interstitial Segment (Intramural Part):
• Inside uterus.
• Narrowest part.
• Anatomical sphincter: Circular muscle fibers present.
2. Isthmus:
• Second narrowest part.
• Physiological sphincter: Product of conception moves to Isthmus from Ampulla.
• Site for female sterilization (Tubal ligation).
3. Ampulla:
• Widest & longest part.
• Site for fertilization.
• Site for ectopic pregnancy.
• Maximum mucosal folds, also known as plicae.
4. Infundibulum:
• Fimbrial part of fallopian tube.

Clinical Approach

• Adnexa:
• Ovary + fallopian tube.
• Peg cells present in lining of fallopian tube.

• Genital Tuberculosis (TB):
• Most commonly affects fallopian tube (Ampulla).
• Can lead to bilateral cornual block.

• Gonococcal infection: Leads to Fimbrial block.

• Investigation of Choice (IOC) for tubal patency: 
• Hysterosalpingography (HSG).

• Site for Tubal Ligation:
• Laparoscopic: Isthmus
• Hysteroscopic (using Essure): Interstitium

Uterus: General Features

Morphology

• Shape: Pear-shaped

• Size: 3 x 2 x 1 inches

Weight

• Non-pregnant: 60 - 80 g

• Pregnant: 1000 g
• (due to hypertrophy predominantly)

Composition

• Smooth muscle fibers

Applied Aspect

• Progesterone:
• Smooth muscle relaxant
• Used in preventing preterm labor

Uterine Cavity

• Type: Potential cavity
• Anterior & posterior walls are opposed

• Volume:
• Non-pregnant: 10 ml
• Pregnant: 5L

• Shape:
• Coronal: Triangular
• Sagittal: Slit-like

Position

• Anteverted & anteflexed

Inspection of Uterus

• Hysteroscopy

Structures Attached at Cornua of Uterus

Anterior to Posterior

• Mnemonic: RTO
• Round ligament → Samson artery (Branch of Inferior Epigastric art)
• Fallopian tube
• Ovarian ligament → Utero ovarian anastomosis

• Suspensory ligament (Infundibulopelvic) → Ovarian artery

• Transverse cervical ligament → Uterine artery, Ureter

Superior to Inferior

• Fallopian tube (Superior)

• Round ligament

• Ovarian ligament (Inferior)

Note

• Cervical Fibroid: Extrauterine fibroids

• Most Common Cause of Failure in Female Sterilization: 
• Identification of the wrong structure - Round ligament

Uterine Supports

Type	Structures
Muscular	Levator ani, Perineal body, Urogenital diaphragm
Fibromuscular	Cardinal, Uterosacral, Pubocervical, Round ligaments
Peritoneal	Broad ligament

• Uterus is normally anteverted and anteflexed.

• Supported by muscular, fibromuscular, and peritoneal structures.

• Mechanical Support (Prevents Prolapse)
• Angle of Anteversion: 90° (Between Cervix and Vagina)
• Angle of Anteflexion: 130° (Between Uterus and Cervix)

• On P/V Examination
• Anteverted Uterus: Fundus > Anterior Lip of Cervix
• Retroverted Uterus: Posterior Lip of Cervix Felt First

Not a true support of the uterus

• Not a true support → does not prevent prolapse

• Round ligament → maintains anteversion
• Homologous to: gubernaculum testis (scrotal ligament).
• Uterine retroversion: results when round ligament laxity occurs.
• From uterine cornu (anterolateral to tube) → through inguinal canal → labia majora.
• Maintains anteverted position of uterus.
• Pain in stretching during pregnancy = round ligament pain.
• Remnant of gubernaculum (female).

• Broad ligament
• Keeps uterus centrally placed
• Double layer of peritoneum from uterus to lateral pelvic wall.
• Contains:
• Uterine tubes
• Round ligament
• Ovarian ligament
• Uterine and ovarian vessels

Clinical Correlation

• Prolapse:
• due to weakness of levator ani and cardinal + uterosacral ligaments.

• Round ligament pain: due to stretch during pregnancy.

• Uterine retroversion: results when round ligament laxity occurs.

1. Muscular Supports

• a. Pelvic Diaphragm
• Levator Ani (Most Important Support)
• especially pubococcygeus
• Failure → uterine prolapse.

• b. Perineal Body
• Superficial & Deep Transverse Perinei
• Bulbospongiosis

• c. Urogenital Diaphragm

2. Fibromuscular (Ligamentous) = Triadiate Ligament

• a. Transverse Cervical (Cardinal / Mackenrodt’s) Ligament
• Main mechanical support of uterus.
• From cervix and upper vagina → lateral pelvic wall.
• Contains uterine vessels.

• b. Uterosacral Ligaments
• Pulls cervix upward and backward.

• c. Pubocervical Ligaments
• Keeps cervix forward.

DeLancey

• three-level systems of genital tract supports:

Level	Structures	Defect Leads To
I	Uterosacral & cardinal ligaments	Uterine descent, enterocele, vault prolapse
II	Pelvic fascia, paracolpos, arcus tendineus, pubocervical fascia, rectovaginal fascia	Cystocele, rectocele
III	Levator ani muscle	Urethrocele, gaping introitus, deficient perineum

Important Questions

Feature	Details
First Step for Prolapse	Retroversion of Uterus (Manually Correctable)
Fixed Retroverted Uterus Seen In	Endometriosis
Ligament Keeping Uterus in Anteverted Position	Round Ligament (RL) > Uterosacral (US) Ligament
Ligament Preventing Retroversion	US Ligament > RL
Secondary Support Ligament	RL
Ligament Without Support Function	Broad Ligament
Part of Levator Ani Damaged Causes Maximum Prolapse Risk	Puborectalis > Pubococcygeus

Peritoneal Reflections

Uterovesical Fold

• Peritoneum from bladder reflected to uterus

• At the level of the isthmus (LUS)

Pouch of Douglas / Cul-de-sac

• Posterior peritoneal reflections between uterus & rectum

• Applied Aspect: Culdocentesis for ruptured ectopic pregnancies

Uterine Isthmus

• Location
• Lower part of uterus between:
• Anatomical internal os
• Histological internal os

• Histological internal os:
• Columnar uterine lining replaced by cervical lining

• Length
• Non-pregnant: 0.5 cm
• During pregnancy:
• Forms lower uterine segment (LUS)
• Identified by a loose fold of peritoneum
• At term: 5 cm
• At labor: 10 cm (5 cm + 5 cm cervix d/t effacement)

Body/Corpus

• Layers: 3
• Endometrium
• Myometrium
• Serosa

• Endometrium layers: 3
• Zona compacta
• Zona spongiosa
• Zona basalis

• Functional layers: (shed during menstruation)
• Zona compacta
• Zona spongiosa

Uterine Innervation

• Sensory Level T10-L1
• Stimulation causes labor pain sensation.
• Stretching and tension of muscles during contractions

• Early labor pain is referred to dermatomes T10-T12

• Late labor pain is referred to dermatomes S2-S4

Contractility

• Coordinated by:
• Uterine muscle itself.
• Hormonal factors.
• Local factors.

• Innervation → transmits sensory signals (e.g., pain).
• Does not directly control contractility.

Cervix

Anterior Division

• Common Branches
• Superior Vesical Artery
• Remnant of Proximal Umbilical Artery
• Middle Rectal Artery
• Obturator Artery
• Internal Pudendal Artery
• Inferior Gluteal Artery
• largest branch

• Males only
• Inferior Vesical Artery
• Supplies:
• Base of Bladder
• Prostate Gland
• Seminal Vesicles
• May give off artery to Ductus Deferens
• Artery to Ductus Deferens (may arise from SVA)

• Female only
• Uterine Artery
• Vaginal Artery supplies:
• Base of Bladder
• Terminal Ureter
• Vaginal Wall

Clinical Approach

Blood Supply

• Descending cervical artery
• Branch of uterine artery
• Prominent at:
• 3 o'clock position
• 9 o'clock position

• Paracervical block positions:
• For analgesia:
• 2 o'clock & 4 o'clock
• 8 o'clock & 10 o'clock
• C/I:
• 3 o'clock
• 9 o'clock

Squamocolumnar junction (Transitional zone)

• Original squamocolumnar junction:
• Squamous epithelium of vagina
• Merges with
• Columnar epithelium of endocervix

• Identified by:
• Nabothian cysts
• Glandular openings

• Position changes with age and hormonal influence
• During pregnancy and OCP use
• Junction pouts out of the os
• After menopause
• Junction gets indrawn inside the os

• Cells are highly sensitive to:
• Irritants
• Mutagens
• Viral agents
• Especially HPV

• Pap smear taken from this zone

Vagina

Nerve supply

Ovary

General Features

• Location
• Present posteriorly
• In adults: 
• Ovarian fossa of Waldeyer
• Lateral pelvic wall
• In intrauterine life: 
• Abdominal organ
• Descends into the pelvis
• Assisted by the gubernaculum

• Dimensions
• Size: 3 x 2 x 1 cm
• Volume: 6-7 cc
• Clinical Significance: 
• ≥ 10 cc suggests Polycystic Ovarian Syndrome (PCOS).

Applied Anatomy: Descent and Ligaments

• Uterus' Role: 
• Prevents further descent of the ovary.

• Gubernaculum:
• Divided by the uterus into two ligaments:
• Ovarian ligament
• Round ligament

Relations of Ovary

• Superior/Anterior: External iliac artery

• Posterior:
• Ureter
• Internal iliac artery

• Lateral:
• Obturator nerve
• Infundibulopelvic ligament

• Medial: Ovarian ligament

Applied Clinical Aspect

• Large Ovarian Mass:
• Can cause pressure on the obturator nerve
• Resulting in pain along the medial side of the thigh.

Female External Genitalia/Pudendum/Vulva

Lymphatic Drainage

• Superficial inguinal LN → Deep inguinal/Femoral LN.

• Sentinel LN: 
• Superficial inguinal LN.
• Exception: 
• Glans of clitoris → direct drainage into deep inguinal
• Cloquet/Rosenmuller's LN.
• If tumor is located within 2 cm of midline
• B/L inguinofemoral LND 
• As lymphatics may possible cross midline if closer than 2cm with midline

Anatomy of Female External Genitalia (Vulva/Pudendum)

Components

• Pubic hair
• Forms at pubarche.
• Corresponds to Tanner stage 3.

Vestibule

• Area Bounded by:
• Anteriorly: Clitoris
• Posteriorly: Fourchette
• Laterally: Labia Minora

• Area Contains:
1. Urethral opening
2. Paraurethral (Skene) gland opening
3. Introitus (vaginal opening) - covered by hymen
4. Openings of ducts of Bartholin glands

Hymen

• Types of Hymen: 
• Annular, Cribriform, Infantile, Septate, Semilunar/Crescentic, Fimbriated.

• Imperforate Hymen:
• No opening in hymen.
• Complication: Cryptomenorrhea.

Condition	On Local Examination	ㅤ
Imperforate hymen (m/v/c)	Nothing given about local examination	ㅤ
Imperforate hymen	Tensed, bulging hymen or Cough impulse present → bluish swelling PR ↳ Bulge anterior Rx ↳ Cruciate Incision	Hematocolpus > hematometra
Transverse vaginal septum	Not tensed, not bulging or Cough impulse absent PR ↳ Bulge at tip of finger → higher up Rx ↳ Excision of septum	Higher hematometra chance. • Can lead to retrograde menstruation. • Potential endometriosis
Vaginal atresia	Vaginal opening absent	ㅤ

• Acute Presentation
• A/c urinary retention
• Imperforate hymen > Transverse vaginal septum

• Key Diagnostic Tool:
• MRI differentiates Imperforate hymen and TVS.

• Management
• Imperforate Hymen
• Cruciate incision on hymen.

Vulval Cysts

1. Paraurethral/Skene Gland Cyst

• Location: Adjacent to urethra.

2. Gartner's Cyst

• Location: Antero-lateral wall of vagina.

• Cannot reduce on its own

3. Bartholin Cyst

• Inflammation of Bartholin Gland

• AKA: Greater Vestibular Gland.

• Can reduce on its own

• Location: 
• B/w minora and hymen
• Between Labia Majora & Minora
• At 5 o'clock/7 o'clock position
• In vestibule, outside introitus (duct opening)
• In postero lateral vaginal wall

• Symptoms:
• Normally not palpable.
• Often asymptomatic.
• Symptomatic:
• Difficulty walking and sitting
• Vulval pain during physical activity
• ↑↑ in size after physical intercourse
• Can resolve spontaneously
• Differentiation from gartners
• Abscess
• Severe pain
• Tense
• Flutuctant
• Edematous
• Erythmatous
• Fever

Management:

• Cystic swelling
• Conservative management.
• If < 3 cm & asymptomatic
• Incision & Drainage (I&D) + Word catheter placement
• If ≥ 3 cm & Symptomatic

• Bartholin Abscess: 
• Irrespective of size
• I&D + antibiotic treatment.
• Maximum 2 times

• Recurrent Cyst: 
• Marsupialization

Biopsy if

• Postmenopausal

• Cyst has solid components

• Cyst adherent to surrounding structures

• Not responding to management

Vulval Cancer

NOTE:

• Dyspareunia

• Itching

• Whitish plaques

 

• Most Common Type: 
• Squamous cell carcinoma

• Second Most Common Type:
• Melanoma
• Adenocarcinoma

• Typical Age Group:
• 50-70 years
• Mean: 65 years

• Most Common Symptom: Pruritus

• Most Common Site:
• Labia Majora
• Labia Minora

• Common Varieties:
• Keratinizing (most common)
• Warty

Risk Factors

• Mnemonic: HPPVVVs

• HPV (HPV 16)

• Paget's disease

• p53 mutation

• Vulval intraepithelial neoplasia (VIN)

• Vulval dystrophy/atrophy

• Vulval warts (Condyloma acuminata)

• Smoking

Not Risk Factors

• These are not risk factors for vulval cancer:
• Condyloma lata
• Herpes simplex virus
• Gravida/parity
• Vulval hamartoma

Spread

• Vascular route → rare

• Lymphatic → m/c route

Lymph node status

• Most important prognostic factor.

• The sentinel lymph node biopsy is helpful

• Superficial inguinal nodes (sentinel node) > Deep inguinal nodes > femoral group of nodes.

Keys Punch Biopsy Forceps

Staging Insights

• Key Staging Points
• Stage IA:
• Size <2 cm and
• Depth <1 mm
• Stage IB:
• Size ≥2 cm
• Depth ≥1 mm
• Lymph Node (LN) Involvement: 
• Occurs in Stage III and IV

Management

Stage 1 & 2:

• Surgery:
1. Tumor Excision:
• Stage IA: Simple partial vulvectomy
• Stage IB/II: Radical partial vulvectomy
2. Lymph Node Dissection
• Stage IA: No LND
• All Other Stages: Inguinofemoral LND
• U/L Inguinofemoral LN dissection only if all criteria met
• Size: <2 cm
• Tumor: >2 cm away from midline
• Local Extension: Absent
• In all other cases, always do B/L
• If LN Palpable
• If LN Positive

Stage 3 & 4:

• Chemoradiation