مواضيع المحاضرة:
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278

  CHAPTER 7

 

lateral to the lateral fornix of the vagina, to enter the bladder.

artery (Figs. 7.18 and 7.19). The ureter then runs forward, 

of the broad ligament, where it is crossed by the uterine 

spine. It then turns forward and medially beneath the base 

behind the ovary until it reaches the region of the ischial 

ward and backward in front of the internal iliac artery and 

cation of the common iliac artery (Fig. 7.18). It runs down

The ureter crosses over the pelvic inlet in front of the bifur

sections.

the pelvic cavity in the female are described in the following 

as described previously. The contents of the anterior part of 

occupy the posterior part of the pelvic cavity (see Fig. 7.5), 

The rectum, sigmoid colon, and terminal coils of ileum 

Pelvic Viscera in the Female

directly in contact with the abdominal wall.

the anterior abdominal wall so that the bladder becomes 

up into the abdomen and peels off the peritoneum from 

to remember that as the bladder fills, the superior wall rises 

not cover the lateral surfaces of the bladder. It is important 

bladder passes laterally to the lateral pelvic walls and does 

The peritoneum covering the superior surface of the 

the erect position, is the rectovesical pouch (see Fig. 7.4).

abdominopelvic peritoneal cavity, when the patient is in 

abdominal wall. It is thus seen that the lowest part of the 

continuous with the parietal peritoneum on the posterior 

surfaces of the upper third of the rectum. It then becomes 

the middle third of the rectum and the front and lateral 

 The peritoneum then passes up on the front of 

pouch.

rectovesical 

aspect of the rectum, forming the shallow 

nal vesicles. Here, it sweeps backward to reach the anterior 

a short distance until it reaches the upper ends of the semi

then runs down on the posterior surface of the bladder for 

nal wall onto the upper surface of the urinary bladder. It 

The peritoneum passes down from the anterior abdomi

pelvis in a sagittal plane (see Fig. 7.4).

The peritoneum is best understood by tracing it around the 

covers and supports the pelvic viscera (see Fig.7.16).

The visceral pelvic fascia is a layer of connective tissue that 

Visceral Pelvic Fascia

openings of the two ejaculatory ducts (see Fig. 7.16).

in females. On the edge of the mouth of the utricle are the 

 which is an analog of the uterus and vagina 

static utricle,

pro

the summit of the urethral crest is a depression, the 

 the prostatic glands open into these grooves. On 

sinus;

prostatic 

On each side of this ridge is a groove called the 

 (see Fig. 7.16). 

urethral crest

longitudinal ridge called the 

 On the posterior wall is a 

portion of the entire urethra.

prostatic urethra is the widest and most dilatable 

The 

with the membranous part of the urethra (see Fig. 7.16).

tate from the base to the apex, where it becomes continuous 

begins at the neck of the bladder. It passes through the pros

The prostatic urethra is about 1.25 in. (3 cm) long and 

The Pelvis: Part II—The Pelvic Cavity

Prostatic Urethra

-

-

Peritoneum

-

-

Ureters

-
-

psoas

ilium

internal iliac artery

uterine artery

ureter

obturator internus

levator ani

posterior fornix

anterior fornix

vagina

bladder

inferior epigastric artery

round ligament of uterus

uterine tube

round ligament of ovary

ovary

external iliac vessels

urethra

FIGURE 7.18

 

y, the uterine tube, and the vagina.

Right half of the pelvis showing the ovar


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 Basic Anatomy 

279

ovarian artery

external iliac
vessels

attachment of
mesovarium

obturator
membrane

obturator
internus

obturator internus fascia

ureter

vagina

levator ani

cervix

pelvic fascia

uterine artery

peritoneum

paroophoron

ovary

epoophoron

psoas

uterine tube

round ligament of ovary

fundus

broad
ligament

round ligament of ovary

uterine tube

round
ligament
of uterus

peritoneum

ureter

vaginal branch

cervix

uterine artery

broad ligament

mesovarium

ovary

A

B

FIGURE 7.19

 

Location and Description

of micturition are identical to those in the male.

supply, lymph drainage, and nerve supply; and the process 

The general shape and structure of the bladder; its blood 

urogenital diaphragm.

 of the bladder rests on the upper surface of the 

neck

The 

internus muscle above and the levator ani muscle below. 

More posteriorly, they lie in contact with the obturator 

 and the pubic bones. 

retropubic pad of fat

in front to the 

 are related 

inferolateral surfaces

body of the uterus. The 

related to the uterovesical pouch of peritoneum and to the 

superior surface

by the vagina from the rectum. The 

 is separated 

posterior surface,

 or 

(see Fig. 7.5). The 

 of the bladder lies behind the symphysis pubis 

apex

The 

clinical importance (see Fig. 7.5).

the bladder to the uterus and the vagina is of considerable 

surface of the urogenital diaphragm. The close relation of 

in the male pelvis, and the neck rests directly on the upper 

absence of the prostate, the bladder lies at a lower level than 

ately behind the pubic bones (see Fig. 7.5). Because of the 

As in the male, the urinary bladder is situated immedi

within the broad ligament. Note that the uterus has been retroverted into the plane of the vaginal lumen in both diagrams.

 Uterus on lateral view. Note the structures that lie 

ovary and part of the left uterine tube have been removed for clarity. 

 Coronal section of the pelvis showing the uterus, broad ligaments, and right ovary on posterior view. The left 

A.

B.

Urinary Bladder

-

base,

 is 

Female Genital Organs

Ovary

Each ovary is oval shaped, measuring 1.5 × 0.75 in. (4 × 2 cm), 

lateral margin of the uterus to the ovary (see Figs. 7.18 and 7.19).

remains of the upper part of the gubernaculum, connects the 

 which represents the 

round ligament of the ovary,

The 

 (see Fig. 7.19).

suspensory ligament of the ovary

is called the 

attachment of the mesovarium and the lateral wall of the pelvis 

That part of the broad ligament extending between the 

 (see Fig. 7.19).

mesovarium

and is attached to the back of the broad ligament by the 

 

Stress Incontinence

ing the urethra and the bladder neck surgically by sutures or 

into the vagina that raises the upper end of the urethra. A 

plished with some success by the introduction of a pessary 

of the bladder and the urethra is restored. This may be accom

is directed to supporting the urethra so that the normal angle 

nence than lean women. The treatment of stress incontinence 

of partial urinary incontinence occurring when the patient 

der is lost. This injury causes stress incontinence, a condition 

stretches the supports of the bladder neck, and the normal 

labor, especially one in which forceps is used, excessively 

tone of the levatores ani muscles. In the female, a difficult 

However, the most important support for the bladder is the 

cia, which in certain areas is condensed to form ligaments. 

The bladder is normally supported by the visceral pelvic fas-

angle between the urethra and the posterior wall of the blad-

coughs or strains or laughs excessively. It has been deter-

mined that obese women have twice the incidence of inconti-

-

more satisfactory permanent result may be achieved by rais-

by a fascial sling or artificial tape.

C L I N I C A L   N O T E S


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280

  CHAPTER 7

 

The Pelvis: Part II—The Pelvic Cavity

Development of the Bladder in Both Sexes

absorbed into the lower part of the bladder so that the ure

The caudal ends of the mesonephric ducts now become 

primitive 

the anterior part of the cloaca on each side permits one, for 

The entrance of the distal ends of the mesonephric ducts into 

 (Fig. 7.20). 

 is described on page 

The division of the cloaca into anterior and posterior parts by 

the development of the urorectal septum

268. The posterior portion forms the anorectal canal

purposes of description, to divide the anterior part of the clo-

aca into an area above the duct entrances called the 
bladder and another area below called the urogenital sinus.

-

ters and ducts have individual openings in the dorsal wall (see 

Fig. 7.20). With differential growth of the dorsal bladder wall, the 

umbilicus (Fig. 7.22). The condition is caused by a failure of the 

The primitive bladder may now be divided into an upper 

the urethra. That part of the dorsal bladder wall marked off by 

ureters come to open through the lateral angles of the bladder, 

and the mesonephric ducts open close together in what will be 

the openings of these four ducts forms the trigone of the blad-

der (Fig. 7.21). Thus, it is seen that in the earliest stages the lin-

ing of the bladder over the trigone is mesodermal in origin; later, 

this mesodermal tissue is thought to be replaced by epithelium 

of entodermal origin. The smooth muscle of the bladder wall is 

derived from the splanchnopleuric mesoderm.

dilated portion, the bladder, and a lower narrow portion, the 
urethra (see Fig. 7.20). The apex of the bladder is continuous 

with the allantois, which now becomes obliterated and forms a 

fibrous core, the urachus. The urachus persists throughout life 

as a ligament that runs from the apex of the bladder to the umbi-

licus and is called the median umbilical ligament.

Congenital Anomalies of the Bladder
Exstrophy of the Bladder (Ectopia Vesicae)
Exstrophy of the bladder occurs three times more commonly 

in males than in females. The posterior bladder wall protrudes 

through a defect in the anterior abdominal wall below the 

 embryonic mesenchyme to invade the embryonic disc caudal to 

of the prostatic urethra is formed from the urogenital sinus (see 

 (see page 212). Its inferior end is absorbed 

In both sexes, the mesonephric (or Wolffian) duct gives origin on 

mesenchyme between the ectoderm and entoderm produces an 

the cloacal membrane (see Fig. 7.22). The absence of intervening 

unstable state, which is followed by breakdown of this area.

Because of the urinary incontinence and almost certain 

occurrence of ascending urinary infection, surgical reconstruc-

tion of the bladder is attempted.

Fate of the Mesonephric Duct in Both Sexes

each side to the ureteric bud, which forms the ureter, the pelvis 
of the ureter,
 the major and minor calyces, and the collecting 
tubules of the kidney

into the developing bladder and forms the trigone and part of the 

urethra.

In the male, its upper or cranial end is joined to the develop-

ing testis by the efferent ductules of the testis, and so it becomes 

the duct of the epididymis, the vas deferens, and the ejaculatory 
duct.
 From the latter, a small diverticulum arises that forms the 
seminal vesicle (see Fig. 4.26).

In the female, the mesonephric duct largely disappears. Only 

small remnants persist—as the duct of the epoophoron and the 
duct of the paroöphoron. The caudal end may persist and extend 

from the epoophoron to the hymen as Gartner’s duct.

Development of the Urethra

In the male, the prostatic urethra is formed from two sources. 

The proximal part, as far as the openings of the ejaculatory 

ducts, is derived from the mesonephric ducts. The distal part 

Fig. 7.21). The 

In the female, the upper two thirds of the urethra are derived 

membranous urethra and the greater part of the 

penile urethra also are formed from the urogenital sinus. The 

distal end of the penile urethra is derived from an ingrowth of 

ectodermal cells on the glans penis.

from the mesonephric ducts. The lower end of the urethra is 

formed from the urogenital sinus (see Fig. 7.21).

E M B R Y O L O G I C   N O T E S

The ovary usually lies against the lateral wall of the pelvis 

germinal 

by a modified area of peritoneum called the 

 This capsule is covered externally 

tunica albuginea.

The ovaries are surrounded by a thin fibrous capsule, 

is lax, the ovary takes up a variable position in the pelvis.

abdominal cavity. After childbirth, when the broad ligament 

nancy, the enlarging uterus pulls the ovary up into the 

the rectouterine pouch (pouch of Douglas). During preg

extremely variable, and it is often found hanging down in 

behind (see Fig. 7.18). The position of the ovary is, however, 

external iliac vessels above and by the internal iliac vessels 

 bounded by the 

ovarian fossa,

in a depression called the 

-

the 

 epithelium.

the ovary becomes progressively scarred as successive 

Before puberty, the ovary is smooth, but after puberty, 

before birth from primordial germ cells.

because the layer does not give rise to ova. Oogonia develop 

 is a misnomer 

germinal epithelium

 The term 

 

corpora lutea degenerate. After menopause, the ovary 

right side and into the left renal vein on the left side.

The ovarian vein drains into the inferior vena cava on the 

Veins

level of the 1st lumbar vertebra.

 arises from the abdominal aorta at the 

ovarian artery

The 

Arteries

female.

 in the sexually mature 

progesterone,

estrogen

mones, 

 and the female sex hor

ova,

of the female germ cells, the 

The ovaries are the organs responsible for the production 

Function

becomes shrunken and its surface is pitted with scars.

-

 and 

Blood Supply


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 Basic Anatomy 

281

mesonephric duct

anorectal canal

ureteric bud

allantois

allantois

bladder

urethra

ureter

remains of mesonephric duct

area of bladder and urethra formed

from mesonephric duct

urethra

bladder

ureter

Male

Female

urogenital sinus

primitive bladder

mesonephric duct

FIGURE 7.20

  Formation of the urinary bladder from the anterior part of the cloaca and the terminal parts of the mesonephric 

ducts in both sexes. The mesonephric ducts and the ureteric buds are drawn into the developing bladder.

ureter

trigone of bladder

urethra

derived from urogenital sinus

remains of mesonephric duct

forming Gartner's duct

mesonephric duct forming

ejaculatory duct

prostatic utricle

prostate gland

Female

Male

FIGURE 7.21

  Parts of the bladder and urethra derived from the mesonephric ducts in both sexes (

drainage of the ovary with those of the testis.)

mesovarium. (Compare the blood supply and the lymph 

sels and nerves finally enter the hilum of the ovary via the 

known as the suspensory ligament of the ovary. The ves

ing through the lateral end of the broad ligament, the part 

iliac vessels (see Fig. 7.19). They reach the ovary by pass

the ovary pass over the pelvic inlet and cross the external 

The blood supply, lymph drainage, and nerve supply of 

plexus and accompanies the ovarian artery.

The nerve supply to the ovary is derived from the aortic 

Nerve Supply

lumbar vertebra.

and drain into the para-aortic nodes at the level of the 1st 

The lymph vessels of the ovary follow the ovarian artery 

Lymph Drainage

end of the urethra in the female and the lower part of the prostatic urethra in the male are formed from the urogenital sinus.

). The lower 

hatch marks

-

-


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282

  CHAPTER 7

 

The Pelvis: Part II—The Pelvic Cavity

trigone of
bladder

ureteric
orfifices

epispadias

embryonic disc

primitive
streak

body stalk

cloacal
membrane

normal path
taken by
embryonic
mesenchyme

cloacal membrane

tail fold

absence of mesenchyme here

is responsible for exstrophy

of the bladder

umbilical cord

A

B

C

FIGURE 7.22

 

oped, but the mesenchyme has failed to enter the ventral body wall between the cloaca and the umbilical cord.

 Fetus as seen from the side. The head and tail folds have devel

onic mesenchyme in the region of the cloaca is shown. 

 Dorsal view of the embryonic disc. The normal path taken by the growing embry

 Exstrophy of the bladder. 

A.

B.

-

C.

-

Position of the Ovary

ovarium. After pregnancy, the broad ligament is lax, and the 

The ovary is kept in position by the broad ligament and the mes-

ovaries may prolapse into the rectouterine pouch (pouch of 

Douglas). In these circumstances, the ovary may be tender and 

cause discomfort on sexual intercourse (dyspareunia). An ovary 

situated in the rectouterine pouch may be palpated through the 

posterior fornix of the vagina.

Cysts of the Ovary

Follicular cysts are common and originate in unruptured graafian 

follicles; they rarely exceed 0.6 in. (1.5 cm) in diameter. Luteal 
cysts
 are formed in the corpus luteum. Fluid is retained, and 

the corpus luteum cannot become fibrosed. Luteal cysts rarely 

exceed 1.2 in. (3 cm) in diameter.

C L I N I C A L   N O T E S

Development of the Ovary

posterior abdominal wall to secrete estrogens. The presence of 

The female sex chromosome causes the genital ridge on the 

estrogen and the absence of testosterone induce the develop-

ment of the ovary and the other female genital organs.

The  sex cords contained within the genital ridges con-

tain groups of primordial germ cells. These become broken up 

into irregular cell clusters by the proliferating mesenchyme 

(Fig. 7.23). The germ cells differentiate into 

primary oocytes become surrounded by a single layer of cells 

oogonia, and by the 

third month, they start to undergo a number of mitotic divisions 

within the cortex of the ovary to form primary oocytes. These 

derived from the sex cords, called the granulosa cells. Thus, pri-
mordial follicles

 have been formed, but later, many  degenerate. 

The mesenchyme that surrounds the follicles provides the 

 ovarian stroma. The relationship of the ovary to the developing 

The ovary may fail to descend into the pelvis or very rarely may 

syndrome. The classic features of this syndrome are webbed 

uterine tube is shown in Figure 7.24.

Ovarian Dysgenesis
Complete failure of both ovaries to develop is found in Turner’s 

neck, short stocky build, increased carrying angle of the elbows, 

lack of secondary sex characteristics, and amenorrhea.

Imperfect Descent of the Ovary

be drawn downward with the round ligament of the uterus into 

the inguinal canal or even into the labium majus.

E M B R Y O L O G I C   N O T E S


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 Basic Anatomy 

283

posterior abdominal wall

mesonephros

mesonephric tubule

genital ridge

sex cords

gut

primordial sex cells

coelomic epithelium

dorsal mesentery

mesonephric duct

genital ridge

primordial follicle

mesonephric

duct

mesovarium

paramesonephric

duct

developing ovary

fimbria

mesonephric tubules

developing

ovary

gubernaculum

mesonephric duct

paramesonephric duct

A

B

C

D

papamesonephric

duct

FIGURE 7.23

  Formation of the ovary and its relationship to the mesonephric and paramesonephric ducts.

ovary

round ligament

of the ovary

epoophoron

round ligament

of the uterus

paroophoron

uterine tube

ovary

round ligament

of the ovary

round ligament

of the uterus

Gartner's duct

uterus

A

B

FIGURE 7.24

  The descent of the ovary and its relationship to the developing uterine tube and uterus.


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  CHAPTER 7

 

The Pelvis: Part II—The Pelvic Cavity

infundibulum

ampulla

isthmus

intramural part

fundus

uterine tube

cavity of uterus

body

internal os

supravaginal cervix

cervical canal

vaginal cervix

external os

vagina

lateral fornix

ureter

uterine artery

ovarian artery

fimbriae

90˚

170˚

A

B

C

D

FIGURE 7.25

 

is divided into four parts:

of the ovary with the cavity of the uterus. The uterine tube 

and 7.19). Each connects the peritoneal cavity in the region 

lie in the upper border of the broad ligament (see Figs. 7.18 

The two uterine tubes are each about 4 in. (10 cm) long and 

Location and Description

Uterine Tube

 Anteverted and anteflexed position of the uterus.

 Anteverted position of the uterus. 

 External os of the cervix: 

 Different parts of the uterine tube and the uterus. 

A.

B.

(above) nulliparous; (below) 

parous. C.

D.

1.

 The 

ovary (see Figs. 7.19 and 7.25).

 which are draped over the 

fimbriae,

processes, known as 

ovary. The free edge of the funnel has several fingerlike 

projects beyond the broad ligament and overlies the 

 is the funnel-shaped lateral end that 

infundibulum

2.

 The 

 is the widest part of the tube (see Fig. 7.25).

ampulla

3.

 The 

just lateral to the uterus (see Fig. 7.25).

 is the narrowest part of the tube and lies 

isthmus

4.

 The 

cular walls. In the young nulliparous adult, it measures 3 in. 

The uterus is a hollow, pear-shaped organ with thick mus

Location and Description

hypogastric plexuses.

Sympathetic and parasympathetic nerves from the inferior 

Nerve Supply

The internal iliac and para-aortic nodes.

Lymph Drainage

The veins correspond to the arteries.

Veins

ovarian artery from the abdominal aorta (see Fig. 7.25).

The uterine artery from the internal iliac artery and the 

Arteries

travel to reach the ovum.

The tube serves as a conduit along which the spermatozoa 

fertilized ovum and transports it to the cavity of the uterus. 

(usually in the ampulla). It provides nourishment for the 

vides a site where fertilization of the ovum can take place 

The uterine tube receives the ovum from the ovary and pro

Function

uterine wall (see Fig. 7.25).

 is the segment that pierces the 

intramural part

-

Blood Supply

Uterus

-




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