Dr. K. Bharathi Professor & Head - PowerPoint Presentation

Slide1

Dr. K. BharathiProfessor & HeadDept. of Prasutitantra & StrirogaNational Institute of AyurvedaJaipur

ANATOMY OF UTERUS

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Garbhashayaशङ्खनाभ्याकृतिर्योनिस्त्र्यावर्ता सा प्रकीर्तिता | तस्यास्तृतीये त्वावर्ते गर्भशय्या प्रतिष्ठिता ||४३|| 

यथा रोहितमत्स्यस्य मुखं भवति रूपतः | 

तत्संस्थानां तथारूपां गर्भशय्यां विदुर्बुधाः ||४४||

(

Sushruta

Shareera

५. शरीरसंख्याव्याकरणशारीरम्

)

गर्भशय्यामनन्तरमावर्तं

 

[

१

]

 

प्रतिपादयितुमाह-शङ्खनाभ्याकृतिरित्यादि|

 

तत्संस्थानामिति

 

अल्पमुखामन्तर्महासुषिरामित्यर्थः||

४३-४४||

 

(

Nibandha

sangraha

commentary)

‘गर्भशय्यानन्तरमकीर्तितां इति पा.|

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Three avarthas of Yoni

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Description of Uterus in Ayurvedic Classics

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THE UTERUSSynonyms: metra, womb, matrixA pear shaped hollow muscular organ

Measuring around 7.5 x 4.0 x 2.5 cm in the longitudinal, transverse, and

anteroposterior

diameters.

It is slightly larger in the

multipara

than in the

nullipara

.

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Anteversion = a tipping forward of an organAnteflexion = bending forward of an organPyriform = pear – shapedHollow = having a space or cavity inside; not solid; empty

Slide7

Divisions1. The corpus uteri: Body that lies above the internal os Cornu =

the area of insertion of the fallopian tubes

Fundus

lies above the insertion of the tubes.

Three structures are attached to the

cornu

round ligament

anteriorly

,

Fallopian tube centrally,

ovarian ligament

posteriorly

.

Slide8

Divisions2. The isthmus:an area 4-5 mm in length that lies between the anatomical internal os above, and the histological internal os below. It is lined by low columnar epithelium and few glands.The isthmus expands during pregnancy forming the lower uterine segment (10 cm) during the last trimester.

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Divisions3. The cervix:The elongated lower part of the uterus Measuring 2.5-3.0 cm. Divided by the vaginal attachment intosupravaginal portion abovevaginal portion (portio-vaginalis) below.

The cervical canal is the cavity that communicates above with the uterine cavity at the internal os and below with the vagina at the external os.

The external os is round in nulliparas and slit shaped in multiparas.

The cervical mucosa has two ridges (anterior and posterior) from which transverse ridges radiate to form the arbor vitae uteri.

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Slide11

Dissection showing the cephalic aspect of the female genitalia and its relations

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Ventral view of a deep dissection of the urinary bladder and the blood supply to the left side of the internal genitalia, showing the relation of the uterine vessels to the ureter

Slide13

PositionThe uterus is kept in an anteverted anteflexed position (AVF), with the external os lying at the level of the ischial spines, by the support of the cervical ligaments, endopelvic fascia and pelvic floor muscles (levator ani). Anteversion: The uterus is inclined anteriorly to axis of the vagina.

Anteflexion:

The body of the uterus is bent forwards upon the cervix.

 

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Relations of the Body of the UterusAnteriorly: The bladder and vesicouterine pouch.Posteriorly: The pouch of Douglas.Laterally: The broad ligament on each side.

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Relations of the Supravaginal cervixAnteriorly: Urinary bladder.Posteriorly: Forms the anterior wall of Douglas pouch.Laterally: 1/2 an inch lateral to the internal os the ureter is crossed by the uterine artery (i.e. ureter below the uterine artery).

The uterosacral, cardinal, and pubocervical ligaments are attached to its posterior, lateral, and anterior surfaces respectively.

Slide16

Ligaments of the UterusThe uterus is partially supported by three pairs of ligaments. The paired round ligaments extend from the anterosuperior surface of the uterus through the internal inguinal rings and through the inguinal canals to end in the labia majors. They are composed of muscle fibers, connective tissue, blood vessels, nerves, and lymphatics.

Slide17

The round ligaments stretch with relative ease, particularly in pregnancy. The uterosacral ligaments are condensations of endopelvic fascia that arise from the posterior wall of the uterus at the level of the internal cervical os. They fan out in the retroperitoneal layer and attach broadly at the second, third, and fourth segments of the sacrum. They are predominately composed of smooth muscle but also contain connective tissue, blood vessels, lymphatics

, and parasympathetic nerve fibers.

Slide18

The paired cardinal (Mackenrodt's) or transverse cervical ligaments arise from the anterior and posterior marginal walls of the cervix and fan out laterally to insert into the fascia overlying the obturator muscles and the levator ani muscles. The cardinal ligaments form the base of the broad ligament. They are composed of perivascular connective tissue and nerves that surround the uterine artery and veins.

The

cardinal and

uterosacral

ligament complex

is collectively called the

parametrium

.

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Histology of the UterusThree layers: 1. Endometrium: (mucosa)2. Myometrium (musculosa) 3. The peritoneal covering or perimetrium

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Histology of the UterusEndometrium: Lined by simple cubical or columnar epitheliumContains tubular glands. Shows cyclic changes with the menstrual cycle under the influence of ovarian hormones

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Histology of the UterusMyometrium Three layers outer longitudinal muscle layermiddle layer of interlacing criss-cross muscle fibres surrounding the blood vessels inner circular muscle layer

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Histology of the UterusPerimetrium:Anteriorly: firmly attached to the fundus and body till the isthmus where it becomes loose and is reflected on the superior surface of the urinary bladder forming the vesicouterine pouch. Posteriorly:

firmly attached to the fundus, body, cervix, and posterior vaginal fornix then is reflected on the pelvic colon forming the

Douglas pouch

.

Laterally:

the anterior and posterior peritoneal coverings blend as the anterior and posterior layers of the

broad ligaments

.

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Histology of the CervixEndocervix: Lined by simple columnar epithelium with compound racemose glands or crypts that are liable to chronic infection. It secretes alkaline cervical mucus.Muscle layer: Outer longitudinal and inner circular muscles.(2 layers only)Ectocervix: Formed of stratified squamous epithelium covering the outer portion of the cervix. The junction between squamous and columnar epithelium at the external os is either abrupt or it may form a transitional zone 1-3 mm known as the transformation zone.

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Blood SupplyArterial supply:THE UTERINE ARTERIES Arise from the anterior division of internal iliac artery. in the base of the broad ligament, crossing above the ureter 1/2 an inch lateral to the supravaginal cervix.2 branches:An ascending

A descending branch

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Blood SupplyThe ascending branches pass upwards in a tortuous manner parallel to the lateral border of the uterus between the 2 layers of the broad ligament to end by anastomosing with branches of the ovarian arteries near the uterine cornu.The descending cervical branch supplies the lower cervix.

Slide26

Blood SupplyVenous drainage:Starts as a plexus between the 2 layers of the broad ligament (Pampiniform plexus) that communicate with the vesical plexus and drains into the uterine and ovarian veins.Lymphatic drainage:

Fundus:

To the para-aortic lymph nodes via ovarian vessels.

Cornu

:

To the superficial inguinal lymph nodes via lymphatics of the round ligament.

Body

:

To the internal then external iliac lymph nodes via the uterine vessels.

Isthmus

: As that of the cervix.

Cervix

:

Two groups of lymphatics:

Primary groups

: Paracervical, parametrial, obturator, internal and external iliac nodes.

Secondary groups

: Common iliac, para-aortic, and lateral sacral lymph nodes.

Slide27

Nerve supply of the UterusThe cervix and body are relatively insensitive to touch, cutting and burning. The cervix is sensitive to dilatation and the body is sensitive to distension.Innervations Parasympathetic form S2,3,4Sympathetic from:T5 and T6 (motor) T10, T11, T12, and L1 (sensory).

Both reach the uterus through branches of inferior hypogastric plexus.

 

Slide28

THE VAGINA

A

fibromuscular

tube from the vulva to the uterus forming an angle of 60° with the horizontal plane.

Vagina = Sheath

Length:

anterior wall is 8-9 cm

posterior wall is 10 -11 cm

Vaginal

Fornices

:

The

cervix projects in the upper blind end of the vagina that forms a pouch (vaginal pouch) around the cervix and is divided into four

fornices

: two lateral, anterior and posterior (deeper)

fornices

.

Slide29

YONIDefinition: ‘Yujyate yoni’Synonyms: गुह्योपस्थमपत्याध्वा योनिः प्रजननं भगम् || (

Paryayaratnamala

– 520)

 

other synonyms –

garbhavartma

,

raktapatha

,

manobhavagara

mukha

Shape:

Shankhanabhi – hollow of the conch shell शङ्खनाभ्याकृतिर्योनिस्त्र्यावर्ता सा प्रकीर्तिता | 

तस्यास्तृतीये त्वावर्ते गर्भशय्या प्रतिष्ठिता ||

(Su.

Sha

. 5/43)

Importance – Surgical anatomy: Is considered as one of the important parts, and hence advised to avoid injury to this while performing

surgey

to extract calculi (

Ashmari

chikitsa

).

 

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Anatomical Relations of the VaginaAnteriorly: Upper 1/3: trigone of urinary bladder Lower 2/3: urethra.

Posteriorly

:

Upper 1/3: peritoneum of Douglas pouch.

Middle 1/3:

ampulla

of rectum.

Lower 1/3: the

perineal

body.

Laterally:

Lower end:

Bulbocavernosus

muscle, vestibular bulb, and

Bartholin

gland.

1 cm above orifice:

urogenital

diaphragm

2½ cm above the orifice:

levator

ani

muscle with the pelvic fascia above it.

The lateral fornix gives attachment, to the lower part of the cardinal ligaments.

The

ureters

pass through the cardinal ligaments 1 cm lateral to the vagina.

 

Slide31

Relations of the Vagina according to AyurvedaSuperiorly – Uterusतस्यास्तृतीये त्वावर्ते गर्भशय्या प्रतिष्ठिता Laterally – extra peshi of female like – shukra artava

praveshini

,

Superiorly –

smaratapatra

(clitoris)

Inferiorly –

bahirmukha

srotas

- external orifice opening outside

Around/ encircled by three

avartas (envelops)

Slide32

Structures of the Vagina: 3 Nadis

–

Sameerana

,

Chandramukhi

,

Gauri

Slide33

Muscular structures of vaginaFour peshi situated in the vaginaTwo Abyantara prasrita (spreaded

) inside

Two –

vritta

(circular) situated at the

mukha

(orifice)

bahya

(externally - laterally)

स्त्रीणां तु विंशतिरधिका | 

…

अपत्यपथे 

[

१] चतस्रः- तासां प्रसृते अभ्यन्तरतो द्वे,मुखाश्रिते बाह्ये च वृत्ते द्वे,

| (Su.

Sha

. 5/39)

‘भगापत्यपथे’ इति पा.|

अपत्यपथे

 

योनौ

 

चतस्रः|

 

चतसृणामेव

 

विवरणमाह-

 

तासामित्यादि|

 

मुखाश्रितेयोनिमुखाश्रिते|

 

अभ्यन्तरतः

 

प्रसृते

 

इति

 

योनेरभ्यन्तरतः

 

प्रसारं

 

प्राप्ते

 

मूत्रस्रोतःस्वरूपे

 

इत्यर्थः|

 

बाह्ये

 

निर्गते,

 

वृत्ते

 

वर्तुले,योनिकर्णिकास्रोतःपार्श्वद्वयगतत्वेन

 

द्वे

 

मांसपेश्यौ|

(

Dalhana

on Su.

Sha

. 5/39)

Slide34

Functions of vagina/Apana vayuArtava vahana/ rakta vahana – carrying down of menstrual blood through the external orifice (

bahirmukha

srotas

)

Garbha

nishkrama

– during the time of

labour

Slide35

Nadis of the vaginaMadanata patraKandarpagehaUpasthagarbha

Slide36

Vaginal SupportsLigaments attached to the upper vagina:Pubocervical ligament anteriorly

Mackenrodt’s

ligament

laterally

Uterosacral

ligament

posteriorly

Levator

ani

muscles

: pubo-vaginalis part

Triangular ligament,

and the

Perineal

membrane.

Vaginal fascia:

Connective tissue fascia that condenses

anteriorly

forming the

vesico

-vaginal fascia and

posteriorly

forming the recto-vaginal fascia.

Slide37

Histology of the VaginaThe cut section of the vagina is “H” shaped with approximation of the anterior to the posterior vaginal walls. It is formed of

Three

layers;

mucosa,

formed of

squamous

epithelium without glands, the

musculosa

,

which is

fibromuscular

with some fibres from the

levator

ani

inserted into it, and the

adventitia,

which is connective tissue continuous with the

paracolpos

.

Slide38

Blood SupplyArterial supply:The vaginal artery (from internal iliac artery)Additional branches from:Middle rectal artery (from internal iliac artery)

Inferior rectal artery (from the internal

pudendal

artery, of the internal iliac artery)

Venous drainage:

A plexus around the vagina (the vaginal plexus), drain into the internal iliac vein by veins that accompany their corresponding arteries.

Slide39

Lymphatic drainage and Nerve Supply

Lymphatic drainage of the vagina

lower 1/3 drains to the inguinal lymph nodes,

upper 1/3 follows lymphatic drainage of the cervix,

middle 1/3, drains in both upper and lower directions.

Nerve supply of the vagina:

The pudendal nerve gives sensory fibres to the lower vagina.

Slide40

Applied AnatomyVaginal Prolapse: Weakness of the vaginal supports (ligaments, fascia and muscles) may lead to: descent of anterior vaginal wall (cystocele or urethrocele), descent of posterior vaginal wall (rectocele or enterocele), or

descent of the vaginal vault after hysterectomy (

vault prolapse

).

Slide41

Applied AnatomyThe posterior fornix: offers a passage to the pouch of Douglas for performing culdoscopy, culdocentesis and for drainage of a pelvic abscess.The lateral fornix:The ureter lies 1-2 cm lateral to it so that it may be injured during clamping the angle of the vagina in hysterectomy operation.

Slide42

Applied AnatomyPudendal nerve block: Transvaginal injection of a local anaesthetic solution around the pudendal nerve as it passes around the ischial spine gives a local anaesthesia sufficient for minor operations on the vulva and vagina, and has been used for low forceps operations in obstetrics.

Slide43

Applied anatomy - AyurvedaYonisamvarana – complications of MudhagarbhaYonibhramsha – bad prognosis of MudhagarbhaYonivyapad treatments – Veshavarabndha

,

Yonipurana

etc

Uttaravasti

Procedures – Insertion of

vastinetra