The Detergents And Disinfectants For Instruments And Surfaces (Hexanios - Surfanios)

External Genital Organs (Vulva - Pudendum)

The vulva contains the following:

• Mons pubis (Mons veneris)

• Labium majus

• Labium minus (nymphae)

• Clitoris

• Vestibule

• Bulbus vestibuli

• Glandula vestibularis major (Bartholin's gland)

• Glandula vestibularis minor: Paraurethral glands (Skene glands)

• Hymen

Mons Pubis (Mons Veneris)

• It is a swelling rich in subcutaneous adipose tissue that extends in front of the symphysis pubis.

Labium Majus

• The mons are folds of fibroadipose skin extending from the pubis to the perineum. It is a homologue of the male scrotum. The labium majus is rich in sebaceous, apocrine and eccrine glands.

Labium Minus Pudendi (Nymphae)

• These are the skin folds located between the labium majus.

• It does not contain hair follicle and subcutaneous tissue , it combines in the posterior part to form the fourchette. The area between the Fourchette and the vaginal opening is called the fossa navicularis.

• The glands of the labia minora are homologous to the glandula preputiales (Littre's glands) located in the penile part of the male urethra.

Clitoris

• It is an erectile tissue, homologous to the male penis in embryological development. It consists of three parts: the corpus, the crus, and the glans.

vestibule

• It is the opening between the labium minus.

• Formations opening to the vestibule:

ostium vagina

Ostium urethra externa

Canal openings of Bartholin's glands (opening posterior to the vestibule)

The duct openings of the Skene glands (opening to the anterior of the vestibule)

Bulbus Vestibuli

• Ostium are hypervascular erectile tissues located under the labium minus on both sides of the vagina. Its posterior end is adjacent to Bartholin's glands.

• The corpus spongiosum is a homologue of the penis.

Glandula Vestibularis Major (Bartholin's Gland)

• On both sides of the vestibule, the bulbus is located under the posterior end of the vestibule. Each gland is folded into the groove between the hymen and the labium minus posterior to the vestibule with a canal.

• It is homologous to the male bulbourethral glands (Cowper's gland).

  Glandula Vestibularis Minor

• Numerous mucous glands located in the vestibule between the urethra and the ostium of the vagina. The glands that open on both sides of the ostium urethra externa are called paraurethral glands (skene glands).

• homologous of male prostate gland 

  Hymen

• It is a circumferential fibrovascular membranous structure located at the entrance of the vagina. It can be annular (most common), semilunar, cribriform, septate, or vertical.

• All these structures are not pathological, but the pathological form is imperforate hymen.

 • The remnants of the hymen after birth are called carunculae hymenales (carunculae myrtiformes ).

Perineum

• It is the layer consisting of muscle and fascia covering the pelvis from below. It is the rhombic region between the symphysis pubis in the front, the tuber ischiadicums and lig.sacrotuberale on the sides, and the coccyx in the back.

• This region can be divided into two parts by an imaginary transverse line passing between the tuber ischiadicums. The triangle in front is called trigonum urogenitale, and the triangle in the back is called trigonum anale.

• The region remaining in the midline between Fourchette and the anus is called the perineal body (central perineal tendon). Rectovaginal fascia attaches to perineal body from inside.

Muscles involved in the structure of the perineal body

1. M. bulbocavernosus

2. M. sphincter ani externus

3. M. transversus perinei superficialis

Superficial Perineal Compartment

• This section is located between the superficial perineal fascia and the inferior fascia of the urogenital diaphragm (perineal membrane).

Superficial perineal compartment muscles

1. M. transversus perinei superfisialis: Urogenital trigone

2.M. ischiocavernosus: Urogenital trigone

3.M. bulbocavernosus (M. bulbospongiosus): Urogenital trigon

4.M. sphincter ani externus: anal trigone

Deep Perineal Compartment

• It is analyzed in two parts.

Urogenital diaphragm muscles

1- M. transversus perinei profundus 

2- M. sphincter urethra

pelvic diaphragm muscles

a. M. levator ani; pubococcygeus (consists of pubovaginalis, puboperinealis, and puboanalis parts), puborectalis, consists of iliococcygeus muscles.

b. M. coccygeus

• Pelvic diaphragm muscles form the primary support structure of the pelvic organs. The urogenital diaphragm muscles strengthen the pelvic diaphragm anteriorly and support the vagina and urethra.

• M. levator ani plays an active role in the prevention of pelvic relaxation, helps micturition and defecation, and supports the fetal head during labor. In case of damage in vaginal deliveries, pelvic organ prolapse is frequently observed.

Vessels and Nerves of External Genital Organs

• Arteries:

A. pudenda interna: terminal branch of A. iliaca interna

A. pudenda externa: branch of A. femoralis

• Veins:

Drains into internal pudendal veins.

• Nerves:

The innervation of the sacral plexus branch n. it comes from pudendus. Fibers transmitting the sensation of pain enter the spinal cord at the level of S2-S4.

• Lymphatics: It happens to superficial and deep ingunial lymph nodes.

Unlike other vulvar structures, lymphatic drainage of the clitoris and Bartholin's gland can also be directly to the pelvic lymphatics.

Internal Genitals

Vagina (Kolpos)

General Information

- The upper 2:3 part of the vagina develops from the paramesonephric (Müller) duct, the lower 1:3 part from the urogenital sinus.

- It is a fibromuscular canal with an anterior wall of 7 cm and a posterior wall of 9 cm in length and 2-3 cm in width, connecting the vulva to the uterus.

- The dead ends between the portio uteri and the vaginal wall in the vagina are called fornix vagina. The deepest is the posterior fornix, which is adjacent to the cul de sac (Douglas pit).

- The anterior wall of the vagina is adjacent to the trigonum vesicle and the urethra, and the posterior wall is adjacent to the Douglas hole and the rectum. The vagina is attached to the arcus tendineus by the structures of the endopelvic fascia on the sides. Weakening of this support can lead to cystocele.

- The vagina has 3 layers:

1-Mucosa:

- Covered by a layer of stratified, non-keratinized squamous epithelium.

- secretion; consists primarily of secretions from the endocervical and bartholin glands, as well as epithelial transudation and dead epithelial cells.

- There are many mucosal folds running transversely in the vaginal wall. These structures, called columna rugarum, contain cavernous tissue and show erectile properties.

2-Muscularis

3-Adventitia: It surrounds the entire vagina and contains connective tissue; Also called paracolpium.

There is no submucosal layer in the vagina.

Vessels and Nerves of the Vagina

Arteries:

 A. iliaca, which is a branch of the interna. It feeds on vaginalis.

Veins:

 V. vaginalis via v. empties into iliaca interna.

Nerves:

- Innervation of the upper 2:3 part; uterovaginal plexus (Frankenhauser ganglion); Fibers transmitting the sensation of pain enter the spinal cord at the T11-L2 level.

- Innervation of the lower 1:3 part; N. pudendalis: Fibers transmitting the sensation of pain enter the spinal cord at the S2-S4 level.

Lymphatics:

- Drainage of the upper 2:3 part; pelvic lymph nodes (as in the cervix)

- drainage of the lower 1:3 part; inguinal lymph nodes (as in the vulva)

Uterus (Metra / Hystera)

General Information

- Embryologically, it is formed by the merging of the paramesonephric (Müller) ducts in the midline.

- uterus; In women who have not given birth, it is 4x6x8 cm in size and 70-90 gr in weight.

- Uterus anatomically consists of two main parts, corpus and collum (cervix).

Corpus: It is examined in three parts:

-Isthmus: It is the region where it joins with the endocervical canal.

-Cornu: It is the funnel-shaped region where the tuba uterinae are opened.

-Fundus: It is the region above the line between the horns.

Cervix: The part inside the vagina is called portio vaginalis (ectocervix). The part of the cervical canal that opens into the uterine cavity is called the internal os, and the part that opens into the vagina is called the external os. The area between these two openings is called the endocervical canal and is approximately 2-3 cm in length.

- The uterus is histologically composed of three layers:

- Serosa layer (perimetrium); visceral peritoneum.

- The muscular layer (myometrium) is the smooth muscle layer.

- mucous layer (endometrium), basal (lower third) and functional layer (upper two-thirds) (stratum parenchyma- stratum spongiosum).

- The anterior surface of the uterus is covered by the visceral peritoneum, and the peritoneum extends to the isthmus and jumps to the bladder from there. This dead end between the uterus and the bladder is called the excavation vesicouterina. The posterior surface of the uterus is also covered by the peritoneum. This peritoneum also extends posteriorly to the vaginal nerve and jumps to the rectum from there. This cul-de-sac between the uterus and the rectum is called the excavator rectouterina (Douglas pit).

- The endometrium is lined with a secreting single-layer columnar epithelium, and this single-layer columnar epithelium continues in the endocervical canal. The columnar epithelium lining the canal close to the external ostium transforms into stratified squamous epithelium when it comes to the porsio vaginalis surface. This transition zone is called the squamo-columnar junction (transitional zone).

- With the effect of increasing estrogen during puberty, glycogen is stored in the superficial layer of the squamous epithelium, lactobacilli in the normal flora (Doderlein bacilli) break down glycogen, producing lactic acid and the vaginal pH becomes 3.5-4.5.

- Subcolumnar reserve cells under the everted columnar epithelium, which encounter the acid environment of the vagina, begin to proliferate and immature squamous metaplasia develops. As a result of metaplasia, the squamocolumnar junction shifts towards the external os and an active squamocolumnar junction occurs.

- The region between the original and active squamocolumnar junctions is called the transformation zone.

- Everting of the endocervical columnar epithelium towards the ectocervix in the reproductive period is called ectropion (eversion), which is different from cervical erosion.

- The squamocolumnar junction is everted towards the extocervix during the reproductive ages, especially in adolescents, pregnancy and combined oral contraceptive use.

- The squamocolumnar junction regresses into the endocervical canal during low estrogenic processes such as the menopausal period, prolonged use of progestin contraceptives, and prolonged periods of lactation.

- As the squamous epithelium moves towards the endocervical canal, it occludes the mouth of the endocervical glands and causes retention cysts, which are called Nabothi cysts.

Ligaments of the Uterus

 Cardinal ligament (Mackenrodt ligament, transverse cervical ligament): It starts from the cervix uteri and the lateral fornix of the vagina and extends bilaterally to the lateral wall of the pelvis. It is the strongest ligament that holds the uterus in place (E-87). The ureter and uterine artery pass through it. It forms the main support of the vaginal vault.

 Sacrouterine ligament: It is the second strongest ligament that holds the uterus in place. It starts from the isthmus uteri, surrounds the rectum and ends in the sacrum. Contains parasympathetic and sympathetic fibers from the inferior hypogastric and sacral plexus (carries autonomic and sensory fibers of the uterus). It is the cauterized ligament in the LUNA (laparoscopic uterine nerve ablation) procedure applied in the treatment of dysmenorrhea and chronic pelvic pain. It supports the vaginal dome.

 ligamentum rotund (round ligament, ligamentum teres uteri): Embryologically, it is the remnant of the gubernaculum. It passes from the corners of the uterus through the inguinal canal and terminates at the labium majus. A piece of peritoneum starts to drag along with the genital branches of n.ilioinguinalis and n.genitofemoralis, and this structure may become cystic in adulthood. This structure in the vulva is called Nuck's canal cyst (homologous to male hydrocele). There are many smooth muscle fibers in this ligament near the uterus, and leiomyoma development is common from here . However, the ends are made of fibro tissue only. It does not provide structural support to the uterus but helps with anteversion. Arterial nutrition of this ligament; It is supplied by the artery of Sampson. This artery is a branch of a.uterina.

 Lig.latum uteri: Peritoneal leaves covering the tuba uterina, Lig.rotundum and Lig.ovarii proprium and extending from the sides of the uterus to the pelvic wall. The Lig. latum is not an suspending ligament and has no supporting role. It prevents the uterus from tipping to the sides. The upper part covering the tuba uterina forms the mesosalpinx. The connective tissue between the two leaves of the Lig.latum close to the uterus is also called the parametrium.

Vessels and Nerves of the Uterus

 Arteries: Uterus, a. a branch of the iliaca interna a. fed by the uterus. Asendan daliyla a. with ovarica, and the descending branch a. anastomose with the vaginalis. It also anastomoses with branches coming from the opposite uterine artery at the fundus level.

 From the branches of the uterine artery, the arcuate arteries are located parallel to the uterine cavity and supply the superficial myometrium. Radial arteries, which are branches of the arcuate arteries, enter the myometrium at a right angle and feed the deep parts of the myometrium. Later, this vascular structure follows the basilar artery in the basal part of the endometrium and the spiral artery in the functional part, respectively

 Spiral arteries respond to hormonal stimuli and are responsible for menstruation formation. There is no anastomosis between the spiral arteries.

 Veins: Forming a plexus, it drains into the vena uterina and then into the hypogastric (v. iliaca interna) vein.

 Lymphatics: Cervix and lower uterine segment lymphatics are poured into the external iliac chain, fundus lymphatics are poured into the paraaortic chain, lymphatics at the level of the round ligament are poured into the superficial inguinal, femoral and then external iliac chain.

 Nerves: The innervation of the uterus is from the uterovaginal plexus (Frankenhauser ganglion). The fibers that cause pain from the uterus enter the spinal cord from the T11-L2 segments.

Tuba Uterina (Fallopian Tubes - Salpinx)

General Information

They are tubular organs of 7-12 cm in length between the ovaries and the uterus. 

Tuba are divided into 4 sections anatomically , They are ordered from uterus to ovary as follows:

 Pars interstitialis: It is the narrowest part of the tuba, the part of the tuba located intramural in the uterine wall.

 Pars isthmica: is the thicker walled section, the tubal segment closest to the uterus

 Pars ampullaris: It is the longest and widest part of the tuba, located outside the isthmus. Ampulla is the part where oocyte and sperm combine and fertilization and it is the part where ectopic pregnancies are seen most frequently.

 Pars infundibulum (fimbria): It is the enlarged part closest to the ovary. In this section, there are fringe-shaped extensions to catch the oocyte expelled from the ovary. The longest of these is called fimbria ovarica (Richard fimbriaa). Unlike other tubal segments, fimbriae are not covered by the peritoneum.

Tuba consists of 4 parts histologically:

 Serosa (peritoneum)

 Adventitia (fibrous and vascular)

 Muscularis: It extends circularly in the inner part and longitudinally in the outer part, and its function is most clearly observed during the ovulation period, during ovum transport. The period when tubal contractions are least observed is during pregnancy.

 Mucosa: A single layer of ciliated columnar epithelium covers the inner surface of the tuba uterina. While the cilia are most densely located at the fimbrial end, the direction of movement is towards the uterus.

Vessels and Nerves of Tuba Uterina

 Arteries: It comes from a.uterina and a.ovarica. Both arteries anastomose in the mesosalpinx.

 Veins: It drains into V.uterina and v.ovarica

 Nerves: It comes from the uterovaginal and ovarian plexus (sympathetic and parasympathetic). Significant sympathetic innervation is observed.

ovaries

General Information

 The ovaries are 5x3x3 cm in size. They are located in the fossa ovarica on both sides of the uterus, just below the bifurcation of the common iliac artery in the small pelvis. They are adjacent to the n.obturatorius under the fossa ovarica. They are not covered by the peritoneum. The ovaries are ligated with their mesenteries from the region called hilus. They are attached to the latum, all the vascular and nerve structures of the ovary enter from the hilus.

 The ovaries are suspended in the uterus by the Lig.ovarii proprium (utero-ovarian ligament). Rovaricus, a branch of a.uterina, passes through this ligament, which is a remnant of the gubernaculum.

 Lig, suspansorium ovarii (infundibulo-pelvic ligament), on the other hand, hangs the ovary on the side wall of the pelvis and a.-v.ovarica passes through it.

The ovaries and the fimbrial part of the tuba are not covered by the peritoneum.

Vessels and Nerves of the Ovary

 Arteries: The main source is a.ovarica. A.ovarica is a branch of the abdominal aorta.

 Veins: The left ovarian vein often feeds into the left renal vein, and the right ovarian vein drains into the inferior vena cava.

 Lymphatics: It is poured into the paraaortic lymphatic chain.

 Nerves: Innervated from the uterovaginal and ovarian plexus. Fibers transmitting the sensation of pain enter the spinal cord from T9-T10 segments.

Important Anatomical Formations

Important Ligaments

Cooper ligament (pectineal ligament)

 This ligament is used in bladder suspension operations (Burch surgery) to suspend paraurethral tissues in cases with stress urinary incontinence.

sacrospinous ligament

 is a ligament that extends from the spina ischiadica to the lateral aspect of the sacrum. N.pudendus and a.pudendalis lie in front of the interna. This ligament is an important point in vaginal surgery and is often used for vaginal suspension. However, since the a.glutealis inferior and its collaterals are located between the sacrospinous and sacrotuberous ligaments, these vessels may be damaged in suspension operations.

sacrotuberous ligament

 It is the ligament that extends from the ischial tuberosity to the lateral of the sacrum. N.pudendus and a.pudendalis lie behind the interna. This ligament is used in vaginal cuff suspension.

Important Vascular Structures

Aortic-internal iliac artery anastomoses

• Ovarian-uterine

• Sacralis media-sacralis lateralis

• Rectalis superior -rectalis media

• Lumbar-iliolumbar

Important Neuronal Structures

Lumbosacral plexus

N. obturatorius runs along the lateral pelvic wall and passes through the obturator foramen. Therefore, this nerve can be frequently injured in radical hysterectomies, paravaginal repairs and trocar-based incontinence/prolapse surgeries. Pudental nerve (S2-4), sphincter urethra, anal sphincter, motor of deep and superficial perineal muscles; It also provides sensory innervation of external genital organs.

Hypogastric plexus (presacral nerve)

 Two hypogastric nerves emerge from this plexus. Cutting the superior fibers of the hypogastric plexus is called presacral neurectomy. In endometriosis cases, this intervention is 50-75% successful in relieving chronic pelvic pain (E-06).

Other Important Pelvic Anatomical Formations

• Promontory: An important reference point in laparoscopy and sacrocolpopexy

• Sacral hiatus: It is important in caudal anesthesia.

• Spina ischiadica: It is the reference point used in pudendal block, sacrospinous fixation, engagement and determination of arcus tendinosis.

• Spina iliaca anterior superior: It is an important reference point for lateral trocar entry in laparoscopy.

• inferior pubic ramus: It is the reference point used in transobturator incontinence operations. TOT

• Arcus tendinosus: It is formed by the thickening of the obturator fascia and is an important lateral reference point in some vaginal suspension operations (paravaginal repair).

Important Neighborhoods

ureters

• Ureters are localized retroperitoneally. As the ureters enter the pelvis, they cross the common iliac artery medial to their full bifurcation region.

• They then cross the Infundibulopelvic ligament from below, in which the ovarian vessels pass.

• The ureter runs just lateral to the uterosacral ligament in the pelvis and crosses the uterine artery from below at the level of the spina ischiadica, 1.5-2 cm lateral to the cervix.

• Finally, the ureter passes through the upper-anterior part of the vagina and enters the bladder.

Areas where the ureter may be injured 

1. At the level of the infundibulopelvic ligament (a. ovarica) (most common)

2. Lateral to the uterosacral ligament, during its course on the lateral wall of the pelvis

3. Inside the cardinal ligament, at the point where they pass under the uterine artery (frequency 2)

4. As they enter the bladder, at the level of the anterior-upper vagina

Retroperitoneal Spaces

• Prevesical space (Retzius): It is opened for bladder neck suspension in incontinence operations (BURCH and TVT).

• Vesicovaginal space: Cystocele development happens here.

• Rectovaginal space: Rectocele development happens here.

• Presacral space: It is opened in presacral neurectomy and sacrocolpopexy operations.

• Paravesical space: It is opened in radical hysterectomies

• Pararectal space: It is opened in radical hysterectomies.