Maternal Anatomy and

Congenital Kamis, 1 Agustus 2019

Genitourinary Tandyo Triasmoro

Abnormalities
  Maternal Anatomy
 Anterior Abdominal Wall
 External Genitalia
 Internal Generative Organs
 Lower Urinary Tract Structure
 Musculoskeletal Pelvic Anatomy

 Congenital Genitourinary Abnormalities

Outline  Genitourinary Tract Development
 Sexual Differentiation
 Disorder of Sex Development
 Bladder & Perineal Abnormalities
 Mullerian Abnormalities
 Uterine Flexion
Maternal Anatomy
Anterior Abdominal Wall
 Skin, subcutaneous layer (fascia), muscles

Abdominal Wall
 Course diagonally towards umbilical (surgically
important) should be occluded during surgery

 Skin, subcutaneous layers, and mons pubis are supplied by the

superficial epigastric, superficial circumflex iliac, and superficial
external pudendal arteries which arise from femoral artery.
Blood vessels  Muscles and fascia are supplied by inferior “deep” epigastric
vessels arisen from external iliac arteries  it anastomoses with
and nervous superior epigastric vessels at the level of umbilical which arises
innervation from internal thoracic vessels
 Anterior abdominal wall is innervated by intercostal nerves (T7-
T11), subcostal nerve (T12) and the iliohypogastric and
ilioinguinal nerves (L1)
Maternal Anatomy
External Genitalia/Generative Organs
  Vulva/Pudenda  consisted of all visible external structure from
symphysis pubis to perineal body, including mons pubis, labia
majora and minora, clitoris, hymen, vestibule, urethral
Vulva opening, greater vestibule (Bartholin’s Glands), minor
vestibular glands, and paraurethral glands.
 It is supplied by pudendal vessels and nerves
  Mons pubis  fat-filled cushion overlying symphysis pubis. After
puberty, it is covered by hair
 Labia Majora  7-8 cm long, 2-3 cm wide, and 1-1.5 cm thick. Lots
of glands (apocrine, eccrine, and sebaceous glands). Beneath skin
is consisted of fibres and fat (rich in venous plexus  may be
varicose during pregnancy!
Mons Pubis,  Labia Minora  has 2 lamellaes, the lower part fuses to make
frenulum, the superior part fuses to make prepuce. Composed of
Labia, Clitoris, connective tissue with numerous vessels, elastin fibres, and few
Vestibules smooth muscle fibres. LACK OF apocrine, eccrine, and hair
follicles, but sebaceous glands are NUMEROUS
 Clitoris  FEMALE EROGENOUS ORGANS. Composed of glans,
body, and 2 crura. Body has two corpus cavernosa. Supplied by
branches of internal pudendal artery
 Vestibules  almond-shaped, has 6 openings (urethra, vagina, 2
Bartholin’s glands, 2 Skene glands)
  Hymen varying thickness, mainly composed by elastic and
collagenous connective tissues. Torn at several sites during first
coitus, could be torn by any means of penetration (using
tampon, cycling, etc)
 Vagina  musculomembranous tube extends to uterus.
ANTERIORLY, separated by connective tissue from bladder and
urethra (VESICOVAGINAL SEPTUM). POSTERIORLY, separated
Vagina & by connective tissue from rectum (RECTOVAGINAL SEPTUM).
Hymen Upper-fourth is separated from the rectum by RECTOVAGINAL
POUCH or CUL-DE-SAC or Pouch of Douglas
 Anterior wall of vagina length is 6-8 cm, posterior wall 8-10 cm
 Upper end subdivided by the cervix into posterior fornix, anterior
fornix, and 2 lateral fornicles
 Vessels  proximal by uterine and vaginal arteries. Posterior wall
by middle rectal artery, and distal wall by internal pudendal
artery
 Anterior/Urogenital
 Area between thigh that resembles bony pelvic outlet: consists of
Triangle
pubic symphysis ANTERIORLY, ischiopubic rami and ischial
tuberosity ANTERORLATERALLY, sacrotuberous ligament
POSTEROLATERALLY, and coccyx POSTERIORLY. Divided two
Perineum Perineal
to triangle ANTERIOR and POSTERIOR
Body
 In the middle of anterior and posterior triangle, lies perineal body
Posterior/Anal
(8mm tall and 14mm wide+thick) junction.  incised during
as a Triangle
episiotomy and may be torn during delivery
  Superficial Anterior Triangle
 Bounded by pubic rami (superior), ischial tuberosity (lateral),
superior transversal perineal muscles (posterior)
 Important structures  Bartholin’s glands, vestibular bulbs, clitoral
body and crura, branches of pudendal nerves and vessels, muscles
(ischiocavernosa, bulbospongiosus, and superficial transversal
perineal)

 Deep Anterior Triangle

 Contains portions of urethra, vagina, internal pudendal artery
Perineum (2) branches, muscles of striated urogenital complex.
 Urethra  3-4 cm long, 2/3 distal fused with anterior vaginal wall,
has 2 layers of smooth muscles (inner longitudinal, outer circular)

 Posterior Triangle
 Contains ischioanal fossae, anal canal, anal sphincter complex,
internal pudendal vessels and pudendal nerves

 Pelvic Diaphragm  consist of levator ani and coccygeus muscles

Pudendal
Innervations and
vessels
 Formed by the anterior rami of
S2-S4 spinal nerves
 Courses behind sacrospinous
ligament within the pudendal
canal  risk of stretch injury
during labor
 Perineum gets supplied by
internal pudendal arteries
Maternal Anatomy
Internal Generative Organs
  Non-pregnant uterus lies between bladder (anterior) and rectum
(posterior)
 Pear shaped, has two major unequal parts (corpus and cervix).
ISTHMUS is the union site of this two. 6-8 cm in nulligravida, 9-10
cm in multiparous. Weighing average 60 g, but can weigh more in
parous women
Uterus  Myometrium contains smooth muscle fibres that united by
connective tissues of elastic fibres which surrounds myometrial
vessels. Endometrium mostly in uterine cavity, composed of
epithelium, glands, and vascular stroma.
 Cervix  divided to 2 portion, upper (portio supravaginalis) and
lower (portio vaginalis)
  Ligaments between uterine towards pelvic  round, broad,
cardinal, and uterosacral ligaments
 Round and broad do not provide any substantial support
 Round ligaments originates from below and anterior to fallopian
tubes. Sampson artery (branch of uterine artery) run within the
ligament.
Ligaments  Broad ligaments are two wing-like structure which extend from
lateral uterus to pelvic side walls
 Cardinal ligaments  thick base of broad ligaments, anchors
medially to uterus and upper vagina
 Uterosacral ligaments  originates with a posterolateral
attachment to the supravaginal portion of the cervix and inserts to
the fascia over the sacrum
  During pregnancy, uterus gets supply from uterine and ovarian
arteries:
 Uterine artery is a main branch of internal iliac artery which enters
the uterus through bro ad ligaments (careful ! near the cervix
crosses the ureter, may be severed during hysterectomy). Courses
Pelvic Blood medially to the lateral side of uterus.
 In the supravaginal portion of cervix, uterine artery divides into two
Supply, branches. Cervicovaginal arteries which supply the upper vagina
and lower cervix and the main uterine artery which penetrates the
Lymphatics, body of the uterus to form the ARCUATE ARTERIES
 The ovarian artery is a direct branch from aorta. Enters the uterus
and through infundibulopelvic ligament
Innervation  Blood supply to the pelvis is predominantly provided by the
branches of the internal iliac artery  anterior and posterior
 Anterior  inferior gluteal, internal pudendal, middle rectal,
vaginal, uterine, and obturator arteries
 Posterior  superior gluteal, lateral sacral, and iliolumbar arteries
Pelvic Blood
Supply,  Lymphatic vessels from uterus divided into 2 sets of group 
Lymphatics, internal iliac nodes and paraaortic lymph nodes
 Cervix  mainly in internal iliac nodes
and
Innervation (2)