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Skandalakis’ Surgical Anatomy > Chapter 26. Female Genital System >

Female Genital System: General

A knowledge of anatomy and physiology is just as essential to the gynecologist as a familiarity with the general principles of surgery; indeed, the very foundation stones of successful work are laid in envisaging the relations of the parts to be dealt with so clearly that the operator divides layer from layer almost as if the coverings of the body were transparent. Without this accurate knowledge of the component parts of the pelvis and abdomen and their mutual relations, to be gained only by actual dissections, surgery is not an art, but at best a haphazard procedure guided by luck; without a knowledge of physiology an operator will often ruthlessly sacrifice organs or parts of organs whose functional activity is essential to the happiness and well-being of the patient.—Howard A. Kelly (1898)1


The female reproductive system consists of the ovaries, uterine tubes, uterine body and cervix, and the vaginal canal leading to the external genitalia of the vulva. These female viscera are in close proximity to the urethra and bladder anteriorly, and the rectum and anal canal posteriorly.

An overview of the embryogenesis of the female reproductive system must include the anatomic entities produced from the wolffian and müllerian primordia (Table 26-1). Specifics about the possible development of each entity will be found in the corresponding sections throughout the chapter.

Table 26-1. Derivation of Reproductive Tract Structures from Wolffian and MüLlerian Primordia

Male Female
Genital ridges  
  Testis   Ovary
    Seminiferous tubules (medulla)     Pfluger’s tubulesa 
    Rete testis     Rete ovariia 
    Gubernaculum testis     Round ligament of uterus and ovary
    Ligament of testis     Ligament of ovary
    Mesorchium     Mesoovarium
Wolffian derivatives  
  Mesonephric tubules  
    Ductuli efferentes Epoophorona 
       Ductuli abberantesa 
Ductuli aberrantes (Haller)a 
       Paradidymis (tubules)a 
    Paradidymis collecting duct ?
  Mesonephric duct  
    Ureter, pelvis, and collecting tubules of kidney Ureter, pelvis, and collecting tubules of kidney
    Trigone of bladder Trigone of bladder
    Proximal ductus epididymis Duct of the epoophorona 
    Distal ductus epididymis ?
    Proximal ductus deferens ?
    Ductus deferens Gartner’s ducta 
    Ejaculatory duct ?
    Seminal vesicle ?
    Appendix epididymisa 
Appendix vesiculosa epoophorona 
Müllerian derivatives  
  Appendix testisa 
Uterine tube distal (fimbria)
Hydatid of Morgagni?a 
  ? Oviduct
  ? Uterus
  ? Cervix and upper vagina
  Prostatic utriclea 
Lower vagina
  Colliculus seminalis Hymen?
Urogenital sinus derivatives  
  Bladder Bladder
  Prostatic urethra above colliculus seminalis Urethra
  Urethra below colliculus seminalis Lower vagina and vestibule
  Membranous urethra Lower vagina and vestibule
  Cavernous urethra Lower vagina and vestibule
  Corpus cavernosum urethra Vestibule of bulb
  Corpus cavernosum penis Corpus cavernosum clitori
  Bulbourethral glands (Cowper’s) Vestibular glands (Bartholin’s)
  Urethral glands (Littré) Minor vestibular glands
  Prostate gland Paraurethral glands of Skene?
  Urethral crest & colliculus seminalis Hymen
External genitalia  
  Glans penis Glans clitoris
  Floor of penile urethra Labia minora
  Scrotum Labia majora
  Processus vaginalis testis Canal of Nuck

aVestigial structures.

Source: Skandalakis JE, Gray SW (eds). Embryology for Surgeons, 2nd Ed. Baltimore: Williams & Wilkins, 1994; with permission.

All the organs of the female reproductive system are concerned with storage and evacuation, functions that can be sustained only if normal anatomic relationships are maintained. In the normal, standing nulliparous female patient, the following anatomic relationships are found:


The lower one-third of the vagina is almost vertical in orientation, while the upper two-thirds of the vagina is almost horizontal.

The cervix is found approximately at the level of the ischial spines, but suspended anterior to a line drawn between the spines.

The urethra is almost vertical in orientation, whereas the bladder lies on top of the almost horizontal anterior wall of the vagina.

The anal canal is almost vertical in orientation, whereas the rectum lies on top of the almost horizontal levator plate (Fig. 26-1).

Fig. 26-1.

A, Lateral radiograph of the opacified vagina and rectum. B, Support structures: lateral view. Bladder, urethra, and uterine corpus have been removed from this diagrammatic sagittal section to reveal attachments of the vagina. A line with a dot at each end indicates the distance spanned by the indicated structure; a line ending in a single dot points to the structure. CL, Cardinal ligament; AT, Arcus tendineus fasciae pelvis; PCF, Pubocervical fasciae; LPI, Levator plate inclination; UGHL, Urogenital hiatus length; USL, Uterosacral ligament; CX, Cervix; R, Rectum; OI, Obturator internus muscle; V, Vagina; LP, Levator plate; PCM, Pubococcygeus muscle. (DeLancey JOL. Vaginographic examination of the pelvic floor. Int Urogynecol J 1994;5:19-24; with permission.)

The goal of successful reparative gynecological surgery, whether via the abdominal or vaginal approach, is to restore these natural anatomic relations.

How can these pelvic organs maintain their central anatomic positions while fulfilling their unique roles of distension and storage? The answer is found in a detailed examination of the endopelvic fascia. This connective tissue network is located in the retroperitoneal areas of the pelvis between the parietal peritoneum and parietal fascia of the muscles of the pelvic wall and floor.2 This three-dimensional meshwork of perivascular and visceral fascial sheaths is ultimately anchored to the parietal fascia lining the pelvic basin. The visceral endopelvic fascia will be further discussed later in this chapter, as well as in the chapter on the pelvis and perineum.

It is not within the scope of this chapter to provide detailed physiology of the female genital system, or of the major hormones associated with it, namely luteinizing hormone, follicle stimulating hormone, estrogen, and progesterone.


The history of the anatomy and surgery of the female genital system is shown in Table 26-2.

Table 26-2. Anatomic and Surgical History of the Female Genital System

Soranus of Ephesus (fl. 117)   Wrote an often-translated chapter on the anatomy of the female genitalia
Galen (130-ca. 200)   Wrote tracts on dissection of the uterus (probably infraprimate) for midwives. Assumed the human uterus to be bicornuate.
Hendrik van Deveter (1651-1724)   Wrote an authoritative and well-illustrated obstetrics text
William Hunter 1774 Wrote Anatomy of the Human Gravid Uterus 
McDowell 1809 Removed a giant pseudomucinous cystadenoma
Roux 1832 Performed the first suture of a ruptured female perineum
Sims 1852 Invented the speculum
Keith 1878 Removed large ovarian cysts
Tait 1879 Devised a method of flap splitting for plastic repair of the perineum
Emmet 1882 Repaired childbirth injury anatomically. Great master and teacher of plastic surgery of the perineum, vagina, cervix, uterus, and bladder.
Kelly 1897 Advocated individual ligation of uterine and ovarian vessels prior to hysterectomy or oophorectomy
1914 Developed anterior vaginal repair and Kelly plication for stress urinary incontinence
Brunschwig 1948 Proposed radical hysterectomy with exenteration procedures
Parsons 1954  
Marshall, Marchette, and Krantz 1949 Developed retropubic cystourethropexy
Bricker 1952 Devised ileal bladder
Mulligan 1953 Inserted plastic tubes into stenosed uterine fallopian tubes to treat infertility
Meigs 1954 Popularized total hysterectomy
Pereyra 1959 Developed needle suspension of the bladder
Burch 1961 Performed retropubic colposuspension
Stamey 1973 To needle suspension of the bladder, introduced several concepts including cystoscopic control of needle placement, visualization of bladder neck closure with elevation of sutures, and the use of bolsters to support the bladder neck
Raz 1981-1985 Introduced an inverted U-shaped incision for needle suspension of the bladder
Gittes and Loughlin 1987 Developed the no-incision modification of the Pereyra technique
Nezhat et al. 1992 Described laparoscopic radical hysterectomy with laparoscopic paraaortic lymphadenectomy
Querleu 1993 Described complete laparoscopic surgical staging procedure for ovarian carcinoma

History table compiled by David A. McClusky III and John E. Skandalakis.


Garrison FH. An Introduction to the History of Medicine (4th ed). Philadelphia: WB Saunders, 1960.

Nezhat CR, Burrell MO, Nezhat FR, Benigno BB, Welander CE. Laparoscopic radical hysterectomy with paraaortic and pelvic node dissection. Am J Obstet Gynecol 1992;166:864-865.

Querleu D. Laparoscopic paraaortic node sampling in gynecologic oncology: a preliminary experience. Gynecol Oncol 1993;49:24-29.



Normal Development

The bilateral mesonephric ducts and genital ridges develop from the intermediate mesoderm at approximately the fifth week of gestation. Primordial germ cells from the yolk sac endoderm migrate to the genital ridge to develop as gonads.

Around the seventh week, sex can be determined by XX or XY genotype. Gross identification of the ovary is possible at 10 weeks. Two X chromosomes (several genes) are required for complete development of the ovary. Female sexual differentiation does not depend on hormones.

At approximately the 12th week, the ovary is located at the inferior part of the pelvic brim. The gubernaculum of the ovary produces the ovarian and round ligaments of the uterus. The persistence of a portion of the processus vaginalis forms the canal of Nuck.

Primordial ovarian follicles are present at approximately the 16th week. Each one forms one oogonium. At birth, each ovary contains 200,000-250,000 follicles.

Congenital Anomalies

The ovarian anomalies (Table 26-3 and Table 26-4) are very closely related to the anomalies of the urinary system. When nephric structures are absent on one side, the ovarian agenesis is primary and the germ cells have migrated to the normal side. In some cases, the solitary ovary is larger than normal. With bilateral (müllerian) agenesis, hormonal treatment is needed. In a patient with müllerian agenesis, Vaughn and Jones3 separated ovaries within bilateral inguinal hernias. Two cases of a rare supernumerary ovary located in the omentum of a neonate were reported by Kuga et al.4

Table 26-3. Absence of the Ovaries

  Sex Chromosomes Germ Cells Nephrogenic Ridge Ovary
Phenotypic females        
  Normal XX Present Present Present
Anovarism XX Absent on affected side  Absent  Absent (agenesis)a; unilateral, rare 
XX Absent  Present Absent (secondary dysgenesis); bilateral or unilateral, very rare 
Turner’s syndrome XO Absent  Present Absent (primary dysgenesis); bilateral, uncommon 

aAssociated with absence of the kidney, ureter, uterine tube and hemiuterus on the affected side.

Source: Skandalakis JE, Gray SW (eds). Embryology for Surgeons, 2nd Ed. Baltimore: Williams & Wilkins, 1994; with permission.

Table 26-4. Anomalies of the Ovaries

Anomaly Prenatal Age at Onset First Appearance (or other diagnostic clues) Relative Frequency Remarks
Congenital absence of one or both ovaries (excluding Turner’s syndrome) Atrophy after 4th week At menarche, if bilateral; otherwise discovery is accidental Very rare  
Congenital absence of one ovary and homolateral kidney and ureter 4th week In childhood Rare Uterine and tubal anomalies
Inguinal herniation and ectopia of ovary Around birth In childhood or later Rare Some cases are acquired, not congenital

Adapted from Skandalakis JE, Gray SW (eds). Embryology for Surgeons, 2nd Ed. Baltimore: Williams & Wilkins, 1994, Table 20.6; with permission.

We quote from Vendeland and Shehadeh,5 who reported the seventh case of accessory ovary in the literature:

Supernumerary and accessory ovaries are rare anomalies. The reported incidence of these conditions is 1:29,000-700,000 gynecologic admissions. Since 1864 there have been only six cases of accessory ovary reported in the literature. Additionally, there have been 26 reported cases of supernumerary ovaries…In 36% of reported cases [of accessory ovary], associated congenital anomalies have been identified. Defects have included accessory fallopian tube, bifid fallopian tubes, accessory tubal ostium, bicornuate and unicornuate uteri, septate uterus, agenesis of kidney or ureter, bladder diverticulum, accessory adrenal gland and lobulated liver…Since accessory ovaries are likely to be asymptomatic, they may be underreported. This condition is associated with a high risk of pelvic and renal anomalies and should lead to further evaluation to allow physicians to provide advice about future reproductive function and management of congenital anomalies.

Surgical Anatomy


The ovaries, right and left, are traditionally described as “almond-shaped,” measuring 1 cm á 2 cm á 3 cm, and weigh approximately 3 to 4 grams each. They are white in color. The ovaries are asymmetrical, the right larger than the left. The roughened appearance of the surface of each ovary after puberty is due to degenerating corpora lutea. In addition to producing a woman’s ova, the ovaries are important endocrine organs.

Each ovary is located in the ovarian fossa on the lateral pelvic sidewall, and is attached to the posterior and superior aspect of the broad ligament by a double peritoneal fold, called the mesovarium. The mesovarium does not cover the ovaries; it only “attaches” to their anterior borders. The mesovarium is a reduplication of the posterior lamina of the broad ligament. It is cuboidal epithelium (formerly referred to as “germinal epithelium,” a misnomer) that covers the ovaries.

The utero-ovarian ligament (proper ovarian ligament, commonly referred to as the ovarian ligament [Fig. 26-2]), which is derived from the embryonic ovarian gubernaculum, attaches the ovary to the body of the uterus. The continuations of the embryonic gubernacula form the round ligaments of the uterus (Fig. 26-2) and pass through the deep inguinal rings to enter the inguinal canals, then attach to the labia majora. The infundibulopelvic ligament (suspensory ligament of the ovary) (Fig. 26-3) is simply the peritoneal covering over the ovarian vessels and accompanying lymph channels and nodes and visceral nerves, as they pass just over and just lateral to the ureter at the pelvic brim.

Fig. 26-2.

A, Derivatives of the gubernaculum ovarii: ligament of ovary and round ligament of uterus. B, Sagittal section through broad ligament of uterus. (Modified from Basmajian JV, Slonecker CE. Grant’s Method of Anatomy (11th ed). Baltimore: Williams & Wilkins, 1989; with permission.)

Fig. 26-3.

Uterus and appendages (from behind). (Modified from Basmajian JV, Slonecker CE. Grant’s Method of Anatomy (11th ed). Baltimore: Williams & Wilkins, 1989; with permission.)

The position of the ovaries is variable. Normally each is located on the lateral pelvic sidewall on either side of the uterus, below and posterior to each uterine tube, resting within the ovarian fossa. Bazot et al.6 stated that the suspensory ligament is a good anatomic landmark for localization of the ovaries and lymph nodes related to ovarian tumors. The ovaries of multiparous women may have a lower position. Hill and Breckle7 stated that the position of the uterus and ovaries can be affected by the degree to which the bladder is filled.

The ovary may be in an abnormal position


Within the posterior wall of the broad ligament (therefore, the mesovarium is absent)

Within the rectouterine pouch (cul-de-sac of Douglas)

Within the sac of a femoral hernia

The ovarian fossa is a very shallow depression of the peritoneum on the lateral pelvic sidewall, bounded as follows:


Superior: External iliac vessels, obturator nerve

Anterior: Attachment of the broad ligament to the pelvic sidewall

Posteroinferior: Ureter


For descriptive purposes, the ovary has two borders — anterior and posterior; two poles — upper and lower; and two surfaces — medial and lateral.



The anterior ovarian border is related to the mesovarium, which contains the vessels and nerves for the hilum.

The posterior ovarian border is free.



The upper pole (tubal extremity) has a special relationship with the uterine tube. The proximity of the tubal extremity and the uterine tube allows the fimbriae to touch the surface of the ovary. The tubal extremity of the upper pole is also related to the peritoneum by the infundibulopelvic ligament (suspensory ligament of the ovary).

The lower pole is connected to the lateral wall of the uterus by the utero-ovarian ligament (proper ligament of the ovary).



The medial surface is related to the uterine tube. A small uncovered area relates to loops of small and large bowel. The medial surface is closely related to the fimbriated end of the uterine tube which practically covers this surface.

The lateral surface is related to the ovarian fossa.


Utero-Ovarian Ligament

The utero-ovarian ligament (proper ligament of the ovary) (Fig. 26-2) is a cordlike structure invested with the posterior layer of the broad ligament. It consists of smooth muscle and connective tissue. The ovarian ligament extends from the lower ovarian pole to the lateral uterine wall. It is located between the mesosalpinx and the mesovarium.

Infundibulopelvic Ligament

The infundibulopelvic ligament (suspensory ligament of the ovary) (Fig. 26-3) is a fan-shaped band of fibromuscular visceral connective tissue containing arteries, veins, lymphatics, and visceral nerves extending from the upper ovarian pole to the lateral pelvic wall. This ligament passes from the abdominal cavity into the pelvic cavity at the level of the pelvic brim, superficial to the bifurcation of the common iliac artery, just lateral to where the ureter passes over the bifurcation of the common iliac vessels. This relationship is not evident unless the operator retracts the infundibulopelvic ligament anteriorly at the level of the pelvic brim.


The mesovarium (Fig. 26-3) is a short peritoneal fold from the posterior surface of the broad ligament to the anterior ovarian wall. It facilitates the passage of ovarian vessels and nerves into the ovarian portae (hila). The mesovarium, the infundibulopelvic ligament, and the utero-ovarian ligament together support the ovary in its position along the pelvic sidewall.

Vascular Supply


The blood supply to the ovaries originates from the aorta as the ovarian arteries, below the renal arteries on the anterolateral surface of the aorta. The ovarian arteries (Fig. 26-4, Fig. 26-5, Fig. 26-6) supply the uterine tubes and the upper portion of the body and fundus of the uterus, and anastomose on the lateral aspects of the uterus with the uterine arteries.

Fig. 26-4.

Uterus viewed from behind after dividing pelvis. Broad ligament and a parietal peritoneum have been removed from right side. Drawn from a dissection. (Modified from Last RJ. Anatomy Regional and Applied (5th ed). Baltimore: Williams & Wilkins, 1972, p. 514; with permission.)

Fig. 26-5.

Pathway of ovarian artery, uterine artery, and vaginal artery. (Modified from Brantigan OC. Clinical Anatomy. New York: McGraw-Hill, 1963; with permission.)

Fig. 26-6.

The blood supply to the female reproductive system. Extensive anastomoses occur between the ovarian and uterine arteries. Cervical branches of the uterine arteries anastomose across the median plane. The four-tiered concept of the reproductive system (A, B, C, D) is based on anatomic, physiologic, and pathologic data and may perhaps have embryologic implications. (Modified from Gardner E, Gray DJ, O’Rahilly R. Anatomy (5th ed). Philadelphia: WB Saunders, 1986; with permission.)

The ovarian arteries travel obliquely downward in the retroperitoneum; they, together with accompanying veins, nerves, lymphatics, and overlying peritoneum, form the infundibulopelvic ligament (suspensory ligament) at the level of the pelvic brim. These vessels are medial to the ureter in the abdominal cavity, and then cross at the pelvic brim to travel laterally and anteriorly (very occasionally, posteriorly) to the ureter in the pelvis.



The ovarian artery and the ovarian branch of the uterine artery are responsible for the blood supply of the ovary.

The tubal branch of the uterine artery supplies the tube. The uterine artery also supplies the uterus and the upper vagina.

A detailed anatomic description is necessary for the surgeon to understand the arterial blood supply of the ovaries and the uterine tubes, especially when dealing with microsurgery. The details of the vascular anatomy are illustrated in Figures 26-6 and 26-7.

Fig. 26-7.

Vascular anatomy of ovary pertinent to ovarian resection and reconstruction. (Modified from Cohen BM. Surgery of the ovary, including anatomic derangements of the fimbrial-gonadal ovum-capture mechanism. In: Hunt RB (ed). Atlas of Female Infertility Surgery (2nd ed). St. Louis: Mosby Year Book, 1992, pp. 389-403; with permission.)


The multiple ovarian veins form a plexus that is located in the area of the mesovarium and the infundibulopelvic ligament. The plexus coalesces to form two veins that are adjacent to the ovarian artery. The two veins then unite to form a single vein. The single vein on the right empties into the inferior vena cava; the single vein on the left empties into the left renal vein.

In an interesting study of both male and female gonadal vein anatomy, Lechter et al. reported several variations in the patterns of vessels emptying into the main gonadal veins8 (Fig. 26-8, 26-9). In this study 88 cadavers were male and 12 were female. To determine whether there are any gender-based differences in gonadal vein formation patterns it may be useful to conduct a study of only female cadavers.

Fig. 26-8.

Anatomic variations of terminations of the gonadal veins. (Modified from Lechter A, Lopez G, Martinez C, Camacho J. Anatomy of the gonadal veins: a reappraisal. Surgery 1991; 109:735; with permission.)

Fig. 26-9.

Number of venous trunks of the gonadal veins. (Modified from Lechter A, Lopez G, Martinez C, Camacho J. Anatomy of the gonadal veins: a reappraisal. Surgery 1991;109:735; with permission.)


The ovarian lymphatics drain to the upper paraaortic nodes, which are located close to the origin of the right and left ovarian arteries, just below the renal vessels.


The ovary receives its visceral sympathetic innervation from the aorticorenal plexus. However, as each ovarian plexus travels with the ovarian vessels to each infundibulopelvic ligament, other sympathetic input may originate from the superior and inferior hypogastric plexuses. The preganglionic sympathetic fibers responsible for ovarian supply are believed to originate in the intermediolateral cell column of the spinal cord at T10 and T11 and travel into the abdomen in the thoracic splanchnic nerves; these fibers synapse in ganglia near the superior mesenteric artery. According to Williams et al.,9 the parasympathetic fibers are provided by the inferior hypogastric plexus, arising, therefore in the pelvic splanchnic nerves at S2, S3, and S4. This innervation is probably vasodilatory in effect.

Visceral sensory fibers from the ovary are carried by way of the thoracic splanchnic nerves to reach spinal nerve levels T10, T11 of the spinal cord. With referral of pain sensations, ovarian pain may therefore be experienced in the periumbilical region, like appendicitis. Unremitting ovarian pain may be treated by division of the infundibulopelvic ligament and the nerves within it.

Ovarian pain may occasionally be distributed by the pathway of the obturator nerve to the triangle of Scarpa at the inner surface of the thigh and down to the knee (Howship-Romberg sign). This could be due to supply of pain fibers to the peritoneum by the obturator nerve. A more likely explanation is the proximity of the obturator nerve to the ovarian fossa in the lateral wall of the pelvis. This allows it to be, at times, readily affected by the troubles of the adjacent ovary, with sensory fibers of the obturator nerve referring the pain of the ovary to the lower limb. Such a sign may also manifest itself with an obturator hernia.


Each ovary is covered with germinal cuboidal epithelium. Characteristically, the cuboidal cells become continuous with the mesothelial cells of the mesovarium at the ovarian porta. This superficial ovarian stroma is not peritoneum.

The ovarian parenchyma under the stroma of the cuboidal cells is formed by two parts: a superficial cortex and a deep medulla. The cortex is dense. It contains reticular fibers and fusiform cells that secrete estrogens. With age, the cortex is changed into a smooth tunica albuginea.

The medulla is more vascular than the cortex, according to Bannister and Dyson.10 It is formed by thin connective tissue, many elastic fibers, and nonstriated myocytes.


The preovulatory follicle and the subsequent corpus luteum establish the cycle of ovarian hormones, primarily estrogen and progesterone, that orchestrates the release of a properly matured ovum with a properly coordinated endometrial development in order to receive a fertilized ovum. This ovarian cycle modulates the hypothalamic-pituitary-ovarian axis through both negative and positive feedback on GnRH (gonadotropin releasing hormone), FSH (follicle stimulating hormone), and LH (luteinizing hormone). A significant amount of ovarian tissue may be surgically excised without loss of ovarian function. Luciano et al.11 concluded that surgical trauma is well tolerated by the ovaries without impairing ovarian function.

We quote from Slowey12 on polycystic ovary syndrome:

Polycystic ovary syndrome is the most common endocrinopathy in women of reproductive age…resulting from insulin resistance and the compensatory hyperinsulinemia. This results in adverse effects on multiple organ systems and may result in alteration in serum lipids, anovulation, abnormal uterine bleeding, and infertility.

Ovaries growing large cysts and/or tumors predispose the ovary to torsion which twists the ovarian vessels in the infundibulopelvic ligament. This leads to ischemia of the ovary. Modern observations show that the ovary may be untorsed. If this maneuver allows the ovary to regain a healthy color, there is no need to do an oophorectomy. Entrapment of the ovary within scar tissue or various hernial sacs within the pelvis may also predispose to acute and/or chronic pain syndromes.

We quote from Kokoska et al.13 on acute pediatric ovarian torsion:

Ultrasonography with color doppler is helpful for differentiating acute ovarian torsion from appendicitis. Although the twisted ovary can rarely be salvaged, the etiology is usually benign. Preoperative serum markers and contralateral ovary biopsy may be unnecessary.

Surgical Applications


The ovaries are most commonly evaluated by vaginal/ rectal palpation and vaginal probe ultrasound study. The ovaries may be palpated at the time of vaginal examination. However, because the ovaries lie posterior to the broad ligament, within reach of a finger in the rectum, a rectovaginal examination is encouraged in order to better assess the condition and size of each ovary. Many practitioners also perform in their offices vaginal probe ultrasound scans with the bladder empty to assess follicular activity of the ovaries, and to determine the presence of cystic or solid tumors.

The infundibulopelvic ligament with accompanying ovarian vessels travels just lateral to, and on top of, the ureter at the level of the pelvic brim. In order to avoid injuring the ureter during ligation or coagulation of the infundibulopelvic ligament, the operator needs to retract this ligament away from the ureter and positively identify the ureter before any procedures are performed on the infundibulopelvic ligament.

The vessels that arise at the hilum and travel into the ovarian parenchyma are difficult to see. Electrocoagulation with compression by absorbable sutures may be used in this area. Oelsner et al.14 reported that through-and-through sutures for ovarian reconstruction have a “detrimental” effect on the ovarian parenchyma.

After removing a paratubal cyst, be certain that the uterine tube itself has not been damaged and remember to close the mesosalpinx.

The cortical ovarian zone has a vascular network under the epithelial covering. Hemostasis is important whenever working with the ovary. This is especially important when excising benign ovarian cysts or tumors.

Treatment of ovarian cysts in the newborn is controversial. Hengster and Menardi15 concluded that “cystectomy is the treatment of choice for larger asymptomatic cysts because of their potential malignancy and serious potential complications.” However, in an editorial von Schweinitz16 advised against operation because a study he coauthored found that ovarian cysts in the newborn demonstrated continuous regression leading to the cyst vanishing in most cases. He advised regular ultrasound of uncomplicated ovarian cysts, and determination of serum levels of -fetoprotein and -human chorionic gonadotropin to rule out a malignant germ-cell tumor.

Benign tumors include:


– Ovarian cysts (polycystic ovary syndrome)

– Solid tumors

The incidence of malignant tumors by histologic type17 is:


– 60% serous cystadenocarcinoma

– 15% pseudomucinous carcinoma

– 10% solid undifferentiated adenocarcinoma

– 6% granulosa cell carcinoma

– 2% dysgerminoma

– 7% other types

Infantile primary ovarian lymphoma has been reported.18

Montero et al.19 studied transcoelomic, lymphatic, and hematogenous spread of ovarian tumors to the peritoneum, pelvic and paraaortic lymph nodes, lung, and pleura.

Partial Oophorectomy, Total Unilateral Oophorectomy, Bilateral Oophorectomy

In the presence of persistent benign ovarian cysts or benign ovarian tumors, a partial oophorectomy can easily be accomplished either at the time of laparoscopy or at the time of laparotomy. Experience has shown that much of the ovary can be excised without compromising ovarian function as regards hormonal and ovum production. Hemostasis can be achieved with sutures, electrocoagulation, or laser energy. Various substances and materials have been used in the past to help avoid subsequent scarring at the operative site.

If the benign process encompasses most of the ovary, a total unilateral oophorectomy may be performed by isolating the ovarian vessels in the supplying infundibulopelvic ligament, appropriately ligating or coagulating them, and then transecting these vessels and removing the entire ovary. In the case of malignant ovarian tumors and cysts, both ovaries need to be surgically removed, and appropriate lymph node sampling within the pelvis and periaortic areas is mandated. In very select cases of chronic pelvic pain, endometriosis, pelvic inflammatory disease and scarring, removal of one or both ovaries may alleviate some or all of the chronic pelvic pain. However, even in light of “obvious” pathology that may cause chronic pelvic pain, not all patients who have bilateral oophorectomy will have relief of their pain. In the case of prior oophorectomy and persistence of pelvic pain, one may have to open and explore the lateral pelvic wall, and ligate the ovarian vessels in the infundibulopelvic ligament in search of an ovarian remnant.

Anatomic Complications of Ovarian Surgery

Ovarian surgery, as mentioned above, consists of partial unilateral oophorectomy, partial bilateral oophorectomy, total unilateral oophorectomy, and total bilateral oophorectomy. During surgery, the primary complication is bleeding.

Postoperative complications include intraperitoneal bleeding and occasional small bowel obstruction.

Uterine Tubes


Normal Development

The genital ducts are of two types: mesonephric or wolffian in the male, and paramesonephric or müllerian in the female (see Table 26-1). The paramesonephric ducts form the uterine tubes.

Congenital Anomalies

Just as anomalies of the ovary may be related to anomalies of the urinary system, anomalies of the uterine tubes may be associated with anomalies of other anatomic entities (Table 26-5). Duplication of the uterine tubes is an extremely rare condition formed by splitting of the müllerian system. It may be unilateral or bilateral, and may be associated with double ovaries and uterus, but not double vagina.

Table 26-5. Anomalies of the Female Reproductive Tract

Anomaly Prenatal Age at Onset First Appearance (or Other Diagnostic Clues) Sex Chiefly Affecteda 
RelativeFrequency Remarks
Aplasia and atresia of the uterus and vagina          
  Complete absence of uterus and vagina 8th week At birth Female Rare Familial tendency suggested
  Absence of vagina 9th week At birth Female Uncommon Familial tendency suggested
  Rudimentary, solid uterus, and vagina 17th week At birth Female Rare  
  Imperforate hymen 5th month In infancy or childhood Female Common  
Duplication of the uterine tubes 6th to 7th weeks Found only with ectopic pregnancy Female Very rare Small asymptomatic duplications may be more frequent
Incomplete fusion of the müllerian ducts:          
  Separate hemiuteri 3rd week? At birth Female Very rare Two separate vaginae
  Uterus didelphys 9th week Asymptomatic until pregnancy occurs Female Uncommon May have septate vagina
  Uterus unicornis 9th week Rare  
  Uterus duplex 9th week Common May have single or double cervix and septate vagina
  Uterus septus 12th week Uncommon  
  Uterus arcuatus 7th month Common?  
Fusion of the labia ? Infancy Female Rare May not be congenital

aAlthough these conditions may occur in males with anomalous or vestigial female structures, these anomalies all occur chiefly in females.

Source: Skandalakis JE, Gray SW (eds). Embryology for Surgeons, 2nd Ed. Baltimore: Williams & Wilkins, 1994; with permission.

Surgical Anatomy

Topography and Relations

The uterine tubes are variously known as the fallopian tubes or oviducts, tubes, or salpinges, from the Greek “salpinx” which means trumpet. Each uterine tube is a cylindrical, convoluted canal with a variable length from 7 to 14 cm. This does not include the intramural portion within the uterine cornu, which has a length of approximately 1.5 cm. The uterine tube is enclosed within the upper margin of the broad ligament.

Three of the four parts of the uterine tube are shown in Fig. 26-10:


Infundibulum, with its abdominal, or pelvic, orifice (external tubal ostium) which is related to the ovary via its fimbria



The fourth, or uterine part, with its uterine orifice (internal ostium), is not shown. This portion is also known as the intramural segment of the tube.

Fig. 26-10.

Uterine tube of an adult woman with cross section illustrations of the gross structure of the epithelium in several portions. a, Infundibulum; b, Ampulla; c, Isthmus. (Cunningham FG, MacDonald PC, Gant NF, Leveno KJ, Gilstrap LC III. Williams Obstetrics (19th ed). Stamford CT: Appleton & Lange, 1993; with permission.)


The infundibulum is the funnel-shaped part of the ampulla, related to the ovary. It is characterized by a peritoneal opening 2 mm in diameter at its proximal end, surrounded by fimbria. The infundibulum belongs to the ampulla. One particularly long fimbria, the fimbria ovarica, is attached to the ovary and assists in ovum pick-up.

The topographic anatomy of the fimbriated end of the salpinx in relation to the ovarian surface is very important for ovum pick-up. According to Cohen,21 the salpingo-ovarian relation may be violated by several occurrences:


Uterine retroversion may produce proptosis of the fimbriae away from the ovary (Fig. 26-11A)

Uterine anteversion may produce the same phenomenon due to traction of the infundibulopelvic ligament and upward displacement (Fig. 26-11B) of the ovary

Fimbriae related to a small surface of a large ovary (Fig. 26-12B)

Stenosis of the peritoneal opening, secondary to pelvic inflammatory disease, endometriosis, or other adhesive processes (Fig. 26-13)

Occasionally, the fimbria ovarica may have a length of more than 4 cm (Fig. 26-14), and therefore have less contact with the ovarian surface, decreasing its efficiency in picking up the released ovum from the ovary

Other pathologic anatomic entities creating obstacles between the ovary and ostium (Fig. 26-15)

Multiple (accessory) fimbriae (Fig. 26-16)

Fig. 26-11.

Effect of uterine position on the spatial relationship between the ovary and the uterine tube fimbriae. A, Uterine retroversion, ligaments lax, proptosis of the fimbriae. B, Uterine anteversion, ligaments taut, fimbriae brush against the ovary. (Modified from Cohen BM. Surgery of the ovary, including anatomic derangements of the fimbrial-gonadal ovum-capture mechanism. In: Hunt RB (ed). Atlas of Female Infertility Surgery (2nd ed). St. Louis: Mosby Year Book, 1992, pp. 389-403; with permission.)

Fig. 26-12.

Relationship between tubal ostium and ovarian surface affected by gonadal enlargement. A, Normal-sized ovary. B, Large ovary. (Modified from Cohen BM. Surgery of the ovary, including anatomic derangements of the fimbrial-gonadal ovum-capture mechanism. In: Hunt RB (ed). Atlas of Female Infertility Surgery (2nd ed). St. Louis: Mosby Year Book, 1992, pp. 389-403; with permission.)

Fig. 26-13.

Stenosed tubal ostium reduces the likelihood of ovum pickup. (Modified from Cohen BM. Surgery of the ovary, including anatomic derangements of the fimbrial-gonadal ovum-capture mechanism. In: Hunt RB (ed). Atlas of Female Infertility Surgery (2nd ed). St. Louis: Mosby Year Book, 1992, pp. 389-403; with permission.)

Fig. 26-14.

Effect of elongation of fimbria ovarica. (Modified from Cohen BM. Surgery of the ovary, including anatomic derangements of the fimbrial-gonadal ovum-capture mechanism. In: Hunt RB (ed). Atlas of Female Infertility Surgery (2nd ed). St. Louis: Mosby Year Book, 1992, pp. 389-403; with permission.)

Fig. 26-15.

Major causes of damage to fimbrial ovum pickup mechanism. (Modified from Cohen BM. Surgery of the ovary, including anatomic derangements of the fimbrial-gonadal ovum-capture mechanism. In: Hunt RB (ed). Atlas of Female Infertility Surgery (2nd ed). St. Louis: Mosby Year Book, 1992, pp. 389-403; with permission.)

Fig. 26-16.

Surgical anatomy of accessory fimbriae. Note transverse and longitudinal accessory folds. (Modified from Cohen BM. Surgery of the ovary, including anatomic derangements of the fimbrial-gonadal ovum-capture mechanism. In: Hunt RB (ed). Atlas of Female Infertility Surgery (2nd ed). St. Louis: Mosby Year Book, 1992, pp. 389-403; with permission.)

Donnez and Casanas-Roux22 stated that the pregnancy rate after fimbrial surgery is related to ampullary dilatation, the percentage of ciliated cells, and thickness of the tubal wall.


The ampulla constitutes the remaining two-thirds of the uterine tube. Anatomically it extends from the distal part of the isthmus to the fimbriated vestibule. It is the widest segment of the tube, being 1 cm in diameter.


The isthmus extends from the tubocornual junction to the most proximal part of the ampulla. It has a diameter of approximately 2 mm. It represents the medial one-third of the tube. Ectopic pregnancy may occur in this segment. DeCherney and Boyers23 reported that segmental resection with anastomosis is preferable to salpingostomy. Hoffman20 stated that the ciliated cells in this segment constitute approximately 54% of the cellular makeup.

Intramural Segment

The uterine segment (intramural) has a length of approximately 1 cm. It is the narrowest portion of the tube, with a diameter of approximately 1 mm. It is the part between the end of the isthmus and the uterine cornu, located within the uterine wall.

Vascular Supply


Two arteries participate in supplying the uterine tubes:


The uterine artery supplies a fundal-cornual branch and a true tubal branch.

The ovarian artery contributes a true tubal branch from its end.

As may be seen in Fig. 26-17, there is rich anastomosis along the mesenteric area of the tube.

Fig. 26-17.

Arterial blood supply of the uterine tube. (Modified from Hoffman JJ. Anatomy and physiology of the uterine tube. In: Hunt RB (ed). Atlas of Female Infertility Surgery (2nd ed). St. Louis: Mosby Year Book, 1992, pp. 3-11; with permission.)

Manuaba24 reemphasized the possibility of damage to ovarian blood vessels during tubal occlusion for voluntary sterilization.


The veins draining the uterine tube parallel the arteries.


The tubal lymphatics have practically the same pathway as the lymphatics of the uterine fundus. These lymphatics follow the uterine and ovarian vessels to the preaortic and aortic lymph nodes.


The tubes are innervated by the sympathetic and parasympathetic systems, through the ovarian and inferior hypogastric plexuses. Pain sensation from the oviduct is transmitted back to the T11, T12, L1, and L2 levels of the spinal cord and corresponding dermatomes.


Each uterine tube has an external layer (serosal), an intermediate layer (muscular), and the innermost layer (mucosal). The serosa is the peritoneum that covers the extrauterine portion of the tube entirely except for its lower part, which is related to the mesosalpinx. The intermediate portion, the muscular layer, consists of two strata: outer longitudinal and inner circular. However, there is an extra stratum located between the circular layer and the mucosa at the uterotubal junction. Hoffman20 presents these strata as inner circular, middle oblique, and outer longitudinal. The rich vascularity in this area has an enigmatic physiologic function.

According to Hoffman,20 the mucosa lining the lumen of the uterine tube is composed of four types of cells: peg, indifferent, secretory, and ciliated. According to the same author, only the secretory and ciliated cells appear to play a role in ovum transport.


The physiology of the uterine tube is not well known; the anatomy is much better appreciated. But Hoffman20 was correct when he emphasized that both disciplines should be respected. Diverse attempts at substituting other structures for the uterine tubes (including artificial tubes, veins or arteries, and the appendix), have not been successful. The tube largely maintains its many physiologic secrets.

How is sperm transport aided? How do the sperm reach the ampulla in an hour and a half? How does the tube transport ova, sperm, zygote, the preimplantation morula, and finally the blastocyst? Are the ciliated mucosal cells responsible for the transmittal of the ovum to the ampulla? More studies are needed to better understand the unknown potentialities of these anatomic entities.

Surgical Applications


Salpingectomy (removal of the uterine tube) is a very common operative procedure on the tube. It is performed in situations where there is irreversible and severe damage to the tube, such as for a tubal hydrosalpinx or pyosalpinx with pelvic inflammatory disease. It is also performed in conditions of the tube that may be life-threatening to the patient, such as in ectopic pregnancy (Fig. 26-18) with or without tubal rupture, and neoplastic tubal tumor.

Fig. 26-18.

Ectopic pregnancy. Diagram shows the various implantation sites, numbered in order of decreasing frequency of occurrence. (Modified from Sabiston DC, Jr. Textbook of Surgery, 15th. ed. Philadelphia: WB Saunders, p. 1518; with permission.)

We quote from Piura and Rabinovich25:

Fallopian tube carcinoma is rarely suspected preoperatively. The symptom complex of “hydrops tubae profluence,” said to be pathognomonic for this tumor, is rarely encountered. The treatment approach is similar to that used for ovarian carcinoma and includes primary surgery comprised of total abdominal hysterectomy, bilateral salpingo-oophorectomy and staging followed by chemotherapy. The prognosis for patients with primary fallopian tube carcinoma is similar to that of patients with primary ovarian carcinoma.


Surgically, great care must be taken in separating the tube away from the ovary in order not to damage the ovarian blood supply. In addition, when removing the tube, whenever possible the operator should leave a 1 cm segment of the tube attached to the cornual region of the uterus in order to decrease the chances of a utero-peritoneal fistula into the pelvic cavity, which can lead to a cornual pregnancy.

A cornual pregnancy is a potentially life-threatening condition. Pressure from a growing cornual pregnancy can cause catastrophic sudden rupture of the uterine cornua which leads to immediate and massive intraperitoneal hemorrhage.

When performing a salpingectomy, the operator should try to preserve as much of the ovary as possible. However, even a partial oophorectomy can be accomplished, yet still allow full hormonal function of the remaining ovarian tissue.

Mild cases of pelvic inflammatory disease, endometriosis externa, prior pelvic and abdominal surgeries, and other adhesion-producing processes can cause occlusion of a tube, thus leading to infertility due to the inability of the released ovum to pass through the tube to become fertilized by the upswimming sperm. Occlusion of the tube can occur at any point along the tube, from the cornual region out to the infundibulum.

In many cases the tube is simply kinked by adhesive disease. The actual lumen, when straightened out, is truly patent.

Gentle microsurgical techniques, both at open laparotomy and through the laparoscope, have been developed in order to lyse adhesions and straighten out the tubal lumen. In cases of actual tubal occlusion due to scar tissue or prior tubal sterilization, microsurgical techniques have been developed to actually excise the scarred portion of the tube that contains the tubal occlusion and then reanastomose the healthy, presumably functioning, portions of the tube. These techniques have evolved since the early 1970s. Textbooks have been written on the details and specific indications for microsurgery for the many different conditions of peritubal adhesive disease and tubal occlusive disease.

Microsurgery pertaining to tubal functioning and fertility is an art and science unto itself. Its techniques and surgical procedures are well addressed in postgraduate gynecological fellowships dealing with reproductive medicine.


The key to microsurgical techniques is the gentle pinpoint handling of the tissues, in order to limit any damage to the tubal lumen and the delicate blood supply to the tube. In addition, observation has shown that as much healthy tube must be preserved as possible.

A healthy tube that is too short will not allow for proper ovum pickup and proper fertilization of any egg that may be picked up by the tube. In addition to the restoration of a damaged tube to as normal a state as possible, microsurgical techniques also concentrate on the restoration of normal fimbriae. This includes proper length of the fimbria ovarica and the relation of the fimbriae to the ovary, which also needs to be freed of any adhesive disease.

The implantation of a fertilized egg into a uterine tube is an ectopic pregnancy which may cause rupture and subsequent hemorrhage. The tube is also a very rare source of pelvic cancer.

Ectopic gestational remnants in the fallopian tube and broad ligament with characteristics of proliferation of intermediate trophoblast were reported by Kouvidou et al.26 The placental site nodule was asymptomatic and benign.

Torsion of the tube is a rare event but can occur in both benign and malignant situations. A rare leiomyoma of the fallopian tube with torsion at the ampullary-isthmic junction of the oviduct was reported by Misao et al.27 Ovarian torsion is usually accompanied by tubal torsion.

Anatomic Complications of Uterine Tube Surgery

The anatomic complications of surgery of the uterine tubes are closely related to the surgery of hysterectomy or other gynecological procedures involving one or both uterine tubes.


Tubal ligation, if inadequately performed, can fail to provide sterilization.

Tuboplasty, if inadequately performed, may not promote conception.

Prolapse of the tube after abdominal or vaginal hysterectomy has been reported. The situation usually presents as a painful vaginal cuff with a friable edematous mass at the vaginal apex. It appears to be granulation but persists after application of silver nitrate. Manipulation of this area is very painful for the patient.



Normal Development

The paramesonephric or müllerian ducts, which are formed in the mesonephros by invaginations of the coelomic epithelium, are responsible for the genesis of the uterus and the upper vagina (Table 26-1).

Uterine epithelium is formed from the urogenital sinus. The uterine walls are formed by the splanchnic mesenchyme. The cervix may be of paramesonephric origin.

Congenital Anomalies

Despite the fact that uterine anomalies, as well as anomalies of some other entities of the female genital tract, are secondary to an incomplete partial or total fusion of the paramesonephric ducts, the question remains whether these anomalies are developmental arrests. Perhaps they are due to genetic factors.

The uterus may be aplastic or hypoplastic. Uterine duplications may be total (uterus didelphys) or partial (uterus arcuatus or uterus bicornis, which is most common). Double uterus may be associated with obstructed hemivagina and renal agenesis28.

We quote from Homer et al.29 on the septate uterus:

A bicornuate uterus results from failure of fusion of the mullerian ducts, whereas a septate uterus results from failure of resorption of the intervening septum. The fibromuscular septum so formed may project minimally from the uterine fundus or may extend to the cervical os, almost completely dividing the uterine cavity in two. Septa also may be segmental, resulting in partial communication between the two sides.

Giraldo et al.30 advise gynecologists to be aware of the possibility of cervical duplication associated with longitudinal vaginal septum and septate uterus. The anomalies can be ameliorated surgically by resection of the uterine and vaginal septum.

Several variations are shown in Fig. 26-19. Further information about congenital anomalies will be found in Table 26-5.

Fig. 26-19.

Schematic representation of the main abnormalities of the uterus and vagina, caused by persistence of the uterine septum or obliteration of the lumen of the uterine canal. (Modified from Sadler TW. Langman’s Medical Embryology, 8th ed. Philadelphia: Lippincott Williams & Wilkins, 2000; with permission.)

Surgical Anatomy


The adult uterus is a thick, flattened, pear-shaped muscular organ. It is located between the bladder anteriorly and the rectum posteriorly; laterally it is enveloped by the right and left broad ligaments. The uterus can be subdivided into the fundus, body, and cervix (see Fig. 26-2A).

The shape and the size of the uterus are variable, depending upon the age and parity of that patient. The uterus weighs approximately 40 to 60 grams in the nulliparous patient and approximately 60 to 80 grams in the multiparous patient. The uterus is typically 8 cm in length from the external os of the cervix to the top of the fundus, and is approximately 5 cm in width at the level of the uterine ostia, which defines the widest part of the uterus.

The endometrial cavity (Fig. 26-20) is a flattened potential space which is triangular in shape, with the apex pointing inferiorly toward the cervix. The walls of the uterus are approximately 2 cm in thickness, principally due to the muscular portion known as the myometrium.

Fig. 26-20.

Reconstruction of uterus, showing shape of its cavity and cervical canal. (Modified from Eastman NJ. Williams Obstetrics (10th ed). New York: Appleton-Century-Crofts, 1950; with permission.)

The numbers 1, 2, 3 serve as a useful mnemonic for the length of the uterus:


1 inch (2.5 cm) equals the length of the cervix (supravaginal and vaginal)

2 inches (5.0 cm) equals the body, including the isthmus

3 inches (7.5 cm) equals the total length of the organ

The widest portion of the uterus at the cornua measures 2 inches.

The uterus is normally anteflexed, with the body bending forward at the isthmus, indenting the bladder. The typical uterus is also anteverted, with the endocervical canal oriented at a 90° angle to the lumen of the vagina (Fig. 26-21).

Fig. 26-21.

A, Three outlines of the uterus, showing a more normal position (anteversion) and a moderate and a more extreme degree of retroversion. The last is most often brought about by filling of the bladder. B, The normal adult uterus is anteverted (i.e., at an angle with respect to the vagina) and anteflexed (i.e., flexed somewhat on itself). C, The solid lines indicate the planes and the angles of anteversion and anteflexion. These are not fixed positions. (Modified from Gardner E, Gray DJ, O’Rahilly R. Anatomy (4th ed). Philadelphia: WB Saunders, 1975; with permission.)

In retroversion (Fig. 26-21A, Fig. 26-22), the uterus is inclined posteriorly toward the rectum. The cervix faces anteriorly.

Fig. 26-22.

Uterine positions. Note that the diagram of retroversion represents an extreme position. The malpositions of the uterus vary in degree according to several factors.

In retroflexion (Fig. 26-22), the body of the uterus is curved posteriorly at the isthmus of the uterus. The cervix is in its normal position.

Various combinations of retroversion and retroflexion can occur. These positions are not pathological but simply normal variations on the position of the uterus (Fig. 26-22). It is not uncommon to find a uterus retroflexed and/ or retroverted toward the rectum posteriorly.

Fullness of bladder and rectum also plays a great role in the position of the uterus.



The thick, convex fundus is that portion of the uterus at and above the level where the uterine tubes enter the uterus; it is covered with peritoneum. The fundus essentially forms the roof for the uterine cavity.


The body of the uterus lies within the pelvic cavity. The uterine cavity lies almost totally within the uterine body. Its right and left lateral aspects are related to the broad ligament.


The narrowed, waistlike, isthmic portion of the uterus leads into the more inferior cervix. The isthmus is known obstetrically as the lower uterine segment. The isthmus was described by Aschoff,31 who stated that the lowest part of the uterine cavity becomes very narrow, forming a canal.


The cervix is approximately 3 to 4 cm in length and consists of a vaginal portion, which is easily seen during speculum examination of the vagina, and a supravaginal portion, which is very important to the endopelvic fascial support system of the cervix and upper vagina. The anterior area of the supravaginal part is related closely to the base of the urinary bladder and is not covered by peritoneum. Its posterior area is covered by peritoneum which forms the rectouterine pouch of Douglas above and the posterior vaginal fornix below. The pouch of Douglas separates the uterus from the rectum.

The cervix enters the vagina by coursing perpendicularly to the anterior vaginal wall, thus explaining the shorter length of the anterior vaginal wall (7 cm) when compared with the posterior vaginal wall (9-10 cm).

The cervix normally has a very dense consistency like a “nose.” During pregnancy, however, this consistency softens significantly, so that the cervix may very well have the consistency of “lips.” The protrusion of the vaginal portion of the cervix into the vagina allows segregation of the proximal portion of the vagina into anterior, posterior, and lateral fornices. Each ureter passes within 1.5 cm of the supravaginal portion of the cervix as the ureter makes it knee-bend underneath the uterine artery to pass medially and anteriorly across the anterolateral fornix to enter the bladder.

Surrounding the supravaginal portion of the cervix is a dense ring of endopelvic fascia into which is anchored the pubocervical fascia, as well as the uterosacral and cardinal ligaments. This endopelvic fascial ring is known as the pericervical fascial ring. This pericervical ring of visceral connective tissue is a key link in the important mechanical continuity of the endopelvic fascia associated with the vagina and cervix, consisting of contributions both from the suspensory ligaments (cardinal and uterosacral ligaments) and the pubocervical fascia.


The ureter is very close (approximately 1-1.5 cm) to the lateral wall of the supravaginal part of the cervix.

Anterior, Posterior, and Lateral Relations of the Uterus


Anterior (Fig. 26-23)


– Vesicouterine pouch

– Some loops of small bowel

– Supravaginal and intravaginal cervix

– Anterior fornix of vagina

Posterior (Fig. 26-23)


– Rectouterine pouch of Douglas with small bowel loops

Lateral (Fig. 26-23)


– Broad ligament with the anatomic entities enveloped

– Ureter with uterine vessels and nerves

– Vesical vessels and nerves

Fig. 26-23.

Relational anatomy of the uterus.

Uterine Cavity

The cavity of the body has a triangular shape (Fig. 26-24), which changes with pregnancy. The cavity is wide at the fundus and becomes narrower and narrower approaching the isthmus (internal os). For all practical purposes, the anterior and posterior walls are in apposition. The isthmic cavity is very narrow but has the ability to dilate. Last32 stated that this part is the “lower uterine segment,” as referred to by the obstetrician.

Fig. 26-24.

Female reproductive organs, posterior view.

There is some confusion in the literature about the internal os and its relation to the isthmus. Is the isthmus the upper one-third of the cervix? Or does it belong to the lowest part of the body, forming the “lower uterine segment”? Regardless, the most important fact is that during pregnancy the isthmus expands, and practically becomes a segment of the body cavity in which the fetus rests.

The endocervical canal is narrow proximally and distally. Its peculiar anatomy includes the formation of one vertical fold anteriorly and one posteriorly. The canal is closed not by apposition but by palmate folds originating from the anterior and posterior vertical folds, which fit against each other.

Pelvic Peritoneum and Its Uterine Relations

The peritoneal relations to the endopelvic female genital organs are illustrated in Fig. 26-25 and Fig. 26-26. The peritoneum travels downward to the pelvic cavity after covering anterior and posterior uterine surfaces. Two spaces are formed: the deep rectouterine space of Douglas and the shallow vesicouterine space.

Fig. 26-25.

The peritoneum of the female pelvis in paramedian section.

Fig. 26-26.

Sagittal view of abdominopelvic cavity. Details of layering of abdominal wall are shown in insets to left. Dotted line indicates extension of peritoneal space lateral and dorsal to spine. (Modified from DeLancey JOL, Richardson AC. Anatomy of genital support. In: Hurt WG (ed). Urogynecologic Surgery. Gaithersburg MD: Aspen, 1992, pp. 19-33; with permission.)

In covering the posterior uterine area, the peritoneum covers the posterior area of the cervix completely. However, anteriorly it covers fundus, body, and the supravaginal (isthmic) part of the cervix. The reader will find more details as well as surgical applications in the chapter about the peritoneum.

Endopelvic Fasciae

The suspensory mechanism of greatest direct support for the pelvic organs is supplied by the cardinal ligament/ uterosacral ligament complex. These structures are part of a continuous network called the endopelvic fascia (Fig. 26-27A) between the peritoneum and the parietal fascia over the muscular pelvic basin. Microscopically, endopelvic fascia is a three-dimensional meshwork of collagen, elastin, and smooth muscle. This meshwork surrounds and supports the viscera in both the abdominal and pelvic cavities. Anatomists and surgeons have artificially described this whole network in a piecemeal fashion, assigning various names to isolated segments.

Fig. 26-27.

A, Endopelvic fascia. B, The pubocervical fascia (ligament) supports the urethra (only the trigone is shown) and is attached laterally to the fascial white lines. The rectovaginal septum is a thin layer of fascia between the vagina and rectum. (A, Modified from Skandalakis LJ, Gadacz TR, Mansberger AR Jr, Mitchell WE Jr, Colborn GL, Skandalakis JE. Modern Hernia Repair: The Embryological and Anatomical Basis of Surgery. New York: Parthenon, 1996; B, Courtesy of Dr. Cullen Richardson. Modified from Brubaker LT, Saclarides TJ (eds). The Female Pelvic Floor: Disorders of Function and Support. Philadelphia: FA Davis, 1996; with permission.)

On visual inspection at the time of detailed anatomic dissections, the endopelvic fascia is actually an interconnected system of sheaths, continuous and interdependent.

The endopelvic fascia serves two important purposes. First, it serves to provide mechanical conduits and supports for the visceral arteries and veins, visceral nerves, and lymph nodes and channels that course in the subperitoneal areas of the pelvis. Secondly, the endopelvic fascia surrounds the organs within the pelvis and serves to anchor them to the parietal fascia of the muscular pelvic basin, thus positioning these organs within the pelvis in their normal anatomic positions.

The vesicovaginal fascia is a fusion of two fasciae, one from the urinary bladder and one from the vagina. Both of these fasciae are derived from the intermediate stratum (the fascia enclosing the adrenals, kidney, ureters, urinary bladder, uterus, and the supplying vessels). If one kidney is absent, the intermediate stratum (i.e., the renal fascia) does not develop in that area.

Levator Plate

The uterus and cervix, as well as the upper two-thirds of the vagina, are suspended over the levator plate.2 This constitutes the most important source of indirect mechanical support for these organs. The levator plate (Fig. 26-28) is formed by the midline fusion of the levator ani muscles between the rectoanal junction and the coccyx.

Fig. 26-28.

Superior view of pelvic floor. (Modified from Retzky SS, Rogers RM, Richardson AC. Anatomy of female pelvic support. In: Brubaker LT, Saclarides TJ (eds). The Female Pelvic Floor: Disorders of Function and Support. Philadelphia: FA Davis, 1996; with permission.)

When a woman is standing upright, the healthy levator plate is almost horizontal in orientation (see Fig. 26-1). When the patient performs a Valsalva maneuver, such as in coughing or laughing, the downwardly directed intraabdominal and intrapelvic forces push the upper two-thirds of the vagina and cervix against the tensed levator plate in a flap-valve action. By this mechanism, these pelvic viscera are impinged within the pelvic cavity and prevented from prolapsing through the levator hiatus toward the vaginal introitus. In addition, the tensing of the levator plate is also accompanied by contraction of the pubococcygeus muscles surrounding the levator hiatus, which further blocks any movement of the vagina and cervix downward. This flap-valve mechanism is dependent upon the suspension of the upper two-thirds of the vagina and cervix over the levator plate.

Ligaments of the Uterus and Cervix

We refer the interested student to the excellent work of DeLancey and Richardson33 on the anatomy of the support of the female pelvic organs. The ligaments that attach to the uterus are:


Broad ligament

Round ligament

Cardinal ligament

Uterosacral (sacrocervical) ligament

Anterior uterine (uterovesical) ligament

Posterior uterine (rectovaginal) ligament

Pubocervical fascia

Utero-ovarian ligament

Rectouterine ligament

The utero-ovarian ligament will not be considered here because it has been discussed in the preceding sections on topography, poles, ligaments, and mesovarium of the ovaries.

There is confusion in the literature about the name, origin, and “anatomy” per se of several of these ligaments. For example, the sacrocervical ligament is occasionally referred to as the uterosacral. Are both the same? Another example is the pubocervical ligament which is perhaps nothing but the pubocervical fascia (Fig. 26-27B). Is the anatomic term “ligament” correct or is it just a fascia?

Broad Ligament

After covering the uterus anteriorly and posteriorly, the pelvic visceral peritoneum extends from each side of the uterus to both lateral pelvic walls, forming the two layered right and left portions of the broad ligament (Fig. 26-29, Fig. 26-30). The broad ligaments have an almost triangular shape. Together with the uterus, they divide the pelvic cavity into an anterior, or vesicouterine, fossa and a posterior, or rectouterine fossa – also known as the cul-de-sac of Douglas (see Figs. 26-2, 26-4). This peritoneal reflection also invests the round ligaments (ligamentum teres uteri), which travel laterally and anteriorly to leave the pelvis via the internal inguinal rings. The broad and round ligaments offer no useful mechanical support to the uterus, cervix, or vagina, in contrast to the cardinal ligaments and uterosacral ligaments, which offer significant suspensory support to the lower uterine segment, cervix, and upper portion of the vagina.

Fig. 26-29.

Uterosacral and lateral cervical (cardinal) ligaments from above and behind.

Fig. 26-30.

Ligaments of the uterus. (Modified from Brantigan OC, Clinical Anatomy. New York: McGraw-Hill, 1963; with permission.)

The broad ligament is the mesentery of the uterus, tubes, and ovaries. Each double-folded broad ligament has four borders — medial, lateral, superior, and inferior. Each of these borders relates with several anatomic entities. The medial border is related to the lateral edge of the uterus and encloses the uterine vessels and the uterus. The lateral border is related to the lateral pelvic wall. The superior border is free and directed anteriorly. It envelops the uterine tube, its vessels, and the ovarian ligament from above downward. It also contains the ovarian vessels and the round ligament. The inferior border forms an extension over the floor of the true pelvis.

Anatomy, embryology, nomenclature, and convenience fight each other for recognition when the broad ligament is being described. The mesosalpinx (Fig. 26-31) is that part of the broad ligament located just beneath the uterine tube. It contains the epoophoron (the parovarium or organ of Rosenmüller), Gartner’s duct, and other vestigial structures from the mesonephric wolffian duct. The mesovarium, an extension of the broad ligament originating from its posterior surface, suspends the ovary. The mesometrium is the area of the broad ligament below the mesovarium. The parametrium consists of the connective tissue elements within the broad ligament just lateral to the body and lower uterine segment of the uterus.

Fig. 26-31.

Diagram of the peritoneal relations of the ovary in a section through the upper part of the broad ligament. At the peritoneal edge about the hilum of the ovary the mesothelium of the peritoneum is continuous with the epithelium of the ovarian cortex. (Modified from Hollinshead WH. Anatomy for Surgeons, vol. 2. New York: Hoeber-Harper, 1961; with permission.)

The inferior border or base of the broad ligament is wide as well as thick. This area contains the portion of the cardinal ligament that invests the uterine vessels and the lower portion of the ureter. The cardinal ligament then continues to follow the uterine artery into the cervix, lower uterine segment, and upper one-third of the vagina.


from the front of the broad ligament, the round ligament stands out; from the back of the broad ligament, the uteroovarian ligament stands out.

The distal portion of the ureter penetrates the cardinal ligament, which forms a ureteric tunnel around the ureter. At this point, the ureter passes underneath the obliquely coursing uterine artery (“water under the bridge”). The uterine venous plexus surrounds the ureter and uterine artery within the base of the cardinal ligament, which is in the base of the broad ligament.

Remember the 4 U’s related to the broad ligament:


Uterine artery (Fig. 26-29)

Ureter (Fig. 26-29)

Uterovesical pouch

Uterorectal pouch

Remember the four M’s from above downward associated with the posterior surface of the broad ligament:



Mesovarium (Fig. 26-30)


Mackenrodt ligament (cardinal, transverse cervical) (Fig. 26-29).

Round Ligament

The round ligaments (Fig. 26-32, Fig. 26-33, Fig. 26-34A) are two flat, narrow cords some 10-12 cm long. They arise from the lateral aspects of the upper part of the body of the uterus. Each travels laterally and anteriorly through the mesometrium and leaves the pelvic cavity through the internal inguinal ring to pass through the inguinal canal (see Fig. 26-2). Near the uterus the round ligament contains much smooth muscle (the continuation of the smooth muscular uterine wall) and connective tissue. More distally, the ligament consists principally of fibrous tissue in its termination near the mons pubis. Together with the ovarian ligament, it represents the embryologic homologue of the male gubernaculum.

Fig. 26-32.

Superior view of ligaments of the uterus. (Modified from Slaby FJ, McCune SK, Summers RW. Gross Anatomy in the Practice of Medicine. Philadelphia: Lea & Febiger, 1994; with permission.)

Fig. 26-33.

Pathways of round ligament, ovarian ligament, and suspensory ligament. (Modified from Brantigan OC. Clinical Anatomy. New York: McGraw-Hill, 1963; with permission.)

Fig. 26-34.

A, The pelvic viscera viewed from above, with peritoneum intact. B, Horizontal section of the pelvic viscera, showing the ligaments of the uterus. The arteries shown are, from posterior to anterior, the middle rectal, uterine, and inferior and superior vesical. (Modified from Gardner E, Gray DJ, O’Rahilly R. Anatomy: A Regional Study of Human Structure (5th ed). Philadelphia: WB Saunders, 1986; with permission.)

The round ligament has a diameter of approximately 3 to 5 mm. It is attached to the anterior and lateral aspects of the uterus just below the insertion of the ovarian ligament and the tubes. The round ligament travels within the broad ligament just beneath its anterior leaflet running upward and outward.

The pathway of the round ligament is as follows: lateral aspect of the uterus to the broad ligament, across the umbilical and obturator vessels to the superior pubic ramus, crossing the external iliac vessels, entering the inguinal canal at the deep inguinal ring, passing through the inguinal canal and usually inserting into the fibrofatty tissue of the mons pubis, and into the proximal part of the labium majus, the homologue of the scrotum. Attah and Hutson34 stated that the round ligament does not reach the labium majus.

Within the inguinal canal, the round ligament is accompanied by an arterial branch (the counterpart of the cremasteric artery) of the inferior epigastric artery and the genital branch of the genitofemoral nerve. These two structures are located just behind the shelving edge of the inguinal ligament and in front of the pectineal line. A branch of the uterine artery passes outward along the round ligament. This vessel, referred to as “Sampson’s artery,” anastomoses with the cremasteric branch of the inferior epigastric artery.

Cardinal Ligament

The cardinal ligament has many names:


Ligament of Mackenrodt

Ligament of Kocks

Uterine retinaculum of Martin

Lateral ligament

Transverse cervical ligament (transverse ligament of cervix)

Sheathlike investments of pelvic structures are provided by the endopelvic fascia. In the example of the cardinal ligament/uterosacral ligament complex (Fig. 26-29, Fig. 26-32, Fig. 26-34, Fig. 26-35, Fig. 26-36), a sheath consisting of collagen bundles, elastic fibers, and smooth muscle surrounds the internal iliac artery and vein and follows the branching of the uterine artery to the endopelvic fascial capsule surrounding the lower uterine segment, cervix, and upper one-third of the vagina.

Fig. 26-35.

Important anatomic features of female pelvic floor. On the viewer’s left the arrangement of levator ani is shown. On the viewer’s right the transverse ligament of the cervix (visceral pelvic fascia) is shown. Note the multiple points of origination of the transverse (cardinal) ligament. A, Anterior; P, Posterior. (Modified from McGregor AL, Du Plessis DJ. A Synopsis of Surgical Anatomy (10th ed). Baltimore: Williams & Wilkins, 1969; with permission.)

Fig. 26-36.

Uterine ligaments from below and side.

Range and Woodburne35 observed that the cardinal ligament is connective tissue enveloping the uterine vessels. They found that although the ligament is composed of much delicate tissue, the collective strength of these fibers is great in affording support to the uterus.

The cardinal ligament follows the pathway of the uterine artery and uterine veins into the base of the broad ligament. Approximately 1.5 cm lateral to the edge of the cervix, the ureter passes underneath the uterine vessels and enters the ureteric tunnel, as mentioned above.

The cardinal ligament is anchored posteriorly to the parietal fascia over the piriformis muscle, the obturator internus muscle, and along the anterior bony border of the greater sciatic foramen. Remember that the piriformis muscle together with its fascia, large nerves, and vessels passes through and fills the greater sciatic foramen. Thus the cardinal ligament may be considered a “vascular leash” that suspends the cervix and upper two-thirds of the vagina over the levator plate. Remember, the levator plate is a dynamic muscular platform that allows entrapment of the upper third of the vagina within the pelvis during stress in order to prevent prolapse of the uterocervix and upper third of the vagina.

Posteriorly continuous with the uterosacral ligament, the cardinal ligament is anteriorly continuous with the arcus tendineus fasciae pelvis. This is the stout connective tissue band that provides a line of fusion between the pubocervical fascia on the anterior wall of the vagina and the superior fascia of the pelvic diaphragm.

Uterosacral Ligament

The uterosacral (or sacrocervical) ligament (Fig. 26-29, Fig. 26-30, Fig. 26-32, Fig. 26-36) is a complex band of connective tissue and smooth muscle. It receives contributions from the tough, presacral fascia of Waldeyer over the 2nd, 3rd, and 4th sacral vertebrae and the piriformis muscle fascia. Within this fascia and invested by it are the pelvic splanchnic nerves and the more inferior portions of the pelvic nerve plexus. Thus the uterosacral ligament may be considered a “neural leash” or “sacral leash,” while, as previously indicated, the cardinal ligament may be thought of as a “vascular leash” in providing direct organ support. Along with the cardinal ligament, the uterosacral ligament helps suspend the upper third of the vagina and cervix over the levator plate.

The uterosacral ligaments are the lateral boundaries of the uterorectal space of Douglas. Campbell36 stated that they are composed of smooth muscle, fibrous tissue, and nerves.

This band of tissue passes lateral to the rectum on a horizontal plane in the standing patient and attaches to the posterior and lateral aspects of the pericervical ring of endopelvic fascia. Just before reaching the pericervical ring, the uterosacral ligament contributes to the formation of the rectovaginal septum, thereby providing a connective tissue hammock for the upper part of the vagina, a stratum of tissue attached above to the peritoneum of the pouch of Douglas, attached below to the perineal body, and suspended laterally between the right and left ischial spines. As noted previously, the uterosacral ligament is continuous anteriorly with the cardinal ligament complex.

The uterosacral ligaments are substantial cords of endopelvic fascia that have a distinct appearance at the time of laparotomy or laparoscopy. They are readily appreciated by palpation during pelvic examination and at the time of surgery. Remember, the uterosacral ligaments are the lateral borders of the uterorectal space or pouch of Douglas, also known as the cul-de-sac of Douglas.

Anterior Uterine Ligament

The anterior uterine ligament (Fig. 26-37) is the peritoneal fold extending from the anterior uterine surface to the urinary bladder. It is the floor of the uterovesical fossa.

Fig. 26-37.

Relations of the ureter, the uterine and vaginal arteries, and ligaments. (Modified from Brantigan OC. Clinical Anatomy. New York: McGraw-Hill, 1963; with permission.)

Posterior Uterine Ligament

The posterior uterine ligament is a peritoneal fold extending from the posterior uterine surface to the rectum. Again, it is simply the floor of the cul-de-sac of Douglas (rectouterine pouch) (Fig. 26-2, Fig. 26-38).

Fig. 26-38.

A, The floor of the rectouterine pouch or cul-de-sac of Douglas is the posterior uterine ligament. The female urethra is about 4 cm long, beginning at the vesical neck and ending at the external meatus. It lies beneath the pubic symphysis with the vesical neck in a high retropubic position. B, The female urethra has a strong muscular wall, composed of smooth and striated muscle. The urethral lining is composed of transitional epithelium, with portions of pseudostratified epithelium. (Modified from Siegel SW. Anatomy and embryology. In: Novick AC (ed). Stewart’s Operative Urology (2nd ed). Baltimore: Williams & Wilkins, 1989, pp. 454-478; with permission.)

Pubocervical Fascia

The pubocervical fascia (ligament?) (Fig. 26-36) follows the anterior uterine aspect and upper vagina. It passes around the urethra to the posterior surface of the pubic bones.

Rectouterine Ligament

The rectouterine ligament is that portion of the network of pelvic visceral fascia that travels from the pericervical ring and upper vagina, around the rectum, to attach to the presacral fascia over the lower sacrum.

Vascular Supply


The uterine artery (see Fig. 26-6) is the medial off-shoot from the internal iliac artery, as the internal iliac artery terminates to become the umbilical artery, the source of the superior vesical artery just proximal to the beginning of the obliterated segment of the umbilical artery. The uterine artery is the chief blood supply to the uterus.

From its origin the uterine artery descends along the pelvic sidewall and then proceeds medially, surrounded by the fibers of the cardinal ligament. The uterine artery then passes over the ureter and ascends tortuously along the lateral aspect of the uterus within the broad ligament (see Figs. 26-4 and 26-5). At the junction of the uterine tubes with the uterus, the uterine artery turns laterally toward the ovarian hilum (see Fig. 26-17, Fig. 26-37).

The uterine artery gives the following branches along its course:


Vaginal artery (Fig. 26-39)

Cervical artery

Anterior and posterior uterine branches

A tubal branch and an ovarian branch that anastomose with the similar branches from the ovarian artery (see Fig. 26-17)

Fig. 26-39.

Uterine and vaginal arteries. Parts of pubic bone and all of the bladder (except for trigone) have been removed. The uterus is asymmetrically placed; hence, one ureter is close to the cervix and the other is far removed from it. (Modified from Basmajian JV, Slonecker CE. Grant’s Method of Anatomy (11th ed). Baltimore: Williams & Wilkins, 1989; with permission.)

The ovarian artery (see Fig. 26-6) also contributes significantly to the blood supply of the uterus. The ovarian arteries originate from the abdominal aorta approximately 1-2 cm below the origin of the renal arteries. On their way downward, they pass over the ureters. These arteries assist vascularization of the ureter by their ureteric branches. They cross the common iliac vessels superficial to the ureter and enter the infundibulopelvic ligament at the pelvic brim just superficial to the bifurcation of the common iliac artery into the external and internal iliac arteries. The ovarian arteries participate in the blood supply of the uterine tubes as well as portions of the broad ligament and upper portion of the uterus.

The branches of the uterine and ovarian arteries invade the uterine wall obliquely. At approximately the middle of the muscular stroma, they form the arcuate arteries. The arcuate arteries produce radial branches, which are destined to take care of the endometrium by their own spiral and basal branches.

The distribution of the uterine artery is as follows:


The vaginal artery arises just before the uterine artery passes over the ureter. There may be two, or even three, vaginal arteries. It (or they) passes underneath the ureter to continue inferiorly toward the vaginal wall. There the vaginal artery forms anterior and posterior branches which, by rich anastomoses between vaginal and uterine arterial branches, form anterior and posterior “azygos arteries” of the vagina. The vaginal artery supplies the vaginal mucosa, the base of the bladder, the vestibular bulb, and provides additional supply to the rectum.

The cervical branch arises from the uterine artery at the area of the isthmus or lower uterine segment. It bifurcates into an anterior and posterior branch.

These branches anastomose with the anterior and posterior branches of the opposite side, thus forming the so-called coronary artery of the cervix. Anterior and posterior uterine branches also arise from the uterine artery. These take care of the anterior and posterior parts of the uterus.

Tubal and ovarian branches are produced by the bifurcation of the uterine artery close to the fundus of the uterus. Both branches pass laterally. The tubal branch goes to the mesoappendix of the uterine tube, and the ovarian branch passes toward the mesovarium of the ovary. The tubal artery anastomoses with the tubal branch of the ovarium. The ovarian branch anastomoses with the main ovarian artery (see Figs. 26-6, 26-17).

According to Clark as cited in Eastman,37 the two uterine sides communicate very well, since fluid injected into one side escapes from the opposite side.


The venous network of the uterus is very rich. These veins form the uterovaginal venous plexus that accompanies the uterine artery. It communicates posteriorly with the rectal or hemorrhoidal plexus and anteriorly with the vesical plexus. The uterovaginal plexus can be divided into two parts: the upper part drains to the uterine veins; the lower part drains to the internal iliac vein via the internal pudendal vein.

A portosystemic anastomosis is located below the rectouterine pouch, or pouch of Douglas, connecting the uterovaginal plexus with the superior rectal vein. The arcuate veins form the right and left uterine veins, which empty into the internal iliac vein. Ovarian and upper broad ligament venous blood is collected in the pampiniform plexus via small veins, and drains into the ovarian vein. The right ovarian vein drains directly into the inferior vena cava, whereas the left ovarian vein drains into the left renal vein.

Pelvic varices may be found in the infundibulopelvic and broad ligaments, with lateral extensions to the cervix and vagina and below the peritoneum of the vesicouterine and rectouterine pouch. The ovarian vein crosses the ureter close to the infundibulopelvic ligament at the pelvic brim.


A rich lymphatic network is present under the peritoneum, especially at the posterior uterine wall; the lymphatic vessels form a peculiar and complicated network (Fig. 26-40). The lymphatics of the uterotubal area drain to the superficial inguinal lymph nodes, following the pathway of the round ligament. The round ligament leaves the pelvis via the internal inguinal ring and inguinal canal to enter the external inguinal ring and area of the mons pubis. The upper part of the uterus (the fundus and part of the upper body) drains into the paraaortic lymph nodes. The lower part of the body of the uterus drains into the external iliac nodes. The cervical lymph nodes drain into the internal and external iliac as well as sacral nodes.

Fig. 26-40.

Lymphatic drainage of the uterus and vagina. (Based on Ellis H. Clinical Anatomy: A Revision and Applied Anatomy for Clinical Students, 4th Ed. Philadelphia: FA Davis, 1969.)

Scheidler et al.38 stated that lymphangiography (LAG), computed tomography (CT), and magnetic resonance (MR) imaging perform similarly in the detection of lymph node metastasis from cervical cancer. As CT and MR imaging are less invasive than LAG and also assess local tumor extent, they should be considered the preferred adjuncts to clinical evaluation of invasive cervical cancer.


Much is yet unknown regarding the innervation of the uterus, with respect to both the anatomic and physiologic aspects of the nerve supply. The uterus has no somatic innervation, only visceral innervation from sympathetic and parasympathetic sources (Fig. 26-41). The parasympathetic efferent (motor) fibers and afferent (sensory) (Fig. 26-42) fibers travel within the nervi erigentes, which pass into the pelvic plexus after leaving the anterior rami of the second, third, and fourth sacral spinal nerve branches. The sympathetic efferent supply (Fig. 26-42, Fig. 26-43) descends through the hypogastric and pelvic plexuses.

Fig. 26-41.

Autonomic plexuses in pelvis. (Modified from Hall-Craggs ECB. Anatomy as a Basis for Clinical Medicine (3rd ed). Baltimore: Williams & Wilkins, 1995; with permission.)

Fig. 26-42.

Probable afferent innervation of female genital tract. Fibers entering the spinal cord through sacral nerves are shown on viewer’s right (blue lines). Fibers associated with sympathetic system and entering spinal cord through thoracic nerves are shown on viewer’s left (red lines). (Modified from Hollinshead WH. Anatomy for Surgeons. New York: Hoeber-Harper, 1961; with permission.)

Fig. 26-43.

Uterovaginal plexus. (Modified from Hollinshead WH. Anatomy for Surgeons. New York: Hoeber-Harper, 1961; with permission.)

The parasympathetic efferent nerve supply originates from the intermediolateral cell column from the second, third, and fourth sacral segments of the spinal cord. The afferent or sensory nerve fibers carry nociceptive as well as sexual sensations to the dorsal root ganglia and posterior horn of the same spinal cord segments.39

The postganglionic sympathetic visceral nerves to the uterus originate from several sources, although the preganglionic fibers arise principally from the intermediolateral cell column of the spinal cord at levels T12 and L1. A considerable portion of the uterine tubes, upper portion of the broad ligament, and perhaps a portion of the uterus are supplied by the sympathetic nerves of the ovarian plexus (Fig. 26-44) that travel with the ovarian vessels in the infundibulopelvic ligament.

Fig. 26-44.

Visceral nerves in the abdomen. (Modified from Steege JF, Metzger DA, Levy BS. Chronic Pelvic Pain: An Integrated Approach. Philadelphia: WB Saunders, 1998; with permission.)

A second sympathetic source originates from the inferior hypogastric plexus. This is a 3 cm á 5 cm plexus of visceral nerves surrounding the ureter and internal iliac artery and branches in the lateral pelvic sidewall, lateral to the uterosacral ligament at the base of the broad ligament. The inferior hypogastric plexus and nerves have sympathetic input from the sacral splanchnic nerves of the sympathetic trunk as well as from the superior hypogastric plexus via the hypogastric nerves (see Fig. 26-41).

The inferior hypogastric plexus divides into further plexuses in order to service the bladder, rectum, and the uterovaginal area. The uterine nerves originate from the uterovaginal plexus (of Frankenhäuser) and enter the upper part of the vagina, cervix, and lower portion of the uterus via the uterine vessels. An aggregation of ganglion cells is found typically near the cervix. Contraction and vasoconstriction of the uterine vessels are produced by sympathetic action, whereas vasodilatation is produced by parasympathetic stimulation.

Many of the pain fibers from the uterine fundus and body pass upward through the hypogastric plexus and then into the lumbar segments of the sympathetic chains. Grasping the cervix will produce severe pain. Division of the hypogastric nerves will produce anesthesia at the area of the fundus but not in the cervix.

Pain fibers from the vagina, cervix, and isthmic regions of the uterus pass to the central nervous system by way of the pelvic splanchnic nerves, accompanying the pelvic parasympathetic nerve supply. Because of the relatively high failure rate of uterosacral ligament transection in relieving chronic pelvic pain, it is believed that most visceral nerve fibers enter into, and travel from, the uterus along the uterine vessels and not necessarily through the uterosacral ligaments. Perhaps the accepted view is that noxious stimuli from the uterine fundus are referred to dermatomes T11, T12, L1, and L2.

Gardner et al.40 stated that doubt surrounds the role of these nerves in uterine function. Perhaps the sympathetic is not only a vasoconstrictor but also is a producer of some motor action. The pathway of S2-S3 (nervi erigentes) is responsible for cervical pain. The lower thoracic and hypogastric nerves are the pathway of pain from the body of the uterus, as during labor.

The above summary of sympathetic and parasympathetic innervation appears relatively simple but, in addition, hormones play a role in uterine function. Presumably there are synergistic and antagonistic actions between the two systems.

The pathway of afferent uterine nerve fibers is as follows:


Uterine body: hypogastric nerves T11-T12 spinal cord

Cervix: lumbar sympathetics first two lumbar ganglia dorsal root ganglia of L1 and L2 spinal cord, or: pelvic splanchnic nerves dorsal root ganglia of S2-S4 spinal cord

In summary, we know very little about uterine innervation. Much of our current thought is speculation based upon studies of rats and cats and a few human studies. Is the uterine body innervated only by the sympathetics? Perhaps. Are cholinergic and adrenergic fibers present only in the cervical musculature10 and the submucosal layers? Perhaps.


The uterus is composed of 3 layers:



Muscular coat


The serosa is the pelvic peritoneum (perimetrium). It covers the fundus and the body of the uterus (Fig. 26-45).

Fig. 26-45.

Anterior, right lateral, and posterior views of uterus of adult woman. a, Uterine tube; b, Round ligament; c, Ovarian ligament; ur, Ureter. (Cunningham FG, MacDonald PC, Gant NF, Leveno KJ, Gilstrap LC III. Williams Obstetrics (19th ed). Stamford CT: Appleton & Lange, 1993; with permission.)

The muscular coat (myometrium) is formed by an abundance of smooth muscle fibers which contain a rich neurovascular network (Fig. 26-46, Fig. 26-47). The myometrium is continuous laterally with the muscular coat of the uterine tube. The fundus and body of the uterus contain more muscular tissue, whereas the cervix contains more fibrous tissue.

Fig. 26-46.

Myometrium: sagittal section of normal adult uterus. (Modified from Eastman NJ. Williams Obstetrics (10th ed). New York: Appleton-Century-Crofts, 1950; with permission.)

Fig. 26-47.

Frontal section of normal adult uterus, showing myometrium and shape of cavity and isthmus. (Modified from Eastman NJ. Williams Obstetrics (10th ed). New York: Appleton-Century-Crofts, 1950; with permission.)

The mucosa of the uterus, or the endometrium, lines the inner surface of the uterine cavity. It is composed of many tortuous glands. The endometrium significantly changes in thickness and cellular character with the cyclical hormonal variation, the menstrual cycle. The endometrium does not have a submucosa. The endometrium is directly fixed to the muscular coat and has tremendous regenerating potential. The endometrium of the nonpregnant uterus presents in three basic phases: menstruation, proliferation (Fig. 26-48A), and secretory (Fig. 26-48B) activity. After a cervical dilatation and curettage, the endometrium is able to regenerate because the mucosa dips deep within the muscular stroma. These intramuscular mucosal glands are not mechanically violated during the procedure. It is not within the scope of this chapter to give detailed histologic descriptions.

Fig. 26-48.

Endometrium. A, Proliferative phase. The gland cells are usually organized in a simple array. B, Secretory phase (21st day of the menstrual cycle). Uterine glands are tortuous, with lumens dilated by accumulation of secretory material. (Junqueiro LC, Carneiro J, Contopoulos AN. Basic Histology, 2nd ed. Los Altos, CA: Lange Medical Publications, 1971; with permission.)

Physiology of Uterus

The uterus is a very thick-walled, muscular organ with three layers. The thin external layer is simply the visceral peritoneum. The thick middle muscular layer, or myometrium, consists of interlacing, circular, longitudinal, and oblique spiral bundles of smooth muscle and large venous plexuses. The myometrium is sensitive to estrogen and progesterone hormones. The endometrium is a mucous membrane from 1 to 6 mm in thickness, depending upon hormonal stimulation. The endometrium develops day by day in specific histologic changes when stimulated by estrogen and/or progesterone according to the ovarian cycle (see Fig. 26-48). The visceral vasculature to the uterus, as well as in the myometrium and endometrium, is likewise very sensitive to the ovarian hormones.

Dysmenorrhea is uterine pain associated with menses. Current theories suggest that the rapid release of synthesized prostaglandins act directly on the myometrium causing intense smooth muscle contractions with resulting constriction of small endometrial blood vessels, tissue ischemia, and subsequent pain. Prostaglandin synthetase inhibitor medication has been shown to be very effective in inhibiting prostaglandin synthesis and in significantly decreasing pain in primary dysmenorrhea. Wilson and colleagues41 found insufficient evidence in controlled trials to recommend the use of uterine nerve ablation to treat primary or secondary dysmenorrhea.

Endometrial tissue may be found associated with anatomic entities close to the uterus such as the uterine tubes and ovaries, and more remote locations in the gastrointestinal tract (e.g., abdominal wall). This ectopic mucosa menstruates in the pelvic cavity or with the organ where it is located. La Greca et al.42 advised that endometriosis of the ileum may produce symptoms mimicking inflammatory bowel disease.

After menopause, with the removal of estrogen and progesterone stimulation, both the myometrium and endometrium atrophy.

Surgical Applications

[In abdominal hysterectomy, the] dissection is always anatomic, bleeding is always under prompt control, and modifications because of pelvic disease are easily undertaken.—Tiffany J. Williams43

Abdominal Hysterectomy

If at all possible, perform a total abdominal hysterectomy in preference to a supracervical hysterectomy. Leaving the cervix in situ may eventually lead to cervical dysplasia and/or cervical cancer. It should be noted, however, that some gynecologic surgeons prefer a supracervical hysterectomy for two reasons: first, to preserve an intact pericervical ring of endopelvic fascia for support; second, to preserve sexual pleasure at the level of the cervix.

Vaginal Hysterectomy

During vaginal hysterectomy, the round and ovarian ligaments, as well as the uterine tubes, are brought down into the vagina as a result of the downward pull on the uterus. Postoperative enterocele or cul-de-sac hernia is prevented in many surgical cases by plicating the uterosacral ligaments in the midline and attaching the vaginal cuff to them. During any pelvic surgery, the operator must always know the whereabouts of the ureters, as well as the bladder and rectosigmoid.

During surgical procedures, division of the round ligament allows for ready, safe access to the retroperitoneal areas of the vesical space-obturator space, and to the pelvic sidewall adjacent to the space of Retzius, the region between the bladder and the pubic bone and rectus muscles. This area is well above the course of the ureter as it travels through the base of the broad ligament and cardinal ligament.

Coagulation and Embolization of Uterine Vessels

Embolization of the pelvic vasculature is used to treat postpartum and postsurgical bleeding. Dover et al.44 reported success in treating symptomatic fibroids by uterine artery embolization. Laparoscopic bipolar occlusion of uterine vessels was employed by Liu45 to reduce the size of symptomatic leiomyomas.



The cardinal ligament, uterosacral ligament, and the levator plate are of special significance in supporting the uterus.

The distal ureter is related to the supravaginal cervix within the broad ligament, below the uterine vessels, and above the level of the lateral fornix, approximately 1.3 cm (approximately ½ inch) or less lateral to the cervix. It can be injured, divided, and ligated during total hysterectomy. Accidental division during surgery produces a very serious anatomic complication.

The ureter runs from the pelvic wall toward the urinary bladder through the base of the cardinal ligament, or it may have a close relation to the pubovesicocervical fascia. These facts should be remembered during abdominal hysterectomy.

During vaginal hysterectomy, the round and ovarian ligaments as well as the uterine tubes are exposed as the uterus is drawn downward.

In vaginal hysterectomy, the uterosacral and cardinal ligaments can be divided and ligated. This represents lower ligation of the broad ligament. Ligation of tubes, ovaries, and round ligaments is upper ligation.

Because their biopsy studies showed a greater density of autonomic nerves and ganglia in the uterosacral ligaments than in the cardinal ligaments at the level of a radical hysterectomy (RH), and because RH disrupts more nerve tissue than does simple hysterectomy, the study of Butler-Manuel et al.46 supports the neurogenic etiology of pelvic morbidity after RH.

The round ligament becomes hypertrophied in pregnancy and may be palpated.

The uterosacral ligament is exposed by cutting the posterior leaflet of the broad ligament. Stay close to the uterine wall to avoid injury to the ureters.

When sutured together, the uterosacral ligaments practically close the posterior pelvis.

Be sure to recognize the urinary bladder, the ureter, and the rectosigmoid.

Both leaflets of the broad ligament should be incised and separated carefully to free the urinary bladder.

Be sure to free the bladder during abdominal hysterectomy. Proceed from the anterior surface of the uterus by a peritoneal incision that is not close to the anterior uterine wall. If necessary, leave myometrium on the bladder rather than the bladder on the uterus.43

When bleeding occurs during hysterectomy, internal iliac (hypogastric) ligation is occasionally required, and may be done with impunity.

To avoid ureteric injuries, the best surgical dissection involves the upper ⅓ of the uterine side; in other words, the best area is close to the fundus.

Remember the relationship between the pubovesicocervical fascia and the ureter. The fascia covers the area between the cardinal ligament and the cervical surface. The ureter is within this fascia, but at the base of the cardinal ligament. Therefore, dissect within the fascial plane above the base of the cardinal ligament.

The cardinal ligaments and uterosacral ligaments are different parts of the same endopelvic fascial complex that suspends the upper third of the vagina and cervix over the levator plate. This suspensory action allows forces from above in the standing female patient to entrap the upper third of the vagina and cervix against the levator plate in order to prevent vaginal and cervical prolapse. This is known as a flap-valve mechanism. The cardinal and uterosacral ligaments and the pubovesicocervical fascia are the main supporters of the female contents after abdominal hysterectomy. They should be sutured to the vaginal angles.

The infundibulopelvic and round ligaments provide minimal support for the vaginal vault. However, their approximation to the vault will help to cover the sutured vaginal wall with peritoneum.

Smith-Bindman et al.47 strongly recommended endovaginal ultrasound for postmenopausal women with vaginal bleeding to diagnose or rule out endometrial cancer and other endometrial disease.

Anatomic Complications of Hysterectomy

Anatomic Complications of Abdominal Hysterectomy

The following are possible anatomic complications of abdominal hysterectomy:


Intrinsic sphincter deficiency48

Injury to the bladder

Injury to one or both ureters

Somatic nerve injury

Intestinal injury


During the performance of a “routine” hysterectomy, whether abdominal or vaginal, injuries to the bladder, ureters, rectosigmoid, and blood vessels have been reported. Injuries to somatic nerves are very unlikely, but have been reported in relation to patient positioning for a particular surgery, particularly in the dorsolithotomy position for a vaginal hysterectomy.

Injury to the Bladder

Always keep in mind the relationship between the bladder and anterior abdominal wall and between the bladder and the cervix. If injury to the bladder is not recognized in the operating room, results may be catastrophic for both the patient and the surgeon.

The urinary bladder can be injured:


During the abdominal incision. It is important to open the peritoneal cavity by incising the peritoneum very high.

During dissection within the vesicouterine and vesicovaginal space. This dissection is best performed sharply trying to find the white shiny surface of the pubocervical fascia.

If the bladder is opened inadvertently, the surgeon must determine whether the ureters are involved also. If the ureters are not involved, then the defect should be closed in two layers, trying to avoid the bladder mucosa. Absorbable 2-0 or 3-0 sutures with an atraumatic continuous or interrupted suture are acceptable. The first layer should be inverted by a continuous or interrupted absorbable suture. A transurethral catheter should drain the bladder for several days to a week, depending upon the size and location of the injury.

Unilateral or Bilateral Ureteric Injury

In spite of the greatest care and knowledge of the anatomic relations, the ureter may occasionally be unexpectedly injured. In fact, this may occur more frequently than is usually recognized.—Michael Newton & John R. Lurain49

The only gynecologist who has not injured a ureter or bladder is one who has done little surgery.—Lawrence R. Wharton, Jr.50

The distal ureter travels within the base of the broad ligament through the base of the cardinal ligament as the uterine vessels travel toward the cervix. The crossing of the ureter below the uterine vessels (Fig. 26-49 and see Fig. 26-37) is in relation to the lateral vaginal fornix and is approximately 1.5-2 cm from the side of the cervix. The ureter can be injured during clamping, ligation, and cutting in this area during a total hysterectomy.

Fig. 26-49.

Some relations of the ureter in the female pelvis. (Modified from Hollinshead WH. Anatomy for Surgeons, Vol. 2. New York: Hoeber-Harper, 1961; with permission.)

Accidental occlusion of the ureter at this point may eventually lead to hydroureter, hydronephrosis, and eventual renal failure of that side. After passing through the ureteric tunnel in the base of the cardinal ligament, the ureter makes a “knee-bend” and travels anteriorly and medially across the anterolateral fornix of the vagina for several centimeters before it enters the bladder.

Injury to the ureter can occur:


When clamping uterine vessels or the uterosacral ligament

When clamping the infundibulopelvic ligament at the pelvic brim

When clamping at the lateral wall of the proximal vagina

During pelvic retroperitonealization

The most common sites of ureteric injury are:


At the lateral pelvic sidewall where the uterine vessels pass over the ureter

At the ureterovesical junction, particularly during the performance of anterior colporrhaphy

At the infundibulopelvic ligament

The damaged ureter should be recognized and repaired immediately. Such repair may include a ureteroureteric anastomosis or a ureterovesical anastomosis.

During any gynecologic surgery, it is recommended that one visualize and/or palpate the ureter as much as possible. The description by Williams43 may be helpful in identifying the ureter: “Peristalsis and the characteristic wavy blood vessels on the ureteral surface are not duplicated by any other structure” (Fig. 26-50).

Fig. 26-50.

Retroperitoneal anatomy, showing relative positions and courses of uterine, ovarian, and iliac vessels as well as ureter and bladder. (Modified from Williams TJ. Abdominal hysterectomy, myomectomy, and presacral neurectomy: with management of bladder injury and attention to thromboembolic disease. In: Ridley JH (ed). Gynecologic Surgery: Errors, Safeguards, and Salvage (2nd ed). Baltimore: Williams & Wilkins, 1981; with permission.)

Nerve Injury

Nerve injury is an extremely rare phenomenon during abdominal hysterectomy. Nerves of the anterior abdominal wall such as the iliohypogastric or ilioinguinal nerve can be injured during the performance or closure of an anterior abdominal incision. Injury to the sacral plexus and nerves is unusual but may occur when performing deep aggressive clamping and ligation of vessels deep in the pelvis near the ischial spine or over the sacrum.

The femoral nerve is located in the iliopsoas groove, well above and well lateral to any operative field for hysterectomy. However, the deep lateral blade of a self-retaining retractor may rest upon the psoas muscle and impinge the femoral nerve against the iliacus muscle which is against the bony backstop of the iliac fossa. Therefore, when placing lateral retractors during the performance of a hysterectomy in a low transverse skin incision, the operator must be sure that the lateral blades of the retractors are not impinging upon the psoas muscle.

During radical hysterectomies and the performance of obturator space lymph node dissections, the obturator nerve may be inadvertently cut. An intraoperative neurosurgical consult is a necessity if this occurs.

Intestinal Injury

Intestinal injury in the operating room is a serious matter. Intra-operative recognition of the problem is essential. A lacerated viscus, whether small or large bowel, should be closed with interrupted nonabsorbable suture. If the injury is extensive and the laceration is long, in some cases a segmental resection and end-to-end anastomosis may be necessary.


Bleeding within the pelvis as a result of a hysterectomy may result from injury to the ovarian vessels, uterine vessels, and/or their tributaries. The surgeon can avoid bleeding by careful localization of the site of bleeding, followed by careful ligation of the bleeding vessel. The course of the ureter must always be known. Never use blind clamping. Open the broad ligament and ligate the vessel that is bleeding. If necessary, an internal iliac (hypogastric) artery ligation may be needed to decrease pulse pressure within the pelvis, and thus promote hemostasis.

Anatomic Complications of Vaginal Hysterectomy and Repair

The technical difficulties in the vaginal hysterectomy are principally raised by the spatial conceptualization of the normal anatomy in the craniocaudal direction and the topographical modifications from the surgical manipulations.—P. Kamina51

Anatomic complications of vaginal hysterectomy include:


Bleeding (very common)

Ureteric injury

Nerve injury

Intestinal injury

Bladder injury

Shortening of the vagina

Stenosis of the introitus


Bleeding may result from incomplete ligation of the infundibulopelvic ligament around the ovary, or more commonly, from incomplete hemostasis at the level of the vaginal cuff, with a resultant vaginal cuff hematoma.

Ureteric Injury

Ureteric injury is less common in vaginal hysterectomy than in total abdominal hysterectomy, because release of the bladder pillars at the beginning of vaginal hysterectomy allows the ureters to retract superiorly and laterally away from the uterine vessels that will soon be clamped.

Kamina51 stated that during vaginal hysterectomy, caudal continuous traction of the cervix is imperative to avoid ureteric injury. Caudal and continuous traction makes dissection easier by:


Breaking the uterus away from its visceral connections

Individualizing the various ligaments

Restoring the peritoneum and fornices

Nerve Injury

Nerve injury during the actual performance of vaginal hysterectomy is rare. The few cases of injury to somatic nerves reported during vaginal hysterectomy are due to patient positioning in the dorsolithotomy position.

Intestinal Injury

A lacerated viscus, whether small or large bowel, should be closed with interrupted nonabsorbable suture. If the injury is extensive and the laceration is long, in some cases a segmental resection and end-to-end anastomosis may be necessary. Intestinal injury from adhesion of the rectosigmoid or small bowel to the fundus of the uterus is unusual and very rare.

Bladder Injury

Bladder injury most commonly occurs during attempts to enter the vesicouterine fold in order to enter the anterior cul-de-sac and retract the bladder anteriorly away from the lower uterine segment. In many instances bladder injury is due to prior scarring in this area from a previous cesarean delivery.

Shortening of the Vagina

Shortening of the vagina occurs very rarely but may be due to excessive excision of vaginal cuff epithelium, thus shortening the vagina to below the level of the ischial spines.

We quote from Yamamoto et al.52:

Preservation of the ovaries appeared to be important in preventing vaginal shortening, and post-operative hormone replacement therapy was not as effective as the preservation of the ovaries. The effect of external irradiation on vaginal shortening was not conspicuous in the case[s in which] the ovaries were preserved.

Stenosis of the Introitus

Stenosis of the vaginal vault as well as the vaginal introitus is, again, due to excessive excision of vaginal epithelium during the performance of an anterior colporrhaphy or posterior colpoperineorrhaphy. After these procedures, a “three-finger” vaginal introitus is preferred, with the vaginal cuff located just above the level of the ischial spines.



Normal Development

The embryogenesis of the vagina is enigmatic. Its genesis may be said to be dual: the upper part of the vagina is of mesodermal origin; the lower part (urogenital sinus) is of endodermal origin.

Congenital Anomalies

Congenital anomalies of the vagina are associated, in most cases, with uterine and vulvar anomalies. The anomalies of the vagina include embryologic agenesis, imperforate hymen, formation of various septa within the vagina itself, and cysts such as a Gartner’s duct cyst or Skene’s duct cyst. Primary vaginal adenocarcinoma arising from a metanephric duct remnant has been reported.53 Asymptomatic cysts do not have to be removed. For further information see Fig. 26-19 and Table 26-5.

Surgical Anatomy

Topography and Relations

The vagina is a musculomembranous tube between the bladder anteriorly and the rectum posteriorly (Fig. 26-51). The vagina starts at the vestibule of the vulva and extends posteriorly to the cervix and uterus. The vagina has a configuration of an “H” cleft with the anterior and posterior walls in apposition. Each anterolateral sulcus of the vagina is attached to the fascial white line (arcus tendineus fasciae pelvis) from the sidewall of the pelvis. The vagina is very distensible, obviously, to accommodate the erect male penis during sexual intercourse and to allow for the birth of an infant.

Fig. 26-51.

Highly diagrammatic representation of the relations of the vagina to several anatomic entities (anteriorly, posteriorly, and laterally).

The cervix projects through the upper anterior wall of the vagina. Therefore, the length of the anterior wall of the vagina, from introitus to cervix is approximately 7 cm anteriorly; the length of the posterior wall to the posterior fornix is approximately 9-10 cm.

Orientation of the Vagina

The following description is presented for the purposes of anatomic orientation. In the normal nulliparous standing female, the bladder, the upper two-thirds of the vagina, and the rectum lie along an almost horizontal axis. The levator plate of the levator ani muscles forms a parallel, horizontal muscular hammock or dynamic back-stop for these viscera. When the upper portion of the vagina is in its normal position, the cervix is found at the level of the ischial spines. The posterior vaginal fornix extends more posteriorly to lie over the coccyx and lower sacrum medially and the sacrospinous ligaments laterally.

Vaginal Support

The supports of the vagina include the:


Arcus tendineus fasciae pelvis

Cardinal ligament/uterosacral ligament complex

Levator ani

Perineal body

Pubocervical fascia

Arcus Tendineus Fasciae Pelvis

The epithelial lining of the vagina is intimately surrounded by a fibromuscular coat, which is thickened anteriorly by the external layer of connective tissue (clinically or surgically named the pubocervical fascia). An oblique band of endopelvic fascia connects each anterolateral sulcus of the vagina to the musculature of the pelvic floor. The arcus tendineus fasciae pelvis, or fascial white line, is a thickening of the parietal fascia over the levator ani muscles which extends from the pubic arch in a straight line to the ischial spine.

Remember, portions of the levator ani, that is, the iliococcygeus muscle and part of the pubococcygeus anteriorly, originate from the arcus tendineus levator ani or muscle white line, which is a thickening of the parietal fascia overlying the obturator internus muscle. This line extends from the lateral posterior aspect of the pubic bone in a curvilinear fashion toward the ischial spine. The muscle white line and the fascial white line usually merge into one white line as they pass posteriorly toward the ischial spine.

Cardinal Ligament/Uterosacral Ligament Complex

The supports of the vagina include the cardinal ligament/uterosacral ligament complex, which was described with the uterus. These ligaments suspend the upper third of the vagina over the levator plate in order to allow the flap-valve mechanism to come into full effect and thus prevent vaginal prolapse.

Levator Ani Muscle

In contrast to the horizontal orientation of the bladder, upper vagina, and rectum, the urethra, the distal one-third of the vagina and the anal canal are almost vertical in orientation. These lower structures are supported by the pubococcygeus muscles of the levator hiatus and the structures of the perineum — the perineal body and the anatomic structures of the urogenital and anal triangles. When these normal anatomic relationships are disrupted, physiologic dysfunctions such as urinary and fecal incontinence, and prolapse of the pelvic organs and vagina can ensue.

Perineal Body

The opening of the vagina is supported by the perineal body. The perineal body is a pyramidal-shaped fibromuscular structure, with the base of the pyramid found between the anus and introitus of the vagina and parallel with the floor in the standing female patient. The apex of the pyramid is located between the lower third and the middle third of the vagina, at the point where the vagina turns from its vertical orientation into its almost horizontal orientation. Supporting structures that stabilize the perineal body include the pubococcygeus muscles, the transverse perinei muscles, and the perineal membrane.

Pubocervical Fascia

“Pubocervical fascia” is simply a clinical/surgical term for the thickened anterior portion of the fibromuscular coat that surrounds the vaginal epithelium. The pubocervical fascia extends from underneath the urethra, laterally to the fascial white lines, and posteriorly to the pericervical ring of endopelvic fascia around the cervix. The cardinal ligament/uterosacral ligament complex from each side inserts into the same pericervical fascia. The pubocervical fascia is a horizontal hammock upon which the bladder rests.

The purpose of the intact pubocervical fascia is to prevent cystocele. Dr. A. Cullen Richardson of Atlanta (personal communication, 1989) has observed that approximately 85% of cystoceles result from a tearing away of the pubocervical fascia from one or both fascial white lines. This constitutes the “paravaginal defect.”

Zacharin54 stated that the levator ani complex and pelvic cellular tissues must be restored in patients with pulsion enterocele.

Vascular Supply


The internal iliac artery and its several branches are responsible for the rich blood supply of the vagina.

The upper part of the vagina is supplied by branches from the uterine artery (see Fig. 26-6).

The middle part of the vagina is supplied by multiple branches from the vaginal artery, with some anastomoses with branches from the middle rectal arteries. These anastomoses form two longitudinal vessels anterior and posterior — the azygos arteries of the vagina.

The lower part of the vagina is fed by branches of the vaginal artery and from the artery of the bulb of the vestibule, a branch from the perineal artery from the pudendal artery.


The vaginal venous blood returns to the vaginal venous plexus and then to the uterine, as well as to the vesical, plexuses. All this venous blood eventually drains into the internal iliac (hypogastric) veins.


The upper part of the vagina contains lymphatic vessels that follow the uterine artery and drain into the external and internal iliac lymph nodes (see Fig. 26-40). The middle portion of the vagina contains lymphatic vessels that follow the vaginal artery and drain into the internal iliac nodes.

The lymph from the lower part of the vagina drains to the sacral and common iliac nodes. The introitus of the vagina or hymenal area drains to the superficial inguinal nodes.


The uterovaginal plexus is responsible for the innervation of the vagina (see Fig. 26-42). The uterovaginal plexus, which is derived from the inferior hypogastric plexus, contains autonomic fibers for the muscular coat of smooth muscle of the vagina. Some vasomotor fibers exist here also; however, there is no vaginal sensation except in the most distal part, which is innervated by pudendal nerve branches.


The vaginal wall is formed by three layers:


Innermost (epithelium —often inaccurately called mucosa)

Intermediate (connective tissue and smooth muscle fibers)

External (superficial muscular coat)

Epithelial Layer (Vaginal Mucosa)

The innermost layer is covered by stratified squamous epithelium. Its appearance is dominated by hormonal influences, responding with cyclic changes. Both anterior and posterior vaginal mucosa possess longitudinal ridges (columns of vagina) and several transverse ridges.

Intermediate Layer

The intermediate tissue between the mucosal and muscular layers consists of connective tissue investing a rich venous network as well as smooth muscle fibers originating from the muscular layer.

External Muscular Coat

The muscular layer is of smooth muscle origin. It consists of two layers, one external longitudinal and the other circular. At its distal, most narrow end, the vagina is surrounded by the striated bulbospongiosus muscles.

The vagina may be envisioned most simply as a hollow fibromuscular tube that is lined on the inside by stratified squamous epithelium. There are no mucosal glands in this epithelium. Lubrication of the vagina during sexual excitement occurs as a result of transudation of serosanguinous fluid from the surrounding venous engorgement. The vaginal epithelium is hormonally manipulated, having cyclic changes. Both the anterior and posterior vaginal epithelium demonstrate longitudinal ridges. These ridges are formed of elastin found in the fibromuscular coat surrounding the epithelium. Loss of these longitudinal ridges is an indication of breaks within the pubocervical fascia (fibromuscular coat around the vagina).


The physiological destiny of the vagina is threefold:


Organ of copulation

Birth canal

Tube for the excretions of uterus, menstrual period, etc.

Details of the vasocongestive and orgasmic reflex are not within the scope of this chapter.

Anatomy of the Vaginal Examination

The vaginal examination is accomplished by inspection and by bimanual examination. Inspection includes visualization of the vulva and surrounding cutaneous areas for pathologic processes such as condylomata, infection of the Bartholin’s glands, imperforate hymen, prolapse of urethral mucosa, or dermatitis.

With the insertion of the speculum into the vagina, the vaginal epithelium can be evaluated for discharges, leukoplakia, cystoceles, prolapse, or rectoceles. Visualization of the cervix and subsequent Pap smear allows cytological examination of the cervix.

A bimanual gynecologic examination allows the physician to evaluate the vaginal introitus, to determine the character or texture of the vaginal epithelium, to detect support defects in and surrounding the vagina, and to palpate the uterus, tubes, ovaries, and any other pelvic mass. The urethra, urinary bladder, and pubic symphysis can be felt anteriorly. Apically, evaluation of cervical and uterine support and the presence of vaginal prolapse and/or cul-de-sac hernia can be determined. Posteriorly, support to the rectum can be evaluated, particularly with a rectovaginal examination.

A rectal examination at this time will also allow the examiner to obtain a small sample of stool which can then be tested for the presence of occult blood. Bimanual examination also allows the practitioner to feel the midplane and outlet of the bony pelvis to evaluate the size of the pelvis in relation to childbearing.

Inspection of the vaginal introitus may include a measurement of the vaginal outlet, which is normally 4 to 6 cm in length in multiparous women. A gaping vaginal introitus points to the disruption of the superficial perineal muscles and detachment of the lower one-third of the vagina from the perineal body. The perineal body itself should not demonstrate an excursion of more than 1 cm upon palpation. A relaxed vaginal outlet with a disrupted perineal body indicates a damaged pelvic floor.

After disassembling a Graves bivalve speculum and placing the lower half in the vagina, the examiner may then assess the anterior, apical, and posterior vaginal walls for defects (Fig. 26-52A). The posterior vaginal wall may be depressed in order to inspect the anterior vaginal wall. Loss of anterior wall support indicates the development of a cystocele (Fig. 26-52B, Fig. 26-53). Lateral tears or paravaginal defects can be diagnosed by both inspection and palpation of the vagina.

Fig. 26-52.

Sites of pelvic support defects. A, Defects in the pelvic supports may occur in three different segments of the pelvic floor: anterior, central, and posterior. B, A cystocele can result from any break in the continuity of the pubocervical fascial, hammocklike supports of the bladder. The three sites of possible defects are indicated. The paravaginal break is the most common, accounting for about 85 percent of all cystoceles and urethroceles. (Modified from Skandalakis LJ, Gadacz TR, Mansberger AR Jr, Mitchell WE, Jr., Colborn GL, Skandalakis JE. Modern Hernia Repair: The Embryological and Anatomical Basis of Surgery, revised 2nd ed. New York: Parthenon, 1996. Plate 2-27; with permission.)

Fig. 26-53.

Diagrammatic sketch showing the pubocervical fascia separated from its attachment into the pericervical ring. Note that the bladder is covered only by vaginal mucosa over the cystocele. (Modified from Skandalakis LJ, Gadacz TR, Mansberger AR Jr, Mitchell WE Jr, Colborn GL, Skandalakis JE. Modern Hernia Repair: The Embryological and Anatomical Basis of Surgery, revised 2nd ed. New York: Parthenon, 1996. Plate 2-30; with permission.)

A ring forceps can be placed gently along the lateral vaginal sulci from the vaginal introitus to the level of the ischial spines. This maneuver reapproximates the pubocervical fascia to the fascial white lines. If the cystocele is due to a lateral or paravaginal defect, the cystocele will disappear. If the bulging cystocele does not disappear with this maneuver, then a midline, or perhaps a transverse, cervical break in the pubocervical fascia is diagnosed. During vaginal palpation, the ischial spine and fascial white line can be felt laterally on each side.

With the lower half of the Graves speculum rotated 180° to support the anterior vaginal wall, the examiner can assess weakness in the posterior vaginal wall or the presence of a rectocele. A rectocele results from a break in the rectovaginal septum, usually being torn from the perineal body. The rectovaginal septum is a separate sheet of endopelvic fascia between the vagina anteriorly and the rectum posteriorly. An intact rectovaginal septum is of great importance in the prevention of rectocele and enterocele formation. A rectovaginal examination in many cases allows the examiner to palpate the rectovaginal septum. This allows for identification of the site of an endopelvic fascial break allowing the formation of the rectocele.

The rectovaginal exam also allows the examiner to assess the integrity of the perineal body. At this time, there is no universally used system for defining and describing the severity of pelvic floor defects such as cystocele, enterocele, and rectocele, though a formal system has been recommended.55

Palpation of the vagina should be performed with the patient both at rest and during straining. An enterocele is manifested as a bulging of the apical portion of the vagina during straining. This usually indicates a break in the attachment of the rectovaginal septum with the uterosacral ligaments.56

Cervical support should also be evaluated during the vaginal examination. The cervix is suspended over the levator plate by the two cardinal-uterosacral ligament complexes. If these structures are intact, the cervix has very little lateral movement. Though pelvic examinations are traditionally done in the dorsolithotomy position in the United States, occasionally pelvic floor defects are not readily apparent until the patient is examined in the standing position.57

Surgical Applications


A patient voiding normally but also experiencing constant urinary leakage should be evaluated for ureterovaginal or vesicovaginal fistula.

Ridley58 advised repair of vesicovaginal fistula by closure of the bladder in two layers, with closure of the vaginal mucosa as a third layer.

Anatomic Complications of Anterior and Posterior


Possible complications involved with the performance of anterior and posterior colporrhaphies to repair cystoceles and rectoceles of the vagina include:



Urethral injury

Bladder injury

Ureteric injury

Intestinal injury

Vaginal strictures



The vaginal wall has an extremely rich blood supply, particularly laterally. Avascular surgical planes such as in the vesicovaginal space and the rectovaginal space are very important to identify and use surgically.

Urethral Injury

Urethral injury may take place during dissection in performing anterior colporrhaphy. Because the vaginal wall envelops the distal urethra, too vigorous a dissection may produce injury or scarring to the urethra. Overmobilization of the urethra will disrupt its nerve and blood supply. Resulting fibrosis and urethral dysfunction may ensue.

Bladder Injury

Aggressive dissection in the vesicovaginal space may result in an inadvertent entry into the bladder. It is important that this be recognized as soon as possible so that ureteric function can be assessed via cystoscopy. With knowledge that the ureters are not involved in the bladder injury, the injury site may then be closed with a running 2-0 absorbable suture and then imbricated with interrupted 2-0 absorbable suture, exercising care to avoid damage to the ureters in the process.

The bladder should be drained with a Foley catheter for approximately a week postoperatively. Hurt and Dunn59 stated: “[I]t is important not to overcorrect the cystocele.” The good surgeon should always remember that “the enemy of good is better.” Moderate correction, not overcorrection, of a cystocele is important. Preservation of the posterior ureterovesical angle is important in avoiding postoperative anatomic genuine stress urinary incontinence.

Ureteric Injury

Ureteric injury can occur during aggressive lateral dissection during anterior colporrhaphy or performance of a vaginal paravaginal defect repair. In some techniques of anterior colporrhaphy, ureteric occlusion can also occur during wide plication of the bladder to correct a midline cystocele.

Intestinal Injury

During the performance of a posterior colporrhaphy to repair a rectocele, the operator may lacerate or perforate the anterior rectal wall, or even damage the sphincteric apparatus of the surgical anal canal. Again, such lacerations should be repaired in two layers with absorbable sutures. The sphincters of the anal canal should also be repaired when seen.

Occasionally during the performance of an enterocele repair, small bowel may be lacerated in the cul-de-sac. It is important that such lacerations be recognized immediately and closed with 2 layers of 2-0 permanent suture: the first layer of bowel (mucosa) closure with absorbable (chromic or Vicryl), and the second layer with nonabsorbable sutures.

Vaginal Strictures

When performing reparative vaginal surgery, the surgeon must be careful not to excise too much of the vaginal epithelium. Vigorous excision of “excess” vaginal epithelium may very well lead to a short vagina with narrow diameter. It is recommended that the patient leave the operating room with her vagina three fingers in diameter (approximately 4 cm), with a length approximately at or superior to the level of the ischial spines.


A narrow, shortened vagina may certainly lead to dyspareunia. According to Hurt and Dunn,59 “The construction of a high perineum is of no advantage to the patient and is often the cause of dyspareunia.”

While Weber et al.60 found that the combination of Burch colposuspension and posterior colporrhaphy was especially likely to result in dyspareunia, they reported that sexual function and satisfaction improved or did not change in most women following surgery for prolapse and/or urinary incontinence.

Female Urethra


Normal Development

The endoderm is responsible for the epithelium of the urethra. The splanchnic mesoderm is responsible for the surrounding smooth muscles and connective tissue.

Congenital Anomalies

Absence of the urethra may be congenital. This deformity occurs secondary to complete hypospadias.

Surgical Anatomy

The female urethra (Fig. 26-38, Fig. 26-54) will be considered in this chapter for surgical purposes only.

Fig. 26-54.

Anatomy of the urethra. A, Sagittal section. B, Cross section. (Modified from Lentz GM. Urogynecology. London: Arnold [a member of Hodder Headline Group. Co-published by Oxford University Press Inc, New York], 2000; with permission.)

Topography and Relations

The length of the female urethra is approximately 4 cm, but is extremely variable. Its diameter is about 6 mm, and it can be dilated up to 1 cm with ease. It extends from the neck of the bladder to the external urethral orifice, which is located between the labia minora, anterior to the vaginal opening, and approximately 2.5 cm below the glans clitoris.

The female urethra is oriented almost vertically in the standing patient. It is fused with the anterior vaginal wall and also with the symphysis pubis by the perineal membrane.

O’Connell et al.61 performed detailed dissection on 2 fresh and 8 fixed human female cadavers ranging in age from 22 to 88. They wrote:

The female urethra, distal vaginal wall and erectile tissue are packed into the perineum caudal (superficial) to the pubic arch, which is bounded laterally by the ischiopubic rami, and superficially by the labia minora and majora. This complex is not flat against the rami as is commonly depicted but projects from the bony landmarks for 3 to 6 cm. The perineal urethra is embedded in the anterior vaginal wall and is surrounded by erectile tissue in all directions except posteriorly where it relates to the vaginal wall. The bulbs of the vestibule are inappropriately named as they directly relate to the other clitoral components and the urethra. Their association with the vestibule is inconsistent and, thus, we recommend that these structures be renamed the bulbs of the clitoris.

O’Connell et al.61 concluded that the dissections “suggest that current anatomical descriptions of female human urethral and genital anatomy are inaccurate.”

Female Continence Mechanism

Tanagho62 wisely stated that the female urethra represents the entire sphincteric mechanism of the urinary bladder in the female. Its two muscular layers (inner longitudinal and outer semicircular) form the sphincteric urethral apparatus in continuation with the detrusor muscle of the urinary bladder. This sphincteric apparatus is more obvious at the middle one-third, according to Tanagho,62 because of the formation of an incomplete ring posteriorly where the arms of the ring travel laterally and fuse to the urethrovaginal septum.

Siracusano et al.63 reported that the following elements contribute to the maintenance of continence:


Maximum urethral closure pressure

Anatomic and functional length of urethra

Ability of perineum to increase the urethral pressure simultaneously with the Valsalva maneuver

Appropriate location of the sphincteric unit

We are grateful to Drs. Sandra S. Retzky and Robert M. Rogers Jr. for permission to quote the following material on urinary incontinence in women:57

The continence mechanism in women centers on the proximal urethra and urethrovesical (U-V) junction. Continence is maintained by multiple structural and physiologic mechanisms that regulate closure of the urethra and support of the bladder and urethrovesical junction. Actual closure of the urethra is produced by three different systems: the involuntary internal sphincter at the vesical neck, the voluntary external sphincter muscles of the urethra, and mucosal coaptation produced by the urethral submucosal vascular plexus. Anatomic support for these structures primarily comes from a fascial layer, the pubocervical fascia, which is attached to the levator ani muscles of the pelvic floor.

Internal Sphincter

Located at the urethrovesical junction, the internal sphincter (Fig. 26-55) is formed by a ring of involuntary smooth muscle from the bladder trigone and two U-shaped loops of smooth muscle derived from the detrusor (bladder) muscle. The trigone, located at the bladder base, is composed of specialized smooth muscle that is histologically distinct from the rest of the bladder. The trigonal musculature (ring) encircles the urethral lumen at the urethrovesical junction. Below the trigonal ring, the detrusor loops open in opposite directions. The more prominent loop (loop of Heiss) passes in front of the internal urethral meatus and opens posteriorly. The second, smaller loop passes under the trigone and opens anteriorly. The proximal urethra passes between these two loops.

Fig. 26-55.

Internal and external sphincters of the female urethra.

The muscles of the internal sphincter are innervated by autonomic fibers. Continuous contraction of the trigonal ring and detrusor loop mechanism is important for maintaining continence at rest. Conditions that affect pudendal nerve function (childbirth injury, prior antiincontinence procedures, myelodysplasia) can damage the internal sphincter and lead to urinary incontinence even when support for this area is normal.

External Sphincter

The second system of urethral closure comprises three small skeletal muscles that envelop the urethra below the level of the internal sphincter. The most proximal and largest of these muscles is the urethral sphincter muscle (sphincter urethrae) (Fig. 26-55, Fig. 26-56). It almost completely encircles the upper portion of the urethra, except posteriorly where the inferior extension of the trigone fills the gap. The compressor urethrae and urethrovaginal muscles form the distal portion of the external urethral sphincter. The urethrovaginal muscle wraps around the distal portion of the urethra and vagina, inserting into the perineal body. The compressor urethrae muscles originate from the medial surfaces of the ischiopubic rami, overlap the urethrovaginal muscle, and course over the anterior surface of the urethra. Both of these muscles act as sphincters of the vagina as well as of the urethra. They are located just above the perineal membrane in the deep compartment of the urogenital triangle in the perineum.

Fig. 26-56.

The muscles of the external urethral sphincter. (Modified from Retzky SS, Rogers RM Jr, Richardson AC. Anatomy of Female Pelvic Support. In: Brubaker LT, Saclarides TJ (eds). The Female Pelvic Floor: Disorders of Function and Support. Philadelphia: FA Davis, 1996; with permission.)

The delicate muscles of the external sphincter act as a unit. They contract voluntarily and prevent incontinence if urine gets past a marginally functioning internal sphincter. The resting tone of the external sphincter muscles also contributes to the pressure inside the urethral lumen. An intraurethral pressure higher than bladder pressure helps maintain continence. Like the internal sphincter, the external sphincter is innervated by fibers from the pudendal nerve and is subject to damage from childbirth injuries and surgery.

Mucosal Coaptation

In addition to the internal and external sphincters, the submucosal vasculature of the urethra is considered to be a part of the continence mechanism. This arteriovenous complex is located between the smooth muscle coat of the urethra and its epithelial lining. Filling of this vasculature with blood improves mucosal coaptation by causing the urethral walls to seal, thus increasing urethral resting pressure and preventing involuntary urine loss. The submucosal plexus and epithelium of the urethra are estrogen-sensitive; during menopause, hormone replacement therapy can improve blood flow to this area.

Endopelvic Fascia

The following material on the endopelvic fascia and muscles of the pelvic floor is based on a chapter written by Retzky, Rogers, and Richardson.2 We recommend the chapter to the reader.

In the normal, nulliparous standing woman, the bladder, proximal two-thirds of the vagina, and rectum lie in an almost horizontal axis. In contrast, the urethra, distal one-third of the vagina, and anal canal are oriented almost vertically. Support for the vesical neck, proximal urethra, and vagina is absolutely critical for female continence. The pelvic element most responsible for maintaining normal relationships between the structures of the lower urinary tract is the endopelvic fascia.

Microscopically, endopelvic fascia is a three-dimensional meshwork of collagen, elastin, and smooth muscle. This matrix surrounds and supports the viscera in both the abdominal and pelvic cavities and extends from the pelvic floor to the respiratory diaphragm. Endopelvic fascia is histologically and functionally different from parietal fascia, which covers the skeletal musculature of the pelvic floor. Endopelvic fascia is a latticework of tissue that encapsulates, suspends, and anchors these organs in a central position. Normal function of the pelvic organs is, to a great extent, position-dependent.

The specific area of endopelvic fascia important for urethrovesical junction support is the pubocervical fascia, or paravaginal tissue. Pubocervical fascia, a sheet of thick fibrous tissue, is located on the vagina underneath the bladder. Pubocervical fascia is anterior vaginal fascia that fuses with vaginal skin, providing a hammock (or sling) for the urethra and bladder. Proximally, the pubocervical fascia attaches to the cervix; distally, it travels beneath the urethra and fuses with the perineal membrane of the urogenital triangle; and laterally, it is connected to the pelvic wall at the fascial white line (arcus tendineus fasciae pelvis). The fascial white line is a linear thickening of the parietal fascia of the levator ani muscles. The fascial white line extends from the ischial spine to the posterior aspect of the pubic bone and forms the lateral support for the bladder, vagina, and rectum.

The pubocervical fascia forms the horizontal platform that supports the bladder, and its anterior portion supports the urethra. The proximal urethra and urethrovesical junction are almost vertical and held in close proximity to the posterior aspect of the pubic symphysis. With increased abdominal pressure, the lower urinary tract is forced inferiorly and compressed against the pubocervical fascia. This urethrovesical junction “trapping” promotes continence.

Muscles of the Pelvic Floor

The levator ani muscles assist in maintaining the proper position of the urethrovesical junction and urethra within the pelvis. They do so through their attachments to the pubocervical fascia at the fascial white lines. The levator ani muscles include the pubococcygeus and iliococcygeus muscles and are part of the pelvic floor. The levator muscles are dually innervated by motor efferents from S2-S4 on their pelvic surface and by branches of the pudendal nerve on their perineal surface.

The terms “pelvic floor” or “pelvic diaphragm” refer to all the muscular components that close the pelvic cavity and their respective parietal fascial coverings. Unlike striated muscles in other areas of the body, the muscles of the pelvic floor, including the coccygeus muscles, are in a constant state of contraction, which allows for the efficient positioning of the urethrovesical junction.

Remember: Multiple structures and physiologic mechanisms ensure continence in women. The primary mechanism of continence is produced by loops of specialized detrusor muscle at the internal urethral sphincter. The urethra, resting on a hammock of connective tissue called the pubocervical fascia, is held in a position that prevents rotational descent into the vagina. Therefore, increases in intraabdominal pressure compress the anterior urethral wall against the posterior urethral wall, which is fixed against the pubocervical fascial backstop. This action adds additional closing pressure to that generated by the internal sphincter mechanism. To further secure urinary continence, the external sphincter mechanism closes the middle portion of the urethra. The submucosal plexus plays a role in the prevention of leakage by sustaining urethral pressure. Usually, incontinence becomes clinically apparent only when multiple failures of these systems take place.

Interesting material on the urethra, urogenital sphincter, and continence can be found in the writings of Oelrich64 and DeLancey.65,66

Vascular Supply


The inferior vesical artery is responsible for the blood supply of the proximal urethra. The uterine artery and inferior vesical artery supply the middle part of the urethra. The distal portion is supplied by the internal pudendal artery.


Venous blood returns into the vesical plexus and also the internal pudendal vein.


The urethral lymphatics follow the pathway of the internal pudendal artery. The majority drain into the internal iliac nodes, with some draining into the external iliac nodes.


Somatic and autonomic nerve fibers innervate the female urethra: the somatic by the pudendal nerve for striated muscle, and the autonomic by parasympathetic fibers.62


The wall of the female urethra is formed by 3 principal layers with a rich vascular submucosa: the muscular layer described above, a transitional mucosal layer proximally, and a stratified squamous layer distally.

According to Stothers et al.,67 the three walls of the female urethra can be well demonstrated with MRI.

After studying 50 male and 15 female cadavers, Rother et al.68 stated that the volume of muscle cells and fibers in male and female urethral sphincter muscles decreases with age, beginning in early childhood.


Four mechanisms affect female urinary continence at the level of the urethra: 1) the involuntary smooth muscle of the internal sphincter at the urethrovesical junction; 2) the voluntary skeletal muscle that comprises the external urethral sphincter; 3) the rich vascular network forming the submucosal seal surrounding the urothelium; and 4) the “flap-valve” mechanism of the “hammock hypothesis” of DeLancey.66

The internal sphincter is primarily under the control of the sympathetic nervous system and alpha-adrenergic receptors, with norepinephrine being the chief neurotransmitter. The external urethral sphincter has innervation from both the pudendal nerve and pelvic plexus of nerves. Aggressive surgical dissection around the urethra can denervate the urethra and weaken its ability to hold back urine. The submucosal vascular seal generates approximately one-third of the total urethral closing pressure. This mucosal seal has a high concentration of estrogen receptors and is definitely affected by estrogen. The attachment of the “hammock” of pubocervical fascia underneath the urethrovesical junction from its lateral attachment to one or both “fascial white lines” allows intrapelvic pressure to compress the urethra against the backstop of pubocervical fascia. The purpose of a retropubic urethropexy or sling procedure is to reestablish this backstop in order to allow the “flap-valve” mechanism to come into full play.

Surgical Applications


Each surgical approach to the female urethra should be tailored to the local pathology and the final diagnosis.

Repositioning of the vesical neck and proximal urethra is the goal of surgery to relieve urinary stress incontinence.

A cystocele or enterocele must be corrected if present.

Ridley58 advocated the following approaches for treating urinary stress incontinence:


– Plication of the paraurethral and bladder neck tissues

– Sling procedures with application of various materials beneath the posterior urethra and bladder neck

– Repositioning of the bladder next to the urethra in the retropubic area

– Combining the above procedures

Anatomic Complications of Female Urethral Surgery

Bredael et al.69 stated that injury of the female urethra is rare with pelvic fractures.

Ridley58 listed the following anatomic complications of female urethral surgery:


Overcorrection or partial obstruction of the urethra by plication

Overcorrection or formation of a posterior urethrovesical angle by the sling or retropubic fixation

Undercorrection of the urethra and bladder weakness by insufficiency of plication, tension on the sling, or retropubic fixation

Injury to the bladder neck during placement of the sling.

Remember to avoid sling tension, but do not place the sling loosely.


Absence of the urethra from surgical or obstetrical errors.70

If bleeding or urethral or bladder injury occurs, the wound should be drained suprapubicly.



Normal Development

The urogenital folds form the labia minora. They do not fuse except at the caudal ends, which form the frenulum of the labia minora.

The labial folds fuse anteriorly to form the mons pubis and the anterior labial commissure; they fuse posteriorly to form the posterior labial commissure. The unfused portions of the labial folds form the labia majora.

In the female, the phallus becomes the clitoris.

Congenital Anomalies

The anomalies of the vulva are the anomalies of the anatomic entities forming this region (see Table 26-5).

Surgical Anatomy

Topography and Relations

The term “vulva” is essentially equivalent to the urogenital region of the perineum. The following anatomic entities collectively form the vulva (Fig. 26-57):


Mons pubis (mons veneris)

Labia majora

Labia minora


Vestibule and its related entities

Fig. 26-57.

The female external genitalia, or vulva. (Modified from Tovell HMM, Young AW Jr. Diseases of the Vulva in Clinical Practice. New York: Elsevier Science Publishing Co., 1991; with permission.)

Mons Pubis (Mons Veneris)

In Latin, mons means “a hill;” veneris originates from the name Venus, the Roman goddess of love. The ancient Greeks called this anatomic area the Hill of Aphrodite (the Greek goddess of love). It consists of fibrofatty tissue (mostly fat) and forms a cushion, resting upon the anterior surface of the symphysis pubis like a dome.

After puberty this area is covered by coarse hair which is said to be different in females and males. It is said that the upper end of the hair pattern in the female is limited in a horizontal fashion, whereas the pubic hair of the male extends upward toward the navel, although this upward extension of the hair is more similar to that elsewhere on the body, not possessing the character of pubic hair. The student occasionally will see the term “escutcheon” applied to this trigonic hairy area. Escutcheon, a word which means shield, comes from the old French or Latin scutum.

Labia Majora

The labia majora, the analogues of the scrotum, are prominent folds on each side of the mons veneris. They form the boundaries of the pudendal cleft, into which the urethra and vagina open. In front, the right and left labia majora unite and form the so-called anterior commissure. The labia majora gradually terminate near the center of the perineum, but occasionally their posterior ends unite to form the posterior commissure, just posterior to the fourchette.

Each labium majus is formed by fibrofatty tissue that is covered by pigmented skin, with typically stiff pubic hair and possessing sebaceous follicles. The internal surface of the labia majora is smooth and without hair. The round ligaments of the uterus may often be traced from the external ring of the inguinal canal to the more proximal, or superior, part of each labium.

The so-called posterior commissure is not usually a union of the labia, but a projection of the perineal body into the pudendal cleft. In extremely rare cases, a foldlike union takes place just behind the fourchette.

The contents of the labia majora are:


Round ligament (partial)

Fibrofatty tissue

Multiple blood vessels

Smooth muscle fibers similar to the dartos muscle of the male

Cutaneous nerves


Labia Minora

The labia minora are the analogues of the corpus spongiosum of the male. The labium minus is a bilateral, hairless, pinkish fold, thin and flat, of variable size and shape. The labia minora are approximately 4 cm in length. They are covered by stratified squamous epithelium and have a very rich network of nerves. Sebaceous follicles are numerous on the apposing surfaces.

At their posterior ends, the labia minora may unite with the labia majora or the two minora may be joined by a transverse fold, the fourchette or frenulum, seen more commonly in virgins. The labia minora bifurcate anteriorly. The lateral parts unite and form the prepuce; the medial parts unite and form the frenulum of clitoris. Gottlicher71 found a third labium located between the labia majora and labia minora in 5.3% of 1180 patients.


The clitoris is the analogue of the male penis without the urethra. The clitoris consists of two crura, the corpus, and the glans. The two crura arise from the bony pelvis; specifically, from the internal surface of the ischiopubic rami, anterior to the ischial tuberosities. Both fuse together approximately at the middle of the pubic arch to form the body, which bends acutely downward and backward. It is fixed to the symphysis pubis by the suspensory ligament of clitoris.

The shaft of the clitoris is formed almost entirely by the junction and fusion of the bilateral corpora cavernosa, which arise from the ischiopubic rami as crura. The crura are covered by the ischiocavernosus muscles, which contract in clitoral erection.

The two corpora are encased in tough fibrous connective tissue and separated by a midline connective tissue septum. The corpus spongiosum of the pendulous part of the male penis does not exist as a counterpart in the female. However, in its place, there are two slender, cordlike structures of erectile tissue which are extensions of the vestibular bulbs into the shaft of the clitoris, wherein they fuse at a commissure, thereafter terminating at the glans clitoris.

The lower, spongy end of the clitoris is slightly enlarged to form the glans clitoris. It is innervated profusely by the terminal branches of the dorsal clitoral nerves, the terminal branches of the pudendal nerves, and is exquisitely sensitive. It, and the lower part of the clitoral shaft, are normally covered by the prepuce provided by the labia minora. When erect, the clitoris has a length of 1-2.5 cm; occasionally it is very enlarged. Barrett and Gonzales72 and Ansell and Rajfer73 reported successful reduction clitoroplasties.

Vestibule and Its Related Entities

According to Woodruff and Friedrich,74 the vestibule is “a ‘collision zone’ formed at the junction of different germ layers.” It is an opening between the right and left labia minora, extending from the clitoris to the fourchette. Between the vaginal orifice and the fourchette is the vestibular fossa.

The vestibule is perforated by several openings:


Opening of the urethra

Opening of the vagina

Right and left ducts of the glands of Bartholin

Openings of several other ducts (Skene’s, etc)75

Urethral Meatus

The external urethral meatus, or opening (Fig. 26-38), is between the labia minora, anterior to the vaginal opening, and approximately 2.5 cm below the glans clitoris.

Opening of the Vagina

The opening of the vagina is a posterior midline cleft with variable appearance due to the variable morphology of the hymen.

Major Vestibular Glands

The major vestibular glands, homologous to the male bulbourethral glands of Cowper, are the glands of Bartholin. They are round or ovoid, the size of a pea or small bean. They are located on either side of the vaginal opening beneath the bulb of the vestibule. The opening of each duct is located between the hymen and the labia minora at the sides of the vestibule, opening at about the 5 o’clock and 7 o’clock positions of the vestibule. During coitus they secrete a small amount of mucus to lubricate the distal vagina.

Sarrel et al.76 reported 4 patients with pain during intercourse due to Bartholin gland pathology. They performed removal of the gland in 3 cases and marsupialization in 1 case with good results.

Minor Vestibular Glands

There are also several other mucous glands. The glands of Skene have ducts opening at the upper portion of the vestibule, lateral to the urethral orifice,75 and into the urethra. These glands may be divided into upper and lower parts as they are related to the urethra. The lower ones open into the vestibule and are identified as paraurethral glands. The upper ones open into the urethra and are known as periurethral glands.

The periurethral glands are considered by some to be the homologues of the prostate. Others, however, disagree. Tepper et al.,77 for instance, reported that the female paraurethral Skene’s glands are homologues of the prostate. These authors stated that 83% were positive for prostate-specific antigen and 67% for prostate-specific acid phosphatase.

Major and minor vestibular glands may suffer infection and become abscessed. Treatment starts with incision and drainage; later, the recurrent cyst may be marsupialized or excised completely.

Vestibular Bulbs

The vestibular bulbs, erectile tissue homologues of the penile bulb, consist of erectile tissue on each side of the opening of the vagina, and are covered by the bulbospongiosus muscles. Approximately 3 cm in length, the bulbs unite in front, forming a thin strand of tissue passing along the inferior surface of the body of the clitoris to reach the glans. The posterior ends of the vestibular bulbs cover the pea-sized vestibular glands of Bartholin.


The hymen is a peculiar anatomic entity without any known function, but is responsible for several medicolegal problems. The hymen is a folded mucous membrane inside the vaginal orifice with an opening of variable shape (semilunar, concave, cribriform, fringed, etc). Occasionally, the hymen does not exist.

Rarely, there is no opening (imperforate hymen), responsible for a condition named hematocolpos (accumulation of menstrual blood and other secretions). The treatment of hematocolpos is simple incision and drainage.

Mor et al.78 reported a high incidence of hymenal tags (5.75%) and bands (2.7%) in an examination of 974 female neonates.

Berenson79 studied the appearance of the hymen at birth and 1 year of age in 62 female babies, and reported the following observations: in 8% the inferior half of the hymen was obscured secondary to labial agglutination at 1 year of age; 58% of the remainder had a marked decrease in the amount of their hymenal tissue between birth and 1 year.

Vascular Supply

Blood Supply

In brief, the blood supply for the region of the vulva is derived by way of the superficial and deep external pudendal branches of the femoral vessels and the posterior labial vessels, derived from the perineal branches of the internal pudendal arteries and veins. Anastomoses of the vulvar vasculature are profuse. Because of the rich blood supply — both arterial and venous — hemorrhage from vulvar injuries or during surgical procedures in the region can be grave. The blood supply is described in greater detail in chapters on the surgical anatomy of the inguinal region and the perineum.


The pattern of lymphatic drainage of the region of the vulva is described in the chapter on the perineum. Lymphedema of the external genitalia was reported by Huang and colleagues,80-82 who performed successful microsurgery.

Bartholdson et al.83 reported that lymph of the labia majora drains to bilateral inguinal nodes and pelvic lymph nodes. These authors advised that carcinoma of the vulva should be treated accordingly. Eicher et al.84 reported that unblocked vulvar lymphatics drain over or under the mons bilaterally into the pelvis through the obturator foramen or the space of Retzius. When the lymphatics are blocked by pressure, they drain to the perianal or the deep external pudendal areas. They travel laterally to the thigh and then to deep femoral nodes. Spread is bilateral.


The anterior cutaneous nerve supply of the vulva is derived from the ilioinguinal nerve and genital branch of the genitofemoral nerve. Posterior labial cutaneous supply arises from the perineal branch of the pudendal nerve and the perineal branch of the posterior femoral cutaneous nerve of the thigh. The anterior sensory supply is gained principally from the first lumbar spinal nerve. The posterior supply originates primarily from the third sacral spinal nerve.

To gain adequate anesthesia of the anterior region, therefore, the differing levels of supply must be given serious and thoughtful consideration. For further details regarding the nerve supply of the region and its surgical applications, please consult the chapters on the abdominal wall, the inguinal region, and the perineum.


The vulva is the obvious external appearance of the female genitalia. This structure is contained within the urogenital triangle and consists of the mons pubis, the labia majora, the labia minora, the clitoris, the urethral meatus, the vestibule, and the hymen. The mons pubis is the lower border of the lower abdominal wall and is a mound of fibrofatty tissue overlying the pubic crest area. The skin is keratinized squamous epithelium containing eccrine glands and hair follicles. The subcutaneous tissue is very fibrous in order to suspend this structure from the aponeuroses and linea alba of the lower abdominal wall. The round ligament passes through the lateral aspect of the mons pubis from the external inguinal ring on its journey to insert into subcutaneous tissue of the ipsilateral labium majus.

The labia majora, or the larger lateral folds of the vulvar skin, course inferiorly and posteriorly to surround the labia minora. The lateral aspects of the labia majora have the same histology as the mons veneris, while the more medial aspects are thinner without hair follicles but with a higher concentration of sebaceous glands. The subcutaneous tissue is very vascularized, areolar, and continuous with Camper’s fascia.

The labia minora are covered by thin, keratinized squamous epithelium overlying dense connective tissue containing erectile tissues that are abundantly vascularized. Its epithelium contains no hair follicles or eccrine glands.

The clitoris is located anteriorly near the meeting of the two labia majora in the midline. The clitoris consists of two crura, a shaft, and a glans. The two crura attach to the inferior pubic rami and are composed of elastic and vascular erectile tissue (corpora cavernosa). Each crus courses anteriorly to unite with its counterpart in the midline to form the shaft of the clitoris. The shaft is suspended from the pubic symphysis by a suspensory ligament. The shaft leads into the glans, which is composed of erectile tissues surrounded by a prepuce anteriorly and a frenulum posteriorly. These structures are covered with a thin keratinized squamous epithelium without glands or hair follicles. The glans is densely innervated by branches from the deep dorsal nerve from the pudendal nerve.


Vulvar tissues act to keep foreign material from entering up into the vagina and assist in directing the urinary stream during voiding. During sexual intercourse, the vulva enhance sexual pleasure through sensory and erectile functions.

In little girls, labial tissues can be fused (synechiae) requiring the use of topical estrogens to dissolve the synechiae and allow separation of the labia. The density of glands and hair follicles in the moist vulvar environment frequently predisposes to acute and chronic folliculitis and attendant itching and burning. Dermal infections are very common in this region of the body. Non-specific irritation of the vestibular glands may lead to vulvar vestibulitis and entry dyspareunia.

Surgical Applications and Anatomic Complications

The most common vulvar procedures are:


Incision and drainage of infected Bartholin’s gland

Removal of Bartholin’s gland

Vulvectomy (simple and radical)

Any lesion found on the vulva should be biopsied because benign and malignant tumors cannot always be readily differentiated by sight. Frequent biopsy of vulvar lesions is advised. Many lesions may easily be biopsied with local anesthesia, a Keyes skin punch, and Monsel’s solution.



To prevent breakdown at the “3-point skin union” over the symphysis pubis, produce a “tongue-shaped” midincisional flap (Fig. 26-58).

If the tip of the “tongue-shaped” flap does not have good blood supply, remove more skin until bleeding occurs, avoiding necrosis.

Removal after dissection of the ganglion of Cloquet (lymphoganglion of Rosenmüller) should be performed carefully. Avoid entrance into the peritoneal cavity. If femoral hernia is present, it should be repaired at the same time. Use the “below the inguinal ligament technique” by suturing the inguinal ligament to the pectineal fascia or to the Cooper’s ligament.

Avoid bleeding in the operating room by isolating and ligating the following vessels:


– Superficial circumflex iliac artery

– Superficial epigastric artery

– Great saphenous vein

– Dorsal artery and vein of the clitoris

– Posterior labial branches of the internal pudendal vessels (Fig. 26-59)

Ligate the lymphatic tissue at the apex of the femoral triangle in the femoral canal to avoid lymphorrhea or lymphocyst.

Use the sartorius muscle (Fig. 26-60) to cover the femoral artery and vein, thus avoiding exposure and secondary bleeding.

With a “fall astraddle,” the vessels most likely to be injured and produce hematoma are:


– Perineal branches of the internal pudendal vessels and their branches

– Branches from superficial and deep external pudendal vessels

– Clitoral vessels

– Rectal vessels

The branches from the superficial and deep external pudendal vessels are in the vicinity of the round ligament.

The internal pudendal vessels are occasionally responsible for the formation of varices in the area of buttocks.

Part of the skin, but most of the fibrofatty tissue of the mons veneris, is removed during vulvectomy for cancer. The justification is to try to contain superficial lymphatics with malignant cells.

During bartholinectomy, bleeding may take place because of the close relation of the Bartholin glands to the highly vascular bulb. Make the incision lateral to the groove but close to the labia minora.

Fig. 26-58.

Outline of the incision used for one-step radical vulvectomy and groin dissection. (Modified from Woodruff JD, Julian CJ. Surgery of the vulva; vulvectomy. In: Ridley JH (ed). Gynecologic Surgery: Errors, Safeguards, and Salvage (2nd ed). Baltimore: Williams & Wilkins, 1981; with permission.)

Fig. 26-59.

Anatomic relationships of perineal vasculature. (Modified from Woodruff JD, Julian CJ. Surgery of the vulva; vulvectomy. In: Ridley JH (ed). Gynecologic Surgery: Errors, Safeguards, and Salvage. Baltimore: Williams & Wilkins, 1974; with permission.)

Fig. 26-60.

Transplantation of sartorius muscle over femoral vessels. (Modified from Woodruff JD, Julian CJ. Surgery of the vulva; vulvectomy. In: Ridley JH (ed). Gynecologic Surgery: Errors, Safeguards, and Salvage (2nd ed). Baltimore: Williams & Wilkins, 1981; with permission.)


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