Page 162 - Clinical Anatomy

ECA2 7/18/06 6:43 PM Page 147

The female genital organs 147

2◊◊The uterosacral ligaments, which pass backwards from the posterolateral
aspect of the cervix at the level of the isthmus and from the lateral vaginal
fornices deep to the uterosacral folds of peritoneum in the lateral bound-
aries of the pouch of Douglas, are attached to the periosteum in front of the
sacroiliac joints and the lateral part of the third piece of the sacrum.
3◊◊The pubocervical fascia extends forward from the cardinal ligament to the
pubis on either side of the bladder, to which it acts as a sling.
These three ligaments act as supports to the cervix of the uterus and the
vault of the vagina, in conjunction with the important elastic muscular
foundation provided by levator ani. In prolapse these ligaments lengthen
(in procidentia —complete uterine prolapse —they may be 6in (15cm) long)
and any repair operation must include their reconstitution.
Two other pairs of ligaments take attachments from the uterus.
1◊◊The broad ligament is a fold of peritoneum connecting the lateral margin
of the uterus with the side wall of the pelvis on each side. The uterus and its
broad ligaments, therefore, form a partition across the pelvic floor dividing
off an anterior compartment, containing bladder (the uterovesical pouch),
from a posterior compartment, containing rectum (the pouch of Douglas or
recto-uterine pouch).
The broad ligament contains or carries (Figs 104, 106):
•◊◊the Fallopian (uterine) tube in its free edge;
•◊◊the ovary, attached by the mesovarium to its posterior aspect;
•◊◊the round ligament;
•◊◊the ovarian ligament, crossing from the ovary to the uterine cornu (see
ovary);
•◊◊the uterine vessels and branches of the ovarian vessels;
•◊◊lymphatics and nerve fibres.
The ureter passes forwards to the bladder deep to this ligament and
lateral to and immediately above the lateral fornix of the vagina.
2◊◊The round ligament—a fibromuscular cord—passes from the lateral angle
of the uterus in the anterior layer of the broad ligament to the internal
inguinal ring; thence it traverses the inguinal canal to the labium majus.
Taken together with the ovarian ligament, it is equivalent to the male
gubernaculum testis and can be thought of as the pathway along which the
female gonad might have, but in fact did not, descend to the labium majus
(the female homologue of the scrotum). Compare this process to descent of
the testis, (page 121).

Vaginal examination

The relations of the vagina to the other pelvic organs must be constantly
borne in mind when carrying out a vaginal examination.
Inspection (by means of a speculum) enables the vaginal walls and
cervix to be examined and a biopsy or cytological smear to be taken. Inspec-
tion of the introitus while straining detects prolapse and the presence of
stress incontinence.
•◊◊Anteriorly—the urethra, bladder and symphysis pubis are felt.
•◊◊Posteriorly —the rectum (invasion of the vagina by a rectal neoplasm