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JEFFCOATES PRINCIPLES OF GYNAECOLOGY PDF

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The eighth edition of Jeffcoate's Principles of Gynaecology presents trainees with the most recent advances in the field. Beginning with an. It is obvious that Dr Tindall, a professor of obstetrics and gynecology at the University of Manchester, revised Professor Jeffcoate's textbook with loving care. Download the PDF to view the article, as well as its associated figures and tables. Jeffcoate's Principles of GYNAECOLOGY Prelims cittadelmonte.info 1 Apr 3: Prelims cittadelmonte.info . cittadelmonte.info . Jeffcoate's Principles of Gynaecologyvi Bora Neharika M MD (Gold Medalist) DRM (Germany).


Jeffcoates Principles Of Gynaecology Pdf

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Jeffcoate's Principles of Gynaecology (7th Ed.) - Ebook download as PDF File . pdf), Text File .txt) or read book online. Jeffcoate's Principles of Gynaecology. Full text is available as a scanned copy of the original print version. Get a printable copy (PDF file) of the complete article (K), or click on a page image below. Download the Medical Book: Jeffcoate's Principles of Gynaecology 8th Edition For Free. This Website we Provide Free Medical Books for all Students and.

This article is only available in the PDF format. Download the PDF to view the article, as well as its associated figures and tables. It is obvious that Dr Tindall, a professor of obstetrics and gynecology at the University of Manchester, revised Professor Jeffcoate's textbook with loving care. Dr Tindall trained under Professor Jeffcoate in Liverpool, and he has endeavored to retain some of the verve and vigor that was breathed into the original book by a renowned and opinionated professor. The original text was written by Professor Jeffcoate in , and he stated plainly in the first edition that he had not "played it safe by stating only generally accepted views, but had attempted to reach a conclusion that satisfied himself as being as rational as present knowledge allowed.

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Jeffcoate's Principles of Gynaecology

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For this to be done safely. In many countries. Diagnostic laparoscopy is used for the investigation of unexplained infertility. Laparoscopy Laparoscopy uses apparatus which incorporates a fibreoptic lighting system for complex inspection of the pelvic organs and for several surgical procedures. The trocar with its sleeve is inserted through this and made to enter the tense peritoneal cavity just below the umbilicus.

The trocar is then replaced by the endoscope. Endoscopy is now so simple and efficient that there is danger of its being used too freely. The gas. Malignant cell growth is accompanied by neovascularisation and angiogenesis. Operative procedures which can be undertaken simultaneously laparoscopically include ovarian biopsy and cystectomy. These vessels are thin-walled and therefore have a low impedance. Commonly used indices of pulsatility in Doppler ultrasound are: It is the difference between maximum and minimum values divided by mean values of the waveform.

These procedures were and still are done using single-puncture laparocators. Low-resistance flows are also seen in the placenta. The RI falls to 0. Endoscopy Visualisation of the pelvic organs by way of endo-scopes has been employed sporadically since the beginning of the twentieth century. Transvaginal colour Doppler blood flow studies are useful in predicting whether tumours are benign or malignant.

Advanced operative laparoscopic work includes laparoscopy-assisted vaginal hysterectomy. The procedure involves insertion of a laparoscope under general anaesthesia through the abdominal wall Figs 1.

This is almost always done using two or more ports. If there is a previous scar near the umbilicus. Gamete or zygote intrafallopian transfer is done laparoscopically as well.

The operator must be reasonably certain that the gut is not adherent to the anterior abdominal wall at the site of entry of the trocar. Monitors with built-in controls permit autoregulation of gas-flow rates. Burn injury is more likely from monopolar than from bipolar coagulation. Each has its own cutting and coagulating abilities and the choice of laser depends on the task at hand.

Complications of laparoscopic surgery can be divided into two phases the first is the creation of the pneumoperitoneum. C trocars and cannulas D The laparoscope in place with the patient in theTrendelenburg position. Injury to major blood vessels. Carbon dioxide embolism can be fatal. To increase the safety of the procedure. For tissue division. Additional ports are located in the iliac fossa medial to the inferior epigastric vessels or suprapubically to permit the insertion of various instruments.

The skin incision is closed with one or two clips or sutures which are removed 5 days later. A camera attachment over the eyepiece. The laparoscope has been inserted through a small incision along the lower rim of the umbilicus.

A Veress insufflation needle for creating a pneumoperitoneum with carbon dioxide. Damage by the lateral trocars can result in damage to the inferior epigastric vessels. The use of a camera and video monitor allows the entire team to visualise the procedure Fig. The complication rate of laparoscopy depends on the experience of the surgeon but for large series it is about 0.

Ureteric damage. The insertion of the Veress needle and the first trocar are carried out blind and are the most hazardous part. Some patient-related parameters such as obesity and a prior history of abdominal surgery may increase the incidence of complications.

Various lasers currently in use include the CO2. Hundreds of instruments have now been designed to facilitate all types of surgery laparoscopically Fig. Suturing and stapling devices can be used as required. At the conclusion of the operation. The proceedings can also be recorded. In the alternative system of open laparoscopy. Bipolar grasping forceps have been inserted through a small suprapubic incision and are being used to manipulate the pelvic organs.

Diagnostic hysteroscope 4 mm with sheath and pressure bag Hysteroscopy is used to exclude intrauterine pathology Fig. Hysteroscopy It is possible to visualise the cavity of the uterus with hysteroscopes incorporating fibre-optics Figs 1. These use simple suspensory chains on sophisticated equipment.

In the diagnosis of endometrial carcinoma. Laparoscopy is contraindicated in severe cardiorespiratory disease. While any of the media maybe used for diagnostic hysteroscopy. This avoids the complications of CO2 insufflation and may be useful in combined laparovaginal procedures.

Several media have been used to distend the uterine cavity: Operating room layout: Instruments for operative laparoscopy: It also offers an opportunity for their removal. Computed Tomography Computed tomography CT is able to demonstrate the pelvic anatomy very clearly.

Lymph node involvement and uterine lesions are well demonstrated.

Jeffcoate’s Principles of Gynaecoloy, 8E (International Edition) (2014) [PDF]

Women with oligomenorrhoea or amenorrhoea may be found to have intrauterine synechiae. CT scanning is especially useful in the evaluation of pelvic masses to identify the organ of origin. The thickness of each slice is mm and the procedure is usually done in the supine position using axial scanning. CTguided procedures such as biopsy or aspiration are sometimes done for diagnostic or therapeutic purposes.

The hysteroscope has a side channel which permits the passage of the distension medium. Hysteroscopy is contraindicated in the presence of infection except in the case of a misplaced IUCD. In the presence of bleeding. The procedure involves dilatation of the cervix followed by introduction of the hysteroscope. Other hysteroscopic procedures include endometrial ablation. Instruments for operative hysteroscopy: Contrast enhancement is the standard technique.

Delayed complications include infection. Axial contrast-enhanced CT showing a simple cyst in the right adnexal region and anterior to the uterus A Clinical Approach to Gynaecology Complications of hysteroscopy include uterine perforation. Synechiae can be divided under hysteroscopic guidance. For operative hysteroscopy. Scanning begins at the level of the iliac crest and moves to the symphysis or ischial tuberosities. Hysteroscopic sterilisation using sclerosing chemicals quinacrine.

An outflow tract allows the fluid passing out to be collected in a bottle. Tumours less than 2 cm in size may not be detected and normal ovaries may not be identified routinely.

Certain atomic nuclei. T2-weighted sagittal MR image showing a large hypointense uterine fundal leiomyoma procedures cannot be performed.

Absence of signals from bony structures means that certain characteristic features such as teeth in a dermoid cyst. The female pelvis is particularly suitable for MRI because it does not move with respiration. Congenital anomalies of the uterus and lesions of the myometrium and endometrium can be most accurately demonstrated by MRI. MRI has several advantages over CT scan.

Data for each set of images is accumulated over about 5 minutes and patients need to remain still for this period. The total process can take minutes. It uses the property of nuclear magnetic resonance NMR. Extending backwards from the mons. Some gynaecologists regard the perineum as part of the vulva. To anatomists. It is very essential to review relevant anatomy before each surgical procedure.

Although the basic facts of anatomy and their relevance to gynaecologic practice do not change with time. It includes the mons veneris. For convenience. We need to study the gynaecologic literature on an ongoing basis— numerous publications have documented the evolution of newer concepts regarding anatomic issues such as pelvic support.

Unlike the rest of the vulva. The mons and labia majora are covered with coarse skin which contains hair follicles. Some of the latter are large. Its length from before backwards.

They vary considerably in size and may be hidden by the labia majora or may project between them. Labia Minora The labia minora are delicate flaps of soft skin lying within the labia majora. The depression between the fourchette and hymen which is found in virgins is the fossa navicularis.

The latter is devoid of fat but is so vascular that it enables the labia to become turgid under conditions of sexual excitement. Clitoris The clitoris is the homologue of the penis and is a small structure lying on the front of the symphysis almost hidden by the foreparts of the labia majora. The median raphe seen in the male is usually. In view of their structure. Only the glans and prepuce are visible. Their outer aspects are covered with hair. They join posteriorly to form a sharp fold of skin.

Anteriorly the labia minora join together and in so doing split to provide the clitoris with a prepuce and frenulum. Except where the labia minora intervene. The labia minora each consist of two layers of nonkeratinized skin with some intervening loose connective tissue.

The clitoris consists of erectile tissue richly supplied with nerves which make it the most erotically sensitive part of the vulva. Because the underlying connective tissue is very loose. Posteriorly they merge into each other and into the perineal skin. Perineum The perineum comprises the less hairy skin and subcutaneous tissue which lie between the vaginal orifice These are homologous to the scrotum.

It has a glans. Smegma is secreted beneath the prepuce. They also contain sebaceous glands. The fourchette is nearly always injured during childbirth. It is one of the signs of loss of virginity. Inspection alone is often insufficient to permit a conclusion that a hymen is intact and unstretched. The hymen is relatively avascular so its tearing usually causes only a slight loss of blood. The urogenital diaphragm triangular ligament and associated structures as seen from below In this case the hymen is unusually well developed to form a thick tough membrane with two small openings posterolateral to the external urethral meatus and indicated by white arrows which allowed the escape of menstrual blood.

The urethra opens on to it. For identification of the structures. Unless the opening is unusually large. It has one or more apertures to allow the outflow of menstrual blood and. This so-called septate hymen would probably have hindered consummation of marriage Fig. Anatomy interference or the insertion of tampons to contain the menstrual discharge. During childbirth the hymen is destroyed.

Hymen The hymen is a delicate incomplete membrane guarding the entrance to the vagina prior to maturity and sexual experience Fig. The normal vulva shaved with the introitus opened to show an intact hymen. On either side of the urethral meatus are tiny depressions called paraurethral pouches with adjacent insignificant folds. They lie postero- Vestibule The definition of vestibule from the Latin vestibulum meaning a forecourt or a hall next to the entrance varies.

Vestibular Bulb The two bulbs are collections of erectile tissue which together are homologous to the corpus spongiosum in the male. The tear is most commonly found posteriorly or posterolaterally.

Each passes backwards from the root of the clitoris. In old age all the tissues atrophy and the skin becomes drier. Its duct is 1. The labia minora shrink and may almost disappear.

Thus the surface columnar cells become flattened when the duct is distended to form a cyst. Deep tearing may leave the perineum shorter than it was originally. The growth of pubic hair is an early sign of puberty. In infancy and childhood the mons veneris and labia majora are devoid of hair. The orifice of the duct is not normally visible but. Each gland is oval in shape and approximately the size of a pea but is impalpable unless hardened or enlarged by disease.

The duct is lined by immature metaplastic squamous epithelium. When the duct is distended by cyst formation this can become flattened to give a false impression of its true morphology Venous Some veins accompany corresponding arteries to the internal pudendal vein.

It is produced mainly in response to sexual excitement when considerable amounts are poured onto the vulva to act as a lubricant for coitus. The vaginal orifice tends to contract. The effect of coitus on the hymen has already been described. Fat reappears in the mons and labia majora as part of sexual development in adolescence. The subcutaneous fat is lessened except in obese women. The impression of the latter is created by a study of pathological states. The fourchette and the perineum are frequently torn during childbirth and thereafter appear scarred.

Arterial The vulva is mainly supplied by branches of the internal pudendal artery. The secretion of the gland is colourless and mucoid and has a characteristic odour. The gland continues limited activity after the menopause. In the very young baby the labia majora are under the influence of maternal hormones and tend to obscure the tiny labia minora.

The gland is lobulated and racemose. The duct is lined by multilayered columnar cells and not by transitional epithelium. Vascular Connections All the tissues of the vulva are extremely vascular. Pubic hair becomes sparse. Changes in the Vulva with Age and Parity The tissues of the vulva are sensitive to sex hormones.

During child-hood the skin of all the tissues is thin and delicate and that of the vestibule reddish in colour. Anatomy Fig. The vagina pierces the triangular ligament and the pelvic diaphragm. The introitus is depicted as multiparous and gapes to show rugae and a central column on the anterior vaginal wall Fig. The two dots represent fixed points. The relations of the bladder. Note that the clitoris lies relatively high on the symphysis pubis.

Lymphatics from the deep tissues accompany the internal pudendal vessels to the internal iliac nodes. That this is so is demonstrated not only by colpographs but by the taking of casts of the vagina in the living woman. Innervation See page VAGINA General Description The vagina is an elastic fibromuscular canal extending upwards and backwards from the vulva at an angle of degrees to the horizontal.

By permission of the Editor. J Obstet Gynaecol Br Empire with the vesical and vaginal plexuses. The vagina is not straight but slightly angulated to conform to the anatomy of the urethrovesical junction.

The long saphenous vein also takes a share of the venous return. Lateral urethrocystograph and colpograph in a normal multiparous woman sitting at ease.

The relation of the tissues of the vulva to the bones of the pelvis. The vagina has a blind upper end except for the cervix with its external os. Lymphatic Drainage is mainly to the superficial inguinal nodes. The cells in the middle and superficial zones contain glycogen.

The surface is normally devoid of keratin but is capable of becoming keratinized if it becomes exposed to the air as in prolapse. Although the width and length of the vagina show considerable individual variations. It shows cyclical histological changes in association with menstruation.

The frequently used term vaginal mucosa is. Photomicrograph x Fig. Because the cervix is inserted below the vault. This is the result of a negative intra-abdominal pressure transmitted to the vagina.

In its lower part it appears H-shaped on cross-section with lateral recesses anteriorly and posteriorly. Photomicrograph x The introitus is functionally closed by the labia which are in contact with each other. A raised double column formed by underlying fascia can often be seen running sagittally down the anterior wall and there is a less definite median ridge on the posterior wall. If the walls are separated.

To the left. This breakdown liberates the contained glycogen which is acted upon by the lactobacillus Fig. The functional width is determined to a large extent by the tone and contractions of surrounding muscles. The section shows the abrupt transition from the single layer of endocervical mucussecreting epithelium on the left.

The epithelium does not contain glands of any kind and does not secrete in the ordinary sense of the word. Running circumferentially from these columns are folds of epithelium rugae which account in part for the ability of the vagina to distend during labour Fig.

Although it may in part represent a transudate globules of fluid. The epithelium is many layered. During menstruation the flow of alkaline blood raises the vaginal pH to levels ranging from 5. Some authorities give the normal range for the adult nonpregnant woman as from 3. Marriage and regular coitus result in some stretching of the vaginal walls. In some women menopausal atrophy is slow to develop. Lactobacilli appear by the third or fourth day when the vaginal acidity approaches that of an adult.

The epithelium is therefore moderately well developed and contains glycogen. The pH varies with the level of the vagina. After the menopause the epithelium atrophies and loses its glycogen. Absorption and reabsorption are believed to occur mainly in the lateral recesses of the lower vagina. The vaginal wall itself and the tissues around it are extremely vascular so they usually bleed freely at the time of injury and operation.

Fascia and Muscle The epithelium rests on a subepithelial connective layer which contains elastic tissue. Throughout childhood. The pH then rises to approximately 7 and remains at that level until the approach of puberty when.

During pregnancy the amount of glycogen is increased to a maximum and the acidity of the vagina is high pH 3. The level varies with the time in the menstrual cycle and the effects of ovarian hormones on the vaginal epithelium and the cervical secretion.

The muscle of the vaginal wall is involuntary in type although there are sometimes a few intermingling voluntary fibres contributed by muscles such as the levatore ani at the sites of their insertions. The pelvic muscles. This property is utilized when therapeutic agents such as oestrogens and glucose are administered locally. This fascial sheath fuses with that covering the levator ani muscles. By days the oestrogen stimulus is lost and the epithelium atrophies becomes devoid of glycogen.

Outside this are muscle coats in which the fibres are nearly all arranged in a crisscross spiral fashion. The acidity of the vagina is of great practical importance for it explains the resistance of the mature vagina to pyogenic organisms.

The amount of the last is governed by the glycogen content of the epithelium and the presence of lactobacilli but. Outside the muscle layers is a strong sheath of connective tissue which has special condensations down the anterior wall to form the pubocervical fascia. Changes in the Vagina with Age and Parity Fig.

Estimates also vary. Lactobacilli are found in fewer numbers and the pH rises to a range of The characteristics of the vagina at different ages By permission of the late Mr R.

Even in nulliparous women. Venous A plexus of veins around the vagina connects with those around the bladder and rectum. Lateral At its orifice the vagina has on either side the sphincter vaginae bulbospongiosus muscle. The Supports of the Vagina See page The lateral fornix is related to the lower parts of the cardinal ligament which are inserted into it Fig. The uterosacral ligaments are just above the posterior fornix.

These lie in the cellular tissue of the base of the broad ligament which is also an important relation. The drainage of the upper vagina is the same as that of the cervix to the internal iliac hypogastric. After the menopause it undergoes contracture in length and width. Above the urethra. The uterus from the side Posterior From below upwards the vaginal wall is in relation to the perineal body.

The fornices become shallow. Anatomy Repeated childbirth leads to oblitera-tion of the rugae and the vagina becomes a smooth-walled and rather patulous canal. When these changes are extreme the vagina is said to become tentshaped. Vascular Connections Arterial These are: Overlying the At a higher level is the levator ani with the paracolpos above. Superior The cervix dips into the upper and anterior part of the vagina.

Its muscles fuse with those of the vaginal coat without the intervention of fascia so it is difficult to separate from the vagina at the time of operation.

Lymphatic The lymphatics of the lower vagina accompany those of the vulva to the inguinal nodes. At the level of the posterior fornix there is only vaginal wall. The Relations of the Vagina Anterior Embedded in the lower anterior vaginal wall is the urethra. Above and to the side are the fallopian tube and ovary Fig.

Stromal cells are spindle-or star-shaped with little cytoplasm so. The latter varies in thickness from 1 to 10 mm according to the phase of the menstrual cycle. The uterus is made up of a body or corpus. It communicates with the vagina through the cervical canal. The more superficial fibres.

The main muscle coat myometrium is lined by endometrium. It is covered by a single layer of cuboidal or columnar epithelium which dips in to form simple unbranched tubular or spiral glands. The opening of the cervix into the vagina is the external os uteri. The ciliae are lost once menstrual shedding starts at puberty.

It weighs g. The glands lie in a stroma which is made up of loosely arranged immature connective tissue cells. The epithelium is ciliated on the surface but not in the glands. The endometrium and. Internal to the muscle layers is a mucous membrane which is directly applied to the muscle without an intervening submucosa. Fibrous and elastic tissues are mixed with the muscle in varying amounts. The wall is cm thick.

The area of insertion of each fallopian tube is termed the cornu. The sides of the uterus between the attachment of the two leaves of the broad ligament. The cavity of the uterus is triangular in shape when seen from the front Fig. Structure The whole of the fundus. The part of the body situated above the level of insertion of the fallopian tubes is described separately as the fundus.

The main mass of the wall is composed of involuntary muscle fibres which for the most part run obliquely in a criss-cross spiral fashion. These are described in Chapter 4. The uterus and broad ligament from behind The mucous membrane lining the canal endocervix is thrown into folds which consist of anterior and posterior columns from which radiate circumferential folds to give the appearance of tree trunk and branches.

The lower half has a thin peripheral layer of muscle the external cervical muscle but is otherwise entirely composed of fibrous and collagenous tissues. The importance of the isthmus is that it is the area which. Histologically the endocervix differs considerably from the endometrium.

The arbor vitae in the cervix. It is covered by a single layer of tall columnar epithelial cells which. The upper part of the cervix is composed mainly of involuntary muscle. A spindle-shaped canal. The mucous membrane of the isthmus is intermediate in structure and function between that of the corpus and that of the cervix.

Anatomy vaginal cervix or portio vaginalis while half is above the vaginal attachment supravaginal cervix Figs 2. Half of it projects into the vagina Fig. The obvious constriction between the uterine cavity and the cervical canal is the anatomical internal os and the isthmus is below this. This arrangement is most obvious in the young nullipara in whom the irregularity of surface can make the passage of a sound difficult. The supravaginal part is surrounded by pelvic fascia except on its posterior aspect where it is covered with the peritoneum of the pouch of Douglas.

The junction between the isthmus and the cervical canal proper. The specimen otherwise shows generalized hypertrophy of the uterus which was associated with pelvic adhesions and which resulted in menorrhagia Cervix The cervix is barrel-shaped. Endometrium in non-secretory proliferative phase. The glands are narrow and tubular.

The vaginal part is covered with squamous epithelium continuous with that of the vagina. The acini secrete an alkaline pH 7. The relative sizes of the uterus at different ages.

At and after puberty. Note also that the length of the cervix in relation to that of the corpus diminishes with increasing development. It is usually sharply defined by an abrupt change in cellular type but there may be a transitional zone mm in width with variable histological features Figs 2.

The cervix shrinks so the vaginal portion no longer projects and the external os becomes more or less flush with the vaginal wall.

This plug prevents vaginal bacteria from invading the uterus by its mechanical and. After the climacteric the uterus atrophies. The physical and chemical properties of cervical mucus vary with the time in the menstrual cycle and with pregnancy. They penetrate the fibromuscular tissue and lie in a stroma more fibrous and dense than that of the endometrium.

The surface epithelium dips down to form complicated glands and crypts which number approximately The epithelium of these glands is taller than that of endometrial glands and the nuclei are always basal in position Fig.

At one stage in intrauterine development the proportions are 5: Changes in the Uterus with Age and Parity In childhood the cervix is longer than the corpus uteri. The size at birth is greater than in a child aged one month because of the effect of oestrogen circulating in the foetus in utero. The junction of the squamous epithelium covering the vaginal cervix and the columnar epithelium of the endocervix is normally situated at the external os.

In infancy. Posterior Posteriorly lies the pouch of Douglas uterorectal pouch with coils of intestine. Version and flexion are not always in the forward direction and approximately 15 per cent of women have uteri which are retroverted or retroflexed or both.

The body of the uterus remains somewhat larger and its structure is slightly modified in that elastic tissue. In old age. The height of the uterus in the pelvis varies with posture and other factors see Chapter 17 but. The endometrium and endocervix are thin and inactive. Anatomy puckered appearance. Lateral Laterally is the broad ligament and its contents. The cervix is modified by childbearing because. As it passes forward to reach the base of the bladder the ureter lies only cm to the side of the supravaginal cervix.

The uterus is normally moderately mobile. Their development at puberty and subsequent cyclical behaviour during the reproductive age are described in Chapters 4 and The Position of the Uterus When viewed from the side. The lower part is closely associated with the base of the bladder from which it is separated only by loose connective tissue. The uterus hypertrophies during pregnancy and involutes afterwards. It follows that the body of the uterus lies normally above the level of the symphysis pubis so.

In addition. The Relations of the Uterus Anterior The upper part of the uterus has the uterovesical pouch and either intestines or bladder in front of it. The bend is situated about the level of the internal os. The vaginal cervix also has the posterior fornix behind it. The amount of elastic tissue found in any myometrium is therefore proportional to the number of pregnancies previously experienced.

The nulliparous external os is circular in shape and gives to the examining finger the same sensation as that obtained by feeling the tip of a nose. Repeated childbearing and advancing years may also lead to a relative increase of fibrous tissue in the myometrium and a consequent increased risk of spontaneous rupture of the uterus during labour. The Supports of the Uterus See page The fundus can therefore rotate round this point.

The multiparous external os appears as a transverse slit and feels somewhat similar to pursed lips. The fimbriated extremity is free of the broad ligament and curls back on itself so that its fimbriae aim to embrace the ovary like the tentacles of an octopus. Also the aortic nodes via lymphatics accompanying the ovarian vessels and the superficial inguinal nodes via lymphatics in the round ligament See also pages 47 and The broad ligament from the side showing the relation of the ureter to the uterine artery.

It has a very narrow lumen 1 mm in diameter and is different from the remainder of the tube in that it is without a peritoneal coat. Infundibulum This is the trumpet-shaped outer end with an opening into the peritoneal cavity abdominal ostium. It has thick walls but the lumen is so narrow that it will only admit the finest probe mm in diameter.

Structure Except for a narrow strip opposite to its attachment to the broad ligament. Interstitial or Intramural Part This is only cm in length and is the part which traverses the uterine wall. The fallopian tube is divided into four parts Fig. Beneath this are an outer longitudinal layer and an inner circular layer of Corpus The same as the cervix. The latter is surrounded by fronds or fimbriae. Each lies in the free upper border of the broad ligament and. Its lumen communicates with the uterine cavity at its inner end and with the peritoneal cavity at its outer.

Inferior The broad ligament and its contents. Both the muscular and secretory activities of the tube are under the influence of ovarian hormones and therefore show cyclical changes during the menstrual life of a woman. The secretory cells have globules of secretion within their cytoplasm see text Lateral On either side is the lateral pelvic wall with the structures thereon.

Posterior Behind the fallopian tubes are the ovaries and the uterorectal pouch with its contents. A higher magnification of the endosalpinx showing ciliated cells. About half the epithelial cells. The resulting product is a serous fluid. This is in accord with the general view that the peristaltic wave is towards the uterus.

It is separated from the mucosa lining the lumen endosalpinx by a delicate connective tissue submucosa. So do the ovary and mesovarium. The mucous membrane is arranged in the interstitial and isthmic portions of the tube in four or five main longitudinal ridges.

Vascular Connections and Innervation The vascular connections and innervation are similar to those of the ovary see pages Relations Superior Above the fallopian tubes lie coils of intestine and the omentum. Anatomy involuntary muscle. The muscle zone is thick at the isthmus and thin at the ampulla. It is lined by columnar epithelium supported by a thin stroma Figs 2. Anterior To the front lie the top of the bladder and the uterovesical pouch.

Yet observations on the tube in situ indicate that the contraction wave is variable and sometimes in reverse. Most of the other epithelial cells have a secretory function. Before puberty and after the menopause the tube is functionally quiet.

Photomicrograph showing the mucosa of the fallopian tube and one of its folds Fig. The part of the ovary attached to the mesovarium is the hilum and all nerves and vessels enter and leave at this point.

It is now recognized that the germinal epithelium does not give rise to germ cells. The obturator nerve crosses the floor of the fossa. These are easily seen because the specimen was obtained from a senile woman in whom the fat and the connective tissue of the broad ligament had atrophied.

The ovaries are equally atrophic. Each is suspended from the cornu of the uterus by an ovarian ligament. The exact position of the ovary and tube varies considerably.

Even when the tunica is unusually thick. In the hilum and adjacent mesovarium are small collections of hilus cells which may be homologous to the interstitial cells of the testis. Primordial follicles are mostly found in the cortex. Each weighs g. The spiral shape of the arterioles in the medulla is seen only in the reproductive years and appears to be controlled by oestrogen. The surface of the adult active ovary is corrugated.

Although in the newborn baby it may show small follicular cysts resulting from the stimulation by chorionic gonadotrophins. The structures can be identified by comparison with Fig. No follicles are found in old age. After the menopause the ovary becomes smaller in size and shrivelled in appearance. So distension of the ovary by ripening follicles or by pathological states does not cause pain. Relations These are similar to those of the fallopian tube.

Changes with Age and Parity In infancy and childhood the ovary is a tiny elongated structure with a smooth surface. The fossa is bounded by the external iliac vessels above and by the internal iliac vessels and the ureter behind. They are attached to the back of the broad ligament by the mesovarium. The ovary is the only organ in the abdomen which is not covered by peritoneum. At a later stage the surface becomes smooth again as in childhood.

Structure The ovary is said to have a cortex outer zone and medulla inner zone but these are not clearly defined. The tunica albuginea is not well developed and not as resistant as the comparable structure in the testis. Both areas have a connective tissue stroma in which can be found blood vessels.

Jeffcoate’s Principles of GYNAECOLOGY

The cortex is covered with germinal epithelium which consists of a single layer of low cuboidal cells but is only seen in early life. The ovary usually lies against the lateral wall of the pelvis in a depression called the ovarian fossa. The dependent small cyst on the right is the hydatid of Morgagni. Elsewhere the muscle is coated with fascia only. Beneath this is a complicated pattern of involuntary muscle which is continued from the bladder into the urethra.

The urethra itself is devoid of true anatomical sphincters but the tone and elasticity of its involuntary muscles keep it closed except during micturition. Where it pierces the triangular ligament. When these are closely coiled they have a circular arrangement which provides good urethral tone and resistance. The urethra probably does not receive voluntary fibres from the levatores ani.

It is short and straight. The shape and position of the fundus of the bladder vary with the volume of the contents. The base of the full bladder is comparatively flat and. Except for the external meatus. The obliquity acts as a valve in that it prevents reflux of urine into the ureter when the bladder is full. The muscle of the trigone is an insignificant structure in women. They resemble this organ in that they are sites for chronic infection.

It joins the bladder base to form what appear on radiographic silhouettes as clearly defined angles. The bladder is a hollow muscular organ with a capacity of ml but with such powers of distension that. These are rudimentary structures homologous to the prostate in the male.

The urethra itself runs upwards and backwards. When they are drawn out their resistance is lowered and the urethra can dilate Fig. Anatomy The ureters enter the bladder on the posterior aspect of its base. The wall of the urethra is made up entirely of involuntary muscle. An intricate decussation at the urethrovesical junction has the effect of forming anterior and posterior slings which function as an internal sphincter Fig.

Sphincter Mechanism As the bladder fills by a succession of drops of urine from the ureters. B Normal nulliparous woman resting easily. The bladder is still contracting but the woman has shut off the stream at the lower end of the urethra tone so that the intravesical pressure is maintained at less than 10 cm of water see Fig. C Normal nulliparous woman raising her intravesical pressure by bearing down. Robert and the Editor.

J Obstet Gynaecol Br Emp A Normal nulliparous woman at ease with the bladder made radio-opaque with a solution of sodium iodide. The anatomy and function of the bladder and urethra as revealed by lateral urethrocystography.

S3 and S4. In untrained animals and children this sets in motion a reflex involving spinal roots S2. The catheter has been removed and the urethra is opening from above downwards. F Micturition inhibited by voluntary contraction of the external urethral sphincter compressor urethrae.

When the volume reaches ml. By permission of Mr H. This reflects opening of the internal urethral sphincter brought about by contraction of the bladder detrusor muscle which is manifested by the crenated outline of the posterior bladder wall. E Voiding is now well established. Action of the detrusor muscle can therefore be voluntarily inhibited and the urge resisted until it is convenient to void.

When this happens the bladder distends further. Active contraction of the bladder is indicated by its ovoid shape and fluffy outline. The urethra is dilated. D Commencing voiding. The urethra is outlined by a soft and pliable catheter filled with radio-opaque fluid. In the adult. The process of micturition is illustrated in Figures 2. A Detrusor inactive so the spirals in the urethra are closely coiled to bring the walls in apposition.

The external sphincter is voluntarily controlled by the central nervous system limit of bladder capacity is approached Fig. The urethra then opens from above downwards.

The external voluntary sphincter lies outside the intrinsic muscle. Their decussation at the urethrovesical junction. The compressor urethrae enables a woman voluntarily to arrest the flow of urine.

This reflex is controlled in trained animals by central inhibition. Continence is therefore normally maintained at the urethrovesical junction.

Except during micturition. The slight increase at that time is the result of the detrusor escaping from inhibition and is accompanied by an intense and irresistible urge to void. The involuntary intrinsic muscle in the urethra is distributed in the form of crossed spirals. The urethral resistance as a whole. B When the detrusor muscle contracts. The nervous control of bladder filling and emptying. It can always be brought into play in an emergency. This fundamental fact explains why a urethrovaginal fistula.

Stretch receptors in the bladder wall transmit sensation of fullness to the spinal cord. During micturition the pressure rises to 30 or 50 cm of water as the result of the contraction of the bladder wall. A basic reflex then provides for stimulation of the involuntary detrusor muscle of the bladder to produce automatic emptying. Above this level the full bladder comes into direct contact with the muscles of the anterior abdominal wall. The external urethral meatus drains with the vulva to the inguinal nodes See page Anterior In front of the urethra and bladder.

A fundamental radiographic sign of a relaxed internal sphincter. Above this the bladder comes into relation with the supravaginal cervix. The tendinous foreparts of this muscle also lie below and to the side of the bladder. The levator ani muscle pubo-rectalis is a lateral relation as it sweeps backwards to be inserted partly into the side of the vagina Fig. The voluntary arrest of micturition shown by a double exposure of the same film.

The vagina as well as the bladder contains radio-opaque material. The flow down the urethra is arrested by the external sphincter and the urethra then closes from below upwards returning to the bladder any fluid within it The urethra has on either side the bulbospongiosus muscle. Lymphatic Lymphatics accompany blood vessels to the internal iliac hypogastric and external iliac nodes.

The fainter shadows illustrate the situation during voiding: Lateral Fig. The mechanism whereby this is achieved is dependent on the action of the involuntary muscle of the bladder and of the urethrovesical junction.

Vascular Connections urethra. It is not dependent on relaxation of the levatores ani. The base of the bladder is Innervation See page 53 and Fig. Venous Vesical and vaginal plexuses and hence to the internal iliac veins. It crosses the base of the broad ligament lying below and at right angles to the uterine artery Fig.

Distortions of pelvic anatomy.

BRITTENY from Georgia
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