So moving onto the uterus now, there are several things to talk about here; the first thing
that I'm going to mention is prolapse.
So if you remember some of the structures supporting the uterus, you've got the uterosacral
ligament attaching from the cervix to the sacrum, the transverse cervical ligament attaching
to the side wall, and the pubocervical extending anteriorly.
So together with the levator ani muscle, which you can see here, which forms the bulk of
the floor of the pelvis, these structures support the uterus.
So if these supporting structures are weakened, then you can descent of the pelvic organs.
So the most important ones are the cardinal ligaments, and the uterosacral ligament, as
well as the levator ani muscle, which supports all the pelvic viscera, and has a sort of
sphincter function around them.
So in terms of the types of the prolapse you can get, it's useful to think in terms of
anterior, middle and posterior compartments.
So anteriorly, you can get a bulging out of the urethra into the anterior vaginal wall,
like that, so this is called a urethrocele.
And likewise, you can get the bladder bulging into the anterior wall, a little bit higher
up, so that's called a cystocele.
So if you get both of the two bulging into the vaginal wall, this is called a cystourethrocele.
So in terms of the middle compartment, you can obviously get the uterus itself prolapsing
through the vagina.
And a uterine prolapse is graded from 1 to 3 depending on the extent of the descent of
the uterus through the vagina.
So a grade 1 prolapse is only slight descent, so you get prolapse that is contained within
the vagina.
In a grade 2 prolapse, the descent is further, so you've got the cervix reaching the level
of the introitus, but the fundus of the uterus remains inside the pelvis.
So a grade 3 prolapse is when you've got the entire uterus, prolapsed outside the vagina,
and this is also referred to as procidentia.
So the causes of prolapse are childbirth - so a vaginal delivery, and then you've iatrogenic
causes, so previous pelvic surgeries, and in post-menopausal women, with low oestrogen
levels, you've got more lax ligaments and the uterus is more likely to prolapse.
And also if there's significant weight adding pressure to these structures, such as in obesity,
that can predispose to uterine prolapse.
And then also in the middle compartment, remember just behind the uterus and posterior to the
supra-vaginal region, you've got the pouch of Douglas, which is this pouch of peritoneum.
So when this herniates down, this is known as an enterocele, and it bulges into the posterior
wall behind the uterus.
So another type of prolapse in the middle compartment, is the vaginal vault prolapse,
so this is something you get after hysterectomy, where the superior end of the vagina prolapses,
and you get inversion of the vagina.
And finally in the posterior compartment, as you may be able to guess, the rectum can
protrude forwards, into the posterior wall of the vagina, and this is called a rectocele.
So moving on, the next thing I'd like to talk about, are benign tumours of the uterus.
So two common benign tumours of the uterus are known as fibroids and intrauterine polyps.
So these two combined - fibroids and polyps are very common causes for heavy menstrual
bleeding, which is known as menorrhagia.
So there are several causes for menorrhagia, but fibroids and polyps are two of the most
common pathological causes for heavy bleeding.
So fibroids are known as uterine leiomyomata, so the single for leiomyomata is leiomyoma.
So these are benign tumours of smooth muscle and connective tissue differentiation.
And they affect the myometrium of the uterus.
So there are three subtypes of fibroid, depending on the location within the myometrium.
So remember the outer layer of the uterus is called the perimetrium.
So this is the outer serosa layer of the uterus, so a fibroid located just below the serous
layer is called a subserosal fibroid.
Fibroids located directly within the wall of the myometrium are called intramural.
So the word mural just refers to the Latin "murus", which wall.
And the final type of fibroid is one which lies just underneath the endometrium, underneath
the mucosa, so this is called a submucosal fibroid.
So like I mentioned, fibroids are a common cause for menorrhagia, but they also cause
pain, which is called dysmenorrhoea, and then you can have other effects from the fibroids,
due to local pressure effects, so a large fibroid could put pressure on the bladder,
leading to frequency or urinary retention.
So polyps are benign tumours which grow into the cavity of the uterus, so intrauterine
polyps are generally endometrial in origin, and they just grow out into the cavity itself
of the endo, of the uterus sorry.
So similarly, these cause menorrhagia and they can also be responsible for intermenstrual
bleeding.
So another common condition, which doesn't really directly relate to the uterus itself,
but I'm mentioning it here because it's a condition which is characterised by ectopic
endometrial tissue.
So you get areas of endometrial tissue that is out of place, and this condition is known
as endometriosis.
So within the pelvic cavity itself, the common sites for endometriosis are the ovaries, which
you can see here.
And in this model, it's actually been dissected away, and you can see this brown coloured
stuff.
So these are called chocolate cysts.
And these are essentially accumulations of blood which appear this dark brown colour.
So these chocolate cysts are also known as endometrioma.
And then as you can see here, endometriosis has an affinity for the pouch of Douglas,
so the recto-uterine pouch.
It can also be found in the vesico-uterine pouch as well.
And other common sites are the utero-sacral ligaments, and it also affects the uterine
tubes.
So endometriosis isn't actually confined only to the, to the pelvic cavity, it also affects
the umbilicus, it can affect wound scars, it can affect the pleura, the pericardium
and even the central nervous system.
So other sites in the pelvic cavity involve the rectum, the vagina and the bladder.
So this ectopic endometrial tissue is just like the endometrial tissue itself.
So it's responsive to changes in hormones, so it actually increases and decreases in
size according to the hormonal stage of the menstrual cycle, so its oestrogen sensitive
tissue, and it therefore regresses after the menopause when oestrogen levels drop, and
also during pregnancy.
So long term, endometriosis can actually cause adhesions between the pelvic viscera, and
you can get fibrosis and ultimately of the pelvic organs.
So the symptoms you get are, sort of chronic pelvic pain that's cyclical in nature.
So you can also get ectopic endometrial tissue within the myometrium.
And this is known as adenomyosis.
So in this condition, symptoms may be absent, but you often get menorrhagia and painful
periods, so dysmenorrhoea.
So finally just to mention a malignant condition, so endometrial cancer, which is cancer of
the endometrium, is the most common malignancy of the female reproductive tract.
It's mostly adenocarcinoma, and it is an oestrogen dependent tumour, so risk factors for endometrial
cancer relate to prolonged exposure to unopposed oestrogen, and that's the main risk factor.
So unopposed just means there is no progesterone along with the oestrogen to modulate the effects
of oestrogen - it doesn't have that protective effect of the progesterone.
So hopefully that should have given you an idea of some of the main clinical conditions
associated with the uterus.