Structure and spatial orientation
Anatomically, the uterus is divided into several parts: the massive fundus (fundus), the main part — the body (corpus), and the cervix (cervix). The transition zone between the body and the cervix is called the isthmus (isthmus uteri). Topographically, the cervix itself is divided into two parts: supravaginal (portio supravaginalis) and vaginal (portio vaginalis).
A critical characteristic of uterine topography is its relation to the pelvic axes. Normally, the organ is oriented in a strictly defined manner:
- Anteversion — anterior inclination of the entire uterus relative to the main longitudinal axis of the pelvis.
- Anteflexio — the physiological curvature where the uterine body is tilted forward relative to its own cervix.
Apparatus fixing the position of the uterus
Fixation of the uterus in the lesser pelvis is the result of three interrelated systems: the suspensory, fixing, and supporting apparatuses.
- Suspensory apparatus. Includes the round (ligg. teretes uteri) and broad (ligg. lata uteri) ligaments. The broad ligament is a peritoneal fold in the frontal plane, with the uterine tubes enclosed in its free margin. The round ligament is covered by the anterior leaf of the broad ligament, extends from the uterine angle to the deep inguinal ring, and contains fibro-muscular fibers.
- Fixing apparatus (retinaculum uteri). Formed by condensations of connective tissue and smooth muscle fibers closely linked with the parietal and visceral pelvic fascia. The main elements are the cardinal ligaments (ligg. cardinalia) — thick bundles at the base of the broad ligaments extending from the cervix to the lateral pelvic wall. This group also includes the uterosacral and pubovesical ligaments (continuing as the vesicouterine ligaments).
- Supporting apparatus. These are the muscles and fasciae of the pelvic floor (perineum). Fixation involves fibers of the deep transverse perineal muscle and the medial bundles of the levator ani muscle (m. levator ani).
Blood supply and venous drainage
The blood supply to the uterus is characterized by abundant anastomoses and derives from three independent sources. The main vessel is the uterine artery (a. uterina), branching from the internal iliac artery. Additional supply is provided by the ovarian artery (a. ovarica from the abdominal aorta) and the artery of the round ligament of the uterus (a. lig. teretis uteri from the inferior epigastric artery).
The topography of the uterine artery is of critical importance in operative surgery. Initially, it is covered by the ureter. At a distance of 4–5 cm from its origin, the artery penetrates the base of the broad ligament of the uterus. Reaching 2 cm short of the cervix, it crosses the ureter. Further on, the artery gives off the vaginal branch (r. vaginalis) and ascends along the lateral margin of the uterus, where within the broad ligament it anastomoses with the ovarian artery and the round ligament artery.
Venous drainage originates from the uterine venous plexus (plexus venosus uterinus), which lies laterally to the cervix and within the parametrial tissue. It broadly anastomoses with the plexuses of the vagina and external genitalia. Drainage proceeds via the uterine veins into the internal iliac veins, and via the ovarian veins into the inferior vena cava.
Lymphatic drainage and innervation
At the base of the broad ligament, lymphatic vessels from the body and fundus of the bladder merge with those from the body and cervix of the uterus. The common lymphatic plexus lies beneath the peritoneum of the rectouterine pouch.
Regional lymph nodes depend on the region of the organ:
- From the cervix, lymph drains to nodes along the iliac arteries and on the anterior surface of the sacrum.
- From the uterine body — to lymph nodes around the aorta and inferior vena cava.
- From the uterine fundus, lymph partially travels along the vessels of the round ligament to the inguinal lymph nodes.
Innervation of the organ is provided by the uterovaginal plexus (plexus uterovaginalis), which represents the middle division of the paired inferior hypogastric (pelvic) plexus.
Briefly: answers to topical questions
Where do the right and left ovarian veins drain?
The right ovarian vein drains directly into the inferior vena cava. The left ovarian vein drains into the left renal vein.
What are the sources of sympathetic and parasympathetic innervation of the uterus?
Innervation of the uterus is provided by the uterovaginal (pelvic) plexus (plexus uterovaginalis, s. pelvicus).
- Sympathetic innervation: sympathetic fibers originate from the celiac plexus, forming the superior hypogastric plexus at the level of the 5th lumbar vertebra, from which fibers extend to the inferior hypogastric plexuses and subsequently to the uterovaginal plexus.
- Parasympathetic innervation: provided by the pelvic nerve (n. pelvicus) or pelvic splanchnic nerves (nn. splanchnici pelvini), branching from the sacral segments of the spinal cord S2–S4.
The surgical rule "Water under the bridge" helps to remember the crossing of the uterine artery and the ureter. "Water" refers to urine in the ureter, and "bridge" refers to the uterine artery. At 2 cm proximal to the cervix, the artery lies strictly superior to the ureter.
Class and exam questions
What is the parametrium and where is it located?
Parametrial tissue (parametrium) is a layer of adipose tissue in the subperitoneal space of the lesser pelvis. It surrounds the cervix, vagina, and lies between the two leaves of the broad ligament of the uterus.
What vestigial structures can be found near the uterus?
In the mesosalpinx, one can find the epoophoron and paroophoron. They regress with age but may become sites for cyst formation.
Where does lymphatic drainage from the uterine fundus go?
Part of the lymph from the uterine fundus travels along the vessels of the round ligament of the uterus and reaches the inguinal lymph nodes.
What else to study on this topic
- Topography and contents of the broad ligament of the uterus
- Course and syntopy of the round ligament of the uterus up to the deep inguinal ring
- Arterial anastomoses within the broad ligament of the uterus
- Connection between the uterine venous plexus and the veins of the vagina
- Formation of the lymphatic plexus of the rectouterine pouch
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