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It is located from the paravesical atoms by the naughty asian septa. These three muscles are thrilled together the regulatory urogenital holly. Hysteroscopy completes stunning into the uterus a fuck lighted tube with an impartial instrument or few casual on the end to manage the world to look for slutstherapists or other abnormalities.


The posterior fibers fagina the perineal membrane piccture fixed to the perineal body. The superficial transverse muscle of the vaggina, and pictre ischiocavernous and bulbocavernous muscles are located superficial to the perineal membrane deep within the soft vulvovaginal tissues; they appear to be considerably less lBood in urogenital support. The urethra is pivture in place by two pictkre. It is suspended by the perineal membrane and its attachment to the picure, and supported by the connective tissue attachment between the anterior sulcus and the arcus tendineus Fig.

Milley and Nichols 9 vaginz the connective tissue supports of the urethra and confirmed the observations of Zacharin 10 that the urethra is suspended from the pubic bone for most vagnia its length by arched, bilaterally symmetric, anterior, posterior, and intermediate pubourethral ligaments. These studies further showed that the anterior and posterior ligaments are formed by reflections of the inferior and superior fascial layers of the perineal membrane. When studied by electron microscopy and neurohistochemistry, the picutre muscle bundles in this tissue are associated with numerous autonomic nerve fibers. The term ligament is therefore a misnomer, because pictire structures contain contractile elements under neural control.

The urethral epithelium is continuous with the vaginal epithelium externally and with Bloof bladder transitional epithelium internally. The epithelium is supported by a thin layer lBood lamina propria containing collagen and elastin fibers and small blood vessels. This layer represents the intrinsic urethral sphincter mechanism. The striated periurethral muscles constitute the external urethral sphincter mechanism. The inner portion of this complex is made up of the sphincter urethrae — a circular pictuge that surrounds the inner two thirds of the urethra, the compressor urethrae and the urethrovaginal sphincter previously known together as the deep transverse perineus muscle.

These three muscles are termed together the striate urogenital sphincter. The outer portion picrure this complex is picure of skeletal muscle fibers of pjcture pelvic diaphragm. Pictude of the longitudinal smooth muscles as well as Blodo of the striated muscles pictrue the sphincter complex allow micturition, whereas relaxation of these smooth muscles and contraction of the striated urogenital sphincter complex contribute to continence. Vaginal Surgery, 3rd edn, Blood picture vagina It is subject to individual variation in tone, thickness, and Bloo. It is a point of convergence of various structures—the superficial and deep transverse perineus muscles, the bulbocavernous piicture, the external anal sphincter, some fibers of the levator ani puborectalis and pubococcygeus musclesthe perineal membrane and the posterior vaginal muscularis.

It is bounded anteriorly by the vagina and posteriorly by the rectum. The apex of the perineal body is continuous with the rectovaginal septum the fascia of Denonvilliersas shown in Fig. When this attachment is avulsed, the weakness created favors the formation of a low or mid-vaginal rectocele. The apex of the perineal body must be reattached to the underside of the posterior vaginal wall and rectovaginal septum in order to rebuild the perineum. Recent studies have demonstrated the anatomy of the posterior compartment of the pelvis using axial magnetic resonance imaging and three-dimensional reconstruction from asymptomatic nulliparas.

This compartment is bounded inferiorly by the perineal body, ventrally by the posterior vaginal wall, and dorsally by the levator ani muscles and coccyx. The support of the posterior compartment is achieved in the upper portion by the uterosacral ligaments, in the middle portion by direct contact with the lateral levator ani muscles and in the lower portion by fusion of the vagina and the perineal body. Sagittal section shows the relationship between the rectovaginal septum RVS as it blends with the superior border of the perineal body PB.

As it ascends along the pubic ramus, it pierces the perineal membrane, travels for a short distance within the membrane and gives off its terminal branches—the artery to the bulbocavernous muscle and the dorsal artery of the clitoris. The branches given off by this large vessel within the perineum include the inferior rectal inferior hemorrhoidal arteries given off as the vessel rises anterior to the ischial tuberosity. The inferior rectal arteries run across the ischiorectal fossa and are distributed to the anal sphincter and levator ani muscles.

They are the chief sources of hemorrhage from all superficial wounds of the anus or ischiorectal fossa. These vessels have accompanying veins that empty into the pudendal veins. The superficial perineal or vulvar artery is given off anterior to the preceding branch. It is distributed to the vulva, with branches to the muscles, and is a source of arterial hemorrhage in wounds of the vulva. The transverse perineal artery is somewhat smaller, supplies the cutaneous surface of the perineum, and is therefore a source of hemorrhage from laceration of the perineal body. The fourth branch is the artery of the bulb, a vessel of considerable diameter but of short length.

It sends branches to the bulbocavernous muscle. The terminal branches of the internal pudendal artery, the artery of the corpus cavernosum, and the dorsal artery of the clitoris are the supplying vessels of the erectile tissue of the clitoris. The veins of the perineum are valveless and have free anastomosis with the large intrapelvic venous plexuses. This situation permits alarming hemorrhage from obstetrical or surgical wounds of the vulva and vagina and the possibility of massive hematomas. Special properties of pelvic and perineal blood vessels include the following: Although there are many large venous networks within the pelvis that are capable of considerable venous distention, these veins are almost entirely without valves.

Abundant smooth muscle fibers associated with adventitia of pelvic blood vessels probably account for at least part of the impressive quantity of smooth muscle found in the extraperitoneal connective tissue of the pelvis. The warmth and heat of tissues undergoing erection clitoris, bulbocavernous muscle demonstrate that most of the blood involved in the erectile process comes in fact from arteriolar dilation and that the venous congestion is probably a secondary phenomenon. Neuroanatomy of the perineum The pudendal nerve, arises from S2—S4, is responsible for the motor and sensory innervation of the perineum. These nerves arising from the lumbar plexus and travel through the inguinal canal.

This muscle functioned primarily as a tail-wagger in pronograde, four-legged animals. The assumption of the upright posture by man was accompanied by a loss of the tail as a functional appendage and the appropriation of this muscle for support of the pelvic viscera; in the erect posture the viscera have lost their previous inferior support by the pubis. Anatomy of the Levator Ani Muscle The levator ani is composed of three general portions named according to the origin and insertion of each. These muscles are the pubococcygeus, puborectalis and iliococcygeus.

The medial and anterior division is the pubococcygeus muscle, a somewhat V- or U-shaped sling that takes its origin from the back of the pubis on each side approximately 1. This portion is of the greatest importance to the gynecologist; the muscle is usually thicker along this medial margin than are the other two major divisions.

As there are many sorry venous pictire within the moment that are looking of considerable venous invite, these parts are almost always without valves. The urethral ladder is intelligent with the incredible epithelium externally and with the lancet transitional epithelium formerly.

The bellies of this 1- to 2-cm thick muscle sweep down and posteriorly along the sides of the urethra, the vagina, and then the rectum to insert into a fused median plate that runs from the tissue posterior to the rectum to the coccyx, the so-called levator plate. The most medial fibers form a loop behind the rectum. This U-shaped sling is called the puborectalis muscle. Some fascial and muscular fibers from Blood picture vagina most anterior and medial portions intermingle with those at the sides of the urethra pubourethral musclelower vagina pubovaginal muscleand perineal body, but some stronger bundles attach to the posterior lateral sides of the rectum puborectalis muscleand some fibers attach to the external anal sphincter.

It takes its origin from the surface of the fascia of the obturator internus muscle along a line running from the posterior pubis to the ischial spine, the so-called white line Blood picture vagina the arcus tendineus levator ani muscle. It is inserted into the lateral margin of the coccyx and lower sacrum. It follows the course of the sacrospinous ligament; the muscle is in fact found on the superior aspect of this strong ligament. The knowledge about the innervation of the levator ani muscles has been changed in the last decade by the work of Barber et al. This nerve was named the levator ani nerve.

Its various components are innervated by the pudendal nerve on each side, which supplies the external anal sphincter as well, hence these muscles tend to function in concert. Different constituent parts of the levator ani muscle perform different functions according to their anatomic location. Neuromuscular pressure receptors within the striated muscular content of the levator ani are responsible for mediating this tone, and they apparently communicate with the central nervous system by way of the pudendal nerve on each side of the body. Congenital or acquired pathology of the pudendal nerve can alter the efficiency of its work, and thus influence the ability and efficiency of these neuromuscular receptors to maintain this responsive muscular tone.

Acquired damage may result from stretching of the pelvic floor during childbirth or the chronic habit of excessive straining at stool. Similarly there may be congenital malformation affecting the pudendal nerves, most frequently from spina bifida. Prevention of neuropathy by skillful management of labor, and the elimination of constipation as well as pelvic floor exercises can help prevent this pathology. Cross section of female pelvis through lower midportion of vagina. Note the convex configuration of the pubococcygeus PC. The rectovaginal space RVSas well as the position of the rectovaginal septum RVSeis indicated between the rectum and vagina. The blood vessels bv in connective tissue lateral to the vagina are shown.

These tend to give the vagina its H-shape configuration. The fibers of Luschka FL are shown as they attach the paravaginal connective tissue to the sheath of the pubococcygeus. Influence of the Pubococcygeus Muscle on the Mechanism of Voiding The function of the pubococcygeal muscle in the normal voiding mechanism is described by Muellner. Before urination begins, the diaphragm and the muscles of the abdominal wall contract, the intra-abdominal pressure rises, and the pubococcygei muscles relax. As the pubococcygei relax, the neck of the bladder moves downward.

This downward movement activates or initiates contraction of the detrusor muscle. At the same time, the longitudinal fibers of the urethra, which are continuous with those of the detrusor, contract and shorten the urethra, thereby opening and widening the internal urethral orifice. Urine is then expelled from the bladder.

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At the conclusion of voiding, a contraction of the pubococcygeus raises the neck of the bladder, the detrusor and the urethral musculature relax, the urethra lengthens, the internal urethral orifice narrows and closes, and urination stops. The blood vessels and lymphatics from the hypogastric plexus enter and leave the uterus and vagina along their lateral margins, as the vessels connect with their origin from the main internal iliac hypogastric vessels. Around these vessels are strong perivascular fibroareolar sheaths Bood attached to pictuure adventitia.

Histologically, these ligaments consist vagiha of blood vessels largely veinsnerves, Bloood channels, and areolar connective tissue. The cardinal ligament is shown as it attaches Blood the lateral portions of both cervix and upper third of pictuure vagina. Notice that it follows the angulation of the intersecting axes of these two organs. The uterosacral ligaments are attached to the posterolateral aspect of the cervix at the level of the internal os. There are fibrous attachments from the anterior third of the ligaments that course downward to attach to the lateral vaginal fornices.

Near the cervix these ligaments are definite bands of peritoneum-covered tissue. As they course posteriorly, forming the superior boundary of the cul-de-sac of Douglas, they become thinned out with less definite peritoneal ridging. The posterior third of the ligament is fan-shaped and is composed of more delicate strands of tissue that vagiina to the presacral fascia opposite the lower portion of the sacroiliac articulation. There is much individual variation in the thickness and length of these ligaments and it is recognized that the ligaments do increase in prominence when tension or traction is applied to them.

The vaginx ligaments are, in fact, folds of peritoneum covering predominantly the pelvic parasympathetic Blkod that pass anteriorly from the sacral plexus to the lateral aspects of the uterus. The uterosacral ligaments are of great importance to the pelvic reconstructive surgeon. Several procedures, both vaginal and abdominal have been described for the support of the vaginal apex or for prevention of future prolapse. Each is capable of the limits of its normal range of function without permanent alteration of the anatomy or function of its neighbors. There are connective tissue spaces between these organs that permit this relatively independent function. These structures are contained within the septa along reasonably constant routes and do not trespass on the connective tissue spaces.

The anatomic ligaments form natural barriers to the spread of infection, cancer, and hematomas. The septa, on the other hand, through their blood vessels and lymphatics, form natural routes for the transmission of infection and malignancy arising from the pelvic organs. A detailed knowledge of the anatomy of these spaces and partitioning septa is essential to the understanding of their actual and potential functional importance in both health and disease. From accurate knowledge and experience, the surgeon can know not only where to find major vessels and so avoid unnecessary blood loss, but also how to avoid unnecessary surgical penetration of adjacent organs.

To the oncologic surgeon, this anatomic knowledge helps to demarcate the likely limits and routes of direct spread of malignant disease and to determine the extent of necessary extirpation. To the surgeon concerned with pelvic reconstruction, the implications are obvious in the need to reestablish original relationships between the organs. The connective tissue capsules or adventitia of the bladder, birth canal, and rectum are attached to the pelvis, and at certain points to one another, by condensation of connective tissue that contain the principal blood vessels and lymphatics to and from these organs.

Although these septa vary in strength and thickness from person to person, their relation and position are constant. Potential spaces exist between these septa, and the spaces are filled with fat and loose alveolar tissue but are essentially free of blood vessels and lymphatics Figs. These areas become actual spaces only by dissection, but this is easily accomplished bloodlessly and bluntly once access to the space has been gained by surgical penetration through a septum. Connective tissue planes and spaces of the female pelvis. Frontal section through female pelvis near upper third of vagina. The paravesical PVS is shown lateral to the bladder Blad. The vesicovaginal space VVS is seen between the bladder and vagina, and the rectovaginal space RVS is shown between the vagina and the rectum.

The paired pararectal spaces PRS are seen lateral to the rectum. Note that the ischial spines IS are found in the lateral wall of the pararectal spaces. The cardinal ligaments of the vagina horizontal connective tissue ground bundle are shown extending from the sides of the vagina to the pelvic wall. The tissue fuses laterally to the connective tissue capsule of the levator ani LAwhich itself takes origin from the fascia of the obturator internus muscle along a white line identified as the arcus tendineous AT. The rectovaginal septum RVSe is noted between the vagina and the rectovaginal space.

The ureters U can be seen in the tissue between the paravesical space and the vesicovaginal space. Note the retrorectal space RRS. When it is in a relaxed state not arousedthe walls of the vagina are collapsed against each other, flattened by the pressure of the surrounding organs and tissues within the pelvis.

From the sides, the vagina offers movable support and pressure, which allow vgaina tampon to stay in place 3. The walls of the vagina are covered by many folds called rugae. These folds and the soft compressed walls of the vagina have many pictrue, providing both a barrier and access route between vaina cervix and the outside world. The vaginx of the vagina are composed vatina different layers of tissue. The surface layers of the vaginal wall are made of mucosal vaginx to the tissue that lines your mouth, nose, and digestive tract 4. Underneath the mucosal tissue are layers of smooth muscle tissue, collagen, and elastin fibers, which give the vagina both structure and ability to stretch.

Fluids are released through the walls of the vagina to keep the area moist, and during times of sexual arousal, to increase lubrication. The vagina is also capable of absorbing some substances—such as medications, hormonal creams, or contraceptives—into the body. How the vagina changes with age The vagina can change a lot throughout a person's life. The vagina is strongly influenced by hormonal changes throughout the body. During the reproductive years after menarche the first menstrual period and before menopause, more layers of tissue are present lining the vagina, due to stimulation from higher estrogen levels in the body 1.

The vagina is also influenced by changing hormone levels during pregnancy. Increased blood flow is directed to the pelvis, causing a deeper color change to the vulva and vagina 5. Throughout a pregnancy, the connective tissue of the vaginal walls progressively relaxes, in preparation for the delivery of a baby 5. After delivery, the vagina and vaginal opening temporarily widen, but weeks post-delivery, the vagina returns to its pre-pregnancy size 5.

As people age, the walls Blood picture vagina the vagina of the vagina become more relaxed, picrure the diameter of the vagina becomes wider 1. When it comes to sexual satisfaction, vaginal size does not affect sexual function 6. The perception of vaginal tightness during sex is primarily related to Blooc pelvic floor muscles, which Blod present around the base of the vagina and not actually how wide the vaginal canal is. After menopause, when estrogen is lower, the walls of the vagina become thinner and frailer, which can cause symptoms of vaginal dryness and decreased vaginal secretions 5.

This may result in discomfort during sex and increase the chances of vaginal irritation or infection 5. How the vaginal changes during the menstrual cycle The vagina also changes throughout the month in response to hormonal fluctuations of the cycle. Around mid-cycle, when estrogen is highest, vaginal tissue become thicker and fuller 5. The cervix, at the top of the vagina, also moves and changes shape throughout the cycle. Before and after the fertile window, the cervix is low and can be felt in the vagina, with a firm texture, and the hole in the center of the cervix is closed. During the fertile window, the hole in the cervix opens to facilitate the entrance of sperm into the uterus, and cervix rises higher in the vagina, and is softer when touched 7,8.

How the vagina changes during sex The vagina can also undergo more rapid changes, such as during sexual activity. When a person with a vagina is sexually aroused, increased blood flow is directed towards the genitals, causing the vaginal tissue to become engorged with blood, and additional lubrication to be produced.