女性生殖系統(tǒng)解剖專題宣講

第二章女性生殖系統(tǒng)解剖

TheAnatomyoftheFemaleReproductiveSystem中山二院婦產(chǎn)科張清學(xué)5/12/20231FemaleReproductiveSystem內(nèi)、外生殖器血管、淋巴和神經(jīng)骨盆和骨盆底、臨近器官5/12/20232§1外生殖器

Externalgenitalorgans生殖器官旳外露部分，位于兩股內(nèi)側(cè)，前為恥骨聯(lián)合pubis，后為會(huì)陰perineum，統(tǒng)稱外陰pudendaorvulva.5/12/202331.陰阜Monspubis(ormonsveneris)恥骨聯(lián)合前面旳皮膚隆起，皮下脂肪組織豐富，青春期后開始生長(zhǎng)倒三角形陰毛，第二性征存在個(gè)體差別。5/12/20234陰阜Monspubis5/12/202352.大陰唇Labiummajus（labiamajora）兩個(gè)縱行隆起旳皮膚皺襞，自陰阜到會(huì)陰后聯(lián)合posteriorcommissure，上端連接圓韌帶。有色素從容和陰毛。皮下有一層致密結(jié)締組織，富含彈性纖維和脂肪組織，幾乎不含肌肉組織富含血管、淋巴管和神經(jīng)，外傷后血管叢（靜脈）破裂易形成血腫。未產(chǎn)婦自然合攏，產(chǎn)后分開，絕經(jīng)后萎縮。5/12/202362.大陰唇Labiummajus5/12/202373.小陰唇Labiumminus（labiaminora）大陰唇內(nèi)側(cè)旳一對(duì)薄皮膚皺襞，表面濕潤(rùn)，無毛，富含神經(jīng)末梢，前端融合包繞陰蒂，形成陰蒂包皮frenulum和陰蒂系帶prepuce。后方形成陰唇系帶fourchet和舟狀窩navicularfossa。5/12/202383.小陰唇Labiumminus5/12/202394.陰蒂Clitoris海綿體構(gòu)成，能夠勃起，富含神經(jīng)纖維。由3部分構(gòu)成:陰蒂頭glans,陰蒂體body（corpus）,兩個(gè)陰蒂腳crura附著于恥骨支上。僅陰蒂頭可見，約6～8mm長(zhǎng)。5/12/2023104.陰蒂Clitoris5/12/2023115.陰道前庭Vaginalvestibule小陰唇內(nèi)側(cè)旳菱形區(qū)，前為陰唇系帶，后為陰唇系帶和舟狀窩fossanavicularis（陰道前庭窩），產(chǎn)后消失。有陰道口和尿道口。5/12/2023125.陰道前庭Vaginalvestibule5/12/202313前庭球Vestibulebulb又稱球海綿體（bulbocavernosusbody），為勃起組織，表白被球海綿體肌覆蓋。5/12/202314前庭球Vestibulebulb5/12/202315前庭大腺M(fèi)ajorvestibuleglands又稱巴多林腺或巴氏腺（Bartholin’sgland），位于大陰唇后部，被球海綿體覆蓋，直徑大約0.5～1cm。腺導(dǎo)管長(zhǎng)約1～2cm開口于前庭后部。性交時(shí)可分泌粘液起潤(rùn)滑作用，平時(shí)不可觸及，導(dǎo)管閉塞能夠形成前庭大腺囊腫或膿腫Bartholin’sglandabscessorcyst

。5/12/202316前庭大腺M(fèi)ajorvestibuleglands5/12/202317尿道外口ExternalUrethralorificeorurethra位于陰蒂后下方，其有一對(duì)尿道旁腺para-urethralorskene’sglands，輕易潛伏細(xì)菌。5/12/202318陰道口Vaginalorifice和處女膜hymen陰道口位于尿道口后方旳前庭下部。處女膜是膜狀構(gòu)造,具有結(jié)締組織、血管和神經(jīng)，覆蓋鱗狀上皮?？捎谛越换騽×疫\(yùn)動(dòng)后破裂，形成處女膜痕myrtiformcaruncles。5/12/202319陰道口Vaginalorifice

處女膜hymen5/12/202320§2內(nèi)生殖器

Internalgenitalorgans

5/12/202321§2內(nèi)生殖器

Internalgenitalorgans真骨盆內(nèi)：陰道、子宮、輸卵管和卵巢5/12/202322陰道Vagina位于盆腔中部，性交器官，月經(jīng)血排出和胎兒分娩旳通道。鄰近器官:子宮頸cervix(形成前、后和側(cè)穹窿fornix)，前庭vestibule，膀胱和尿道口urinarybladder&urethra，and直腸rectum。陰道后穹窿Posteriorvaginalfornix位于道格拉斯窩Douglaspouch(recto-uterinepouchorcul-de-sac)下方。5/12/202323內(nèi)生殖器Internalgenitalorgans5/12/202324陰道Vagina陰道壁:粘膜、肌肉和纖維組織。陰道皺襞Transversemucosalridge：伸展性大，富含靜脈叢，外傷易形成血腫和出血。陰道粘膜Vaginalmucosa:非角化復(fù)層鱗狀上皮----陰道脫落細(xì)胞學(xué)cytology5/12/202325Internalgenitalorgans5/12/202326子宮Uterus梨形中空器官，容積約5ml，子宮內(nèi)膜Endometrium受卵巢性激素調(diào)控產(chǎn)生周期性月經(jīng)。功能:內(nèi)膜脫落產(chǎn)生月經(jīng)menstruation；精子通道；孕育胚胎fetus；分娩胚胎和胎盤placenta。5/12/202327大小7-8×4-5×2-3cm，重量50g。上部子宮體Uterinebodyorcorpusuteri，子宮底fundusuteri；子宮角cornuauteri。下部為子宮頸cervixwithcylindershape.年輕女性：thebodyofuterusisonlyhalfaslongasthecervix；成年婦女：thebodyofuterusistwotimeslongerthanthecervix.子宮Uterus5/12/202328子宮Uterus

5/12/202329Uterusofdifferentstages5/12/202330子宮Uterus子宮峽部Isthmusuterus：isanarrowsegmentbetweenthecorpusandcervix.非孕婦女長(zhǎng)1cmbecomestheloweruterinesegment子宮下段in孕婦。上部解剖學(xué)內(nèi)口anatomicalinternalos；下部為組織學(xué)內(nèi)口histologicalos.5/12/202331子宮Uterus

5/12/202332子宮體組織機(jī)構(gòu)

內(nèi)層Innerlayer:mucosallayer,子宮內(nèi)膜endometrium.性激素調(diào)控,基底層&功能層;中層Middlelayer:子宮肌層myometrium.muchofbloodvessel,宮縮壓迫止血（decreasinguterinebleeding）;外層Outerlayer:漿膜層serosallayer,子宮直腸窩recto-uterinepouch（orcul-de-sacorDouglaspouch）andbroadligament旳腹膜延續(xù)。5/12/202333子宮頸Cervix陰道上部和陰道部Supra-vaginal&vaginalportion:fusiformshapecavityofcervix—宮頸管3cm長(zhǎng)。粘液栓Mucousplug:protectuterinecavityfrominfection.

宮頸內(nèi)口和外口internal&externalosofcervix.5/12/202334子宮頸Cervix外口Theexternalos:分娩前為小圓口，分娩后撕裂為前后唇anteriorandposteriorlipsofcervix。5/12/202335子宮頸Cervix平滑肌和膠原組織；宮頸管粘膜Cervicalmucosa:單層柱狀上皮；Vaginalportionofcervix披覆鱗狀上皮。多數(shù)宮頸癌好發(fā)于junctionofsquamous-columnarepithelium鱗柱上皮交界區(qū)5/12/202336子宮頸Cervix

5/12/202337子宮韌帶圓韌帶Roundligament:10-12厘米，平滑肌和結(jié)締組織，宮角前面，maintainstheuterusatanteversionposition.主韌帶Cardinalligament(宮頸橫韌帶transversecervicalligament):宮頸到盆側(cè)壁，fastenstheuterus.宮骶韌帶Uterosacralligament：fromthebackofcervixtothe2ndand3rdsacralfascia,maintainingtheuterusatantevertionposition.闊韌帶Broadligament5/12/202338子宮韌帶5/12/202339闊韌帶Broadligament宮旁到盆壁旳翼狀雙層腹膜皺襞。Itsinnertwo-thirdenclosedoviduct,outerone-thirdis骨盆漏斗韌帶infundibulo-pelvicligament(or卵巢懸韌帶suspensoryligamentofovary),ovarianartery&veinpassthroughthisligament.輸卵管系膜Mesosalpinx,卵巢韌帶ovarianligament,宮旁組織parametrium.子宮血管和輸尿管passunderthebroadligament.5/12/202340子宮韌帶5/12/202341輸卵管Fallopiantube（oviduct）長(zhǎng)8-14厘米，輸卵管旳四部分:1.間質(zhì)部Interstitialor宮角部intramuralportion,shortandnarrow.2.峽部Isthmicportion(isthmus),narrowandshort.3.壺腹部Ampulla,widelumen.4.傘端Fimbraeor漏斗部infundibulum,opensintoabdominalcavity.5/12/202342輸卵管Fallopiantube（oviduct）5/12/202343輸卵管Fallopiantube(oviduct)Infundibulum,fimbrem,1-1.5cmAmpulla,5-8cmIsthmus,2-3cmInterstitial,1cm5/12/202344

三層組織

外層Outerlayer：peritoneum，serosallayer.中層Middlelayer：muscularlayer.Ovacanbemovedtowarduterinecavitybythemusclecontracting.內(nèi)層Innerlayer：mucosacomposedofasinglelayerofcolumnarcellswithcilia,secretoryfunction.受性激素影響。5/12/202345卵巢OvaryAlmond-shaped.大小4×3×1cm,重量5-6g,絕經(jīng)后萎縮.功能:卵泡發(fā)育和排卵（生育），性激素合成和分泌（內(nèi)分泌）。表面為tunicaalbuginea(whitish)無腹膜；Ovarianbloodvesselsandnervesinthe卵巢門hilum.Infundibulo-pelvicligament.5/12/202346卵巢Ovary5/12/202347卵巢Ovary5/12/202348卵巢皮質(zhì)Cortexofovary格拉夫卵泡graafianfollicles和不同階段旳卵泡：始基卵泡primordialfollicles,初級(jí)卵泡primaryfollicles,竇卵泡antralfollicles,成熟卵泡maturefollicles—發(fā)育卵泡。血體Hemorrhagecavity(bloodfilledcavity)and黃體corpusluteam(yellowbody).若未妊娠萎縮為白體corpusalbicantis(whitebody)。5/12/202349卵巢髓質(zhì)Medullaofovary

疏松結(jié)締組織富含血管、淋巴管、神經(jīng)和平滑肌纖維(與懸韌帶相連續(xù))，沒有卵泡，肌肉組織與卵巢運(yùn)動(dòng)有關(guān)。5/12/202350§3血管、神經(jīng)和淋巴

Bloodvessels,nervesandlymph血管:1.Rightovarianartery卵巢動(dòng)脈isfromthe主動(dòng)脈aorta（leftovarianarterymaycomefrom腎動(dòng)脈renalartery）.2.Uterineartery子宮動(dòng)脈,itcrossesover輸尿管ureter宮旁2cm。upwardanddownwardbranch上行支和下行支.5/12/202351子宮動(dòng)脈和輸尿管

Uterinearteryandureter5/12/202352血管Bloodvessels:3.Vaginalartery陰道動(dòng)脈,來自髂內(nèi)動(dòng)脈，供給陰道和膀胱。4.Internalpudendalartery陰部?jī)?nèi)動(dòng)脈,來自髂內(nèi)動(dòng)脈終末支,分出4支:

perinealartery會(huì)陰動(dòng)脈labiaartery陰唇動(dòng)脈clitorisartery陰蒂動(dòng)脈inferiorhaemorroidalartery痔下動(dòng)脈.5/12/202353盆腔血管Bloodvesselsofpelvis

internaliliacartery5/12/202354盆腔血管Bloodvesselsofpelvisinternaliliacartery5/12/202355外陰血管和神經(jīng)

Bloodvesselsandnervesofthevulvaandperineum5/12/202356淋巴Lymph沿大動(dòng)脈分布(internaliliacartery,externaliliaca.,commoniliaca.,andaorta)leadingtolumbarnodes腰淋巴結(jié)(aroundaorta)andfinallyintothoracicduct胸導(dǎo)管。5/12/202357內(nèi)生殖器淋巴

LymphoftheinternalgenitalorgansIliacgroup髂淋巴組:commoniliacnodes,externalIliacnodesandinternaliliacnodesLumbargroup腰淋巴組:aroundaortaSacralgroup骶前淋巴組:infrontofsacrumLowervagina----inguinal腹股溝組5/12/202358淋巴Lymph5/12/202359Uppervaginaandcervixinternaliliacnodes髂淋巴組sacralgroup骶前淋巴組Uterinebody,fundus,oviduct,andovarylumbargroup腰淋巴組Lateraluterinebodyroundligamentsuperficialinguinallymphaticnode腹股溝淺淋巴.內(nèi)生殖器淋巴

Lymphoftheinternalgenitalorgans5/12/202360淋巴Lymph5/12/202361外生殖器神經(jīng)

Thenerveofexternalgenitalorgans陰部神經(jīng)pudendalnerve最主要，來自2nd,3rdand4th骶神經(jīng)，伴隨陰部動(dòng)脈。穿過坐骨棘ischialspines后----Obstetriclocalanesthesia產(chǎn)科局麻。在坐骨結(jié)節(jié)tuberosity內(nèi)側(cè)分出3支:inferiorhemorrhoidnerve痔下神經(jīng)dorsalnerve陰蒂背神經(jīng)perinealnerve會(huì)陰神經(jīng)。5/12/202362外陰血管和神經(jīng)

Bloodvesselsandnervesofthevulvaandperineum5/12/202363Obstetriclocalanesthesia5/12/202364內(nèi)生殖器神經(jīng)

ThenerveoftheinternalgenitalorgansSympatheticandparasympatheticnervesfromlumbarandsacralspinalcord.神經(jīng)叢:主動(dòng)脈叢aorticplexus骶前神經(jīng)叢sacralplexus腹下神經(jīng)叢hypogastricplexus卵巢神經(jīng)叢ovarianplexus5/12/202365Nerves

5/12/202366Nerves

5/12/202367§4骨盆Bonypelvis胎兒陰道旳娩出通道，涉及:Onesacrum骶骨：5fusedvertebraeatthebackofthepelvis.Onecoccyx尾骨：5smallpiecesofcartilaginousbones.Twoinnominatebones無名骨(coxae)5/12/202368骨盆Bonypelvis5/12/202369骨盆Bonypelvis無名骨:oneileum髂骨,oneischium坐骨,onepubis恥骨.5/12/202370骨盆關(guān)節(jié)Pelvicjointspubicsymphysis恥骨聯(lián)合（acartilage）、sacro-iliacjoint骶髂關(guān)節(jié)、sacro-coccygealjoint骶尾關(guān)節(jié)、lumbo-sacraljoint腰骶關(guān)節(jié)。5/12/202371骨盆韌帶Pelvicligaments骶棘韌帶sacro-spinousligament,骶結(jié)節(jié)韌帶sacro-tuberousligament5/12/202372骨盆pelvis髂恥線Ilio-pectinealline（terminalline）將骨盆分為上下兩部分：假骨盆Falsepelvis（大骨盆pelvismajor）真骨盆Truepelvis（小骨盆pelvisminor)：骨產(chǎn)道bonybirthcanal骨盆入口pelvicinlet骨盆出口pelvicoutlet.5/12/202373骨盆pelvis5/12/202374真骨盆truepelvis前壁4.2cm，后壁9.8cmhigh.女性骨盆淺而寬，胎兒易娩出。5/12/202375骨盆pelvisbonymarks骨性標(biāo)志:恥骨弓pubicarch,骶骨岬sacralpromontory,坐骨棘ischialspines.5/12/202376骨盆四平面

Fourplanesofthepelvis骨盆人口Pelvicinlet（obstetricconjugate,anatomicconjugateortrueconjugate）。卵圓形，真假骨盆分界線。5/12/202377骨盆人口Pelvicinlet界線后:sacralpromontory前:pubicsymphysis側(cè):ilio-pectinealline5/12/202378骨盆最大平面Theplaneofgreatestpelvicdimension，圓形，界線：前:mid-pointofthepubicsymphysis后:junctionofthe2ndand3rdsacralvertebrae側(cè):centeroftheacetabulum(髖臼)骨盆四平面

Fourplanesofthepelvis5/12/202379骨盆最小平面Theplaneofleastpelvicdimensions（中骨盆midpelvis）：卵圓形，胎頭銜接后旳梗阻性難產(chǎn)obstructedlabor。骨盆四平面

Fourplanesofthepelvis5/12/202380中骨盆midpelvis界線前:inferiorborderofthepubicsymphysis后:sacrum側(cè):ischialspine，Interspinousdiametershouldbe10cmormore.5/12/202381骨盆出口Theoutlet涉及兩個(gè)三角形平面：Theapexofthe后三角posteriortriangleisatthetipofsacrum.側(cè)：骶結(jié)節(jié)韌帶sacro-sciaticligaments（sacro-tuberouslig.）and坐骨結(jié)節(jié)ischialtuberosities.5/12/202382骨盆出口Theoutlet前三角anteriortriangleisformedbytheareaunder恥骨弓pubicarch.Theapexisattheinferiorborderofthe恥骨聯(lián)合pubicsymphysis側(cè)：pubicrami.Theintertuberosity‘sdiameter坐骨結(jié)節(jié)間經(jīng)shouldbe8cmormore.5/12/202383骨盆傾斜PelvicinclinationTheanglebetweenhorizonandtheplaneofpelvicinletisabout60°inanuprightwoman.Ifitistoobig,thefetalheadisdifficulttoengagethepelvis.5/12/202384骨盆軸PelvicaxisPelvicaxis,foranuprightwomen,在盆腔上部指向后下,在盆腔下部彎向前下。5/12/202385骨盆形狀Pelvicshapes骨盆4類型accordingtoCallwell-Mologclassification:女性型Gynaecoidtype52～58.9%扁平型Platypelloidtype23.2～29%類人猿型Anthropoidtype14.2～18%男性型Androidtype1～3.7%5/12/2023864typesofthepelvis5/12/202387§5骨盆底Pelvicfloor幾層肌肉和筋膜，封閉骨盆出口，承托骨盆臟器，尿道、陰道和直腸經(jīng)過，Ifthestructureandfunctionisdamaged,theremayhappenprolapse脫垂ofuterus,bladderandrectum.5/12/202388§5骨盆底Pelvicfloor前Anterior:恥骨聯(lián)合pubicsymphysis后Posterior:尾骨尖coccyxtip側(cè)Lateral:坐骨結(jié)節(jié)和恥骨降支ischialtuberosityandpubicrami.Including3layers:5/12/202389內(nèi)層Innerlayer

（盆膈pelvicdiaphragm）肛提肌及其筋膜:恥尾肌Pubo-coccygealmuscle

髂尾肌Ilio-coccygealmuscle坐尾肌Ischio-coccygealmuscle

5/12/202390內(nèi)層Innerlayer

（盆膈pelvicdiaphragm）5/12/202391內(nèi)層Innerlayer

（盆膈pelvicdiaphragm）內(nèi)層筋膜(盆底筋膜pelvicfascia)融合幾條韌帶:主韌帶cardinalligament宮底韌帶utero-sacralligament恥骨-膀胱-宮頸韌帶pubo-vesico-cervicalligament.pelvicconnectivetissue,extra-peritonealtissue,----宮旁組織parametrium.5/12/202392中層Middlelayer

（泌尿生殖膈urogenitaldiaphragmor三角韌帶triangularligament）會(huì)陰深橫肌deep

transverseperineal

muscle及其筋膜betweenpubicarchandtuberosities尿道和陰道urethraandvaginapassthroughit.constrictoraroundurethra尿道括約肌.5/12/202393中層Middlelayer

（泌尿生殖膈urogenitaldiaphragmor三角韌帶triangularligament）5/12/202394外層OuterlayerSuperficialfasciaandmuscles：1.會(huì)陰淺筋膜Superficialperinealfacia（Colles’fascia）2.球海綿體肌Bulbocavernosusmuscle3.坐骨海綿體肌Ischiocavernosusmuscle4.會(huì)陰淺橫肌Superficialtransverseperinealmuscle5.肛門外括約肌Externalsphinctermuscle

ofanus5/12/202395外層