The lymphatic system of the genital organs. Innervation of female genital organs

Blood supply to the internal genital organs carried out mainly from the aorta (the system of the common and internal iliac arteries). The main blood supply to the uterus provided uterine artery (a uterina), which departs from the internal iliac (hypogastric) artery (a iliaca interna). About half the time uterine artery spontaneously departs from the internal iliac artery, but it can also start from the umbilical, internal genital and superficial cystic arteries

Uterine artery goes down to the lateral pelvic wall, then passes forward and medially, located above the ureter, to which it can give an independent branch. At the base of the wide uterine ligament, it turns medially towards the cervix. In the parametrium, the artery connects with its accompanying veins, nerves, ureter and cardinal ligament. The uterine artery approaches the cervix and supplies it with several tortuous penetrating branches. The uterine artery then divides into one large, very sinuous ascending branch and one or more small descending branches that supply blood upper part the vagina and the adjacent part of the bladder. The main ascending branch runs upward along the lateral edge of the uterus, sending arcuate branches to its body. These arcuate arteries surround the uterus beneath the serous layer. At certain intervals, radial branches depart from them, which penetrate into the intertwining muscle fibers of the myometrium. After childbirth, the muscle fibers contract and, acting as ligatures, compress the radial branches. The arcuate arteries rapidly decrease in size towards the midline, so there is less bleeding with midline uterine incisions than with lateral incisions. The ascending branch of the uterine artery approaches the fallopian tube, turning laterally in its upper part, and divides into the tubal and ovarian branches. The tubal branch runs laterally in the mesentery of the fallopian tube (mesosalpinx). The ovarian branch is directed to the mesentery of the ovary (mesovarium), where it anastomoses with the ovarian artery extending directly from the aorta

The ovaries are supplied with bloodof ovarian artery (a.ovarica), extending from the abdominal aorta to the left, sometimes from the renal artery (a.renalis). Going down together with the ureter, the ovarian artery passes along the ligament that suspends the ovary to the upper part of the wide uterine ligament, gives a branch for the ovary and tube; the terminal section of the ovarian artery anastomoses with the terminal section of the uterine artery.

IN blood supply to the vaginain addition to the uterine and genital arteries, branches of the lower urinary and middle rectal artery are also involved. The genital arteries are accompanied by corresponding veins. The venous system of the genital organs is very strongly developed; the total length of the venous vessels significantly exceeds the length of the arteries due to the presence of venous plexuses that are widely anastomosed among themselves. The venous plexuses are located in the clitoris, at the edges of the vestibule bulbs, around the bladder, between the uterus and the ovaries. IN innervation of the female genital organsthe sympathetic and parasympathetic parts of the autonomic nervous system, as well as the spinal nerves, are involved.

The fibers of the sympathetic part of the autonomic nervous system, innervating the genitals, originate from the aortic and celiac ("solar") plexuses, go down and form at the level of the V lumbar vertebra upper hypogastric plexus (plexus hypogastrics superior)... Fibers that form right and left lower hypogastric plexus (plexus hypogastrics sinister et dexter inferior)... Nerve fibers from these plexuses go to a powerful uterovaginal, or pelvic, plexus (plexus uterovaginal, s.pelvicus).

Uterovaginal plexus are located in the parametric tissue on the side and behind the uterus at the level of the internal os and cervical canal. Branches fit to this plexus pelvic nerve (n.pelvicus), related to the parasympathetic part of the autonomic nervous system. Sympathetic and parasympathetic fibers, extending from the utero-vaginal plexus, innervate the vagina, uterus, internal departments fallopian tubes, bladder. The ovaries are innervated sympathetic and parasympathetic nerves from the ovarian plexus (plexus ovaricus).

The generalized data on the innervation of the genitals are as follows.

Figure: Uterine nerves.

1 - gangl. celiacum; 2 - gangl. renale; 3 - gangl. ovaricum; 4 - gangl. mesentericum infer .; 5 - plexus uterinus magnus; 6 - plexus hypogastricus; 7 - nn. sacrales I - IV; 8 - gangl. cervicale; 9 - rectum; 10 - plex. ovaricus; 11 - uterus.

Most of the nerves leading to the uterus are of sympathetic origin; along the way, spinal fibers from n are attached to them. vagi, phrenici, splanchnici, nn. communicantes et plexus sacralis. In particular, the sympathetic fibers of the plexus hypogastricus, the plexus of which originates from the plexus aorticus, lying on the large abdominal vessels, take a large part in the innervation of the uterus. The aortic plexus joining the branches from gangl. renale n. solare below the site of the aortic bifurcation, goes along the anterior surface of the V lumbar vertebra in the form of a flat strand (plex. hypogastricus super.). At level I of the sacral vertebra plex. hypogastr super, divided into two branches, forming a plexus - plex. hypogastr. inferior, or ganglion hypogastricum. They are located in the sacral cavity, close to the isthmus uteri. These ganglia represent the end of the paravertebral sympathetic system in the pelvis. Plex. hypogastr. superior, or presacral nerve, is well accessible at the promontory level. Plex. hypogastr. inferior, in addition to the uterus, innervates the rectum, bladder, ureters and vagina. This plexus is paired, located on the sides of the cervix, some authors rank as ganglia, while the majority considers it a typical plexus, and GF Pisemsky called it "the main plexus of the pelvis" (plexus fundamentalis pelvis).

The uterus is innervated by that part of the plex. hypogastr. inferior, which forms the so-called Rhine plexus (the front of the lower edge of the plex. hypogastr. infer.). The Rhine plexus is referred to as plex by some authors. uterovaginalis, s. uterinus magnus. The Rhine plexus receives branches: 1) from the anterior roots of the II, III and IV sacral nerves, due to the 4-6 nn fibers extending from the last. erigentes (nn.erigentes are also called nn.pelvici). The latter are connected along the way with branches from the sacral ganglia of the sympathetic borderline trunk; 2) from the sacral and coccygeal section of the border sympathetic trunk; 3) via plex. hypogastr. infer, from the lumbar sympathetic trunks, as well as from the X, XI, XII thoracic nerves; 4) from plex. haemorrhoid. infer., departing from plex mesenter infer., which establishes a functional relationship between the genital apparatus and the rectum. The pelvic plexus, according to S. D. Astrinsky, containing mainly sympathetic fibers, also contains nn fibers. pelvici and is therefore a mixed plexus.

Thus, the uterus is innervated mainly by sympathetic nerves from the borderline sympathetic trunk of the lower hypogastric plexus, and also due to parasympathetic system (pelvic nerves).

Previously, it was believed that the motor nerves for the uterus are the branches of the lower hypogastric plexus, acting through the Rhine plexus, and the pelvic nerves are the motor nerves for the cervix. However, even in previous works (Dembo) there were indications that irritation of the pelvic nerves by electric current causes the same contraction of the uterus as irritation of the hypogastric nerves. At the end of the last century, the prevailing opinion was that in both systems - sympathetic and parasympathetic - there are motor and sensory nerves, namely: centrifugal motor and centripetal sensory. While studying bioelectrical phenomena in the uterus, some authors found that stimulation of the hypogastric nerve by faradic current causes either an inhibitory or an intensifying effect, depending on whether the uterus is pregnant or not; irritation of the pelvic nerves had the same effect on the pregnant and non-pregnant uterus in the form of an acceleration of the rhythm and an increase in the amplitude of contractions.

The view of the sympathetic innervation of the uterus (from the hypogastric nerve system) as exclusively motorized has been shaken in recent decades. Experimental work has shown that some sympathetic nerves going to the uterus, and not only preganglionic, but also postganglionic, directly innervating the uterus, are cholinergic. Irritation of the hypogastric nerve led to the release of acetylcholine, and contractions of the uterus occurred; injections of physostigmine (the paralyzing effect of cholinesterase, which destroys acetylcholine) increased uterine contractions. These facts indicate the exceptional role of acetylcholine in the emergence and development of uterine contractile activity, which was especially emphasized by A.P. Nikolaev (1945). Based on the data of the school of I.P. Pavlov, which established that only the tonotropic effect belongs to the sympathetic system, and the tonomotor effect is due to the nerves that have vasodilating fibers (i.e., parasympathetic, cholinergic), A.P. Nikolaev considers acetylcholine to be a substance that has main role in the development of neurohumoral influences on muscles and, in particular, on the uterus and its motor function. Thus, the tonomotor function, according to modern views, does not belong to the sympathicus system as a whole, but to the vagus system and cholinergic areas of the sympathetic nervous system, as well as to their mediator, acetylcholine.

The extensive innervation of the cervix and lower segment of the uterus consists of the external extramural plexus, rich in ganglia, and the juxtamural, located under the peritoneum directly at the myometrium and the muscle layer of the vagina, especially on the posterior side. The juxtamural plexus consists of macro- and microganglia, anastomosed with each other, the upper border of this plexus is the level of the internal pharynx. Extra- and juxtamural plexuses are most developed on the sides of the uterus, braiding the cervix from here. The juxtamural plexus lies on the myometrium and is embedded in the superficial layers of the musculature, the ganglia of this plexus are located exclusively in the cervical region.

Neurohistological studies of the body of the uterus have shown that the uterus is not devoid of ganglion cells. It contains ganglia located at irregular intervals from the side of attachment of the wide ligaments. So, Sophoterov, examining the extirpated uterus, found its ganglion cells in the myometrium. According to D. Sinitsin, the nerve fibers of the ganglionic formations are distributed between the muscle layers in the form of plexuses and give the nerve endings to individual muscle cells, as well as to the integumentary and glandular epithelium of the uterine mucosa

Nerve fibers entwine the glands and end on glandular cells in the form of buttons, lumps or bunches.

Functionally, these nerve endings are receptors. “The uterus is a huge receptive field by which the mother's body is turned to the fetus (NL Garmasheva). TP Bakkal discovered morphological receptors in the wall of the uterus at the border with the mucous membrane, in addition, she found them in the uterine veins and veins of the ovaries.

Modern research, based on the teachings of I.P. Pavlov, believe that the uterus, thanks to its abundant innervation, receives from the central nervous system - the cerebral cortex - numerous activating and inhibiting impulses. The reflex activity of the uterus is extremely varied and rich. The most complex and diverse rhythmic, progressive contractions of the parturient uterus. Impulses to the uterus can sometimes come from distant parts of the body. Stimulating activity mammary glands, especially at the end of pregnancy, causes uterine contractions, sometimes very intense and painful. Even more important are psychogenic influences that can slow down to a pathological degree contractile activity uterus.

The fallopian tubes receive their nerve fibers partly from the ovarian plexus, partly from the Rhine plexus. After the nerve fibers form the superficial subserous plexus, they penetrate deeper - between the smooth muscle fibers, longitudinal and circular, and form a second, intramuscular plexus, from which the nerve branches go to the mucous membrane. Along with this sympathetic innervation of the tube, there is additional innervation from ganglion centers, which have not yet been sufficiently studied.

The ovaries are innervated by fibers n. spermatid, which depart from the paravertebral ganglia, lateral to a. mesenterica inf. The distribution of these fibers is limited, however, by the blood vessels and the ovarian stroma. The innervation of the ovary has been studied in recent years by A. Z. Kocherginsky on human embryos; this author described a very long neural path from the spinal cord to the ovary.

According to B.P. Khvatov, the nerve trunks penetrate the ovarian gate along with the blood vessels on early stages organ development. However, in the cortex, nerve fibers are found much later, when the development of vesicular follicles occurs. By the period of puberty, new nerve trunks enter the cortical substance, innervating the follicles.

It should not be forgotten that the bladder and rectum have a common innervation with the uterus; the practical significance of this circumstance lies in the fact that the overflow of these reservoirs can reflexively cause a weakening of the labor activity of the uterus.

The vagina is supplied with branches from the Rhine plexus; these branches are located mainly in the upper two-thirds of the vagina and form a plexus with small ganglia.

The external genitals and the perineum are innervated mainly by n. pudendi and its twigs. Partial participation in the innervation of the external genital organs is taken by n. ilioinguinalis, n. perineus, branches n. cutanei femoris poster, etc.

Barrel n. pudendi enters the cavum ischiorectale at the medial part of the ascending ramus of the ischium.

Physiological data on the reception of the uterus were obtained mainly by domestic authors; understanding them is very important for many obstetrics issues.

For obstetrics, it is especially important to know those reflex reactions of the maternal organism that arise in response to physiological changes in the state of the fetus associated with its development and growth.

The experimental data of the laboratory headed by NL Garmasheva give grounds to believe that the maternal organism is able to analyze various changes in the state of the fetus and, adapting to these changes, satisfy its needs.

The first link, with the excitation of which begins the analytic and adaptive reaction of the mother's body during pregnancy, is the sensitive nervous apparatus of the uterus, its receptors. Violation of this reaction can cause pathology of pregnancy or labor.

Reflex reactions arising from excitation of uterine receptors are subject to the same physiological laws as reflexes of other interoreceptors. They can be suppressed by deep anesthesia, perverted, if they are accompanied by a painful reaction. One of the features of the reception of the uterus is its great dependence on the amount and ratio of ovarian, pituitary, and other hormones in the body (NL Garmasheva et al.).

The female genital organs are divided into external (vulva) and internal. The internal genital organs provide conception, the external ones participate in sexual intercourse and are responsible for sexual sensations.
Internal genital organs include the vagina, uterus, the fallopian tubes and ovaries. To the outside - the pubis, large and small labia, clitoris, the vestibule of the vagina, large glands of the vestibule of the vagina (Bartholin's glands). The border between the external and internal genital organs is the hymen, and after the onset of sexual activity - its remains.

External genital organs
Pubis(Venus tubercle, lunar hillock) - the lowest part of the anterior abdominal wall women, slightly elevated due to a well-developed subcutaneous fat layer. The pubic area has a pronounced hairline, which is usually darker than on the head, and in appearance is a triangle with a sharply defined upper horizontal border and apex directed downward. The labia (pudendum) are folds of skin located on both sides of the genital slit and the vestibule of the vagina. Distinguish between large and small labia
Large labia - folds of the skin, in the thickness of which there is a fat-rich fiber. The skin of the labia majora has many sebaceous and sweat glands and is covered with hair from the outside during puberty. In the lower parts of the labia majora there are Bartholin glands. In the absence of sexual stimulation, the labia majora are usually closed in the midline, which provides mechanical protection for the urethra and vaginal opening.
Small labia located between the labia majora in the form of two thin delicate skin folds of pink color, limiting the vestibule of the vagina. They have a large number sebaceous glands, blood vessels and nerve endings, which allows them to be considered an organ of the sexual sense. The small lips converge over the clitoris to form a fold of skin called foreskin clitoris. With sexual arousal, the labia minora are saturated with blood and turn into elastic rollers that narrow the entrance to the vagina, which increases the intensity of sexual sensations when the penis is inserted.
Clitoris - the female external genital organ, located at the upper ends of the labia minora. It is a unique organ whose sole function is to concentrate and store sexual sensations. The quantity and appearance the clitoris have individual differences. The length is about 4-5 mm, but in some women it reaches 1 cm or more. With sexual arousal, the clitoris increases in size.
Vaginal vestibule - slit-like space, bounded laterally by the labia minora, in front by the clitoris, and behind by the posterior commissure of the labia. From above, the vestibule of the vagina is covered with the hymen or its remains. On the eve of the vagina, the external opening of the urethra opens, located between the clitoris and the entrance to the vagina. The vestibule of the vagina is sensitive to touch and at the time of sexual arousal is filled with blood, forming an elastic elastic "cuff", which is moistened by the secretion of large and small glands (vaginal lubrication) and opens the entrance to the vagina.
Bartholin's glands (large glands of the vestibule) are located in the thickness of the labia majora at their base. The size of one gland is about 1.5-2 cm.The glands, during sexual arousal and intercourse, secrete a viscous, grayish, protein-rich fluid (vaginal fluid, lubricant)

Internal genital organs
Vagina (vagina) - the internal genital organ of a woman, which participates in the process of sexual intercourse, and in childbirth is part of the birth canal. The length of the vagina in women, on average, is 8 cm. But for some, it may be longer (up to 10-12 cm) or shorter (up to 6 cm). The inside of the vagina is lined with a mucous membrane with many folds, which allows it to stretch during childbirth.
Ovaries- female sex glands, from the moment of birth they contain more than a million immature eggs. The ovaries also produce the hormones estrogen and progesterone. Due to the constant cyclical change in the content of these hormones in the body, as well as the release of hormones by the pituitary gland, the oocytes mature and their subsequent release from the ovaries. This process is repeated approximately every 28 days. The release of an egg is called ovulation. In the immediate vicinity of each ovary is a fallopian tube.

Fallopian tubes (fallopian tubes) - two hollow tubes with holes that go from the ovaries to the uterus and open at its top. There are villi at the ends of the tubes near the ovaries. When the egg leaves the ovary, the villi, with their continuous movements, try to grab it and drive it into the tube so that it can continue its path to the uterus.
Uterus - a hollow, pear-shaped organ. It is located in the pelvic cavity. During pregnancy, the uterus enlarges as the fetus grows. The walls of the uterus are made up of layers of muscle. With the onset of contractions and during labor, the muscles of the uterus contract, the cervix stretches and opens and the fetus is pushed into the birth canal.
Cervix represents her lower part with a passage connecting the uterine cavity and the vagina. During childbirth, the walls of the cervix become thinner, the cervical pharynx expands and takes the form of a round opening with a diameter of about 10 centimeters, due to this, it becomes possible for the fetus to exit the uterus into the vagina.
Hymen (hymen) - fine fold the mucous membrane in virgins, located at the entrance to the vagina between the internal and external genitals. Each girl has individual, only her inherent characteristics of the hymen. The hymen has one or more holes of various sizes and shapes through which blood is released during menstruation. On first intercourse, the hymen ruptures (defloration), usually with the release of a small amount of blood, sometimes with a sensation of pain.
Blood supply to the external genital organsmainly carried out by the internal genital (pudendal) artery and only partially by branches femoral artery... The internal genital artery (a.pudenda interna) is the main artery of the perineum. It is one of the branches of the internal iliac artery (a.iliaca internaYa) and supplies blood to the skin and muscles around the anus. The perineal branch supplies the structures of the superficial perineum and continues as rear branchesgoing to the large and small labia. The internal genital artery supplies blood to the bulb of the vestibule of the vagina, the large gland of the vestibule and the urethra.
External (superficial) genital artery (r.pudenda externa, s.superficialis) departs from the medial side of the femoral artery (a.femoralis) and supplies the anterior part of the labia majora.
Blood supply to the internal genital organs carried out mainly from the aorta (the system of the common and internal iliac arteries).
The main blood supply to the uterus provided by the uterine artery (a uterina), which departs from the internal iliac (hypogastric) artery (a iliaca interna).
The ovaries are supplied with blood from the ovarian artery (a.ovarica), extending from the abdominal aorta to the left, sometimes from the renal artery (a.renalis).
In the blood supply to the vagina, in addition to the uterine and genital arteries, the branches of the lower urinary and middle rectal artery are also involved.

1. Blood supply to the female genital organs:

AND) Uterus - It occurs due to the uterine arteries, arteries of the round uterine ligaments and branches of the ovarian artery.

1) Uterine Artery (A. Uterina) departs from the hypogastric artery (a. hypogastrica) in the depth of the small pelvis close to the lateral wall of the pelvis, approaches the lateral surface of the uterus at the level of the internal pharynx. Before reaching the uterus 1-2 cm, it intersects with the ureter, located above and in front of it, and gives it a branch (ramus uretericum). Further, the uterine artery is divided into 2 branches: the cervico-vaginal (ramus cervicovaginalis), feeding the cervix and the upper part of the vagina, and the ascending branch going to the upper corner of the uterus. Having reached the bottom, the uterine artery is divided into 2 terminal branches, going to the tube (ramus tubarius) and to the ovary (ramus ovaricus). In the thickness of the uterus, the branches of the uterine artery are anastomosed with the same branches of the opposite side.

2) Artery Round Uterine Ligaments (A. Ligamenti Teretis Uteri) is branch a. epigastrica inferior. It approaches the uterus in a round uterine ligament.

Blood from the uterus flows through the veins that form UterinePlexus (PlexusUterinus) , in 3 directions:

1) v. ovarica (from the ovary, tube, and upper uterus)

2) v. uterina (from the lower half of the body of the uterus and the upper part of the cervix)

3) v. iliaca interna (from the bottom of the cervix and vagina).

Plexus uterinus anastomoses with the veins of the bladder and plexus rectalis.

B) Ovary - receives nutrition from the ovarian artery (a. Ovarica) and the ovarian branch of the uterine artery (g. Ovaricus).

The ovarian artery extends with a long, thin trunk from the abdominal aorta (below the renal arteries). Sometimes the left ovarian artery can start from the left renal artery (a.renalis sinistrae). The ovarian artery descends along the psoas major muscle retroperitoneally, crosses the ureter and passes in a ligament that suspends the ovary, giving a branch to the ovary and tube, and anastomoses with the terminal section of the uterine artery, forming an arterial arch with it.

Venous outflow from the ovary is carried out by vv. ovaricae that correspond to the arteries. They start from the plexus pampiniformis (plexus plexus), go through the lig. suspensorium ovarii and flow into the inferior vena cava (right) and into the left renal vein (left).

IN) Vagina: the middle third gets its nourishment from a. vesicalis inferior (branch a. hypogastricae), its lower third - from a. haemorrhoidalis media (branch a. hypo-gastricae) and a. pudenda interna.

The veins of the vagina form venous plexuses along its lateral walls, which anastomose with the veins of the external genital organs and the venous plexuses of the neighboring organs of the small pelvis. The outflow of blood from these plexuses occurs in v. iliaca interna.

D) OutdoorSexualOrgans feed from a. pudenda interna (clitoris, perineal muscles, lower vagina), a. pudenda externa and a. lig. teretis uteri.

2. Innervation of female genital organs: uterusANDVagina -Plexus hypogastricus inferior (sympathetic) and nn. splanchnici pelvini (parasympathetic), Ovary - plexus coeliacus, plexus ovaricus and plexus hypogastricus inferior, OutdoorSexualOrgans -Nn. ilioinguinalis, genitofemoralis, pudendus and from truncus sympaticus.

The ovaries and uterus supply blood to three pairs of arteries - the ovarian, middle and posterior uterine arteries, which approach them from the left and right sides.

The ovarian artery in the form of an independent trunk begins in the area lumbar from the lower aorta steak. It is divided into an ovarian branch and an anterior uterine artery, which supplies blood to the ovary, oviduct, and the upper portion of the uterine horn. The ovarian branch, dividing into 6-8 thinner branches, forms the ovarian plexus and enters the ovary in the region of the vascular margin. The middle uterine artery is very developed; it originates from the initial part of the umbilical artery, which departs from the internal iliac artery. The branches of the middle uterine artery go to the horns, the body of the uterus and form numerous connections between themselves and with the branches of the anterior and posterior uterine artery. During pregnancy, the diameter of the artery increases by 4 times. In mares, the middle uterine artery extends from the external iliac artery. The posterior uterine artery extends from the internal iliac artery and branches at the back of the uterus, into the vagina and into bladder... In the mare, the posterior uterine artery branches off from the hemorrhoidal artery. The external genital organs are supplied with blood from the internal pudendal artery, which originates from the internal iliac artery, and in mares from the obturator artery and the perineal artery. From the genitals, blood is withdrawn by the veins of the same name, which enlarge more than the arteries during pregnancy. Lymphatic vessels supply lymph to lymph glands pelvis and sacrum.

The nerves of the genital organs form the seminal and pelvic plexus, the copulation organs are innervated by the branches of the sacral plexus. Along with this, the so-called nerve centers, consisting of large nerve cells and fibers, are found in the uterus. The cervix is \u200b\u200bricher in nerve elements than the horns. On the lateral and lower surface of the uterus, there is a nerve plexus with nodes of various sizes. There are especially many nerves in the ovary. Some of them enter with a powerful beam into the vascular zone of the ovary and innervate the vessels, while others, the so-called follicular nerves, branch out in the follicle, penetrate into its epithelium and reach almost to the egg cell. Nerve fibers are also present in the corpus luteum of the ovary; they pass between the radial septa and luteal cells. Nerve elements present in the genitals enhance the function of the ovaries, uterus, both through the central nervous system when exposed to stimuli, and directly on the reproductive organs (massage, irritation of the clitoris).

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