2

Blood Vessels, Lymphatic Drainage and

Innervation of Pelvic Organs

THE PELVIC BLOOD VESSELS Branches

The following branches are given off:
Arterial supply Venous drainage
Ureteric—as it crosses it
ARTERIAL SUPPLY Descending cervical
Sources Circular artery to the cervix: This is formed by
anterior and posterior branches of the artery to the
Anterior division of internal iliac artery
cervix of both sides
Ovarian artery
Segmental arcuate arteries: These are the branches
Superior rectal artery.
from the ascending part. These pierce about
INTERNAL ILIAC ARTERY one-third of the myometrium and then divide
Internal iliac artery is one of the bifurcations of the into anterior and posterior branches. These
common iliac artery. The bifurcation occurs over anastomose with the corresponding branches of
the sacroiliac articulation. It measures about 2 cm. the opposite side in the midline. Thus, the middle
Ureter lies anteriorly and the internal iliac vein of the uterus is comparatively avascular. From
posteriorly. It soon divides into anterior and posterior the arcuate arteries, a series of radial arteries
divisions. Only the anterior division supplies the arise almost at right angles, which stretch through
pelvic viscera. The branches are schematically the entire length of the myometrium. Near the
mentioned overleaf. myoendometrial junction, the radial arteries are
divided into:
Uterine artery (a) Short basal artery—supplies the basal endo-
Origin: The uterine artery arises either directly metrium.
from the internal iliac artery or in common with the (b) Spiral artery which proceeds as far as super-
obliterated umbilical artery.
Course: It runs downwards and forwards along the
lateral pelvic wall almost in the same direction as the 2.1A and B).
ureter until it reaches the base of the broad ligament. Fundal branch
It then turns medially and crosses the ureter anteriorly
Twigs to round ligament
from above and at right angle to it; about 1.5–2 cm
lateral to, at the level of internal os. On reaching the Tubal branch
side of the uterus, it runs upwards and takes a spiral Ovarian anastomotic branch.
course along the lateral uterine wall between the
layers of broad ligament. It ultimately anastomoses Vaginal artery
end on with the tubal branch of the ovarian artery in Origin: The vaginal artery arises either from the
the mesosalpinx. uterine artery or directly from the anterior division of
 Chapter 2 BLOOD VESSELS, LYMPHATIC DRAINAGE AND INNERVATION OF PELVIC ORGANS 27

the internal iliac artery. It is in relation to the lateral Other arteries contributing to azygos arteries
fornix and then runs down along the lateral wall of are: (i) Descending cervical, (ii) Circular artery to
the vagina. Numerous transverse branches are sent the cervix, (iii) Inferior vesical, and (iv) Internal
off anteriorly and posteriorly, which anastomose with pudendal.
the similar branches of the other side to form azygos Vesical arteries: These are variable in number. They
arteries of the vagina—one anterior and one posterior. supply the bladder and the terminal part of the ureter.

A B
Fig. 2.1:
28 TEXTBOOK OF GYNECOLOGY

Inferior vesical artery supplies the middle-third of The veins may not follow the course of the artery
vagina and urethra. They have no valves.
Middle rectal: It arises either directly from the
anterior division of the internal iliac or in common OVARIAN VEINS
with inferior vesical artery. It supplies the lower-third The ovarian veins on each side begin from the
of the vagina. pampiniform plexus, which lies in between the layers
Internal pudendal artery: It is one of the parietal of broad ligament near the mesovarium. Beyond the
branches of the anterior division of the internal infundibulopelvic ligament, there are two ovarian
veins on each side, which ascend up along the course
iliac artery. It leaves the pelvic cavity along with its
of the corresponding artery. Higher up, the veins
vein and pudendal nerve through the greater sciatic
become one and ultimately drains into left renal vein
foramen and reenters the ischiorectal fossa to lie in the
on the left side and inferior vena cava on the right side.
pudendal canal (Alcock’s canal) after winding round
the ischial spine. Here, it gives off inferior rectal artery. UTERUS, VAGINA, AND BLADDER
Thereafter, it sends numerous branches to supply the
Venous drainage from the uterine, vaginal and vesical
perineal and vulval structures, including the vestibular
plexuses chiefly drain into internal iliac vein.
bulb and clitoris. The terminal branches of the artery
anastomose with superficial and deep pudendal RECTUM
arteries—branches of the femoral artery. This will help Venous drainage from the rectal plexus drains via
in maintaining the blood supply of the bladder when superior rectal vein into the inferior mesenteric
the vesical branch of the internal iliac artery is ligated. vein. The middle and inferior rectal veins drain into
the internal pudendal vein and thence to the internal
Ovarian artery
iliac vein.
Each ovarian artery arises from the front of the aorta, a
little below the renal artery. It enters the pelvic cavity Applied Anatomy
after crossing the external iliac vessels. It then runs
medially along the infundibulopelvic ligament to enter
the mesovarium. As it enters the hilum of the ovary, it The free anastomosis between the superior rectal
breaks up into numerous branches to supply the organ. veins of the portal, the middle and inferior rectal
veins of the systemic system explains the liver
Branches given to structures other than the ovary are: metastases from the genital organ.
Ureter The uterine veins communicate with the vaginal
plexus; thus, accounting for vaginal metastases
Uterine tube
in endometrial carcinoma or choriocarcinoma.
Round ligament A free communication between pelvic plexuses
Uterine anastomotic. with the sacral and lumbar channels of the
vertebral venous plexus explains not only the
Superior rectal artery development of vertebral metastases but also
explains the intracranial malignant metastases
This artery is a continuation of the inferior mesen-
bypassing the lungs through jugular vein. This
teric artery and descends down to the base of pelvic collateral pathway is also related with supine
mesocolon. It then divides into two and each courses hypotension syndrome in late pregnancy.
down on either side of the rectum to supply it by
numerous branches.

PELVIC VEINS PELVIC LYMPHATICS

The peculiarities of the pelvic veins are: The knowledge of the lymphatic channels and the
There is a tendency to form plexuses draining lymph nodes from the genital organs is of
The plexuses anastomose freely with each other paramount importance either in inflammatory or
 Chapter 2 BLOOD VESSELS, LYMPHATIC DRAINAGE AND INNERVATION OF PELVIC ORGANS 29

specially in malignant diseases. The following groups Efferents from the deep nodes pass through the femoral
of nodes are involved. canal and drain to the external iliac nodes.

INGUINAL NODES (FIG. 2.2) PARAMETRIAL NODE

Superficial: There are two groups. One lying hori- It is of small size, inconsistently present in the
zontally and parallel to the inguinal ligament and the parametrium near the crossing of the ureter with the
other is placed vertically along the long saphenous vein. uterine artery.
Superficial group receive afferents from gluteal Internal iliac nodes receive afferents from all the
region, anterior abdominal wall below the umbilicus, pelvic viscera, deeper perineum, muscles of the thigh
vulva, perineum, vagina below the hymen, anal canal and buttock. These glands receive the afferents from
below the Hilton’s line and cornu of the uterus (along the obturator (obturator canal) and the sacral nodes
the round ligament). The efferents from the superficial (along the median and lateral sacral vessels).
inguinal lymph nodes drain into the deep inguinal
nodes and external iliac lymph nodes passing through EXTERNAL ILIAC NODES
the inguinal canal. There are three groups: (i) Lateral—lateral to external
Deep inguinal lymph nodes: These nodes receive iliac artery, (ii) Middle (anterior)—in between the
afferents from deep femoral vessels, glans clitoris and artery and vein, and (iii) Medial—medial to the vein.
few from superficial inguinal nodes. They are 5–6 in These glands receive drainage from the cervix, upper
number and lie on the medial side of the femoral vein. vagina, bladder, lower abdominal wall and from the
The uppermost gland of this group is called the gland inguinal nodes. Afferents are from internal iliac,
of Cloquet or the gland of Rosenmüller, which lies inferior epigastric, circumflex iliac and obturator
beneath the inguinal ligament in the femoral canal. nodes. The efferents ultimately drain into the common
iliac group. In carcinoma cervix, the medial and
middle groups are involved.
Common iliac lymph nodes are arranged in three
groups: (i) Lateral, (ii) Intermediate and (iii) Medial.
They receive afferents from external and internal iliac
nodes and send efferents to the lateral aortic nodes.

SACRAL GROUP
It consists of two sets of glands; one lateral group,
which lies lateral to the rectum and a medial group
lying in front of the sacral promontory. The lymphatics
from these groups pass on either to the inferior lumbar
group or to the common iliac group.

LUMBAR GROUP
It consists of two sets of glands—(1) Inferior group,
which lies in front of the aorta below the origin of
inferior mesenteric artery. (2) Superior group, which
lies near the origin of the ovarian artery. These two
groups receive all the lymph from the pelvic organs.
Thereafter, it passes up to cisterna chyli situated over
the body of 12th thoracic vertebra. The lymph is
finally carried upwards via the thoracic duct which
Fig. 2.2:
opens into the left subclavian vein at its junction
with left internal jugular vein.
30 TEXTBOOK OF GYNECOLOGY

LYMPHATICS OF THE CORPUS (FIG. 2.2) Secondary group

The lymphatics from all the primary groups drain into
INTRINSIC PLEXUS
common iliac and superior lumbar group.
Two plexuses are demonstrated: (i) Basal layer of
the endometrium and (ii) Subserosal layer. The LYMPHATICS FROM THE FALLOPIAN
lymphatics from the basal layer run through the TUBE AND OVARY
myometrium in close relation to the blood vessels to The intrinsic plexuses of the fallopian tube are situated in
reach the subserosal plexus. the mucosal and subperitoneal layers. The afferents from
these plexuses pass up along with ovarian lymphatics
EXTRINSIC DRAINAGE to superior lumbar group. There is free anastomosis
(i) From the fundus and the adjoining part of the between the ovarian lymphatics of each side across the
body along ovarian lymphatics superior uterosacral ligament or via the subperitoneal lymphatic
lumbar (para-aortic) group of glands. plexus of the fundus of the uterus.
(ii) From the cornu along the round ligament
LYMPHATICS OF THE VAGINA
(iii) Rest of the body of uterus external iliac group. The intrinsic plexuses are situated in the mucosal
(iv) Adjacent to cervix into cervical lymphatics. and muscle layers. (i) Upper two-thirds drain into the
glands like those of the cervix. (ii) Lower one-third
LYMPHATICS OF THE CERVIX (FIG. 2.3) drains into inguinal and at times into external iliac
The lymphatics from the cervix drain into the nodes.
following lymph nodes coursing along the uterine
veins. LYMPHATICS OF THE VULVA (FIG. 2.4)
Primary groups There are dense lymphatic plexuses in the dermis
of the vulva, which intercommunicate with those of
1. Parametrial group—inconsistent. subcutaneous tissue (see p. 335).
2. Internal iliac group. The lymphatics of each side freely communicate
3. Obturator group. with each of them
4. External iliac—anterior and medial group. The lymphatics hardly cross beyond the labiocrural
5. Sacral group. fold

Fig. 2.3:
 Chapter 2 BLOOD VESSELS, LYMPHATIC DRAINAGE AND INNERVATION OF PELVIC ORGANS 31

Labia Minora and Prepuce of Clitoris

Intercommunicating with the lymphatics of the
opposite side in the vestibule and drains into superficial
inguinal nodes.
Glans of clitoris: Drains directly into the deep
inguinal and external iliac glands.
Bartholin’s glands: The lymphatics drain into
superficial inguinal and anorectal nodes.
Node of Cloquet: It was previously thought to be
the main relay node through which the efferents from
the superficial inguinal nodes pass to the external
iliac nodes. Recent study shows its insignificant
involvement in vulval malignancy, and thus, it is not
considered to be the relay node. The efferents from
the superficial inguinal may reach the external iliac
group bypassing the node of Cloquet.
Fig. 2.4:
LYMPHATICS OF BLADDER
The vulval lymphatics also anastomose with the AND URETHRA
lymphatics of the lower-third of the vagina and
Bladder: The lymphatics drain into hypogastric group
drain into external iliac nodes
of glands external iliac.
Lymphatics from the deep tissues of the vulva
accompany the internal pudendal vessels to the Urethra: Upper half drains like that of bladder; lower
internal iliac nodes half drains into superficial inguinal node.
Superficial inguinal lymph nodes are the primary
lymph nodes that act as the sentinel nodes of the PELVIC NERVES
vulva. Deep inguinal lymph nodes are secondarily
Somatic Autonomic
involved. It is unusual to find positive pelvic
glands without metastatic disease in the inguinal SOMATIC
nodes
Both the motor and sensory part of the somatic supply
Gland of Cloquet or Rosenmüller, which is the to the pelvic organs are through:
upper most deep femoral nodes is absent in about (i) Pudendal nerve—S2, S3, S4.
50 percent of cases. (ii) Ilio-inguinal nerve—L1, L2.
Labia Majora (Anterior Half) (iii) Genital branch of genitofemoral nerve—L1, L2.
Lymphatics intercommunicate with the opposite side (iv) Posterior cutaneous nerve of thigh.
in the region of mons veneris Superficial inguinal
nodes. PUDENDAL NERVE
Thus, there is bilateral and contralateral spread of The sensory component supplies the skin of the
metastasis in malignancy affecting the areas. vulva, external urethral meatus, clitoris, perineum
and lower vagina. The motor fibers supply all the
Labia Majora (Posterior Half) voluntary muscles of the perineal body, levator ani
Drains into Superficial inguinal Deep inguinal and sphincter ani externus. Levator ani, in addition,
External iliac. receives direct supply from S3 and S4 roots.
32 TEXTBOOK OF GYNECOLOGY

Fig. 2.5:

While the anterior half of vulval skin is supplied by of 5th lumbar vertebra and more often wrongly called
the ilioinguinal and genital branch of genitofemoral presacral nerve. While passing over the bifurcation
nerves, the posterior part of the vulva, including the of aorta, it divides into right and left hypogastric
perineum is supplied by the posterior cutaneous nerve nerves. The hypogastric nerve joins the pelvic
of thigh. parasympathetic nerve of the corresponding side and
forms the pelvic plexus (right and left) or inferior
AUTONOMIC hypogastric plexus or Frankenhauser plexus. This
The autonomic supply is principally from the plexus lies in the loose cellular tissue, posterolateral to
sympathetic and partly from the parasympathetic the cervix below the uterosacral folds of peritoneum.
systems. The pelvic plexus then continues along the course of
the uterine artery as paracervical plexus (Fig. 2.5).
SYMPATHETIC
The sympathetic system carries both the sensory and PARASYMPATHETIC
motor fibers. The motor fibers arise from the segments The parasympathetic fibers (nervi erigentes) are
D5 and D6 and the sensory fibers from the segments derived from the S2, S3, and S4 nerves and join the
D10 to L1. The fibers from the preaortic plexus of the hypogastric nerve of the corresponding side to form
sympathetic system are continuous with those of the pelvic plexus. The fibers are mainly sensory to the
superior hypogastric plexus. This plexus lies in front cervix. Thus, from the vaginal plexus, the nerve fibers
 Chapter 2 BLOOD VESSELS, LYMPHATIC DRAINAGE AND INNERVATION OF PELVIC ORGANS 33

OVARIAN PLEXUS
Applied Anatomy
Ovarian plexus is derived from the coeliac and renal
Epidural analgesia or paracervical block during ganglia. The fibers accompany the ovarian vessels to
labor is effective due to blocking of the sensory supply to ovary, Fallopian tube and the fundus of the
impulses carried via sympathetic or para- uterus. The sensory supply of the tube and ovary is
sympathetic fibers. from D10 to D12.
Presacral neurectomy, although rarely done,
either for intractable dysmenorrhea or endome-
triosis is to divide the sensory impulses carried
from the uterus (see p. 180).
While simple hysterectomy rarely disturbs the
APPLIED ANATOMY
paracervical plexus, but the radical hysterectomy
does and, in such cases, there may be marked Ligation of Internal Iliac Artery and Development
atonicity of the bladder because of the division of of Colateral Circulation
the sacral connection of the uterovaginal plexus Systemic artery Internal iliac artery
(see p. 349).
1. Lumbar (aorta) with IIiolumbar
Myometrium contains both alpha and beta
adrenergic and cholinergic receptors. Strong stimu- 2. Middle sacral
lation of the receptors with beta mimetic drugs, (aorta) with Lateral sacral
such as isoxsuprine will inhibit myometrial activity. 3. Superior rectal
(inferior mesenteric)
with Middle rectal
pass on to the uterus, upper-third of vagina, urinary
4. Ovarian (aorta) with Uterine
bladder, ureter and rectum.

KEY POINTS
Only the anterior division of the internal iliac artery supplies the pelvic viscera.
The uterine artery arises either directly from the internal iliac artery or in common with obliterated umbilical
artery.
Vaginal artery arises either from the uterine artery or directly from the anterior division of internal iliac artery.
The azygos arteries (two) are formed by vaginal, descending cervical, inferior vesical, and internal pudendal
arteries.
The ovarian artery arises from the aorta below the renal artery. The ovarian veins drain into inferior vena cava
on the right side and into the left renal vein on the left side.
The free anastomosis between the superior rectal veins of the portal, the middle and inferior rectal veins of the
systemic system explains the liver metastases from the genital organs.
The gland of Cloquet lies beneath the inguinal ligament in the femoral canal.

of glands.
Levator ani is supplied by pudendal nerve and receives direct supply from S3 and S4 nerve roots. Levator ani
muscle supports the pelvic viscera and prevents pelvic organ prolapse (see p. 198).
5 6

10
to L1 2
, S3 and S4 nerves. The sensory supply of the tube
10 12
.
Myometrium contains both alpha and beta adrenergic and cholinergic receptors.