The Bartholin’s glands or greater vestibular glands are pea sized glands, situated posteriorly on either side of the vaginal opening. They secrete mucus and help in vaginal lubrication. They drain through ducts into the vaginal vestibule, opening at 4 and 8 o’clock positions. Blockage of these ducts can lead to the formation of Bartholin’s cyst. Infection may follow leading to a painful abscess. Infection is typically polymicrobial, with E.coli, PVL positive S.aureus, Streptococcus, P.aeruginosa and Neisseria being common pathogens. Adenocarcinoma and squamous cell carcinomas can occur in postmenopausal women. Asymptomatic cysts can be left untreated. Treatment methods are incision and drainage (high risk of recurrence), Word catheter treatment (low risk of recurrence), marsupialization (not done if an abscess is present), CO2 laser (good results with minimal side effects) and excision (definitive treatment). Adjunctive antibiotic therapy with ceftriaxone, ciprofloxacin, doxycycline or azithromycin is given. Biopsy is recommended in postmenopausal women or when there is a suspicion of carcinoma.
Pouch of Douglas box: Also known as the recto-uterine pouch or posterior cul-de-sac, it is a potential space located between the uterus anteriorly and the rectum posteriorly. It is the most dependent area of the peritoneal cavity in females, in an upright position. It is normal to have a small amount of fluid, like a few millilitres, in the pouch of Douglas, secondary to menstruation and ovulation. Pathological fluid collection however can be seen in pelvic abscesses, endometriosis, PID, ectopic pregnancy, metastasis from gastrointestinal malignancies etc. Diagnosis can be made by culdocentesis where a needle is inserted through the posterior fornix of the vagina to reach the recto-uterine pouch. Infections and malignancies can spread to the hepatorenal space, also called Morrison’s pouch via communications between the recto-uterine and hepatorenal spaces, as is seen in Fitz Hugh-Curtis syndrome. The Morrison’s pouch is the most dependent area of the peritoneal cavity in the supine position.
Box: The uterine artery passes anterior to the distal ureter (water under the bridge). It is important to isolate the distal ureter from the uterine artery during a hysterectomy, to avoid injury to the ureter. Accidental ligation will present as urinary retention and lower abdominal pain.
Box for different types of ovarian follicles:
i) Primordial Follicles: These small follicles are found towards the outer edge of the cortex. They consist of an oocyte surrounded by a single layer of flattened follicular epithelial cells called granulosa cells. It is surrounded by a thick glycoprotein layer called zona pellucida.
ii) Primary Follicle: It is larger than the primordial follicle. It has an oocyte surrounded by two or more layers of granulosa cells, zona pellucida and a capsule called theca.
iii) Secondary Follicle: They are larger than the primary follicle and show small intrafollicular spaces filled with fluid which coalesce to form the antrum. The granulosa cells at this stage are called cumulus oophorus. The theca differentiates into an internal, rounded cell layer called theca interna and an external, fibrous, spindle cell layer called theca externa.
iv) Graffian follicle: It contains the secondary oocyte surrounded by the zona pellucida and corona radiata (seen after ovum is released from the follicle), a prominent antrum surrounded by membrana granulosa, cumulus oophorus, theca interna and theca externa.
v) Corpus Luteum: After ovulation, the Graffian follicle collapses, the granulosa cells enlarge and become vesicular to form granulosa lutein cells. They form folds, in between the folds can be seen theca interna cells which are now called theca lutein cells.
vi) Corpus Albicans: If pregnancy does not occur, the corpus luteum degenerates to become pale looking, atretic corpus albicans.