Lymphatic Drainage and Innervation of Female Genital Organs

Chapter 1

spinal cord) and parasympathetic (S two, three and four segments) nerve supply.

LYMPHATIC DRAINAGE OF FEMALE PELVIS (Fig. one point nineteen)

The lymphatic drainage of female pelvis and genital organs is clinically important as genital malignancies spread through them and the adequate removal of them is mandatory for success of radical surgeries for genital cancers. The main lymph nodes are located along the pelvic vessels and are named after them. Smaller lymph nodes lie close to the visceral structures and are named after them. The various lymph node groups are shown in Table one point three and Figs. one point nineteen A and B.

Lymph from vulva and perineum is drained through superficial and deep inguinal nodes, then through external iliac lymph nodes, common iliac lymph nodes and pre- and para- aortic lymph nodes. Lymph from upper vagina, cervix and uterus is drained through internal iliac, common iliac, pre- and para-aortic lymph nodes. From para-aortic and pre-aortic lymph nodes, lymphatic drainage is through lumbar lymphatic trunks and the cisterna chyli at the level of second lumbar vertebra. From here all the lymph is carried by the thoracic duct (which transverses through thorax) to drain into the junction of left subclavian and internal jugular vein. Thus tumor cells after penetrating or by passing the pelvic or para- aortic lymph nodes can rapidly metastasize to distant organs through these veins. The lymphatic drainage from individual female genital organs is described below.

One. Lymphatic drainage from ovaries and Fallopian tubes: The lymphatic channels lie in the mucosal and subperitoneal layer of the Fallopian tubes. They drain along the infundibulopelvic ligaments along ovarian vessels through a plexus of lymphatic vessels to the para-aortic lymph nodes on both sides and then to thoracic duct. Thus there is early metastatic spread of Fallopian tube and ovarian cancer. Two. Lymphatic drainage of uterus: From the fundus and upper part of body (corpus), most lymphatics drain into pre- and para- aortic lymph nodes along the ovarian vessels. Few lymphatics from uterine cornu also drain into superficial inguinal lymph nodes along the round ligaments of uterus. From the lower part of the body, lymphatics drain into external iliac lymph nodes via broad ligament.

Three. Lymphatic drainage of cervix: Cervix has more extensive lymphatic drainage which drains in three directions.

(i) Laterally, the lymphatics drain into parametrial, paracervical lymph node, obturator nodes and external iliac lymph node. Obturator nodes are important and are for stan. Sup inguinal sentinel (primary drainage site) lymph nodes for cervical malignancies.

may drain directly to the deep inguinal node. During radical vulvectomy for carcinoma vulva, superficial and deep inguinal lymph nodes are removed. If the inguinal nodes are not involved, pelvic lymphadenectomy is not generally needed. As the lymphatic channels, especially in medial and clitoral lesions, may cross over to both sides, usually bilateral inguinal lymphadenectomy is performed in carcinoma vulva. Lymphatic drainage of bladder and urethra? Bladder and upper urethra drain into iliac nodes (internal and external) while lower half of urethra drains into superficial inguinal lymph nodes.

(ii) Posterolaterally) the lymphatics drain into internal iliac lymph nodes along the uterine vessels.

(iii) Posteriorly, the lymphatics drain into sacral nodes along the uterosacral ligaments. Sacral nodes lie on median and lateral sacral vessels and are member of internal iliac lymph nodes.

Four. Lymphatic drainage of vagina Upper two-thirds of vagina is drained along with lymphatics vessels of the cervix as described above Lower one-third of vagina is drained along with lymphatics of vulva and perineum as described below.

Lymphatic drainage of rectum and anal canal: Upper rectum drains into internal iliac and para-aortic lymph nodes. Lower rectum and anal canal drain with perineum and vulva into superficial inguinal nodes.

Lymphatic drainage of vulva and perineum (Fig. one point nineteen B) The vulva is first drained into superficial and deep inguinal lymph nodes and then secondarily to the pelvic lymph nodes. Labia majora and minora drain primarily into the superficial inguinal lymph nodes which are ten to twenty in number distributed horizontally one centimeter below the inguinal ligament and extend down vertically along the saphenous vein. The saphenous venous opening (fossa ovalis) is an oval opening in fascia lata which allows communication between superficial and deep inguinal nodes and divides them into four groups. Most vulval drainage occurs into medial and upper quadrant nodes. The superficial nodes lie in the membranous layer of subcutaneous tissue just superficial to the fascia lata.