Acta Radiologica

ISSN: 0001-6926 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/iaro20

The normal anatomy of the uterine artery

To cite this article: (1955) The normal anatomy of the uterine artery, Acta Radiologica, 43:sup122,
21-36, DOI: 10.3109/00016925509170755

To link to this article: http://dx.doi.org/10.3109/00016925509170755

Published online: 14 Dec 2010.

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 The Normal Anatomy of the Uterine Artery

STUDIES ON OPERATION AND AUTOPSY SPECIMENS PUBLISHED

I N T H E LITERATURE

It was considered expedient, apart from describing in more detail the

anatomy of the uterine artery, also to discuss the anatomy of the ovarian artery,
because it is not possible to determine the line of demarcation between the two
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arteries, owing to large connecting branches.

Distribution of the uterine artery. It has been found that during fcetal lifc
the uterine artery specifically supplies the uterus, and the distribution of the
ovarian artery is limited to the ovary. After the descent of the ovary into the
true pelvis the two arteries anastomose. In the newborn the anastomosing
branches are small whilst in adult and parous women they are large (DUBREUIL-
CHAMBARDEL, 1925-1926).
There still is much difference of opinion as to the distribution of the uterine
and ovarian arteries in the adult woman. Various reasons account for the
conflicting data published. O n e reason is that the distribution of these arteries
shows great variation. Another reason is that the variability of their distribu-
tion has escaped attention in a number of investigations, owing to the small
number of cases studied. Moreover, large anastomosing branches make interpreta-
tion difficult, and it is generally hard to say where one artery ends and the
other begins.
Some authors (LUSCHKA, 1864; HYKTL, 1873, and others) believed that the
ovarian artery was the larger vessel, supplying the adnexal organs and also a
large part of the uterus. This artery was therefore considered to be of greater
importance than the uterine artery to the blood supply of the uterus (Fig. 3).
T h e majority of workers have expressed the view that the uterine artery
generally supplies the entire uterus and also a large portion of the adnexa but
that its distribution shows great variation (Fig. 4). Thus, it has been reported
that in rare exceptions the uterine artery, apart from supplying the uterus, may
also supply the entire adnexal organs, and the ovarian artery may supply both
the adnexa and the uterus. According to SOULICOUX (1 894) the line of demarca-
tion between the distribution of the two arteries lies below the level of the

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Fig. 3. Radiograph of normal uterus and adnexa taken after arterial injection. Both adnexa
and the corpus uteri are seen t o be supplied by the ovarian arteries (rare anomaly!). s, ovarian
artery; z, tuba1 arcade; m, fundal branch; g, distal part of the ovarian artery along lateral
margin of the uterus. This part of the ovarian artery is seen to give off numerous tortuous
branches t o the uterine wall (arcuate arteries).

ovary. NACEL (1897) supported this view but stressed that the point where the
ovarian artery anastomoses with the uterine artery cannot be localized
accurately. FREDET(1 899) believed that the uterine artery, apart from supplying
the uterus, also supplied the medial portion of the ovary and the tube in most
cases. H e pointed out, however, that the ovarian artery was the larger in rare
cases and then also participated in the blood supply of the fundus. DUBREUIL-
CHAMBARDEL (1925-1926) expressed the view that the distribution of the two
arteries did not follow any hard and fast rule. H e stated that it was rare for the
ovarian artery to participate in the blood supply of the uterus, and for the
uterine artery to supply the entire adnexal organs. H e believed that the line of
demarcation between the distribution of the two arteries generally lay in the
vicinity of the ovary. According to JOACHIMOVITS (1931) the uterine artery
supplied the uterus, the major portion of the tube, and a small portion of the
ovary. MASSABUAU, GUIBAL, and JOYEUX (1936) supported the view that the

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Fig. 4. Drawing of normal uterus and adnexa (seen from behind). The uterine and adnexal branches are schematically represe
d, uterine artery in parametrium; g, uterine artery along lateral margin of the uterus; h, intramural blood vessels; m, fundal bra
p, medial tubal branch; 0, medial ovarian branch; n, ramus ovaricus proprius; z, tubal arcade; j, ovarian arcade; x, infundi
branch; s, ovarian artery. The right tube is mainly supplied by the medial tubal branch; the left is supplied by the medial t
branch and infundibular branch. The lateral tubal branch is absent on both sides.
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.-
X-ray Film

FOR SUPERIOR RADIOGRAPHIC RESULTS

 line of demarcation between the distribution of the two arteries was hard to
define but believed that it lay somewhere below the hilum of the ovary, and
[hat either artery alone supplied the entire ovary in some cases.
In contrast, BROEKAERT (1892) held the view that the distribution of the
uterine artery was considerably larger than that of the ovarian artery, the
former generally supplying the entire uterus and the entire adnexa, whilst in
rare exceptions only did the ovarian artery participate in the blood supply of
the adnexal organs.
W i d t h of the wterine artery. According to LUSCHKA(1864) the width of
the uterine artery was about 2 mm. in non-parous women. BROEKAERT (1892)
observed that before puberty the uterine artery was narrow but later increased
in width. SOULIGOUX (1894) reported that its circumference was 14 mm. at the
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point where it crosses the ureter, i. e. this measurement corresponds to a diameter

of 2.2 mm. According to HOVELAQUE (quoted by DIEULAF~, 1935) its width
showed great variation; on comparing two normal cases he found that the
width could in one case be double that in the other. GREGOIRE (quoted by
DIEULAFB) considered the diameter of the uterine artery to vary between 2-3
mm. in normal cases.
Origin of the uterine artery. The uterine artery arises from the internal iliac
artery (BROEKAERT, 1892; NAGEL, 1897, and others). DUBREUIL-CHAMBARDEL
(1925-1926) investigated 100 cases and found that in 64 the uterine artery
arose directly from the internal iliac artery; in 20 cases the uterine artery and
the internal pudendal artery arose by a common trunk which sprang from the
internal iliac artery. In the remaining 16 cases the uterine artery and the vaginal
artery arose by a common trunk. In 11 of these cases the common trunk arose
directly from the internal iliac artery whilst in 5 it arose from the internal
pudendal artery.
T h e main trunk of the uterine artery. BROEKAERT (1892) divided the main
trunk of the uterine artery into three parts as follows: (i) the 1st part running
close to the lateral pelvic wall, (ii) the 2nd part, running in the parametrium,
(iii) the 3rd part running along the lateral margin of the uterus.
T h e 1st part is more or less straight even in parous women, and does not
show any noteworthy variations in its course (DUBREUIL-CHAMBARDEL, 1925-
1926). It runs obliquely downwards and forwards for a distance of 4 cm.
(NAGEL, 1897) or of 6-7 cm. (PORIER, quoted by NAGEL); then it curves medially
and runs into the parametrium.
T h e 2nd part runs medially in the parametrium from the lateral pelvic wall
to the uterus (Fig. 4). According to BROEKAERT it reaches the latter at the level
of the cervix, according to FREDET(1899) it does so at the junction of cervix and
corpus. The course of this part is fairly straight in young girls and non-parous
women whilst in parous women it was found to be tortuous (REDLICH, 1909). It

23
 runs in front of the ureter crossing the latter at a point 15 mm. from the
border of the uterus (DUBREUIL-CHAMBARDEL, 1925-1926).
Thc 3rd part, also termed the marginal artery, runs along the lateral margin
of the uterus towards the uterine cornu where it divides into its terminal
branches (Fig. 4). According to many workers (HYRTL, 1873; BROEKAERT, 1892;
DAVIDSOHN, 1892; FREDET, 1899; REDLICH, 1909; DUBREUIL-CHAMBARDEL,
1925-1926, and others) its course is straight or almost straight in young girls
and nulliparac, whilst in parous women it is markedly tortuous (Fig. 5). In
elderly nullipara: its course has at times also been found to be slightly tortuous.
Its tortuosity is then believed to be due to degenerative changes (DUBREUIL-
CHAMBARDEL). In addition, in nullipara: it has usually been found to run at a
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A 8

Fig. 5. Radiographs of two spccirncns of one half of a uterus taken after arterial injection.
A, half-uterus from a nullipara. T h e uterine artery, as it runs along the lateral margin of the
uterus, is almost straight and is seen to give off numerous tortuous intramural branches.
Thc arrow points to the fundal branch which is seen to be non-tortuous for a short distance
below its point of origin.
B, half-uterus from a parous woman. T h e uterine artery is markedly tortuous in its course
along the lateral margin of the uterus, and gives off numerous intramural branches.

24
 short distance from the lateral uterine margin whilst in parous women it has
mostly been seen to run close to or within the uterine wall (BROEKAERT,
REDLICH).
Ureteric branch. The ureteric branch arises from the main trunk of the uterine
artery at the point where the latter crosses the ureter (NAGEL,1897; JOACHIMO-
VITS, 1931). As a rule this branch supplies the distal part of the ureter.
Cervico-vaginal branch. According to DUBREUIL-CHAMBARDEL (1925-1926)
the cervico-vaginal branch arises from the uterine artery in 91 per cent of cases
(Fig. 4). The point of origin generally lies medial to the point where the uterine
artery crosses the ureter. In the other 9 per cent the cervico-vaginal branch arises
directly from the internal iliac artery. Occasionally, it divides into two branches,
viz. a cervical branch and a vaginal branch. The width and length of the cervico-
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vaginal branch show great variation (HYRTL, 1873). It runs medially and
downwards towards the cervix and the upper portion of the vagina, supplying
both. According to FREUND(1904) the branches in the cervical wall run
slightly more downwards as compared to similar branches in the corpus uteri
which run somewhat transversely. REDLICH (1909) found that the cervix was
less vascular than the corpus. SOLUTUCHIN (1937) noted that prior to puberty
the cervix contained a larger number of blood vessels than the corpus, whilst
after puberty the reverse held good. ADACHI(quoted by JOACHIMOVITS, 1931)
repcrted that the course of the blood vessels in the cervical wall was less
tortuous than that of the intramural blood vessels in the corpus.
Intra-mural blood vessels in the corpus (Figs. 3, 4 , 5, 6,A). As the uterine
artery runs along the lateral uterine margin it gives off numerous short,
perpendicular branches in the uterine wall. HYRTL (1873), DAVIDSOHN (1892-
1893), and NACEL(1897) reported that the number of these branches varied
but in no case did they find less than 8 or more than 24. These short branches
again give off branches which run transversely to the anterior and posterior
uterine walls, the posterior branches being generally wider (HYRTL). These
branches havc been termed arcuate arteries on account of their shape (FAULKNER,
1944). I n describing the intra-mural blood vessels HOLMCREN (1938), and
FAULKNER reported that the arcuate arteries run between the outer and middle one
third of the uterine wall (Figs. 4,6 A). The arcuate blood vessels give off numer-
ous branches which usually run transversely. Some of these, the so-called peripheral
arteries, run towards the outer surface'and lateral one third of the uterine wall
whilst others run radially to the endometrium, and have therefore been termed
radial branches. The peripheral branches anastornose with similar branches on
the contralateral side, the anastomosing branches being at times very large.
Apart from transverse anastomoses, vertical anastomoses have been encountered,
particularly on the lateral aspect of the uterus (HYKTL, 1873; FREDET,1899,
and others). A characteristic feature of the intra-mural blood vessels is that they

25
 are markedly spiral even in non-parous women (HYRTL; HOLMGREN). According
to SOLUTUCHIN (1937) the intra-mural blood vessels are slightly less spiral in
nulliparz.

. ,&..
..
. . ..
. .
, ...
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. .
I .
Fig. 6 .
A, Radiograph of a cross-section about 1 cm. thick of a normal uterine wall taken after
arterial injection. The larger tortuous arteries running between the outer and middle one
third of the uterine wall represent the arcuate arteries from which the so-called peripheral
arteries originate. The latter, some of which are shown, run through the outer one third of
the uterine wall. Several radial arteries are seen running medially.
B, Radiograph of normal adncxa taken after arterial injection (the ovarian artery and its
branches are not visible). The unmarked upper arrow points to the fimbriated end of the
tube; the lower unmarked arrow points to the ovary; z, tuba1 arcade; j, ovarian arcade.

Fundal branch (Figs. 3, 4, 5 A). The fundus is supplied by one of the terminal
branches of the uterine artery. FREDET(1899) described this branch as follows:
generally the uterine artery gives off only one fundal branch which often
divides into several branches a short distance from its point of origin; at times
the uterine artery gives off several fundal branches, their points of origin lying
in close proximity. The point of origin of the fundal branch is occasionally
situated just below the uterine cornu. According to JOACHIMOVITS (1931) it is
then a continuation of the main trunk of the uterine artery. As a rule, however,
the fundal branch arises from the uterine artery more laterally at the point
where the latter curves laterally and runs towards the adnexa. Owing to its
mode of origin the fundal branch runs back to the uterus which led FREDETto
term it retrograde fundal branch. The fundal branch has in some cases been
found to arise from the tuba1 branch of the uterine artery (JOACHIMOVITS).
Often its course is at first straight but on reaching the uterus it again becomes
tortuous, its distribution in the fundal wall being similar to that of the intra-

26
 mural blood vessels (Fig. 5 A). Large superficial anastomoses running
transversely between the two sides are often seen.
Medial tubal branch (Figs. 4, 6 B). JOACHIMOVITS (1931)studied the adnexal
blood vessels and described the medial tubal branch as follows: the medial tubal
artery is the largest of the tubal blood vessels in typical cases. It may arise
(i) from the main trunk of the uterine artery, the point of origin being then
situated near the uterine cornu, (ii) from the ovarian branch of the uterine
artery, (iii) from the ovarian arcade, (iv) from the fundal branch of the uterine
artery. It follows a tortuous course, running up to the tubal isthmus, and
anastomoses with the tubal arcade. The latter is tortuous and runs in the!
mesosalpinx parallel to the tube and at a distance of l / ~ lcm. from it, and up to
the fimbriated end of the tube (Figs. 3, 4, 6B). In some cases the medial tubai
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branch is the sole artery to the tubal arcade. Often, however, a branch of the
ovarian artery, i. e. the lateral tubal branch, takes part in the blood supply of
the tubal arcade, the anastomosis taking place either near the middle part of
the tube or slightly lateral to it. Apart from the lateral tubal branch the ovarian
artery also gives off another branch which is usually small and runs to the
fimbriated end of the tube. This branch has been termed infundibular branch.
The tubal arcade gives off several small tortuous branches which run perpendicu-
larly towards the tube and supply the tubal wall. According to JOACHIMOVITS
the topography of the adnexal blood vessels shows great variation. Thus, the
tubal arcade may at times be absent, the tubal branches running directly to the
tubal wall where they divide into smaller branches. Occasionally, the medial
tubal artery may be the lesser developed or may be absent, the branches of the
ovarian artery being the sole blood vessels to the tube. In rare cases there are two
medial tubal arteries, one arising from the main trunk of the uterine artery, and
the other from the fundal branch of the uterine artery.
Medial ovarian branch (Figs. 4, 6 B). According to JOACHIMOVITS (1931)the
anatomy and course of the medial ovarian branch is as follows: the medial
ovarian branch arises from the main trunk of the uterine artery lateral to the
uterine cornu. It runs along the lower border of the ovarian ligament (NAGEL,
1897) forming together with the lateral ovarian branch of the ovarian artery
the ovarian arcade. The ovarian arcade follows a tortuous course and gives off
a varying number of small tortuous branches which divide dichotomously in
the mesovarium, and run towards the hilum of the ova.ry. A small branch, not
consistently present, and arising either directly from the main trunk of the
uterine artery near the uterine cornu or from the medial portion of the ovarian
arcade, is the ramus ovaricws proprius medialis which also runs towards the
ovary (Fig. 4, left adnexa). The course and distribution of the medial ovarian
branch of the uterine artery show great variation. In 12 of 30 cases investigated
MOCQUOT A N D ROUVILLOIS (1938) found the uterine artery and the ovarian

27
 artery to give off an identically large branch and that these two branches
formed the cvarian arcade (Fig. 4, left adnexa). In a further 12 cases they noted
that both the medial ovarian branch and the lateral ovarian branch of the
uterine artery divided into two branches just before reaching the ovary. Two
of these branches formed the ovarian arcade which was not seen to give off
branches to the ovary. The other branches gave off several small branches which
ran directly to the medial and lateral portions respectively of the ovary (Fig. 4,
right adnexa). In 4 cases they found that the medial ovarian branch of the
uterine artery was the only vessel supplying the ovary, whilst in 2 cases the
blood supply of the ovary was derived solely from the lateral ovarian branch
of the ovarian artery.
Lastly, the main trunk of the uterine artery gives off a small branch near
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the uterine cornu; it runs towards the round ligament of the uterus and
anastomoses with a branch that corresponds to the external spermatic artery in
the male which arises from the inferior epigastric artery. According to SAPPEY
(1878) this small branch enlarges when required, and may then participate in
the blood supply of the uterus, BALDWIN(1920), however, considered this
artery to be of minor importance, and reported that in 3,000 cases operated on
he encountered only 1 case in which hrmorrhage from this small artery occurred
following transection of the round ligament.
Auomalies. REDLICH(1909) reported that a duplication of the main trunk of
the uterine artery on the same side occurred in 1.6 per cent of cases. BROEKAERT.
(1 892) has also encountered such duplication. As it runs in the parametrium, the
uterine artery has been found to divide into several branches running towards
the uterus in 3.2 per cent of cases, the marginal artery being then absent (REDLICH).
J O A C H I M O V I T S (1931) has encountered cases in which there were small branches
in the broad ligament which ran towards the w a r y and arose from the main
trunk of the uterine artery low down in thc parametrium. Occasionally, these
arterics were quite large. According to several workers the two uterine arteries
may often differ in length and width in a given case.

PERSONAL ARTERIOGRAPHIC STUDIES

As it was felt that it might be helpful at this point to discuss the radiologicai
appearance of the uterine artery and its branches, which can be demonstrated
by arteriography, the ncrmal arteriogram is described (i) from the data available
and quoted on the anatomy of these blood vessels, (ii) from experience gained

28
 by studying antero-posterior views of the true pelvis in the 448 cases on which
the present investigation is based.
T h e point of origin 0; the uterine artery was generally not visible owing to
superimposition of other blood vessels in the true pelvis (Fig. 7).
The part of the main tritnk of the uterine artery running along the laterai
pel,vic wall was often clearly visible. A s a rule, it was non-tortuous and arched
with a lateral convexity (Figs. 7, 11, 12). Differentiation of this part of the
niain trunk of the uterine artery from the internal pudendal and the obturator
arteries was at times difficult in this part. I n contrast to the latter arteries the
uterine artery was seen to curve medially before reaching the parametrium
and could then be easily identified.
T h e part of the main trunk of the uterine artery running in the parametrium
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was cnsily identifiable (Figs. 7, 8, 10, 11, 12, 13, 14); it was usually seen to run
horizontally and to follow a tortuous course. The ureteric branch was not vi-
sible, probably bccause it was too small to show up. The cervico-vaginal branch
was visible relatively frequently (Figs. 7, 8, 14). Its width and length varied
greatly.
The part of the main trunk of the uterine artery running along the Lateral
margin of the uterus was easily defined (Figs. 7, 8, 10, 11, 12, 13, 14). It was
seen to follow a more or less tortuous course; in parous women it was generally
inarkcdly tortuous, It was found that its arteriographic appearance was
depcndent 011 the position of the uterus. This is illustrated by Fig. 9 which
shows its appearance in antero-posterior, oblique, and axial projections. In
most cases the pattern of its course was identical with that seen on films taken
in oblique projections of the uterus.
Of the intraniural blood vessels only the arcwatc arteries were clearly visiblc
(Figs. 8, 11, 12, 13, 14). The number of the latter arteries varied greatly. Thc
radid and peripheral arteries could not be identified with certainty, probably
because they are too small t o be visualized. Large anastomosing branches were
occasionally visible between the two uterine arteries (Fig. 13). The fundai
artery was very often seen (Figs. 8, 12, 13, 14); frequently its retrograde course
could also be identified.
In about half of the cases one adnexaf branch was visible. It generally
followed a more or less tortuous course and was seen to run upwards and
laterally (Figs. 11, 14). It was rare for this branch t o divide into branches.
More than one adnexal branch was very rarely seen. As a rule, it was not
possible to say whether the branch seen was the medial tuba1 branch or the
medial ovarian branch.
As the width and the length of the uterine arteries show great variations their
arteriographic apperance also varies greatly. Occasionally they were found to
be very narrow and short; often they differed in width and length on the two

29
 sidcs (Figs. 13, 18). In such cases the larger artery was at times seen to give off
branches which ran towards the opposite side. In women of reproductive age
the uterine arteries were generally clearly visible, whilst they were usually
either narrow and short or not identifiable in post-menopausal women.
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Fig. 7. Arteriogram and hysterogram. The arteries on the left side of the true pelvis are
visible. a, internal iliac artery; b, internal pudendal artery; c, uterine artery along lateral
pelvic wall; it is seen to originate from the pudendal artery; d, uterine artery in parametrium;
e, cervico-vaginal branch; g, uterine artery along lateral margin of the uterus.

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Fig. 8 . Arteriogram and hysterogram. T h e arteries on the left side of the true pelvis are
visible. d, uterine artery in parametrium; e, cervico-vaginal branch; g, uterine artery along
lateral margin of the uterus. Several intramural blood vessels are seen to originate from this
part of the uterine artery; one of them is indicated by h ; m, fundal branch.

31
 Schematic representation of Arteriographic appearances of the uterine artery
the appearances of the ute-
rine artery

Antcro-
posterior
projection:
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Oblique
projection:

Axial
projection:

Fig. 9. Schematic represencation of the appearances of the uterine artery and its arteriographic
appearances in different projections of the uterus.

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Fig. 10. Arreriogram. Both uterine arteries are visible. d, uterine artery in parametrium;
c, cervico-vaginal branch; g, uterine artery along lateral margin of the uterus. T h e intramural
blood vcsscls are not visiblc.

3 33
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Fig. 11. Arteriogram. Both uterine artcries are visible.

A, film taken immediately after completion of the injection of opaque medium. c, uterine
artcry along lateral pelvic wall; d, uterine artery in parametrium; g, uterine artery along
latcral margin of the uterus.
U, film takcn about 2 seconds after film A. g, uterine artery along latcral margin of the uterus.
T h e intramural blood vessels are clearly visible, and are seen to be markedly tortuous.
k. left adnexal branch.

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Fig. 12. Arteriogram. Both uterine arteries arc visible.

A, film taken immediately after completion of the injection of opaque medium. c, uterine
artery along lateral pelvic wall; d, uterine artery in parametrium; g, uterine artery along
lateral margin of the uterus.
B, film taken about 2 seconds after film A. g, uterinc artery along lateral margin of the
uterus, now faintly outlined; m, fundal branches. The latter arc seen t o be non-tortuous
for a short distance below their point of origin.

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Fig. 13. Arteriogram and hysterogram. Both uterine arteries are visible. T h e right uterine
artery is narrow. The right half of the uterus is mainly supplied by the left uterine artery.
d, uterine artery in parametrium; g, uterine artery along lateral margin of the uterus. The
left uterine artery is seen to give off numcrous intramural blood vessels; one of the latter
(h) is wide and runs towards the right half of the uterus. m, fundal branch.

Fig. 14. Arteriogram and hysterogram. The right uterine artery is visible. d, uterine artery
in paramctrium; e, cervico-vaginal branch; g, uterine artery along lateral margin of the uterus.
Several intramural blood vessels are seen to originate from this part of the uterine artery,
one of them (m) being the fundal branch. A tortuous adnexal branch (k) originates at the
level of the uterine cornu.