What is the origin and course of the uterine artery?

Uterine Artery: Origin and Course

The uterine artery most commonly originates from the anterior division of the internal iliac artery (also known as the hypogastric artery), crosses over the ureter at the level of the uterine-cervical junction, and ascends along the lateral border of the uterus within the broad ligament. 1

Origin

• Primary origin: The uterine artery arises from the anterior division of the internal iliac artery in approximately 61.72% of cases 2
• Alternative origins include:
  • Umbilical artery: 13.93% of cases 2
  • Inferior gluteal artery: 5.22% of cases 2
  • May arise as a common trunk with the inferior gluteal artery (bifurcation) or with both superior and inferior gluteal arteries (trifurcation) 3

The median distance from the origin of the anterior division of the internal iliac artery to the origin of the uterine artery is 12.00 mm 4

Course and Relations

Initial Course

• After originating from the anterior division of the internal iliac artery, the uterine artery courses medially and anteriorly toward the uterus 1
• The artery travels within the parametrium (the main uterine lymphatic trunks also condense in this region) 5

Critical Anatomical Relationship

• The uterine artery crosses over (anterior to) the ureter at the level of the uterine-cervical junction 1
• This crossing point is the most clinically significant anatomical relationship, occurring just before the artery enters the uterus 1
• The classic surgical teaching "water under the bridge" refers to the ureter passing beneath the uterine artery

Terminal Course

• After crossing the ureter, the artery ascends along the lateral border of the uterus within the broad ligament 6
• The vessel then divides into uterine and cervical branches 1
• The uterine artery runs tortuously along the lateral uterine margin, giving off branches to supply the uterine body 1

Clinical Significance for Doppler Assessment

For ultrasound evaluation, the uterine artery should be identified:

• As it crosses over the hypogastric (internal iliac) vessels 1
• Pulsed Doppler velocimetry should be obtained immediately after the vessel crosses the hypogastric artery and before it divides into uterine and cervical branches 1
• Color Doppler can demonstrate the vessel as it originates from the anterior division of the hypogastric artery 1

Common Pitfalls

• Anatomical variation is common (approximately 38% of cases have non-standard origins), which can complicate surgical procedures and embolization 2
• During laparoscopic dissection, the uterine veins lie very close to the artery, and venous bleeding can be difficult to control without ligating the vessels 6
• The obliterated umbilical artery serves as a key landmark during surgical dissection to reduce the risk of misidentifying the uterine artery 6
• Surgeons must exercise extreme caution when the uterine artery arises from atypical origins (umbilical or inferior gluteal arteries), as meticulous dissection is required 7