What is the origin, course, and support of the uterine artery?

Uterine Artery Anatomy

Origin

The uterine artery most commonly originates from the anterior division of the internal iliac artery (also called the hypogastric artery), though significant anatomical variations exist. 1

• The anterior division of the internal iliac artery serves as the primary origin in approximately 62% of cases based on meta-analysis data 2

• Alternative origins include:

  • Common trunk with the umbilical artery in 62.7% of cases (most frequent variant pattern) 3
  • Direct branch from the internal iliac artery in 25.6% of cases 3
  • Umbilical artery with pooled prevalence of 13.93% 2
  • Inferior gluteal artery with pooled prevalence of 5.22% 2
  • Superior gluteal artery in 9.3% of cases 3
  • Internal pudendal artery in 2.3% of cases 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

After originating from the anterior division of the internal iliac artery, the uterine artery courses medially and anteriorly toward the uterus, traveling within the parametrium. 1

• The artery travels within the broad ligament as it approaches the uterus 1
• The uterine artery crosses over the ureter at the level of the uterine-cervical junction—this is the most clinically significant anatomical relationship and represents a critical surgical landmark 1
• After crossing the ureter, the vessel divides into uterine and cervical branches 5, 1
• The artery then ascends along the lateral border of the uterus within the broad ligament 1

Anatomical Support and Relationships

The uterine artery is supported within the parametrium and broad ligament, where the main uterine lymphatic trunks also condense. 1, 6

• The parametrial pathway contains the main uterine lymphatic trunks that condense alongside the uterine artery and lead to pelvic lymph nodes (external iliac, hypogastric, obturator regions) 6
• The vessel's relationship to the ureter follows the surgical mnemonic principle: "water (ureter) under the bridge (uterine artery)" at the uterine-cervical junction 1

Clinical Significance for Imaging and Procedures

For Doppler ultrasound evaluation, the uterine artery should be identified as it crosses over the hypogastric (internal iliac) vessels, with pulsed Doppler velocimetry obtained immediately after this crossing and before the vessel divides into uterine and cervical branches. 1

• The uterine artery can be demonstrated by color Doppler velocimetry as it originates from the anterior division of the hypogastric artery 5
• Successful identification of the uterine artery by Doppler is achievable in approximately 95-98% of cases at all gestational ages 5
• The artery shows progressive decrease in impedance with advancing gestational age, reflecting maternal adaptation to pregnancy from trophoblastic invasion of maternal spiral arterioles 5

Common Pitfalls

• Failure to recognize anatomical variations during uterine artery embolization for postpartum hemorrhage or fibroid management can lead to incomplete treatment, as the vessel may originate from the umbilical, inferior gluteal, or superior gluteal arteries rather than directly from the internal iliac artery 7, 2, 3
• Inadvertent ureteral injury during pelvic surgery occurs when surgeons fail to identify the uterine artery crossing over the ureter at the uterine-cervical junction 1
• During laparoscopic procedures, meticulous dissection is required when the uterine artery does not arise typically from the internal iliac artery, as atypical origins increase surgical complexity 8