Lecture 10

Theme
-Urinary system II;
Ureters;
Urinary bladder;
Urethra.

Mariam Chkholaria
Reading Materials:
Gray`s anatomy:3rd ed. Drake, RIchard and other,
pages:379-385,462-468
Urinary system

The kidneys;
Ureters;
Urinary bladder;
Urethra.
Kidneys
The kidneys excrete end-products of
metabolism and excess water. These actions are
essential for the control of concentrations of
various substances in the body, maintaining
electrolyte and water balance approximately
constant in the tissue fluids.
The kidneys also have other functions,
producing and releasing erythropoietin, which
affects red blood cell formation; renin, which
influences blood pressure; 1,25-di-
hydroxycholecalciferol (the metabolically active
form of vitamin D), which is involved in the
control of calcium absorption and mineral
metabolism; and various other soluble factors
with metabolic actions.
Kidneys
The bean-shaped kidneys are retroperitoneal in
the posterior abdominal region.
In adults, each kidney is typically 11 cm in
length, 6cm in breadth and 3 cm in antero-
posterior dimension. The left kidney may be 1.5
cm longer than the right;
The average weight is 150 g in men and 135 g in
women.
the kidneys extend from approximately
vertebra TXII superiorly to vertebra LIII inferiorly,
with the right kidney somewhat lower than the
left because of its relationship with the liver.
 Although they are similar in size and shape, the
left kidney is a longer and more slender organ
than the right kidney, and nearer to the midline.
Each kidney has:
Anterior and posterior surface,
medial concave and lateral convex margins,
superior and inferior poles.
Ureters
The ureters are muscular tubes that
transport urine from the kidneys to the
bladder. They are continuous superiorly
with the renal pelvis, which is a funnel-shaped
structure in the renal sinus.
The renal pelvis narrows as it passes
inferiorly through the hilum of the kidney and
becomes continuous with the ureter at the
ureteropelvic junction.
Inferior to the ureteropelvic junction, the
ureters descend retroperitoneally on the
medial aspect of the psoas major muscle.
 At the pelvic brim, the ureters cross either
the end of the common iliac artery or the
beginning of the external iliac artery, enter the
pelvic cavity, and continue their journey
to the bladder.
Ureters
Each measures 25–30 cm in length.
At three points along their course the
ureters are constricted:
The first point is at the ureteropelvic
junction.
The second point is where the ureters cross
the common iliac vessels at the pelvic brim.
• The third point is where the ureters enter
the wall of the bladder.
Kidney stones can become lodged at these
constrictions.
Ureteric vasculature and lymphatics

The ureters receive arterial branches from

adjacent vessels as they pass toward the
bladder:
 The renal arteries supply the upper end.
The middle part may receive branches from
the abdominal aorta, the testicular or ovarian
arteries, and the common iliac arteries.
In the pelvic cavity, the ureters are supplied
by one or more arteries from branches of the
internal iliac arteries.

In all cases, arteries reaching the ureters

divide into ascending and descending
branches, which form longitudinal
anastomoses.

The venous drainage of the ureters generally

follows the arterial supply.
Ureteric vasculature and lymphatics

Lymphatic drainage of the ureters follows a

pattern similar to that of the arterial supply.
Lymph from:
 the upper part of each ureter drains to the
lateral aortic (lumbar) nodes,
 the middle part of each ureter drains to
lymph nodes associated with the common
iliac vessels,
the inferior part of each ureter drains to
lymph nodes associated with the external
and internal iliac vessels.
Ureteric innervation
Ureteric innervation is from the renal, aortic,
superior hypogastric, and inferior hypogastric
plexuses through nerves that follow the blood
vessels. Visceral efferent fibers come from both
sympathetic and parasympathetic sources,
whereas visceral afferent fibers return to T 11 to
L2 spinal cord levels.
Ureteric pain, which is usually related to
distention of the ureter, is therefore
referred to cutaneous areas supplied by T11 to
L2 spinal cord levels. These areas would most
likely include the posterior and lateral
abdominal wall below the ribs and above
the iliac crest, the pubic region, the scrotum in
males, the labia majora in females, and the
proximal anterior aspect of the thigh.
Pelvic parts of the urinary system

The pelvic parts of the urinary system consist of:

 the terminal parts of the ureters,
 the bladder,
and the proximal part of the urethra.

The ureters enter the pelvic cavity from the

abdomen by passing through the pelvic inlet. On
each side, the ureter crosses the pelvic inlet and
enters the pelvic cavity in the area anterior to the
bifurcation of the common iliac artery.

From this point, it continues along the pelvic wall

and floor to join the base of the bladder.
Pelvic parts of the urinary system
In the pelvis, the ureter is crossed by:
•the ductus deferens in men, and
• the uterine artery in women
Urinary bladder
Pelvic part of the urinary system -the urinary
bladder is the most anterior element of the
pelvic viscera. Although it is entirely situated in
the pelvic cavity when empty, it expands
superiorly into the abdominal cavity when full.
 The empty bladder is shaped like a three-sided
pyramid that has tipped over to lie on one of its
margins.
It has:
 an apex,
 a base,
 a superior surface,
 and two inferolateral surfaces.
Urinary bladder
 The apex of the bladder is directed toward the
top of the pubic symphysis; a structure known as
the median umbilical ligament (a remnant of the
embryological urachus that contributes to the
formation of the bladder) continues from it
superiorly up the anterior abdominal
wall to the umbilicus.
The base of the bladder is shaped like an
inverted triangle and faces posteroinferiorly. The
two ureters enter the bladder at each of the
upper corners of the base, and the urethra drains
inferiorly from the lower corner of the base.
Inside, the mucosal lining on the base of the
bladder is smooth and firmly attached to the
underlying smooth muscle coat of the wall-unlike
elsewhere in the bladder where the mucosa is
folded and loosely attached to the wall. The
smooth triangular area between the openings of
the ureters and urethra on the inside of the
bladder is known as the trigone.
Urinary bladder
 The inferolateral surfaces of the bladder are
cradled between the levator ani muscles of the
pelvic diaphragm and the adjacent obturator
internus muscles above the attachment of the
pelvic diaphragm.
The superior surface is slightly domed when the
bladder is empty; it balloons upward as the
bladder fills
Urinary bladder
The neck of the bladder surrounds the
origin of the urethra at the point where
the two inferolateral surfaces and the base
intersect. The neck is the most inferior part
of the bladder and also the most "fixed"
part. It is anchored into position by a pair
of tough fibromuscular bands.
In women, these fibromuscular bands
are termed pubovesical ligaments.
Together with the perineal membrane and
associated muscles, the levator ani
muscles, and the pubic bones, these
ligaments help support the bladder.
In men, the paired fibromuscular bands
are known as puboprostatic ligaments
because they blend with the fibrous
capsule of the prostate, which surrounds
the neck of the bladder and adjacent part
of the urethra.
Urinary bladder
 The bladder is supplied principally by the
superior and inferior vesical arteries
derived from the anterior trunk of the
internal iliac artery, and supplemented by
the obturator and inferior
gluteal arteries. In females, additional
branches are derived from the
uterine and vaginal arteries.
The veins that drain the bladder form a
complicated plexus on its inferolateral
surfaces and pass backwards in the lateral
ligaments of the bladder to end in the
internal iliac veins.
The nerves supplying the bladder arise
from the pelvic plexuses, a mesh of
autonomic nerves and ganglia lying on the
lateral aspects of the rectum, internal
genitalia and bladder base. They consist
of both sympathetic and parasympathetic
components, each of which contains both
efferent and afferent fibres.
Urinary bladder
Lymphatics that drain the bladder begin
in mucosal, intermuscular and
serosal plexuses.
There are three sets of collecting vessels;
most end in the external iliac nodes.
Vessels from the trigone emerge on the
exterior of the bladder to run
superolaterally.
Vessels from the superior surface of the
bladder converge to the posterolateral
angle and pass superolaterally to the
external iliac nodes (some may go to the
internal or common iliac group).
Vessels from the inferolateral surface
of the bladder ascend to join those from
the superior surface or run to the lymph
nodes in the obturator fossa.
Urethra
The urethra begins at the base of the
bladder and ends with an external opening
in the perineum. The paths taken by
the urethra differ significantly in women
and men.
In women, the urethra is short, being
about 4 cm long. It travels a slightly curved
course as it passes inferiorly through the
pelvic floor into the perineum, where it
passes through the deep perineal pouch
and perineal membrane before opening in
the vestibule that lies between the labia
minora.
 The urethral opening is anterior to the
vaginal opening in the vestibule. The
inferior aspect of the urethra is bound
to the anterior surface of the vagina. Two
small paraurethral mucous glands (Skene's
glands) are associated with the lower end
of the urethra. Each drains via a duct that
opens onto the lateral margin of the
external urethral orifice.
Urethra
In men, the urethra is long, about 20 cm,
and bends twice along its course.
The urethra in men is divided into:
 preprostatic,
 prostatic,
 membranous,
 and spongy parts.

1) The preprostatic part of the urethra is

about 1 cm long, extends from the base of
the bladder to the prostate, and is
associated with a circular cuff of
smooth muscle fibers (the internal urethral
sphincter). Contraction of this sphincter
prevents retrograde movement of semen
into the bladder during ejaculation.
Urethra
2) The prostatic part of the urethra is 3 to
4 cm long and is surrounded by the
prostate. In this region, the lumen of the
urethra is marked by a longitudinal midline
fold of mucosa (the urethral
crest). The depression on each side of the
crest is the prostatic sinus; the ducts of
the prostate empty into these two
sinuses. Midway along its length, the
urethral crest is enlarged to form a
somewhat circular elevation (the seminal
colliculus). A small blind-ended pouch -
the prostatic utricle (thought to be the
homologue of the uterus in women)
opens onto the center of the seminal
colliculus. On each side of the prostatic
utricle is the opening of the ejaculatory
duct of the male reproductive system.
Therefore the connection between the
urinary and reproductive tracts in
men occurs in the prostatic part of the
urethra.
Urethra
3) The membranous part of the urethra
is narrow and passes through the deep
perineal pouch. During its transit through
this pouch, the urethra, in both men and
women, is surrounded by skeletal
muscle of the external urethral sphincter.
4) The spongy urethra is surrounded by
erectile tissue (the corpus spongiosum) of
the penis. It is enlarged to form a bulb at
the base of the penis and again at the end
of the penis to form the navicular fossa.
The two bulbo-urethral glands in the deep
perineal pouch are part of the male
reproductive system and open into the
bulb of the spongy urethra. The external
urethral orifice is the sagittal slit at the end
of the penis.
Vascular supply, lymphatic drainage and
innervation

In female:
 The urethra is supplied principally
by the vaginal artery, but also receives
a supply from the inferior vesical
artery.
The venous plexus around the
urethra drains into the vesical venous
plexus around the bladder neck and
into the internal pudendal veins.
The urethral lymphatics drain into
the internal and external iliac nodes.
 Innervation
Parasympathetic preganglionic axons
arise from neuronal cell bodies in
the intermediolateral column of the
second to fourth segments of the
sacral spinal cord, run in the pelvic
splanchnic nerves, and synapse in
the vesical plexus in or near the bladder
wall. Postganglionic fibres are
distributed to the smooth muscle of the
urethral wall. Somatic fibres to the
striated muscle are also derived from
the second to fourth segments of the
sacral spinal cord, and run in the pelvic
splanchnic nerves but do not synapse in
the vesical plexus. Sensory
fibres run in the pelvic splanchnic
nerves to the second to fourth
segments of the sacral spinal cord.
Postganglionic sympathetic fibres arise
from the plexus around the vaginal
arteries.
Vascular supply, lymphatic drainage and
innervation
In male:
 The urethral artery arises from the
internal pudendal artery or common
penile artery just below the perineal
membrane, and travels through the corpus
spongiosum to reach the glans penis. It
supplies the urethra and the erectile tissue
around it. The urethra is also supplied by
the dorsal penile artery, via its circumflex
branches on each side and in a retrograde
fashion from the glans, by its terminal
branches. The blood supply through the
corpus spongiosum is so plentiful that the
urethra can be divided without
compromising its vascular supply.
Vascular supply, lymphatic drainage and
innervation
In male:
The venous drainage of the anterior
urethra is to the dorsal veins of the
penis and internal pudendal veins, which
drain to the prostatic plexus.
The posterior urethra drains into the
prostatic and vesical venous plexuses,
which drain into the internal iliac veins.
Lymphatic vessels from the posterior
urethra pass mainly to the internal iliac
nodes; a few may end in the external iliac
nodes. Vessels from the membranous
urethra accompany the internal pudendal
artery. Vessels from the anterior urethra
accompany those of the glans penis, most
ending in the deep inguinal nodes; some
may end in superficial nodes, while others
may traverse the inguinal canal to end in
the external iliac nodes.
Vascular supply, lymphatic drainage and
innervation
In male:
 The prostatic plexus supplies the
smooth muscle of the prostate and
prostatic urethra. On each side, it is
derived from the pelvic plexus and lies on
the posterolateral aspect of the seminal
vesicle and prostate. The sympathetic
autonomic nerves that supply the internal
urethral sphincter are derived from the
pelvic plexus as it descends in the pelvis
adjacent to the inferior prostatovesical
pedicle and prostate, and function to
prevent retrograde ejaculation.
Parasympathetic preganglionic axons arise
from neuronal cell bodies in
the second to fourth sacral spinal
segments.