ANATOMY OF THE ADRENAL GLAND AND URINARY TRACT

I. THE ADRENAL/SUPRARENAL GLANDS

o An endocrine gland situated above the kidney with an outer cortex and an inner
medulla
Cortex- develops from the coelomic mesothelium
Medulla- formed from the sympathochromaffin cells of the neural crest

o Cadmium yellow in color and contained within the intermediate stratum of the
retroperitoneum within the GEROTAS FASCIA in the epigastric region

o Wt= 4-8 grams (mean weight of 8 g based on Gray's Anatomy)

o 3 segments: head, body and tail

o Surrounded by connective tissue containing perinephric fat, enclosed within the

renal fascia

o Have separate fascial capsules which permits removal of a kidney without

removal of the suprarenal.(It does not move with the kidney)

o Separated from the kidney by the perirenal fat

o CLEAVAGE PLANE
A small space filled with connective tissue between the inferomedial angle
of the adrenal and kidney

MEAN TRANSVERSE
SUPRARENAL DIMENSION
PART
Right Left

Body 61 mm 79 mm

Limb 28 mm 33 mm

DIFFERENCES and RELATIONSHIPS

RIGHT Adrenal LEFT Adrenal

o Pyramid-shaped and smaller o Crescenteric/semilunar in shape

o Has two well-developed limbs
giving a cross-sectional
appearance (broad-headed
arrow)
o Anteromedial aspect lies under
posterolateral wall of the inferior
vena cava
o Anterocranial portion is
bordered by bare area, Right lobe
of liver
o Posterior surface
Superior: Crus of
diaphragm
Medial: R. Celiac ganglion
o Superiorly: diaphragm
o Inferiorly: Right kidney
VASCULATURE
and larger
o Flattened in the anteroposterior
plane
o Anteroinferior: body of
pancreas
o Cranioanterior: cardiac portion
of the stomach
o Posteriorly: left crus of
diaphragm
o Posterolateral aspect is
associated with craniomedial
aspect of the Left kidney
o Superiorly: spleen
o Inferiorly: renal vessels
Arterial Supply

o Head
SUPERIOR suprarenal arteries (often small and absent) from the inferior
phrenic artery which is a branch of the abdominal aorta

o Body
MIDDLE suprarenal artery arises from the lateral aspect of the abdominal
aorta at the level of superior mesenteric artery

o Tail
INFERIOR Suprarenal Arteries from renal arteries

Venous Supply

o Right kidney
Right suprarenal vein- short and almost immediately drains into IVC

o Left kidney
Left suprarenal vein- passes inferiorly and drains into the left renal vein

Lymph Drainage

o Drains into the lateral groups of para-aortic nodes

INNERVATION

o Only the medulla is innervated and the origin of innervation is primarily of

sympathetic derivation namely:
Preganglionic fibers from T10-L1 carried by greater splanchnic nerve and
celiac ganglion and terminates and synapses in continuity with large
chromaffin cells within the renal medulla.
MICROSCOPIC ANATOMY
Adrenal CORTEX

1. Zona GLOMERULOSA
Outermost and narrow region consisting of small polyhedral cells in
rounded clusters

Produces MINERALOCORTICOIDS that help in the regulation of blood

pressure and electrolyte balance, which include aldosterone

ELECTROCORTIN, the major regulator of salt balance, which acts to

stimulate Na+ reabsorption in the distal convoluted tubules

2. Zona FASCICULATA
Consists of large polyhedral basophilic cells arranged in straight columns,
two cells wide, with parallel fenestrated venous sinusoids between them

Secretes GLUCOCORTICOIDS especially CORTISOL, which affect

carbohydrate metabolism by stimulating gluconeogenesis in many cells and
glycogen synthesis in the liver

3. Zona RETICULARIS
Consists of branching interconnected columns of round cells whose
cytoplasm contains SER, lysosomes and sex hormones

Produces ANDROGENS that are converted to fully functional sex hormones

in the gonads and other target organs

Adrenal MEDULLA

o Dark red/greyish/brown depending in its blood content

 o Composed of groups and columns of CHROMAFFIN CELLS
(PHAEOCHROMOCYTES) derived from the neural crest and intimately related
to the sympathetic nervous system

o Synthesizes, stores and releases neuroactive CATHECOLAMINES: epinephrine,

norepinephrine into the venous sinusoids

o Chromaffin cells are separated by wide venous sinusoids and supported by a

network of reticular fibers

SURGICAL APPROACHES

o Transabdominal
Simulataneous exploration through a single incision

o Thoracoabdominal
Excellent exposure to a single adrenal and its surrounding anatomy

THE KIDNEY

SURFACE ANATOMY

o The kidney lies between T12 and L2 vertebrae and thus, to a considerable extent,
within the thoracic cage
 o Boundaries of the renal fossa:
Medially : Psoas muscle
Posteriorly : Quadratus lumborum muscle
Laterally : Broad abdominal muscles
Superiorly : Diaphragm

o Factors influencing the size/weight of the kidney

General stature
Age
Gender (Males have bigger kidneys)
Congenital/surgical absence of its mate
Heredity and hormonal influence (sensitivity of tissues to hormones)

GROSS ANATOMY

o Paired, reddish brown, bean-shaped organs

o Convex outer border, concave inner border
o 10-11 cm long,5-6 cm long,2.3-3.0 cm thick
o Weighs 150 g in males, 135 g in females
o The right kidney lies lightly lower than the left because of the large size of the
right lobe of the liver
o Covered posteriorly by bones and muscles so the kidneys are not easily injured
unless a broken rib is present
o In persons with poorly developed abdominal muscles, lower pole of the right
kidney can be palpated in the right lumbar region at the end of deep inspiration

COVERINGS

o Fills the gap between the 12th rib and the iliac crest
o Very thick facia that consists of 3 layers:
a. Anterior
- Arises from anterior surfaces of the lumbar transverse processes near
their roots
- Anterior to the psoas muscle (also known as psoas fascia)

b. Middle
- Arises from tips of the transverse processes of lumbar vertebrae
- Anterior to erector spinae

c. Posterior
- Arises from tips of lumbar, sacral, and thoracic vertebral spines
(psoas fascia springs from this layer) and goes laterally

o The posterior and middle layers are denser and stronger than the anterior layer.
o The 3 layers pass laterally and fuse near the outer border of the quadratus
lumborum muscle.
o Fusion of 3 layers forms the APONEUROSIS of origin of the transversus
abdominis muscle from which the internal oblique muscle partly arises.

o Sacrospinalis muscle group

Found between the posterior and middle layers of lumbodorsal fascia

o Quadratus lumborum
Situated between middle and anterior layer
RENAL FASCIA
o Derived from the transversalis fascia splits at the lateral border of the kidneys
into:
a. Anterior (Prerenal) fascia
- extends medially in front of kidney & its vessels, aorta, and vena cava
to merge with layer of opposite side

b. Posterior (Retrorenal) fascia

- extends medially behind the kidney and blends with fascia of
quadratus lumborum and psoas major muscles

o Between anterior and posterior fascia, the perirenal fascial space of Gerota is
formed.

o The 2 layers of renal fascia fuse at the upper pole of the kidney but remain
separated at the lower pole.
This allows removal of kidney with its capsule, leaving suprarenals in situ.
Reduction of perirenal fat predisposes to mobility of the kidney
FAT SURROUNDING THE KIDNEY

o PARARENAL fat
Lies behind the kidney, between aponeurosis of origin of transversus
abdominis and the posterior layer of renal fascia.
Varies in thickness
Revealed upon incision of transversus muscle

o PERIRENAL fat
Lies in the perirenal space of Gerota
Revealed upon incision of posterior layer of renal fascia
Runs completely around the kidney forming a fatty capsule, passing
medially to the hilum and insinuating itself between the renal vessels
Almost semiliquid consistency, allowing amount of movement transmitted
from diaphragm

o Arranged in order (VISCERAL to PARIETAL)

a. Fibrous capsule - surrounds the kidney and is closely applied to its outer
surface; normally stripped easily.
b. Perirenal fat - covers the fibrous capsule.
c. Renal fascia - a condensation of connective tissue that lies outside the
perirenal fat
- Encloses the kidneys and suprarenal glands
- It is continuous laterally with the fascia transversalis
d. Pararenal fat - lies external to the renal fascia and forms part of the
retroperitoneal fat
o Kidneys rest on 4 muscles:
Above diaphragm
Laterally transversus
Medially psoas
Between transversus and psoas quadratus lumborum

o HILUM
Vertical slit bounded by thick lips of renal substance found at the medial
concave border of each kidney
Leads to the renal sinus which is the space within the hilum
Lies on the transpyloric plane, about three fingerbreadths from the midline
Opposite to L1
Contains: (from front to back)
- renal Vein,
- two branches of the renal Artery,
- Ureter
- third branch of the renal Artery
 - Acronym: VAUA

Also contains:
- Calyces (short, funnel-shaped tubes that unite to form the ureter)
- Pelvis of the ureter (dilated proximal end of ureter)
- Lymph vessels
- Sympathetic fibers
INTERNAL GROSS ANATOMICAL FEATURES

CORTEX
o Dark brown and extends into the medulla between adjacent pyramids as the renal
columns
MEDULLA
o Light brown and composed of about a dozen renal pyramids

o Renal PYRAMIDS
base oriented toward the cortex
apex, or renal papilla, projects medially

o MEDULLARY RAYS
striations extending from the bases of the renal pyramids into the cortex

o Renal PELVIS
Upper expanded end of the ureter
Divides into two or three major calyces, each of which divides into two or
three minor calyces
- Each minor calyx is indented by the apex of the renal pyramid, the
renal papilla.

o Renal CALYCES
These are collecting structures that receive urine from collecting tubules
8-18 calyces drain the upper and lower pole
2 parallel rows of anterior and posterior calyces drain the middle portion of
the kidney
They accommodate several papillae which invaginate the calyces.
- DUCTS OF BELLINI duct that communicates with the calyces
- AREA CRIBROSA perforations on the papillae

Anterior Relations

o Right kidney
Above - suprarenal gland and liver
Medially - 2nd part of the duodenum
Below- right colic flexure
o Left kidney
Laterally - spleen
Front - stomach
Pancreas transversely across the hilum to the
splenic area
Suprarenal gland
Left colic flexure
Coils of jejunum in contact with anterior and medial portion of lower lobe
Posterior Relations
Diaphragm (superior)
Costodiaphragmatic recess of the pleura
12th rib for the right kidney, and 11th (the left kidney is higher) and 12th
ribs for the left kidney
Psoas (medial)
Quadratus lumborum (posterior)
Transversus abdominis (lateral)

o The subcostal (T12), iliohypogastric, and ilioinguinal nerves (L1) run downward
and laterally

BLOOD SUPPLY

ARTERIES

RENAL ARTERY
o Arises from the AORTA at the level of the L2 just below the origin of the superior
mesenteric artery
o Takes roughly 20% of the cardiac output

o RIGHT Renal Artery

Longer and often higher, passing posterior to the inferior vena cava, right
renal vein, head of the pancreas, and descending part of the duodenum.

o LEFT Renal Artery

Lower and passes behind the left renal vein, the body of the pancreas, and
splenic vein
It may be crossed anteriorly by the inferior mesenteric vein
SEGMENTAL ARTERIES
o Enter the hilum of the kidney and are distributed to different segments or areas
of the kidney

o Apical Segment
Occupies the anteromedial region of the superior pole.

o Superior (anterior) segment

Includes the rest of the superior pole and the central anterosuperior region.

o Inferior Segment
Encompasses the whole lower pole

o Middle segment
Lies between anterior and inferior segments

o Posterior Segment
Includes the whole posterior region between the apical and inferior
segments.
LOBAR ARTERIES
o One for each renal pyramid
o Initial branches of segmental arteries are lobar

o Interlobar Arteries
Run toward the cortex on each side of the renal pyramid.

o Arcuate Arteries
Arises at the junction of the cortex and the medulla
Arch over the bases of the pyramids.

o Interlobular Arteries
ascend in the cortex

o Afferent Glomerular Arterioles

Mainly the lateral rami of interlobular arteries
A few arise from arcuate and interlobar arteries when they vary their
direction and angle of origin
Deeper arterioles incline obliquely back towards the medulla
Intermediate arterioles pass horizontally
Superficial arterioles approach the renal surface obliquely before ending in
a glomerulus
VEIN

o Renal vein
Emerges from the hilum in front of the renal artery
Drains into the IVC
The left renal vein is three times longer than the right (7.5 cm and 2.5 cm
respectively) and for this reason, the left kidney is the preferred side for live
donor nephrectomy

o Relations
Renal capsule- covers the kidney
Perirenal fat
Gerotas fascia
Pararenal fat
Dorsally, osteomuscular wall
Ventrally, abdominal viscera

INNERVATION

o The renal plexus innervates the kidneys.

o It arises from
Aorto-Renal Ganglion
 middle and inferior Splanchnic Nerves
Intermesenteric Nerves
Lumbar Sympathetic Chain

o The plexus continues into the kidney accompanying the vasculature.

It is primarily VASOMOTOR in function.

o Axons from plexuses around the arcuate arteries innervate juxtamedullary

efferent arterioles and vasa recta, which control the blood flow between the
cortex and medulla without affecting the glomerular circulation

o AFFERENT FIBERS enter the spinal cord in T10 T12

LYMPHATICS

o Lymphatic vessels accompany the arterial tree from interlobular to renal artery

o From the renal pedicle, lymphatic channel drain to lymph nodes along the
inferior vena cava and the lateral aortic nodes.

o Renal capsule and perirenal tissue have reached lymphatics that communicate
with the renal lymphatic vessels.

o Renal lymphatic vessels begin in three plexuses, around the renal tubules, under
the renal capsule, and in the perirenal fat

o Lateral aortic lymph nodes around the origin of the renal artery
MICROSCOPIC ANATOMY

o MICROSTRUCTURE
The renal parenchyma is composed of URINIFEROUS TUBULES contained
within the supporting connective tissue through which the vasculature,
lymphatics and innervation are carried.
Uriniferous tubules include a nephron which produces urine, and the
collecting duct, which completes the concentration of urine.
The nephron includes the renal corpuscle, and the renal tubule.
The renal or Malpighian corpuscle is composed of two portions; the
glomerulus and the glomerular or Bowmans capsule.

o NEPHRON
Consists of:
- (1) Renal Corpuscle, concerned with filtration from the plasma.
- (2) Renal Tubule, concerned with selective resorption from the
filtrate to form the urine
- (3) Collecting ducts that carry fluid from the renal tubules to the
minor calyx.

o RENAL CORPUSCLE
Glomerulus + glomerular (Bowmans) capsule
one million renal corpuscles in each kidney, number decreases with age;
A LOST NEPHRON CAN NEVER BE REPLACED

o GLOMERULUS
Collection of convoluted capillary blood vessels (VASCULAR TUFT)
The arterioles enter (and exit) the capsule opposite the proximal end of the
collecting tubule
Invaginates the blind proximal end of the renal tubule.
The capillary network arises from the afferent arteriole which enters the
capsule opposite the proximal end of the collecting tubule
The capillary terminates in the afferent arteriole in the same location
o BOWMANS CAPSULE
A blind expanded end of a renal tubule, and is invaginated by the
glomerulus
Lined by a simple squamous epithelium on its outer (parietal) wall;
Its glomerular, juxtacapillary (visceral) wall is composed of specialized
epithelial PODOCYTES
The cavity between the visceral and parietal epithelium is called URINARY
SPACE, which is continuous with the proximal convoluted tubules.

o Features of the Renal Corpuscle:

PODOCYTES are stellate cells that have foot processes (pedicels) that
interdigitate to form a 25 nm gap called filtration slits

The 1fenestrated endothelium, glomerular 2basement membrane (basal

lamina) and 3podocytes make up the FILTRATION MEMBRANE, that
allows passage of water and various small molecules and ions
Irregular MESANGIAL CELLS secrete glomerular mesangium, a
specialized connective tissue which binds the loop of glomerular
 capillaries and fills the spaces between endothelial surfaces that are not
invested by podocytes.

Mesangial cells clear the glomerular filter of immune complexes and

cellular debris

RENAL TUBULE

o PROXIMAL Convoluted Tubule (in the CORTEX)

 It is lined by cuboidal or low columnar epithelium with tall microvilli on its
luminal surface to facilitate transport of ions and small molecules
It is rich in mitochondria that supply ATP needed in the transport process

o LOOP OF HENLE (found in the MEDULLA)

Descending thin segment (30 m in diameter), lined by low cuboidal to
squamous cells
Ascending thin segment has the same structure with the descending thin
segment
Ascending thick segment (60 min diameter) composed of cuboidal cells
like those in the distal convoluted tubule
The THIN SEGMENT play a passive role in ion transport
The thick segment has more active metabolic role
The THICK LIMB of the loop of Henle is the source of TammHorsfall
protein urine

o DISTAL Convoluted Tubule (in the cortex)

Cells are cuboidal and resemble those in the proximal tubule. They have
few microvilli, and rich in mitochondria, indicating active metabolic
activity.
Enzymes concerned in active transport of sodium, potassium and chloride
are abundant
Subdivided into three parts:
- Pars recti
- Pars convoluti
- Macula densa (part of the juxtaglumerular apparatus and forms the
1st part of the distal convoluted tubule and is a constituent of the
juxtaglomerular apparatus)
o COLLECTING DUCT
Collecting ducts originate in the cortical medullary rays and open into
wider papillary ducts which open on to a papilla, their numerous orifices
forming a perforated area cribrosa
Lined by simple cuboidal or columnar epithelium. Cells have relatively few
organelles and only occasional microvilli.
A second cell type, INTERCALATED or DARK CELLS (also present in the
distal convoluted tubule) have longer microvilli and more mitochondria
and secrete H+ into the filtrate

o Other Renal Cells

Medullary interstitial cell secrete prostaglandins and may contribute, with
cortical tubular cells, to the renal source of erythropoietin.

JUXTAGLOMERULAR APPARATUS
- The JGA describes the collection of structures at the hilum of the
glomerulus, which includes the 1afferent arteriole, the 2efferent
arteriole and the 3macula densa and the cushion of cells at the
vascular pole, called the LACIS cells which are continuous with the
mesangium.

- It provides a tubuloglomerular feedback system which maintains

systemic arterial blood pressure.

- The juxtaglomerular cells are large, rounded cells and contain many
mitochondria and dense, renin-containing vesicles.
 - MACULA DENSA of the distal tubule is a cluster of up to 40 tightly
packed cells in the tubule wall
They are OSMORECEPTORS, sensing the NaCl content of the
filtrate
Regulates filtration rate by releasing the inhibitory NITRIC
OXIDE

- The extraglomerular mesangial cells which form a network (LACIS

cells) of stellate cells that connect the macula densa and
juxtaglomerular cells and transmit sensory signals.

THE UPPER URINARY TRACT

o The calyces, renal pelvis and ureter form collecting structure between the renal
parenchyma and the urinary bladder.
o The renal calyces: 8-18 in number, draining the upper and lower poles and 2
parallel rows of anterior and posterior calyces draining the middle portion of the
kidney

o RENAL PAPILLA
The upper and lower calyces are frequently compound accommodating
several papillae which invaginate the calyces, the communication occurring
through the DUCTS OF BELLINI.
- The perforations are known as the AREA CRIBROSA.

o RENAL PELVIS
The coalescence of several calyces into a larger chamber is called a major
calyx or an infundibulum which generally numbers 2 or 3.
- The major calyces fuse to form a renal pelvis.

o URETEROPELVIC JUNCTION
The ureters are paired muscular tubes connecting the renal pelvis to the
urinary bladder.
- The junction is called the ureteropelvic junction which is the first
anatomical constriction of the ureter.

- The 2nd artifactual waist is at the crossing of the iliac vessels.

- The 3rd constriction is at the ureterovesicle junction.

o UTEROVESICOTRIGONAL COMPLEX
The musculature of the terminal ureter may be divided into a 1juxtavesical
segment , 2intramural segment and 3submucosal part.

The intramural portion is composed of longitudinal fibers separated from

the adventitia by a fibromuscular tissue-lined space called WALDEYERS
SHEATH.

The longitudinal muscle fibers of the roof and the floor of the ureter pass
medially and inferiorly to form the superficial ureteric trigone.

The trigone of the bladder then consists of the three layers of muscle:
- a superficial or submucosal layer continues with the ureteric muscle
- a middle layer continuous with Waldeyers sheath
 - Deep trigonal muscle which is the bladder muscle wall itself

URETERS
o Two muscular tubes that convey urine from the kidneys to the urinary bladder
through peristaltic contractions
o 25-30 cm long, 3 mm in diameter, thick walled and continuous with the renal
pelvis
o The junction of is called the ureteropelvic junction
o Has three constrictions:
At the ureteropelvic junction
At the crossing of the iliac vessels
At the ureterovesical junction
- These are the common sites of renal stone impaction

o The musculature of the terminal ureter may be divided into a juxtavesical

segment, intramural segment and submucosal part

o The intramural part is composed of longitudinal fibers separated from the

adventitia by a fibromuscular tissue-lined space called Waldeyers sheath
o The ureters pierce the posterior aspect of the bladder and run obliquely for a
distance of 1.52.0 cm before terminating at the ureteric orifices

o The longitudinal muscles of the roof and floor of the ureter pass medially and
inferiorly to form the superficial ureteric trigone

o The trigone of the bladder then consists of three muscular layers:

Superficial or submucosal continuous with the ureteric muscles
Middle layer - continuous with the Waldeyers sheath
Deep layer the bladder muscle wall itself

BLOOD SUPPLY

o The ureter is supplied by branches from the renal, gonadal, common iliac,
internal iliac, vesical and uterine arteries, and the abdominal aorta

o Venous drainage follows the arterial supply

LYMPHATICS
 o Lymphatic capillaries in the wall of the ureter coalesce and pass diagonally
outward through the muscular walls of the ureter. Then they course proximally
and distally for greater or lesser distances before exiting to pass to regional lymph
nodes

INNERVATIONS

o The renal calyces, pelvis and ureter are innervated by the ANS. The
parasympathetic contribution is from the S2-S4 segments of the spinal
cord. The lower ureter by the pelvic splanchnic nerve.

o The sympathetics is from T12-L2 by the thoracic and lumbar splanchnic

nerves and then by the celiac and superior Hypogastric and renal plexuses.
WALLS OF URETER

o Layers:
ADVENTITIA - containing intertwined mass of collagen fibers, blood
vessels and nerve endings
MUSCLE layer - composed of smooth muscle cells running in all directions
MUCOUS layer - consists of transitional cell epithelium separated from the
muscle by fibrous lamina propria or submucosa

Transverse section of ureter. The walls are muscular

and are lined by a specialized urothelium.
URINARY BLADDER
o Spherical in shape when full but tetrahedral when empty
o Mucosa is smooth in the distended bladder and wrinkled if the bladder is
contracted and empty
o Stores urine at a maximum capacity of 500 mL
o Has 4 angles, 4 surfaces and 4 ducts, each duct attached to each angle.
o Urachus attaches to the anterior angle (apex).
o Right and left ureters attach to the posterolateral angles.
o Urethra attaches to the inferior angle.
o Angles of the tetrahedron are formed by the ureterovesical junction, the
urachovesical junction and the urethrovesical junction.
o The juncture of the urachus and the bladder is called the apex and the juncture
between the urethra and the bladder is the neck of the bladder.
o The elevation of the posterior lip of the vesical neck produced by the underlying
prostatic tissue has been called the uvula of the bladder.

o The superior boundary of the trigone is lying between the two ureteral orifices
and is called the interureteric ridge or crest or the MERCIERS BAR
The sides of the trigone is called BELLS MUSCLE.

o The bulk of the bladder is formed of the collective DETRUSSOR

MUSCLE.
The layering occurs only at the bladder neck.

o MALE: Lies posterior to the symphysis pubis; situated immediately behind the
pubic bones within the pelvis.

o FEMALE: Lies at a lower level than in the male pelvis

o APEX
Points anteriorly and lies behind the upper margin of the symphysis pubis
Median umbilical ligament connects the urinary bladder to the umbilicus

o BASE (posterior surface)

Faces downward and backward forming the base or fundus of the urinary
bladder.
No peritoneum exists between the rectum and the posterior surface; they
are separated by the vasa deferentia, the seminal vesicles, and the
rectovesical fascia (DENONVILLIERS FASCIA).
 - Male: separated from the rectum by the vasa deferentia, the seminal
vesicles, and the rectovesical fascia
- Female: separated from the rectum by the vagina

o SUPERIOR SURFACE
Covered with peritoneum
Forms the apex of the bladder continuous with median umbilical ligament
Passes upward in the midline between transversalis fascia and peritoneum

Relations
- Males: coils of ileum or sigmoid colon
- Females: uterovesical pouch of peritoneum and to the body of the
uterus

o INFEROLATERAL SURFACES (2)

Anterior relation: retropubic pad of fat in the space of Retzius and the
pubic bones
 Posterior relation: obturator internus muscle above and the levator ani
muscle below

o NECK
Held in position by the puboprostatic ligaments (male), or pubovesical
ligaments (female) which are thickenings of the pelvic fascia
Male: rests on the upper surface of the prostate
Female: rests on the upper surface of the urogenital diaphragm

o Other important structures:

Bladder Interior
TRIGONE
- Area of mucous membrane covering the internal surface of the base of
the bladder
- Superior angles : openings of the ureters : inferior angle : internal
urethral orifice
- Ureters pierce the bladder wall obliquely, and this provides a valve-
like action, which prevents a reverse flow of urine toward the kidneys
as the bladder fills

INTERNAL URETHRAL ORIFICE

- Found at the apex of the trigone
- An elevation known as the uvula or vesical crest
- Pushes the posterior margin of the internal urethral orifice slightly
forward.
- The uvula represents a bulging of the prostate, and if enlarged it may
block the orifice

RETROTRIGONAL FOSSA
- The interior of the fundus of the bladder.
- May be a site of urine accumulation when the prostate hypertrophies
(resulting in increased Intravesical pressure).
- Foreign bodies may accumulate in this fossa and cause bladder
rupture

DETRUSSOR
- Three layers of interlacing smooth muscle bundles composing the
muscular coat of the bladder
BLOOD SUPPLY

o ARTERIES
Superior and inferior vesical arteries (branches of internal iliac arteries)

o VEINS
Vesical venous plexus (drains into the internal iliac vein)

o LYMPH DRAINAGE
Internal and external iliac nodes

o NERVE SUPPLY
Inferior hypogastric plexus
Sympathetic preganglionic fibers: 1st and 2nd lumbar ganglia
Parasympathetic preganglionic fibers: pelvic splanchnic nerves (S2-S4)

o RETROPUBIC SPACE OF RETZIUS

Space behind the pubic bone and in front of the urinary bladder.
Bounded anteriorly by the posterior sheath of the rectus muscle and the
posterior surface of the pubis.
Limited below by the puboprostatic or pubovesical ligaments.
Extends as far back as the internal iliac artery.
It is an extraperitoneal space filled with fatty and areolar tissue.

o RELATIONSHIPS
Superior and posterior surface are covered by peritoneum closely adherent
with minimum extraperitoneal connective tissue. This is the only serosal
layer of the bladder.
Inferolateral aspect - obturator internus and levator ani muscles
Bladder neck - intrinsic to the prostate
Anterior surface - under the pubis and investing fascia of the rectus
abdominis muscle.
Posteriorly in the males - base of the bladder is in opposition to the
rectum

LIGAMENTS OF THE BLADDER

o Condensations of the intermediate stratum of retroperitoneal connective tissue

from the tendinous arc of the pelvic sidewall to the bladder carrying the
vasculature.
 1. Lateral true ligaments - ventrally
2. Posteriorly - dorsally
3. Puboprostatic ligament - anchors bladder from the neck to the pubis in the male
4. Pubovesical ligament in the female
5. Urachus called the median umbilical ligament- fix the apex of the bladder to
the umbilicus
6. Obliterated umbilical arteries extend from the external iliac artery over the
anterior surface of the bladder toward the umbilicus on each side- they are called
the lateral umbilical ligament.

o Ligaments that stabilize the bladder anteriorly:

Median umbilical ligament
Lateral umbilical ligament

VASCULATURE

o A complete set of vesical arteries is found only in the newborn infants.

Obliteration of the umbilical arteries and the occlusion of some of its branches
lead to the reduced number of vessels seen in the adults.

o A complete set of vessels branches from distal to proximal on the vascular tree
would consist of:
Urachal
Two superior vesicals
A middle vesical
One or two superior vesicals
Vesiculo-deferential
Inferior vesical
o SUPERIOR VESICAL artery supplies the:
Superior part of the bladder
Branches of the urachus
vas deferens
Occasionally produce the middle vesical artery which supplies the middle
and lower part of the urinary bladder

o INFERIOR VESICAL artery- courses along the levator ani muscles to the lower
part of the urinary bladder and sends branches to the seminal vesicles, prostate
and vas deferens

o VESICULODEFERENTIAL artery (in the male) - forms the main vasculature to

the trigone to the female, the trigone is vascularized by the uterine artery.
 o Superior and inferior vesical arteries are branches of the anterior division
of the hypogastric (internal iliac) artery.

VENOUS DRAINAGE

o Campbell. Veins of the urinary bladder drain into the 1plexus of Santorini,
2
lateral vesical plexuses, lateral ligaments of the prostate to empty into the
3
hypogastric veins.

o Gillenwatetr, et al. the venous drainage of the bladder is by means of extensive

vesical and prostatic plexus which form 2-5 (usually 3) that drain to the internal
iliac veins. In the female, only vesical plexuses are found.

INNERVATION

o From the pelvic plexus-otherwise referred to as the vesical plexus from the S2 to
S4 spinal cord segments by means of the pelvic splanchnic nerve.

o T10 to L2 cord segments by means of the presacral nerves.

o Detrussor - mainly supplied by the parasympathetic nerves has an exceedingly

sparse sympathetic nerve supply

o Bladder neck- richly supplied by plexus of sympathetic terminals

o In contrast, in the female, the bladder neck and the urethral muscle are supplied
by numerous parasympathetic nerves that are identical to those innervating the
detrusor, and a poor supply of sympathetic innervation.

o In both sexes, the pudendal nerve carries somatic fibers from S2 to S4 spinal cord
segments, which supply the striated muscles of the pelvic floor. The extrinsic,
 external urethral sphincter however, which is striated is supplied by the pelvic
splanchnic nerve.

LYMPHATICS

o The superior middle and lower bladder portion drain into the middle and
internal group of the external iliac chain.

o The base drains to nodes near the bifurcation of the iliacs.

COATS/LAYERS OF THE BLADDER

1. Serous/adventitial coat
eritoneum restricted to the upper surface and a small part of the base in
males.

2. Fascial coat
Extraperitoneal tissue that sheathes the bladder. Thins on the upper
surface to bind the serous coat to the muscular coat.

3. Muscular coat
Nonstriated muscle arranged obliquely and circularly around the bladder.
Forms the sphincter of the bladder at the neck

4. Submucous coat
layer of adipose that connects the muscular and mucous coats.

5. Mucous coat

MICTURITON
o Reflex action controlled by higher centers in the brain, initiated by stretch
receptors in the bladder wall when the urine reaches about 300 mL
 o Afferent impulses
S2-S4
1st and 2nd lumbar ganglia

o Efferent parasympathetic impulses

S2-S4
Leads to contraction of the detrusor muscle and the relaxation of sphincter
vesicae

o PUDENDAL nerve
Relaxation of the urethral sphincter
PROSTATE
o Pyramidal in shape with a base (firmly adherent to the base of the bladder) and
an apex (firmly adherent to the urogenital diaphragm)

o Thin prostatic capsule

o Substance is traversed by three luminal structures: posterior urethra (1),

ejaculatory ducts (2)

o Orifices of the ejaculatory ducts- two smaller crypt noted on either side or
somewhat posterior of the verumontanum.

o Prostatic sinus- the depression on either side of the urethral crest, numerous
small openings are noted in these sinuses which represents the openings of the
urethral glands (of Littre) and the prostatic ductules.

o PREPROSTATIC SPHINCTER
Thought to prevent retrograde ejaculation, consists of rings of smooth
muscle around the dorsal aspect of the urethra interdigitating ventrally
with the fibers of the anterior fibromuscular stroma

o Prostatic shape-like a chest nut, size: L=3.4 cm W= 4.4cm T= 2.6 cm

URETHRA

MALE
o 1820 cm long, and extends from the internal orifice in the urinary bladder to the
external opening, or meatus, at the end of the penis.

o 2 Parts:
a. Anterior Urethra
- Approximately 16 cm long
- Lies within the perineum (proximally) and the penis (distally),
surrounded by the corpus spongiosum

- Subdivisions:
1. Bulbar urethra (proximal)- surrounded by the bulbospongiosus
and is entirely within the perineum
2. Pendulous or penile component which continues on to the tip of
the penis.

b. Posterior Urethra
- 4 cm long and lies in the pelvis proximal to the corpus spongiosum,
where it is acted upon by the urogenital sphincter mechanisms

- Subdivisions:
1. Preprostatic
o 1 cm in length, and extends from the base of the bladder
to the prostate.

2. Prostatic
o 34 cm in length and tunnels through the substance of
the prostate, closer to the anterior than the posterior
surface of the gland.

3. Membranous
 o Shortest (22.5 cm), least dilatable and, with the
exception of the external orifice, the narrowest section

FEMALE

o 4 cm long and 6 mm in diameter.

o Begins at the internal urethral orifice of the bladder, approximately opposite the
middle of the symphysis pubis

o Runs anteroinferiorly behind the symphysis pubis, embedded in the anterior wall
of the vagina.

o Suspended beneath the pubis by the posterior pubourethral ligaments and

anteriorly by the suspensory ligament of the clitoris.