LECTURE 2 - ANATOMY OF THE URETERS, BLADDER AND URETHRA

C. PARSONS
LEARNING OBJECTIVES

To identify and describe structures of the urinary system, from ureters to urethra
To become familiar with blood supply, drainage and innervation of these
structures
To understand the control and process of urination

URETERS
RENAL PELVIS
The ureters begin at the hila of the renal
pelvis, called the ureteropelvic
junction. The renal pelvis originate
from the major calices, which
themselves are formed by multiple
minor calices.
The ureters are paired muscular
tubes 25-30 cm in length that
forces the path of the urine into the
bladder. They descend on the medial
aspect of the psoas major muscle, and
at the pelvic brim, they cross the
common iliac artery just where it
bifurcates into the external and internal
iliacs. However sometimes they cross a bit
more laterally than that (individual
variations) and hence instead cross the external iliac artery. They then curve along the
lateral wall of the pelvis, before curving inward anteromedially
to enter the bladder.
There are 3 major points of constriction of the ureters, which
are of clinical significance because this is usually where kidney
stones lodge:
1. Ureteropelvic junction
2. Crossing external iliacs
3. As ureter traverses the bladder
o The ureters enter the bladder a little bit
obliquely through the bladder walls about 2.5 cms
apart from one another

BLOOD SUPPLY TO URETERS

Blood supply to the ureters is varied. Branches from the renal artery,
gonadal artery, the aorta itself and branches from the internal iliac
artery may be commonly involved in the ureter blood supply. Note that
branches supplying the abdominal part of the ureters approach medially,
while in the pelvis, the vessels approach laterally to the ureters.
Venous drainage in the abdominal region is usually toward the renal and
gonadal veins, while venous drainage in the pelvic region is generally
towards various venous plexuses, especially the vesical venous plexuses
which occupies the fundus region of the bladder.

VENOUS DRAINAGE OF THE PELVIS

Most of the pelvic viscera, other than the blood supply associated with the superior part
of the rectum (the superior rectal vein is associated with the inferior
mesenteric vein, which is part of the hepatic portal system this is
depicted in purple), is drained through the inferior vena caval
system (blue), via the internal iliac.
In many cases the veins are similarly named to the arteries.

PELVIC VENOUS PLEXUSES

These are a fine network of veins surrounding the pelvic viscera:

Rectal
Vesical
Prostatic
Uterine
Vaginal

These mostly drain into branches of the internal iliac, but also form anastomoses with
veins from the portal system. In cases of liver disease, where you have reduced portal
blood flow, alternative routes of blood flow may form through the caval system.

INNERVATION OF URETERS
Nervous supply is from the local autonomic plexuses.
Innervation of the ureters is normally through T11-L1 which is
referred to as above the pelvic pain line, which spans the upper
part of the bladder too.
The pain from the ureters is referred to the ipsilateral lower
quadrant, particularly the inguinal region. For example, pain from a
kidney stone would be referred pain, and you would perceive it
from the ipsilateral lower quadrant loin to groin pain.

URINARY BLADDER
The bladder has strong muscular walls of detrusor muscle and is
highly distensible. It is the reservoir for urine, and varies in size and shape depending on
the fullness of the bladder and also other viscera.
In adults, it occupies the lesser pelvis when empty and extends to the abdominal cavity
when full. In children less than 6 years old, the bladder is abdominal, and is only truly
pelvic during puberty.
The floor of the bladder is firmly anchored or youd have a floating bladder expelling pee
everywhere, whereas the superior surface is surrounded with looser connective fascia
and is hence able to expand up into the abdominal cavity.
In its empty state (refer to diagram) it resembles a
tetrahedron.

The apex is:

o Oriented to the top of pubic symphysis
o Urachus (median umbilical ligament) arises
from the apex umbilicus
The base is:
o Triangular
o Ureters enter at 2 superolateral corners
o The urethra exits at the inferior corner (neck of
the bladder) of the trigone bounded by the
triangle
The inferolateral surfaces are:
o Bounded by the levator ani muscles of the
pelvic diaphragm and obturator internus muscles

The trigone area is characterised as being a smoother surface that is highly mucosal. The
surface is intimately associated with
the underlying muscle in the trigone
region, and is more loosely
connected in areas outside the
trigone.

WALL OF BLADDER
Detrusor muscle forms the wall of the bladder. In
males the muscle forms the internal urethral
sphincter which contracts to prevent ejaculatory reflux of semen back into the bladder
this sphincter usually has some sympathetic tonic contraction in its normal state.
In males, muscles in the neck of the bladder are continuous with fibromuscular tissue of
the prostate (which is almost adjacent to the bladder in males). In females, the muscular
walls of the bladder are continuous with those of the walls of the urethra.
Loops of the detrusor muscle also form circular sphincter-like rings around the ureteric
orifices. When the detrusor muscle is contracted, the circular muscles of the detrusor
muscles around the orifices also contract, preventing reflux of the urine back up the
ureters in the contracted state.

important in
things are. The

Above
diagram is not
terms of labels just shows where

male
diagram
shows a full bladder while the
female one is collapsed. In males, the urethra has 2 curvatures as it runs through the
penis. One obvious difference between males and females is that there is a relatively
short urethra in females when compared to males. In females it is ~4 cm while in males
it is ~20 cm.

ARTERIAL SUPPLY OF THE BLADDER

The bladder is supplied by branches of the internal iliac. The anterosuperior region is
supplied by the superior vesicle artery. In males, the fundus and neck are supplied by the
inferior vesicular artery, while in females it is supplied by the vaginal arteries. The
obturator and inferior gluteal arteries also supply branches to the bladder in a less
significant manner.
Venous drainage to the bladder corresponds to arterial supply

MALES
Vesical venous plexus, which is
continuous with the:
Prostatic plexus
o Combined, these plexuses
cover the inferior ureter,
fundus of bladder, prostate

FEMALES
Vesical venous plexus
o Covers the neck of bladder
and associated urethra
(pelvic portion)

INNERVATION OF THE BLADDER

The bladder is mainly innervated by the vesical plexus,
a plexus which basically lies on the plexus. It is a
mixed sympathetic/parasympathetic supply:

Sympathetic:
o Inferior thoracic, upper lumbar
regions supply sympathetic fibres to
the plexus
Parasympathetic::
o Sacral S2-S4 arising from pelvic
splanchnic and inferior hypogastric plexus

The external urethral sphincter is under somatic

control and there are hence somatic sensory fibres
running up from this part of the urethra, eventually joining with the sacral plexus.

URETHRA
MALES
The urethra is a muscular tube about 20 cm long (18-22 cm range). The internal urethral
orifice is the beginning of the urethra and the urethra ends at the external urethral
orifice. There are four parts:

Intramural or preprostatic urethra

o Just at the exit of the bladder,
occupying the internal urethral orifice
(?)
Prostatic urethra
Internemediate/membranous
urethra
Spongy urethra
o Basically travels through the length of the

penis

The urethra has purposes in both reproduction and voiding

of urine.
The urethral crest is bordered by the fenestrated prostatic sinuses (2 nd diagram). Through
these fenestrations, the prostatic fluid is released in the emission stage, just prior to
ejaculation. The ejaculatory duct is where the ductus deferens enters the urethra. It is at
the top part of the 2nd diagram at the first schematic constriction that the urethra has its
dual purpose.

Entering the urethra are also ducts coming from the bulbourethral glands (bottom of 2 nd
diagram, near bulb of penis), near
the spongy part of
the urethra.
BLOOD SUPPLY AND DRAINAGE
TO MALE URETHRA
Proximally (area around the
prostate gland in the bladder), the
urethra is supplied by prostatic
branches of the inferior vesicle
and middle rectal arteries. It is drained by the
prostatic plexus
Distally, the urethra is supplied
by the dorsal artery of the penis, which itself is a branch of the internal pudendal artery.

FEMALES
In females the urethra is 4 cm long and 6 mm in
diameter (not 6cm as Carl Parsons has written in
his lecture). The internal urethral orifice does not
have a sphincter. The female urethra is more
distensible and hence easier to pass a catheter up
through, as it has a lot of elastic fibres
incorporated in its walls. The external urethral
orifice lies within the vestibule of the vagina. Vaginal
and internal pudendal arteries supply the area, while the veins of the same name drain it.
The image shows the female bladder and urethra. The image shows the external
sphincter deep in the perineal pouch, in the floor of the pelvis

CONTROL OF URINATION
Urination is under both reflexive control
and somatic). The spinal cord sends
parts of the bladder but toilet training
control over the voiding of urine.
There are parasympathetic motor fibres
to the detrusor muscle of the bladder,
providing contraction of the detrusor
muscle. The preganglionic parasympathetic
components come from branches of S2S4. Close to the bladder, we have
parasympathetic ganglion, situated
close to the bladder. There are
mechanoreceptors in the wall, or
stretch receptors, which provide an
indication of when the bladder is
distending. These mechanoreceptors are
nerve endings of cell bodies located
within the dorsal root ganglion, which

and voluntary control (both autonomic

reflex loops down to control
means we have voluntary

the
pick up

signals from the receptors located in the detrusor muscle. They have the ability to send
these signals up into the brainstem (NTS usually involved) hence involving central control
of the system.
When we get the filling sensation, it sends outflow through the sympathetic system,
which relaxes the detrusor muscle (acting against the parasympathetic system) and also
in males, tightens the internal sphincter, providing some tone for the internal sphincter.
When we have a full bladder, the afferent activity increases, and there is a centrally
mediated increase in parasympathetic tone which tends to contract the detrusor muscle
and bladder, overriding sympathetic signals there is also a decrease in sympathetic
tone. In males, the internal urethral sphincter in males at this time is relaxed, and the
only thing that stops the urine from flowing out is the external urethral sphincter, which
is under voluntary control. In babies and people lacking voluntary control (e.g. due to
high SCI), the urine is stored in the bladder until it reaches tipping point, and then all
rushes out it doesnt drip out as it is being formed.

SUMMARY

Urine formed in the kidney is conveyed by ureters to

the bladder, and voided
via urethra
Renal caliculi may lodge in narrowings of ureters
Arterial supply of the urinary tract shows individual
variation, drainage often
follows supply
Voiding urine involves interplay between autonomic and somatic nervous systems