Urinary System Anatomy PDF
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University of the East Ramon Magsaysay Memorial Medical Center
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Summary
This document provides a detailed overview of the urinary system, beginning with gross anatomy. It covers the functions of kidneys, anatomy of ureters, the urinary bladder, associated blood vessels, and neural connections.
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I. GROSS ANATOMY OF THE URINARY SYSTEM Parts of the Urinary System Kidneys Description: 1. Paired organs responsible forfiltrationof bloodto form urine. 2. Located retroperitoneally on either side of the vertebral column. Functions:...
I. GROSS ANATOMY OF THE URINARY SYSTEM Parts of the Urinary System Kidneys Description: 1. Paired organs responsible forfiltrationof bloodto form urine. 2. Located retroperitoneally on either side of the vertebral column. Functions: 1. Filter bloodto remove: Excess water Salts Wastes of protein metabolism 2. Return nutrients and chemicalsto theblood. 3. Play a critical role in maintaininghomeostasis,including: Electrolyte balance Blood pressure regulation Acid-base balance Urinary Passages 1. Ureters ○ Description: Longmuscular tubes(approximately25-30 cm in length). Transport urine from therenal pelvisof the kidneys to the urinary bladder. ○ Mechanism: Peristaltic waves propel urine towards the bladder. 2. Urinary Bladder ○ Description: Ahollow viscuswithstrong muscularwalls(detrusor muscle). Temporarily stores urine until voiding. ○ Capacity: Can expand significantly due to its distensibility. ○ Location: Empty state: Lies in thelesser pelvis. Filled state: Can ascend into theabdominal cavity. 3. Urethra ○ Description: A passageway for the excretion of urine from the bladder to the external environment. Length varies by sex: Males: ~18-20 cm (also serves as a passage for semen). Females: ~4 cm. ○ Function: Facilitates the act ofmicturition (urine voiding). Functions of the Urinary System A. Excretory Function Filtration and Excretion of Metabolic Wastes: ○ Removes nitrogenous wastes (e.g., urea, creatinine) and other metabolic byproducts. ○ Ensures the elimination of toxins and waste products through urine. B. Maintenance of Body Homeostasis 1. Acid-Base Balance: ○ Regulates blood pH by excreting hydrogen ions (H⁺) and reabsorbing bicarbonate (HCO₃⁻). 2. Fluid Balance: ○ Maintains normal body fluid levels by: Eliminating excess waterwhen hydration is high. Conserving waterduring dehydration. 3. Electrolyte Balance: ○ Adjusts the reabsorption and excretion of essential ions like sodium (Na⁺), potassium (K⁺), and calcium (Ca²⁺). C. Endocrine Function 1. Erythropoietin (EPO): ○ Stimulates the production ofred blood cells (erythrocytes)in the bone marrow. ○ Released in response tolow oxygen levelsin the blood. 2. Renin: ○ Plays a role in theRenin-Angiotensin-AldosteroneSystem (RAAS): Regulatesblood pressureby: Controlling blood volume. Increasing vasoconstriction. 3. Activation of Vitamin D: ○ Converts inactive Vitamin D intocalcitriol, aidingin: Calcium absorption. Bone health. D. Reproductive Function Male Urethra: ○ Dual function: 1. Passageway forurine excretion. 2. Serves as a conduit forsemen transportduring ejaculation. I. GROSS ANATOMY OF THE KIDNEYS Surface Anatomy of the Kidneys General Characteristics Shape: ○ Paired,bean-shaped, and ovoid. ○ Lateral Surface:Convex. ○ Medial Surface:Concave, containing therenal hilum(entry for renal vessels, nerves, and ureter). Position: ○ Retroperitoneal: Located on the posterior abdominal wall, behind the peritoneum on either side of the vertebral column Dimensions of Each Kidney Weight:120–170 g. ength:10–12 cm. L Width:5–6 cm. Thickness (Anteroposterior):2.5–3 cm. Vertebral Level S pansT12 to L3vertebrae in theerect position. Right kidneyis slightly lower than the left due tothe liver. Positional Changes Thekidneys moveduring respiration and posture changes: ○ Shift2–3 cm verticallywith diaphragm movements duringdeep breathing. ○ Inferior pole of the right kidney lies afinger'sbreadth superiorto the iliac crest. Clinical Correlation T heretroperitoneal locationmakes the kidneys vulnerable to trauma. Respiratory movementallows palpation of the kidneyduring a deep breath (especially in thin individuals). Theright kidney's lower positionincreases its risk for exposure during abdominal surgery. PRINCIPAL RELATIONS OF THE KIDNEYS ANTERIOR RELATIONS General Overview ○ Theprincipal anterior relationshipof the kidneysis withabdominal viscera andmesenteries. ○ Thesuprarenal glandscap the kidneys superomedially,with theright suprarenal glandbeingpyramidal-shapedand theleftsuprarenal gland beingcrescent-shaped. RIGHT KIDNEY 1. Medial Relations ○ Descending part of the duodenum. 2. Lateral Relations ○ Ascending colon. 3. Superior Contact ○ Right colic flexure (hepatic flexure). ○ Upper 1/3 of the kidney:in contact with theliver. 4. Peritoneal vs. Retroperitoneal Relations ○ Theanterior surfaceof the right kidney is coveredbyperitoneumwhere it relates to theliverand otherintraperitoneal organs. ○ The area where the kidney contacts theduodenum, suprarenalgland, and colonic structureslacks peritoneum, indicatingretroperitonealzones. LEFT KIDNEY 1. Medial Relations ○ Tail of the pancreas. ○ Spleen. 2. Superior Contact ○ Left colic flexure (splenic flexure). ○ Descending colon. 3. Peritoneal vs. Retroperitoneal Relations ○ Theanterior surfaceof the left kidney relates tointraperitoneal organssuch as thestomach, jejunum, ileum, spleen, and pancreaswhere the peritoneum is present. ○ Areas in contact with thedescending colon, suprarenalgland, and colonic flexurelack peritoneal coverage, representingretroperitonealzones. SUPEROMEDIAL CAPS R ight Kidney:Capped by theright suprarenal gland(pyramidal-shaped). Left Kidney:Capped by theleft suprarenal gland(crescent-shaped). INTRAPERITONEAL VS. RETROPERITONEAL RELATIONS 1. Intraperitoneal Organs: ○ Liver ○ Jejunum ○ Ileum ○ Stomach ○ Pancreas (partly intraperitoneal) 2. Retroperitoneal Organs: ○ Suprarenal glands. ○ Descending duodenum. ○ Descending colon. ○ Right and left colic flexures. POSTERIOR RELATIONS OF THE KIDNEY GENERAL CHARACTERISTICS T hekidneysareretroperitoneal organsthat primarily rest on theposterior abdominal wall muscles. Theirposterior relationsinvolve structural and neurovascularelements that contribute to the kidney'sanatomical bed. UPPER 1/3 OF THE KIDNEY Lies on the following structures: ○ Arcuate ligament of the diaphragm. ○ 11th and 12th ribs(protection from trauma). LOWER 2/3 OF THE KIDNEY Lies on the following structures: ○ Quadratus lumborum muscle: Forms alarge portionof the kidney's posterior bed. ○ Medial (concave) side: Related to thepsoas major muscle. ○ Lateral (convex) side: Associated with theaponeurosis of the transversusabdominis muscle. This aponeurosis contributes to theremaining portionof the kidney's posterior bed. NEUROVASCULAR RELATIONS T hree major nervescross diagonally on the posterior surface of the kidney as they pass over thepsoas muscle: 1. Subcostal nerve (12th intercostal nerve)and vessels. 2. Iliohypogastric nerve. 3. Ilioinguinal nerve. The three key nerves at risk during flank incisions for kidney surgery are: . S 1 ubcostal nerve (T12) 2. Iliohypogastric nerve (L1) 3. Ilioinguinal nerve (L1) Clinical Relevance: T hese nerves run along the posterior abdominal wall near thequadratus lumborum andpsoas majormuscles, making them susceptible toinjury. Damage to these nervescan causesensory deficitsin the lower abdomen, groin, and upper thigh, as well asweakness in abdominal wallmuscles, potentially leading to hernia formation. Thestandard flank incision(such as thelumbodorsalor subcostal incision) provides direct access to the kidneywhileavoiding entry intothe peritoneal cavity, reducing the risk ofbowel injury and adhesions. Theposterolateral approachallows access to the kidneywith minimal disruption of abdominal organs. Key Anatomical Relations of the Kidney 1 External Features of the Kidney Each kidney has: S urfaces→Anterior(related to abdominal organs)&Posterior(related to muscles, nerves) Margins→Medial(contains hilum) &Lateral(convex) Poles→Superior(near adrenal gland) &Inferior 2 Oblique Orientation T helumbar vertebral columnprotrudes into the abdominal cavity, causing the kidneys to be positionedobliquelyrather than perfectlyvertical. This meansthe superior pole is closer to the midlinethan the inferior pole. 3 Radiographic Considerations I nanterior views (AP radiographs), the kidney’stransverse diameter appears foreshorteneddue to its oblique placement. Thesuperior polesarecloser to the midline than theinferior poles,creating anangled orientationrather than a flat, frontal projection. Thehilumfaces anteromedially, affecting its visibility in imaging. Renal Coverings & Clinical Correlation he kidneys are enclosed in layers of fascia and fat, which serve as protection, support, and T insulation. 1. Layers from Deep to Superficial . K 1 idney 2. Renal Capsule– Fibrous connective tissue directlycovering the kidney 3. Perirenal (Perinephric) Fat– Fat surrounding thekidney and extending into the renal sinus 4. Renal Fascia (Gerota’s Fascia)– Fibrous membraneenclosing the kidney, suprarenal glands, and perinephric fat ○ Consists ofanterior and posterior layers ○ Encloses the kidneys, suprarenal glands, and perinephric fat 5. Pararenal (Paranephric) Fat– Fat outside the renalfascia, mainly posterior 2. Functions of Each Layer Renal Capsule irm fibrous connective tissue covering the kidney. F Provides structural support to the renal parenchyma. In a normal person, it can be easily stripped off. In cadaveric kidneys, it adheres firmly to the renal parenchyma. Perirenal (Perinephric) Fat F atty tissue immediately outside the renal capsule. Surrounds the kidney and extends into the renal sinus, cushioning the renal vessels. Renal Fascia (Gerota’s Fascia) Membranous condensation of extraperitoneal fascia. lends with the vascular sheath of the abdominal aorta and inferior vena cava. B Encloses the kidneys, suprarenal glands, and perinephric fat. Separated from the suprarenal glands by a thin septum. Attachments of the Renal Fascia: Superiorly: ○ Anterior and posterior layers fuse and are continuous with the diaphragmatic fascia. ○ This secures the kidney and suprarenal glands, with thesuprarenal gland primarily attached to the diaphragm. Laterally: ○ Fuses with the transversalis fascia. Medially: ○ Continues as the sheath for renal vessels, blending with their vascular sheaths. ○ Prevents fluid from spreading to the contralateral side. Inferiorly: ○ The anterior and posterior layers areloosely attachedand do not fuse. ○ Theperinephric spacebetween these layers narrowsinferiorly and medially, eventually joining theiliac fascia. ○ Theinferomedial angle of the perinephric spaceisitsweakest point, allowing fluid collection to extend into the pelvis. Pararenal (Paranephric) Fat L ocated external to the renal fascia. Derived from extraperitoneal fat in the lumbar region. Accumulatesposterior and posterolateralto the kidney. 3. Clinical Correlation T heattachments of the renal fasciadetermine the possiblespread of infections, blood, or fluidaround the kidney. Perinephric abscesses or pusfrom one kidneycannotcross to the opposite kidney due to thefusion of the renal fascia with the vascularsheath medially. However, due to theloose inferior attachment, perinephricabscessescan extend into the pelvis. Parts of the Kidney he kidneys areovoid-shaped organswith aconvexlateral borderand aconcave medial T borderwhere therenal hilumis located. 1. Renal Hilum and Sinus R enal Hilum: Adeep vertical slitat the medial border leading to therenal sinus. Renal Sinus: A cavity surrounded byperinephric fatcontaining: ○ Renal vessels(arteries and veins) ○ Lymphatic vessels ○ Nerves Arrangement of structures at the hilum (anterior to posterior): . R 1 enal vein(most anterior) 2. Two renal segmental arteries 3. Renal pelvis/Ureter(most posterior) 2. Renal Cortex O uter regionof the kidney, consisting of acontinuous band of brownish tissue surrounding the renal medulla. Includes: ○ Renal Columns (of Bertin): Extensions of corticaltissue between medullary pyramids, dividing the renal medulla. ○ Medullary Rays: Cortical radiations appearing as striationsthat extend into the medulla. Note: The name is a misnomer, as these structuresoriginate in the cortex and extend toward the medulla. 3. Renal Medulla I nner regionof the kidney, made up of6-10 conical-shaped renal pyramids. Eachrenal lobeconsists of arenal pyramidand itsassociatedcortical tissue (at its base and sides). Key Structures of the Medulla: Renal Pyramid ○ Apex: Also called therenal papilla, where filtrateexits. ○ Base: Faces thecortexand is associated withmedullaryrays. Area Cribrosa ○ Smallperforated openingsat therenal papilla, allowingurine passage into the minor calyx. 4. Renal Calyces and Pelvis Minor Calyx: ○ Cups the renal papillato collect urine. ○ Several minor calycesmergeto form amajor calyx. Major Calyx: ○ Formed by theunion of 2-3 minor calyces. ○ Merges to form therenal pelvis. Renal Pelvis: ○ Funnel-shapedstructure at the superior end of theureter. ○ Urine passes from the renal pelvis → ureter → bladder → urethra for excretion. Embryology of the Kidney Fetal and Newborn Stage: ○ Therenal lobesare distinctly outlined on the kidney’ssurface. ○ Innewborns and infants, the kidneys appearlobulatedon X-rays due to the protrusion of renal lobes. Adult Stage: ○ he renal lobesfuseover time, resulting in asmooth kidney surface. T ○ The lobulated appearancedisappears during pubertyas the lobes flatten. Renal Lobe Composition: ○ 1 renal pyramid + its surrounding cortex=1 renal lobe Arterial Supply of the Kidneys . Arrangement of Structures at the Renal Hilum (Anterior to 1 Posterior) - "VAUA" Mnemonic: . 1 enal Vein R 2. Renal Artery 3. Ureter 4. Segmental Artery 2. Renal Arteries M ain arterial supply of the kidneys Branches of the abdominal aorta, arising at the levelofL1-L2, just inferior to the superior mesenteric artery Right Renal Artery ○ Longerthan the left renal artery ○ Passesposterior to the inferior vena cava (IVC) Left Renal Artery ○ Arises slightly higherthan the right renal artery 3. Segmental Arteries N ear therenal hilum, eachrenal artery divides into five segmental arteries, each supplying a different kidney segment: ○ Apical (Superior) Segmental Artery ○ Anterosuperior Segmental Artery ○ Anteroinferior Segmental Artery ○ Posterior Segmental Artery ○ Inferior Segmental Artery Segmental arteries are end arteries, meaning: ○ They donot anastomose significantlywith each other. ○ Each arterysupplies a specific, independent segmentof the kidney. 4. Clinical Correlation: Partial Nephrectomy P artial nephrectomyis a surgical procedure where adiseased kidney segment is removedwhile preserving the remaining viable kidneytissue. This is possible due to thelack of significant anastomosisbetween segmental arteries, allowingeach segment to function independently. Venous Drainage of the Kidneys 1. Venous Drainage Pathway F ollows the course of the arterial supply Drains directly into the inferior vena cava (IVC) Major veins involved: ○ Right Renal Vein→ Drains directly into the IVC ○ Left Renal Vein Three times longerthan the right renal vein Crosses the midline, passingbetween the superiormesenteric artery (SMA) and the abdominal aortabefore draining intothe IVC Receives tributaries from: 1. Inferior phrenic vein 2. Left suprarenal vein 3. Left gonadal vein Male:Left testicular vein Female:Left ovarian vein 4. Left ascending lumbar vein 2. Lymphatic Drainage Aortic (para-aortic) and caval (paracaval) lymph nodes . Clinical Correlation: Renal Vein Entrapment Syndrome (Nutcracker 3 Syndrome) Cause: ○ Compression of theleft renal veindue todownwardtraction of the superior mesenteric artery (SMA) ○ Often secondary totumors or aortic aneurysm Clinical Manifestations: ○ Nausea & vomiting ○ Hematuria / Proteinuria(due to venous congestion) ○ Left abdominal flank pain ○ Left testicular pain(left-sided varicocele) Diagnosis: ○ Ultrasound ○ CT scan Innervation of the Kidneys 1. Renal Nerve Plexus P rimary nerve supply of the kidneys Consists ofsympathetic and parasympathetic fibers Derived from: ○ Abdominopelvic splanchnic nerves Lesser splanchnic nerve(T10-T11) Least splanchnic nerve(T12) ○ Celiac ganglion and plexus ○ Aorticorenal ganglion 2. Functional Role of Renal Nerve Plexus Indirect contactwith: ○ Renal vasculature ○ Renal tubules ○ Juxtaglomerular cells Plays a crucial role inregulating systemic bloodpressure 3. Effects of Sympathetic Stimulation . D 1 ecreases renal blood flow (RBF)→ By causing vasoconstriction 2. Decreases glomerular filtration rate (GFR)→ By reducingperfusion pressure 3. Increases sodium and water reabsorption→ By enhancingproximal tubule and loop of Henle function 4. Stimulates renin release→ Fromjuxtaglomerular cells,leading to activation of the renin-angiotensin-aldosterone system (RAAS) III. URETERS Ureters 1. Overview aired muscular tubes P Retroperitoneal(like the kidneys) Length:25-30 cm Thick-walled and narrow Function: ○ Peristaltic contractionspropel urine from the kidneys to the urinary bladder 2. Course of the Ureters riginate at the renal pelvis (hilum of the kidney) O Run inferiorlytowards the abdomen Cross over the pelvic brimat the bifurcation of thecommon iliac arteries Continue along the lateral wall of the pelvis Enter the urinary bladderobliquely 3. Superior and Inferior Relations S uperiorly:Begins as thefunnel-shaped renal pelvis Inferiorly:Becomes continuous with theurinary bladder 4. Parts of the Ureter . 1 enal Pelvis– Expanded funnel-shaped origin in the kidney R 2. Abdominal/False Ureter– Located in the abdominalcavity 3. Pelvic/True Ureter– Located in the pelvic cavity 4. Intravesical Ureter– Terminal part that penetrates the urinary bladder wall Ureteric Relations 1. Abdominal Ureter Location: ○ Descendsretroperitoneallyalong themiddle aspectof the psoas major muscle Blood Vessel Relations: ○ Right ureter:Lieslateral to the IVC ○ Left ureter:Lieslateral to the abdominal aorta ○ Gonadal vessels (testicular or ovarian arteries and veins)cross overthe ureter 2. Pelvic Ureter Course: ○ P assesover the common iliac arteryorthe beginning of the external iliac artery ○ Enters thepelvic ring, transitioning into thepelvicureter 3. Intravesical Ureter Course: ○ Runsparallel to the internal iliac arteries ○ Passes through themuscular wall of the bladderinaninferomedial direction Clinical Significance Surgical importance: ○ Care must be takennot to retract the abdominal ureterlaterallytoprevent damageto its fragile small vessels Male and Female Ureteric Relations Female Ureter Course: ○ Passesunder the uterine vessels ○ Locatednear the isthmus of the uterusas it entersthe bladder Clinical Significance: ○ During hysterectomy (uterus removal),theureter isat risk of accidental injurydue to its close relationship with theuterineartery ○ Theuterine artery may be mistakenly ligated alongwith the ureter Mnemonic: "Water Under The Bridge" ○ Water→ Ureter (carries urine) ○ Bridge→ Uterine vessels (which pass over the ureter) ○ Gonadal vesselsalso act as a bridge over the abdominalureter Male Ureter Course: ○ Thevas deferens (ductus deferens) crosses superiorto the ureter ○ This occursat the posterolateral angle of the bladder B. Neurovasculature of the Ureters 1. Arterial Supply of the Ureters Abdominal Portion M ain Supply:Renal arteries(constant) Additional branches (Medial Longitudinal Anastomosis): ○ Gonadal arteries ○ Abdominal aorta Pelvic Portion Main Supply: ○ Common iliac arteries ○ Internal iliac arteries Distal Ureter Supply: ○ Superior and Inferior Vesical Arteries(branches ofinternal iliac) ○ Inferior Vesical Artery:Consistently supplies thedistal ureter 💡 Surgical Consideration: T he arteries supplying the ureters are locatedmediallyand formascending and descending branches, creating alongitudinal anastomosisalong the ureteric wall. Avoid lateral retraction of the ureterduring surgery,as this maydisrupt delicate arterial branchesand causeischemia. 2. Venous Drainage of the Ureters Abdominal Ureter: ○ Drains intorenal and gonadal veins 3. Innervation of the Ureters Nerve Plexuses Involved: enal plexus(upper part) R Abdominal aortic plexus Superior hypogastric plexus & hypogastric nerve(intermediatepart) Inferior hypogastric plexus(lower part) Visceral Afferent Pain Fibers U reteric pain followsT11 - L2 spinal segments Referred pain:From theloin to the groin(along dermatomessupplied by T11 - L2) 💡 Pain Pathway Explanation: E xcessive dilation orspasm of the ureter(e.g., duetoureteric calculi) causes intermittent, severe pain Referred pain areas: ○ Ipsilateral lower quadrantof the abdomen ○ Lumbar region ○ Groin area ○ Anterior proximal thigh ○ Scrotum (males) / Labia majora (females) Reason for referred pain: ○ Sensory inputs from both theskin (higher regions)andureter (lower regions) converge at the same spinal level, leading to misinterpretationof pain location. 4. Lymphatic Drainage of the Ureters Ureteric Part Primary Lymph Nodes Superior Lumbar nodes Middle Common iliac nodes Inferior Common, external, and internal iliac nodes Note: L ymphatic vessels from thekidney and upper uretermay draindirectly into lumbar nodes near the origin of the gonadal artery. . Clinical Correlation: Ureterolithiasis (Ureteric 5 Calculi) Pathophysiology: ○ Stones gettrapped at ureteric constrictions, leading todistention and obstruction ○ Causesrhythmic, sharp pain(ureteric colic) Pain Distribution (Referred Pain): ○ Sensory fibers travel toT11 - L2 spinal levels, sopain is feltfrom the loin to the groin ○ Dermatomes affected: Ipsilateral lower abdomen Groin & proximal thigh Scrotum (males) / Labia majora (females) Confirmatory Diagnosis: ○ Ultrasound ○ CT Scan Key Takeaways ✅ Arteries run medially; avoid lateral traction during surgery ✅ Pain from ureteric stones follows T11-L2 ("lointo groin") ✅ Distal ureter is consistently supplied by the inferiorvesical artery ✅ Lymphatic drainage varies based on ureteric level Ureteric Constrictions and Clinical Relevance heureteris a muscular tube that transports urinefrom therenal pelvisto theurinary T bladderviaperistalsis. Along its course, the ureterhasthree anatomical constrictions, which arecommon sites for ureteric stone obstruction. Theseconstrictions are particularly important inradiographic imaging and clinical diagnosis. Three Anatomical Constrictions of the Ureter hese narrow regions can bevisualized using contraststudiesand are sites whereureteric T calculi (stones)are more likely to becomeimpacted. 1. Ureteropelvic Junction (UPJ) ○ Location: The transition between therenal pelvisand theproximal ureter. ○ Significance: The renal pelvis is wider, and thissudden narrowingcan hinder the passage of larger stones. 2. Pelvic Brim ○ Location: Where the ureter crosses theexternal iliacarteryat the level of the pelvic inlet. ○ Significance: The ureter must pass over the bony structure of the pelvic brim, which creates a natural site forobstruction. 3. Ureterovesical Junction (UVJ) ○ Location: Where the ureter passes through themuscularwall of the urinary bladder. ○ Significance: This is thenarrowest part of the ureter,making it themost common site for stone impaction. Clinical Significance 1. Ureteric Colic and Pain Referral O bstructed urine flowdue to a stone can causehydronephrosis(dilation of the renal pelvis and calyces) andureteric colic. Pain characteristics: ○ Severe, intermittentflank pain(loin-to-groin pattern). ○ Pain intensity fluctuates withperistaltic contractionsof the ureter. ○ Referred pain followsT11–L2 dermatomes, affectingareas like thelower abdomen, inguinal region, and genitalia. 2. Radiological Identification I ntravenous Urography (IVU)orCT Urography (CTU)can help visualize the constrictions and detect ureteric stones. Ultrasoundis used for detectinghydronephrosisandassessing renal function. 3. Ureteric Calculi (Kidney Stones) and Their Management S mall stones(
