Urinary Tract Lecture 3 PDF

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 Copyright notice Material which is made available by way of an electronic database may be subject to certain licensing conditions. These conditions normally entail that you may only use the material for your own private study and research at the University and not for any other purpose. It is expected of you to adhere to these conditions at all times. Printed material is also only made available for class discussion, private study and research purposes. Further reproduction of such material is prohibited /Materiaal wat by wyse van elektroniese databasis aan u beskikbaar gestel is, mag onderhewig wees aan bepaalde lisensievoorwaardes. Sulke voorwaardes behels normaalweg dat u die materiaal slegs vir u eie private studie en navorsing aan die Universiteit kan gebruik en vir geen ander doeleindes hoegenaamd nie. Daar word van u verwag om te alle tye aan hierdie voorwaardes gehoor te gee. Gedrukte materiaal word eweneens slegs vir klasbespreking, private studie en navorsingsdoeleindes beskikbaar gestel. Die verdere reproduksie daarvan is ontoelaatbaar. 2  Outcomes Describe the anatomy of the ureters: Course on the posterior abdominal wall and in the pelvis (male and female). Sections where constrictions are commonly situated. Blood supply. Nerve supply. Describe the anatomy of the urinary bladder: General location, shape & structure. Relations of the bladder. Blood supply. Nerve supply. Lymphatic drainage. Describe the structure & course of male & female urethra. Name and describe the branches of and structures supplied by the internal iliac artery in both the male and female pelvis and name the structures that are supplied by each branch. 3 URINARY TRACT 4 Overview 5  Urinary Tract - overview Course Constrictions Structures Ureters crossing Blood supply Nerve supply Location Shape and structure Urinary Relations bladder Blood supply Nerve supply Lymphatic drainage Course (male and Urethra female) Structure 6 Ureters 7  Ureters: Course Muscular ducts: 25-30 cm long. Retroperitoneal throughout course. Transport urine from the kidney to the bladder. Abdominal part Run inferiorly from renal pelvis at hilum. Crosses brim of pelvis at bifurcation of common iliac arteries. Pelvic part Run along lateral wall of pelvis. Swing anteromedially opposite ischial spine, superior to levator ani muscle. enters base of urinary bladder at upper corners. Passes obliquely through the bladder muscle – forms one-way valve. 8  Ureters: Constrictions Three Constrictions: 1. Junction of ureters and renal pelvis. 2. Where ureters cross brim of pelvic inlet over the common iliac artery. 3. During passage through wall of urinary bladder. 9 Structures crossing ureters MALE FEMALE Abdominal part: crossed anteriorly by ovarian artery in females and testicular artery in males (39). Ductus (vas) deferens Ovarian artery 10  Ureters: Blood supply Abdominal part: Mainly from the renal artery (from the medial side of ureter) Drained by renal and gonadal veins Pelvic part: From common iliac, internal iliac and gonadal arteries. Branches anastomose along length of urethra. Terminal end supplied by uterine arteries in female, and inferior vesical arteries in male. Venous drainage - names correspond to arteries. 11  Ureters: Nerve supply Renal, abdominal aortic, and superior & inferior hypogastric plexuses. Pain sensation: visceral afferent fibres to spinal ganglia and cord regions T11-L2. Ureteric pain: usually referred to lower quadrant of the anterior abdominal wall, including the groin. 12 Urinary Bladder 13 Urinary bladder - Overview Hollow organ with strong muscular walls. Distensible. Temporary reservoir for urine. Most anterior of the pelvic organs. Situated in pelvic cavity when empty. Expands into the abdominal cavity when full. 14  Urinary bladder: Location Adults: Empty bladder partially superior & posterior to pubic bones (retropubic space). Superior surface level with superior margin of pubic symphysis. Superior to pelvic floor, almost entirely within lesser pelvis. Inferior to peritoneum. Full bladder – extends into greater pelvis in extraperitoneal fat of anterior abdominal wall Infants and young children: Located in abdomen even when empty → enters pelvic cavity around 6 years of age. 15  Urinary bladder: Shape Empty: pyramid-shaped (that has fallen onto one margin) with four surfaces: Superior (only surface covered with peritoneum). Posterior. Two inferolateral. Parts: Apex – behind symphysis pubis. Base (Fundus) – opposite apex. Body – between apex & base. Neck – inferior at meeting of base and inferolateral surfaces.  Urinary bladder: Parts Apex Points towards top of pubic symphysis Median umbilical ligament (remnant of the urachus) continues superiorly up anterior abdominal wall to umbilicus. Base Inverted triangle shape, points posteroinferiorly. Ureters enter at the upper corners. Urethra drains from lower corner. Smooth triangular area between ureters & urethra – trigone Inferolateral surfaces Between levator ani and obturator internus muscles above attachment of pelvic diaphragm. 17  Urinary bladder: Structure Wall composed of smooth muscle – detrusor muscle: Forms internal urethral sphincter at neck (only in males). Urinary continence, prevents reflux of semen into bladder in males. Loops that encircle ureteric orifices –form valves to prevent backflow of urine. Trigone of urinary bladder: smooth area containing ureteric orifices & internal urethral orifice. Neck surrounds internal urethra orifice. Anchored by fibromuscular bands: pubovesical ligaments (in females); pubroprostatic ligaments (in males). 18  Urinary bladder: Relations Posterior: Seminal glands (males). Vas deferens (males). Rectovesical space and septum (males). Superior part of vagina (females). Anterior: Pubic symphysis. Pubic bones. Retropubic space. Superior: Peritoneum. Small intestines. Vesico-uterine space (females). Infero-lateral Levator ani & obturator internus muscles.  Urinary bladder: Blood supply Branches of internal iliac arteries. Male Superior vesical artery supplies anterosuperior parts. Inferior vesical artery supplies fundus and neck in males. Vaginal artery supplies fundus and neck in females. Branches of obturator & inferior gluteal also contribute small branches. Female 20 Urinary bladder: Blood supply Female Venous drainage via vesical venous plexus into internal iliac veins: veins have same names as arteries. Vesical venous plexus also drains internal structures & penis of male (prostatic plexus) In females, vesical plexus receives blood from clitoris and communicates with vaginal & uterine venous plexuses. Male 21  Urinary bladder: Nerve supply Sympathetic fibers from inferior thoracic and upper lumbar (T11-L2 or L3) to the vesical plexuses through the hypogastric plexuses and nerves. Parasympathetic fibers from S2, S3 and S4 conveyed by pelvic splanchnic nerves and inferior hypogastric plexus (contract bladder). Motor to detrusor muscle and inhibitory (relaxation) to the internal urethral sphincter of bladder (only present in males). Sympathetic innervation at ejaculation in males: contraction of internal urethral sphincter (prevents semen from entering bladder). Reflex information & pain follow parasympathetic fibers below pelvic pain line (subperitoneal part of bladder) or sympathetic fibers for above pelvic pain line (superior surface) 22 https://sites.google.com /a/umich.edu/bluelink/c urricula/first-year- medical- curriculum/sequence-5- gastrointestinal/perineu m/perineum-lo-10 23  Urinary bladder: Lymphatic Drainage Inferior part & neck of bladder: drain to internal iliac nodes. Supero-lateral part into external iliac nodes. Neck also drains into sacral and common iliac nodes. 24 Urethra 25  Urethra: Female Begins at base of bladder at internal urethral orifice. Ends at external opening in perineum. Course is different in males and females. Females: conveys urine only. Males: conveys urine and semen (not at the same time). Female urethra: short (4cm). Passes inferiorly through pelvic floor into perineum. Passes through deep perineal pouch & perineal membrane. Female External urethral sphincter (skeletal muscle) surrounds urethra in the pouch. Opens into vestibule (between labia minora). Urethral opening: anterior to vaginal opening. Posterior part of urethra is attached to anterior surface of vagina. Paraurethral mucous glands (Skene’s glands) open onto lateral margin of external urethral orifice. 26  Urethra: Male Male Male urethra: long (20cm). Two bends along its course. Begins at base of bladder and passes inferiorly through prostate gland. Passes through deep perineal pouch and perineal membrane to enter root of penis. As it exits deep perineal pouch, bends anteriorly in the root of penis. When penis is flaccid, 2nd bend inferiorly when passing to the body of penis. When erect, no bend between root and body. Divided into preprostatic, prostatic, membranous and spongy parts. 27  Urethra: Male Preprostatic part: 1cm long, extends from base of bladder to prostate gland, is associated with internal urethral sphincter (smooth muscle). Prostatic part: 3-4cm long, surrounded by prostate gland. Lumen is marked by longitudinal midline fold of mucosa: urethral crest. Depression on each side of crest: prostatic sinus Ducts of prostate empty into sinuses. Seminal colliculus: circular elevation midway along urethral crest. Prostatic utricle (blind ended pouch) opens into seminal colliculus. On each side of prostatic utricle is the opening of the ejaculatory duct (conveys sperm from testis into urethra). Membranous: passes through deep perineal pouch, surrounded by external urethral sphincter (skeletal muscle). Spongy: surrounded by erectile tissue (corpus spongiosum) of penis. Enlarged at end of penis: navicular fossa. Bulbourethral glands in the deep perineal pouch open into the bulb at the base of the penis. External urethral orifice: sagittal slit at end of penis. 28  Internal Iliac Artery https://www.youtube.com/watch?v=j8vRnioqVfU 29 2+4+4 30 2+4+3 31  Internal iliac artery Arises from common iliac artery. Descends posteromedially into the lesser pelvis, medial to external iliac vein & obturator nerve, lateral to the peritoneum. Supplies pelvic viscera, pelvic walls & floor, perineum, gluteal region. Divides into anterior and posterior divisions. Many variations and connections (anastomoses) between branches. 32 Artery Course Distribution Anastomoses Umbilical Course along lateral pelvic To placenta (prenatal). Postnatally None usually wall, ascend anterior obliterates (medial umbilical ligament). abdominal wall to the Part remains patent. umbilicus. Superior vesical Passes from patent umbilical Superior part of bladder. Inferior vesical artery to superior aspect of (males). bladder. Vaginal (females). Obturator Anteroinferiorly on obturator Pelvic muscles, ilium, head of femur, Inferior epigastric; fascia of lateral pelvic wall, muscles of medial thigh. umbilical. exits via obturator canal Inferior vesical Subperitoneal in lateral Inferior aspect of bladder, pelvic part Superior vesical (males) ligament of bladder, gives rise of ureter, prostate & seminal glands. artery to prostatic artery. Middle rectal Descends to inferior rectum Inferior part of rectum, seminal glands Superior & & prostate (males), vagina (females) inferior rectal arteries Uterine Runs anteromedially in base Uterus, ligaments of uterus, medial Ovarian artery; (females) of broad ligament, gives rise parts of uterine tube & ovary, superior vaginal artery to vaginal, crosses ureter to vagina reach lateral aspect of cervix 33 Artery Course Distribution Anastomoses Vaginal (females) Divides into vaginal (descends on Vaginal: lower vagina, vestibular Uterine artery; superior vagina) & inferior vesical branches bulb, adjacent rectum. vesical artery (passes to bladder) Inferior vesical: fundus of bladder Superior gluteal Passes between lumbosacral Piriformis, gluteal muscles, tensor Lateral sacral, inferior trunk & anterior ramus of S1, exits fasciae latae gluteal, internal pelvis via greater sciatic foramen pudendal, deep& lateral (above piriformis) circumflex femoral arteries Iliolumbar Ascends anterior to sacroiliac joint Psoas major, iliacus, quadratus Circumflex iliac artery; & posterior to common iliac lumborum; cauda equina of spinal 4th lumbar artery vessels & psoas major. Divides cord into iliac & lumbar branches Lateral sacral Anteromedial aspect of piriformis, Piriformis, structures in sacral canal, Medial sacral arteries branches enter pelvic sacral erector spinae, overlying skin foramina Inferior gluteal Exits pelvis via greater sciatic Pelvic diaphragm (coccygeus, Deep femoral artery foramen (below piriformis) levator ani), piriformis, quadratus femoris, superior hamstrings, gluteus maximus, sciatic nerve 34 Artery Course Distribution Anastomoses Internal Exits pelvis via greater sciatic Main artery of perineum, supplying the None usually pudendal foramen (below piriformis), muscles& skin of anal and urogenital enters perineum by passing triangles, erectile tissues of penis and through lesser sciatic clitoris. foramen, passes through the pudendal canal to the urogenital triangle 35 THANK YOU FOR LISTENING 36