Anatomy

Tuesday, November 18, 2014

9:17 AM

+ Clinical Supplement, Section E. Abdomen & Section F. Pelvis and Perineum

78. Renal cysts: Large, fluid-filled cysts are common in older individuals; multiple cysts may lead to renal
failure (e.g. polycystic kidney disease)

79. Renal carcinoma: arise most commonly from the tubular epithelium, associated with hematuria and back
pain; can metastasize via renal veins to the lungs.

80. Renal hypertension: The kidneys play an important role in monitoring blood pressure. Stenosis of a renal
artery reduces blood flow through the kidney (the kidney detects lower pressure) resulting in elevated blood
pressure.

81. Renal transplantation: Transplanted kidneys are typically placed along the iliac fossa; the transplanted
renal arteries are anastomosed with the internal iliac artery

82. Ureteric calculi: Kidney stones may pass into the renal pelvis and ureter; may refer pain anywhere from
the back to the external genitalia [See #87 Abdomen]

83. Nephroptosis: inferior displacement of the kidney due to insufficient peri-renal adipose tissue; may be
associated with flank or groin pain and hematauria

84. Constrictions: the ureters are constricted in three places (i.e. where a kidney stone can become lodged):
a. at the junction of the renal pelvis and ureter
b. crossing the pelvic inlet
c. passage through the wall of the bladder
d. **stones may also become lodged where the testicular/ovarian vessels cross the ureter

85. Obstructions of the ureter (from any cause) can lead to hydronephrosis enlargement of the ureter, renal
pelvis and/or calyces

86. Abdominal organs are supplied with a sympathetic innervation in a viscertomal pattern (i.e. organs are
innervated in a rostro-caudal sequence that is directly related to the early gut tube):
i. Kidney T10 - L1
j. Upper ureter T10 L1
k. Lower ureter L1 - L2

87. Map of referred pain from thoraco-abdominal organs:

6. Damage to the perineal body/pelvic floor - disruption of the perineal body (e.g from episotomy) can result
in dysfunction of the muscles of the levator ani and herniation of pelvic contents:
a. cystocele collapse of the bladder into the anterior wall of the vagina; can occur also with injury to the
supportive structures of the vagina
b. rectocele anterior and inferior protrusion of the rectum
c. enterocele anterior and inferior protrusion of the rectovaginal pouch

7. Rupture of the male urethra:

a. Recall - the superficial fascia of the abdominal wall (Scarpas) continues onto the penis and scrotum as
Dartos fascia and that the deep investing fascia extends over the shaft of the penis as Bucks fascia and
over the superificial perineal muscles (external perineal fascia).
b. Lacerations of the spongy urethra + Bucks fascia intact = urine spreads along the shaft of the penis
c. Laceration of the spongy urethra + Bucks fascia torn = urine leaks into the superficial pouch
(scrotum) along the shaft of the penis and along the anterior abdominal wall, deep to Scarpas fascia

11. Suprapubic cystotomy when the bladder is full or distended (or in children), it can be approached
immediately superior to the pubic symphysis, avoiding entering the peritoneal cavity. What structures are in
danger in this procedure? No idea, superficial inguinal ring perhaps?

12. Bladder infections are much more common in females. The female urethra is shorter, more distendable
and opens to the vaginal vestibule

20. Autonomic control of micturition:

a. somatic [S2-4] voluntary relaxation of the external sphincter urethrae (internal sphincter is
autonomic control)
b. sympathetics (filling and holding) inhibit the detrusor/excite the internal sphincter
c. parasympathetics (emptying) excite the detrusor/inhibit the internal sphincter
d. damage to voluntary pathways [trauma to pudendal n] = leak incontinence from paralysis of voluntary
sphincters
e. damage to peripheral ANS routes
i. sensory neurogenic bladder (cant sense fullness/reduced urge) with urinary retention
(infection risk!) and overflow incontinence
ii. motor neurogenic bladder (detrusor areflexia, flaccid bladder = increased capacity and cannot
empty bladder = overflow incontinence); painful retention and impaired emptying because the
detrusor cannot contract = infection risk!
iii. Can be caused by trauma, tethered cord syndrome, lesions to cauda equina/conus medullaris,
spinal stenosis, disc herniation, neuropathies, tabes dorsalis, diabetes mellitus, pelvic surgery
f. destruction of sacral spinal cord
i. autonomous bladder [all parts paralyzed] continuous dribble of urine
ii. there is flaccid bladder tone (increased capacity), loss of sensation/urgency; residual urine is high
= infection risk!
iii. can be caused by trauma, neural tube defects, syringomyelia, spina bifida
g. spinal cord injury (above lumbo-sacral segments)
i. bladder is initially flaccid and areflexic but becomes (after days to weeks) spastic/hyperactive with
increased tone and decreased capacity = the bladder fills to a low volume and reflexively empties

ii. there is detrusor-sphincter dyssynergy = involuntary detrusor contractions without relaxation of

the external urethral sphincter
iii. can be caused by multiple sclerosis, spinal cord trauma, syringomyelia, tethered cord syndrome
h. nocturnal enuresis
i. abnormal changes in bladder pressure?
ii. delayed maturation of bladder; small bladder
iii. possible link to ADH secretion? Overactive detrusor

Gross Anatomy
Resources: Grays Anatomy for Students, 2nd edition

Objectives:
1

Describe the basic organization and support (arterial supply, venous and lymphatic drainage,
innervation) of the kidneys and ureters (pages 355 - 361).
The kidneys The kidneys are a retroperotineal organ situated near T12, with the right kidney being a bit
lower due to the liver being right above it. Both kidneys are associated location wise with the Twelfth rib.
The kidneys also mark locations of the flexures of the ascending (right kidney) and descending (left
kidney). The muscles that touch the kidney include the quadratus lumborum on the immediate back,
psoas major medially, diaphragm superiorly, and the transversus abdominis muscle laterally. There is a
layer of supportive fat around the kidneys (perirenal fat) and the renal fascia enclosing the fat. The
diagram below illustrates the organization of the kidneys inner parts:

Arterial Supply The Renal Artery, which comes straight off the Aorta
Venous Supply Right renal vein comes off the IVC, left renal vein goes across the aorta and crosses
underneath the Superior Mesenteric Artery and can be compressed there from an aneurysm.
Remember that the left renal vein also supplies the left gonadal vein whereas the right gonadal vein
goes right into the IVC.

Lymphatics Lateral Aortic Nodes (Lumbar nodes)

Innervation mainly T10-L1 for the Kidneys sympathetics, while vagus controls the
parasympathetics.

Ureter tubes that transport urine to the bladder, is fed by the calices of the kidney to condense into the
ureter. Ureters can be constricted along the ureteropelvic junction, the pelvic brim, and where the
ureters enter the wall of the bladder kidney stones can be lodged here.

Arterial supply as you can see, it receives many offshoot arteries from major arteries, like the renal
arteries, the aorta, gonadal arteries, and the internal iliac. Veins are pretty much the same thing.
Lymphatics upper part near the kidney drains into the lateral aortic nodes (lumbar nodes). The middle
part drains to lymph nodes of the common iliac, while the inferior portion goes to external and internal
iliac nodes.
Innervation T11 to L2 for sympathetic.

Recognize the clinical correlations related to the kidneys and ureters (pages 361 364).
a See also Clinical Supplement, Section E. items 78 85, 86 i through k + 87.

Urinary Tract Stones Pain radiates from the lower back and swings forward to the groin. Blood in the urine
may occur from these sharp stones made of calcium phosphate and other salts that precipitate out and
scratching the urinary tract. Ultrasound scanning to look at dilated renal pelvis and the calices will help
diagnosis as well as IV urogram.

Urinary Tract Cancer mostly renal cell carcinomas which come from the proximal tubular epithelium, with
5% of tumors being transitional cell tumors arising from the urothelium (epithelium of the ureter) of the renal
pelvis (these will be associated with transitional carcinomas within the bladder). Renal cell tumors have the
propensity to spread into the renal vein, which sets it apart from other tumors. Tx- surgical removal.

Nephrostomy Making a hole into the kidney to drain urine, usually indicated for pts with ureteric obstruction,
like say a kidney stone. Ultrasound guides the needle to the renal pelvis, and which guides the drainage
catheter.

Kidney Transplant common procedure for patients with end stage renal failure. Risk with tissue rejection is
always present. Many of the vessels are taken as well, including the corresponding ureter, when taking a
donor kidney out. The kidney is placed in the right or left iliac fossa, which places it pretty close to the front of
the abdomen. The abdominal wall muscles (external oblique, internal oblique, transverse abdominis, and
transervsalis fascia) are divided to allow entry. The donor artery is anastamosed to the recipient external iliac
artery, so the iliac system becomes the new arterial supply for the kidneys.

Recognize the clinical correlations related to the bladder and ureters (pages 446 447).
a See also Clinical Supplement, Section F. items 6, 7, 11, 12 + 20

Bladder Infection Women are more susceptible due to the short length of the urethra children under 1 year
of age have the chance for the infection to go up the ureter into the kidneys, eventually causing renal failure
in serious cases. Tx includes antibiotics.

Urethral Catheterization drain urine from a patients bladder when the pt is unable to pee.
In Men annoying since the penis has a spongy urethra (thin urethral wall and angles superiorly to go
into the deep perineal pouch), a membranous portion (keeps going superiorly), and a prostatic part
(anterior curve)
Women easier since the urethra is short/straight

Notes sheet
Tuesday, November 18, 2014
2:03 PM

Anatomy: Urinary System

Kidneys

Transpyloric Plane: superior to R hilum & inferior to L hilum RIGHT is LOWER

Hila: L1-L2
Kidney: T11-L3& under ribs 11 &12
Psoas Abscessdt TB & can displace kidneys
Tissue Support: Capsule (lines sinus), Perirenal Fat, Renal Fascia (Gerotas Fascia)attached to aorta, IVC & some
of ureter, Pararenal Fat, Peritoneum

Trabecuale between fat & kidney to attach & support kidney

Fat, fascia & a. & v. hold kidneys in place

Hilum: Vein Artery Pelvis
Blood Supply: SD

Renal A divides into 5 segments& all are END arteries that supply specific section of kidney
Apical, Anterior Superior, Anterior Inferior, Inferior & Posterior
Each br into: InterlobarArcuate Afferent etc

Left: Gonadal V. drains

Right: IVC

SMA crosses L Renal VCOMPRESSES

Transplant: LEFTlong renal vein to attach it & keep it in PELVIS
Renal Cell Carcinoma: hematuria, loin pain, mass, invade renal v & IVC
Innervation:

Sympathetics: T10-L1/2

Parasympathetics: Vagus

Referred Pain: T10-L1 dermatomes

Anatomical Constriction Pointscommon places for stones

Ureter Renal pelvis & entry to bladder

R Common Iliac A.

Gondal Vessels
Lymphatics: LUMBAR Nodesaka Lateral Aortic

Ureters

Relations: on top of psoas, posterior peritoneum, under ductus deferens, under uterine a., posterior to ovary

Injury ureter during hysterectomy

Enter bladder at Oblique Angleprevents reflux

Bladder fills & closes off intramural part of ureter

Blood Supply: each part supplied by vessels in the area
Innervation:

Upper:
SympathT11-L2
ParasymCN X

Lower:
SympathT11-L2
ParasymS2-4 pelvic splanchics

Referred pain: T11-L2 dermatomes

Bladder

Over pubic symphysis

Parts: fundus, neck, apex, superior surface & 2 inferolateral surfaces
Ligaments:

Neck: puboprostaticM & pubovesicalF

Posterior: rectovescial

Median umbilicalattaches bladder to umbilicus

Trigonesmooth mucous layer
Detrusormuscular layers
Blood Supply: superior vesical, inferior vesicalM, & vaginalF

Venous: vesical plexus & prostatic plexus

Innervation: Sym: T11-L2 & Para: Pelvic Splanchnics
Lympatics: internal & external iliac nodes

Male Urethra

Preprostaticbladder neck
Prostaticreceives openings of ejac& prostatic ducts

Crest from trigone, colliculusejac duct & sinusprostatic ducts

Membranousdeep perineal space, sphincter urethra
Spongy/Penilecorpus spongiosum
Blood Supply: inferior vesical, middle rectal & internal pudendal
2 bends in urethra

Female Urethra

Shorter: bladder anterior wall of vagina between clitoris & vagina opening
Urethral gland openins&paraurethral duct openins

Misc Clinical

Varicocele: bag of worms, tortuous testicular v.

Superior Mesenteric Artery Syndrome: compresses L renal vein & duodenumdifficulty w/ eating, hematuria,
proteinuria, varicocele & typical pt is tall & skinny
Perinephric Abscess: renal fascia keeps it from spreading but could affect duodenum & pancreas

Prostate

Lobes

Anteriorto ureter
Posteriorto ureter & inferior to ejac duct DRE palpation
Lateralto ureter
Middlebetween ureter &ejac duct
Blood Supply: inferior vesical, internal pudendal & middle rectal

Venous: prostatic plexuscommunicates w/ vesicular plexus &internal vertebral plexus (Batsons Plexus)
*Prostate cancer can metastasize to spine*
Innervation:

Symp: L1-L2 inferior hypogastric

Parasym: Pelvic Splanchnics

Lympathics: internal iliac & sacral nodes
BPH45-50yr, blocks urine flow

Transurethral resection
Biopsy: transrectalmust give antibiotic prophylaxis

Penis: Innervation: Symp: L1-L2 in. hypogastric & Para: pelvic splanchnics

Urine ExtravasationRuptured Urethra

1. Damage above UGDurine leaks into pelvic cavity

2. Rupture Urethra w/ Bucks Fascia intacturine into penis shaft
3. Ruptured Urethra w/ Bucks Fascia tornurine into superficial perineal space, under Colles Fascia into scrotrum,
under superifical fascia of penis, under Scarpas Fascia in lower ab
4. Rupture Membranous Urethracontained to under UGD

Micturition

Parasympathetics: S2-4

Stimulates detrusor & inhibits internal sphincterurinate

Sympathetics: T11-L2

Inhibit detrusor & stimulate internal sphincterno urination

External Sphinctervoluntary control via Pundenal n.

Pelvic Lymphatics

Ureter: iliac nodes

Bladder: external iliac nodes
Urethra: Female & Prostatic/membranous Minternal iliac
Urethra: Spongy/Penileinguinal nodes
Prostate: internal iliac & sacral nodes

Pelvic Autonomics

Sympathetic: preganglionics cell bodies in IML T10-L2

Enter chain via white ramusT1-L2 only

Note: Gray ramiall levels for body wall innervation

Traverse chain W/OUT synapsing splanchnic nerves hypogastric plexus (synapse)

GVA travel w/

Levels:
Ureter: T11-L2
Gonads: T10-11
Epidid, ductus, SemVes: T11-12
Bladder: T11-L2
Prostate: T11-L1
Uterus: T12-L1
Uterine Tube: T10-L1
Parasympathetics: S2-4 w/ preganglionic cells bodies in IML like area

Axons traverse ventral root spinal n. ventral ramus

Pregang axons leave ventral ramus as PELVIC SPLANCHNICS

Synapse at organ or in hypogastric plexus

Hypogastric Plexus

Pre & Post ganglionic Sympathetics

Associated GVA pain: t10-L2

Pre & Post Ganglionic Parasympathetics

Associated GVA interoceptive & pain S2-4
Inferior Hypograstric Plexus

Lateral to pelvic viscerabreaks up into smaller plexuses to supply organs

Other Plexuses: Middle Rectal, Vescial, Prostatic, Uterovaginal

High Yield Pelvic Lymphatics

Anal: Above Pectinateinternal iliac & Below Pectinatesuperficial inguinal

Ureter: superiorlumbar, middlecommon iliac, lowerex & in iliac
Bladder: external iliac
Prostate: in & ex iliac & sacral
Ovaries & Testes: lumbar
Uterus: body, fundus & tubelumbar, in & ex iliac & superficial inguinal, Cervixex, in & com iliac
Vagina: upperex & in iliac, middlein iliac, lowersuperf inguinal
External Genitalia:superfinguain, deep structuresiliac

Histology
Tuesday, November 18, 2014
9:33 AM

HISTOLOGY
Resource:Histology: A text and Atlas, 6th edition
1
1

1
1

Understand the basic organization and function of the urinary system (pages 698 - 699)
Describe the basic histological features of the kidney (pages 700 713 stop at The juxtaglomerular
apparatus regulates). Note specifically:
The organization and features of the cortex and medulla

Organization of the nephrons and associated collecting ducts

Describe the pattern of blood supply, lymphatic drainage and innervation to the kidney (pages 721
723).
Describe the structure and basic histological features of the ureter, urinary bladder and urethra (pages
723 726). Be able to identify each region of the air way in histological sections. Study the following
virtual slides: http://zoomify.lumc.edu/histonew/renal/renal_main.htm
Use Plates 74 - 79 to guide your study.

You need to able to distinguish each of these regions on histological sections.

Kidney DMS151

Kidney, rabbit PAS DMS026

Urinary bladder (distended) #160

Urinary bladder, relaxed-distended DMS042

Embryo
Tuesday, November 18, 2014
9:24 AM

Resources: Human Embryology Study Notes [Development of the Urinary System]

Objectives:
1
1
1

Describe the embryological development of the kidneys and morphological changes that occur during
development.
Describe the development of the bladder and prostate.
Describe the anomalies associated with development of the urinary system [limited to those included in
the Study Notes].

Tuesday, November 18, 2014

2:03 PM

Embryo: Urinary System

Kidney Development

Intermediate Mesodermextends from cervical to pelvic regions

EpitheliumCT of ducts

Pronephrosearly, cervical region, non-fxnal

Mesonephros
EMBRYONIC kidney: embryo urinates into amniotic sac to contribute to amniotic fluid levelpoly
vsoligohydraminos
Lumbar region
Has all parts of kidney
Tubules join Mesonephric Duct (Wolffian)extends caudally
Urogenital Ridgedeveloping gonad
Ceases urinary fxn
Male Mesonephric Duct ductus deferens, seminal vesicles, ejac. duct, etc
Female Mesonephric Duct can become cysts in vagina/broad ligament, can Gartners cysts

Metanephros
MATURE Kidney
Sacral region
Ureteric Bud grows off of mesonephric duct to form kidney

Dilatesrenal pelvis, calyces & collecting tubules

Ureteric bud grows into metanephric mesoderm
Metanephric mesoderm (blastema)nephrons (DCT, Loop, PCT, glomerulus)
JOIN ureteric bud & metanephric mesoderm
Collecting tubules surrounded by metanephric tissuecollecting tubule causes metanephric tissue
differentiation
Vascular Mesoderm Glomeruli & Vasa Recta

Developmental Changes

Migration: pelvis lumbar

Blood Supply: internal iliac iliac aorta
Rotation: anterior hilum medial hilum
Lobulation: lose lobulation dt CT overgrowth

Bladder

Cloaca: endodermal lined, common opening

Divided by urorectal septum

Allantois: growth of GI tubeforms Bladder (ENDODERM)
Bladder is continuous anteriorly w/ allantois stalkUracus& becomes median umbilical ligament
Bladder continuous w/ lower end of mesonephric duct

Ureter

Mesonephric duct absorbed into bladder wall

Ureters initially form as outgrowth of mesonephric duct
Intermediate Mesodermlater covered by endodermal epithelium
Ureter intermediate mesoderm
Mesonephric duct ductus deferens

Trigone of Bladder

Derived from Mesonephric Ductsintermediate mesoderm meets endoderm

Overgrown by endoderm of bladder

Urethra

From bladder ENDODERM

Malesterminal portion from invaginated ECTODERM

Prostate

Endodermal outgrowth from URETHRA

Surrounding mesenchyme forms stroma & smooth muscles

Congenital Anomalies

Wilms Tumor: congenital kidney tumor

Accessory Renal Arteries

Commondt kidney ascent & switching blood supply

Can obstruct ureter
Hydronephrosisrenal pelvis fills w/ urine
Ligate infarct/necrosis in that portion of kidney
End arteries w/ no collateral circulation

Supernumerary Kidneys: Multiple kidneysdt multiple ureteric buds

Renal Agenesis

Ureteric bud fails to reach metanephric mesodermusually LEFT

Common in kids w/ single umbilical a.
Associated w/ oligohydraminos
Bilateralincompatible w/ life

Pelvic Kidney:

Ectopic kidney
Ascent blocked by umbilical artery
Pancake or Fused Kidneyboth kidneys fused in pelvis w/ 2 ureters

Ectopic Kidney

Fused Kidneycan migrate toward nl spot & carry other w/ it

Crossed Renal Ectopiaseparate kidneys that migrate to wrong side

Horseshoe Kidney

Metanephric mesoderm fuses while in pelvis

Normal ascent stopped by INFERIOR MESENTERIC ARTERY

Bifid Ureter: Ureteric bud divides prematurelydouble ureters

Ectopic Ureter: ureter opens anywhere except into bladderie into urethra

Polycystic Kidney

Cysts on kidneygenetic
Large kidney Kidney failure
Abnl connectionscant drain properly
Adult: AD, expanding cysts on BOTH kidneys, cysts anywhere along nephrons, mutations in PKD1 or PKD2,
massively enlarged, hematuria, proteinuria, have mitral valve/<3 issues, ruptured brain aneurysms
Kids: AR, PKHD1 mutations, dilations of nearly ALL collecting tubules, renal failure

Exstrophy of the Bladder

VENTRAL WALL DEFECTnot enough mesoderm between bladder & body wall so bladder fuses w/ body
wall

Bladder mucosa exposed to exterior

Urachal Fistula: lumen of allantois does NOT closeabnl communication between bladder & outside via anterior ab wall so
leaks urine (UMBILICUS)

Urachal Cysts: only portion of allantois remainsNO communication from bladder to outside so just fluid filled cyst

Urachal Sinus: urachus remains open through umbilicus but loses connection w/ bladder

Megaloureter: enlarger ureter w/ no motilityprone to infection

Postcaval Ureter: right ureter passes BEHIND IVCcan be obstructed

Obstructive Genitourinary Defect: stenosis/ atresia of urinary tract, any level