ANATOMY OF URINARY

BLADDER
Dr. SOORYA SRIDHAR.
POST GRADUATE M.D ANATOMY.
NARAYANA MEDICAL COLLEGE,
NELLORE.
INTRODUCTION
A reservoir
Varies in Size, Shape, Relations.
Capacity : Mean Vesical Capacity.120-320ML ( Thompson 1919)
Physiological. 280ml.(Micturition Occurs)
Maximum filling of 500ml maybe tolerated beyond which
=> Pain => Tension of wall => Reflex Contractions.

Shape: Empty: Tetrahedral.
Full : Ovoid.
Position: Empty: Entirely in the lesser pelvis.
Full : Extends Antero Superiorly into
the Abdominal Cavity.

Parts
Fundus ( BASE)
Triangular, Postero-Inferior.
In Females: Related to Anterior Vaginal Wall.
In Males: Related to Rectum seperated above by Recto
Vesicle Pouch and below by the Seminal Vescicles, Ductus
Deferens, RectoVescical Fascia in triangular area between
Bladder, Seminal Vescicles & Rectum.


Neck:
Lowest , Most Fixed.
3-4cm behind Symphysis Pubis ( Above Plane of Inferior
Aperture of Lesser Pelvis)
Pierced by Internal Urethral Orifice.
No constriction in Neck of Bladder specifically ( Greys 38ed pg 1838)
In Males: Rests on : Base of Prostrate.
In Females: Pelvic fascia surrounds the Upper Urethra.

Apex:
Faces the Upper Part of the Symphysis Pubis.
Median Umblical Ligament ( Urachus) ascends behind
Anterior Abdominal wall to Umblicus.
Median Umblical Fold formed by the Peritoneal fold.
Superior Surface:
Triangular.
Bounded by Lateral Borders from the apex to the ureteric
entrance through the POSTERIOR BORDER joining them.
In males: Completely covered by Peritoneum, Extends slightly
to base
continued Posteriorly into the Recto Vescical Pouch,
Laterally into Paravesical Fossae,
Anteriorly into Median Umblical Fold.
In contact with Ileum(terminal) & Sigmoid Colon.


In Females : Mostly covered by Peritoneum, Posteriorly
reflected to Uterus at Level of Internal Os => Forming
VESCICO- UTERINE POUCH. Posteriorly area devoid of
Peritoneum contains FIBRO- AREOLAR Tissue seperates
from Supra Vaginal Cervix.


Infero-Lateral Surface:
Two in Number.
Not covered by Peritoneum.
In Males: Seperated from Pubis and PuboProstratic Ligaments by
Adipose Retro Pubic Pad of Fat- Anteriorly.
Fascia from Levator Ani and Obturator Internus Posteriorly.
In Females: PuboProstratic Ligaments are replaced by
PuboVescical Ligaments.
At Birth: Internal Urethral Orifice at level of Upper
Symphyseal Border, more abdominal than Pelvic.
Progressively descends reches the Adult position shortly after
Puberty.
LIGAMENTS OF THE BLADDER
Stout Bands of Fibro Muscular Tissue Extending from Bladder
Neck to Inferior Aspect of Pubic bones.
In Males: Pubo Prostratic Ligaments
In Females :Pubo Vescial Ligaments
Extensions of Pubo Urethral Ligaments.(Superior)
PuboVescical Ligament : Lie on each side of Median Plane-
Leaving a midline hiatus => small veins pass.
Other ligaments are formed by condensation of connective
tissue around Neuro Vascular Structures.
Apex Umblicus:
Remains of Urachus below -> Median Umblical Ligament.
Lumen of Urachus may persist throuchout life and may
communicate with cavity of Bladder.


FALSE LIGAMENTS:
From Superior Surface of Bladder, Peritoneum is carried as
a series of Folds.
Median Umblical Fold: Anterior, one fold.
Lateral Medial Umblical Fold: over Obliterated
Umblical Artery, Anterior, two- one on each side.
Lateral False Ligament: Reflections of Peritoneum
to the Lateral walls of the Pelvis, Two.
Posterior False Ligament: SacroGenital Fold of
Peritoneum.

INTERIOR OF BLADDER

Internal structure
Vesical Mucosa: Attached loosely over the subjacent muscle.
Highly folded when Bladder Empty, Folds Effaced when Bladder
Fills.
Trigone:
The Trigonal Angles are formed by:
Antero-Inferior Angle: Internal Urethral Orifice.
Postero- Lateral Angles: Ureteric Orifices.
Superior Trigonal Boundary: Curved inter ureteric Crest,
Between 2 Ureteric Orifices. (Guides Cystoscopy =>
Visualized as a Pale band)
Produced by the Continuation of the Internal Longitudinal
Muscle into the Vescical wall.

Laterally this ridge extends beyond the Ureteric Openings as
URETERIC FOLDS. ( Terminal Part of Ureter running
Obliquely through Bladder wall)

Ureteric Orifices:
Slit Like.
Postero Lateral Trigonal Angles.
Empty Bladder: Distance 2.5cm apart from each other and
from Internal Urethral Orifice.
Distended Bladder: Measurements Doubled.
Internal Urethral Orifice:
At trigonal Apex.
Cresenteric in Section.(Esp., in males due to elevation
because of Median Prostratic lobe) => UVULA of Bladder.
MICROSTRUCTURE
3 Layers.
Outer Advential Layer Connective Tissue.]
Non Striated Muscle Coat.
Inner Mucous Membrane.
SEROUS LAYER:
Restricted to the Superior aspect. In males includes parts of
Posterior Surface.
Consists of Mesothelium, Underlying Connective Tissue
MUSCULAR LAYER:
DETRUSOR Muscle: Large, Inter Lacing bundles of Non Striated
Muscle Cells arranged as a complex meshwork.
Exchange of Fibers between adjacent Muscle Bundles withing
Bladder wall occurs. Similar to Muscle coat of Ureter.
Therefore, Appears as a Single Unit of Interlacing Smooth Muscle.
Longitudinal Muscle Bundle:
Inner & Outer layer.
Posteriorly pass over Base of Bladder and fuse with
Capsule of Prostrate / Anterior Vaginal wall respectively.
Anteriorly, Outer Longitudinal Muscle Bundle continue as
the Pubo-Vescical Ligament.
Other Fiber Bundles carried onto Anterior Aspect of
Rectum -> Recto Vescical Muscle.
3 Layers are present. Ill defined.
Inner and Outter - Longitudinally Oriented Muscle
Bundles.
Middle Circular Muscular Layer.

Basal Lamina:
Electron Dense.
Surrounds each non-Striated myocyte.
Two main types of Junctions.
Close Region Junction Common.
Electrotonic spread excitation occurs in the non striated muscle
of the bladder wall, the region of close approach represents the
Morphological feature enabling the Physiological event.
Peg-Socket.
Intermediate.
GAP Junction Not Present.

Within the Smooth Muscle Bundle- Cells are closely packed
together => Basal Lamina of one cell confluent with the
neighboring cell.
TRIGONE:
2 Layers.
Superficial Trigonal Muscle.
Deep Trigonal Muscle. ( Indistinguishable from
Detrusor Muscle Cells, therefore called TRIGONAL
DETRUSOR MUSCLE)

SUPERFICIAL TRIGONAL MUSCLE:
Composed of relatively small diameter muscle bundles,
continous proximally to Intra Mural Ureters.
The muscle layer of the Superficial Trigone is Relatively
thin, becomes gradually thicker superior end forms -
>InterUreteric Crest.
In Both sexes Superficial Trigonal Muscle continues with the
Smooth Muscle of Proximal Urethra.
In Males: extends along Urethral Crest upto Ejaculatory Duct
opening.
Dorschner et al (1994 a) described presence of two muscular
structures,
Musculus InterUretericus from the Muscular systems of both
Ureters and forming Muscular component of InterUreteric
Ridge.
Musculus Sphincter Trigonalis / Musculus Sphincter
vescicae.

This study also reported in men Lower part of Sphincter
Trigonalis is pervaded by Prostratic tissue, s/o dual function of
this muscle.
Urinary continence.
Preventing Retro Grade Ejaculation.
Aiding release of Prostratic secretion.

Uretero Vescial Junction:
Distal end of Ureter, surrounded by incomplete collar of
Detrusor, non-striated muscle.
Forms a Sheath of Waldeyer Seperated from Ureteric Muscle
Coat by Connective Tissue Sleeve.
Ureters Pierce the Wall of the Bladder and run for about 1-2.5
cms
terminates at the Ureteric Orifice. -> Prevents Urinary Reflux
into Ureter.
No Evidence of Classic Urethral Sphicter Mechanism in man
( Noordzij & Dabhoiwala 1993)
Longitudinal oriented muscle bundles of terminal ureter continue
into the bladder wall and become continuous with the Superficial
Trigonal Muscle (Tanagho et al 1970)
NECK OF BLADDER:
Non Striated muscle.
Histology, histochemistry, pharmacologically distinct from
the Detrusor muscle proper ( Kluck 1980)
Considered a separate functional unit.
Different in male and female.
Male Bladder Neck
Non Striated Muscle Cells form
a complete Circular collar.
Extends distally to surround
Pre Prostratic portion of
Urethra.
Female Bladder Neck
Distinct non striated muscle
fiber.
Large diameter of fasciluli
Detrusor replaced in the
region by fasciculi of
smaller diameter.

male
Distally the Bladder Neck
merges with and becomes
indistinguishable from
musculature in the stroma
& Capsule of the Prostrate
gland.

Female
The muscle extends
longitudinally or Obliquely
in the Urethral wall.
Therefore, no smooth
muscle sphincter.

Mucosa:
Similar to Ureters.
Epithelium supported by Loose Connective Tissue
Lamina Propria- Fibro elastic connective tissue, thick layer
formed 500 Mm in Fundus and 100 Mm in the Trigone.
Small diameter bundles also occur in the Subepithelial
connective tissue -> incomplete, Rudimentary MUSCULARIS
MUCOSAE.
Soft connective tissue region beneath the Urothelium -> in
region of Trigone => Densely packed. ->Deeper Regions =>
Loosely packed.
Non Trigonal Epithelium :
6 cell thickness.
Consist of Highly differentiated Superficial or Luminal cells.
Classified according to position.


1. Layer of small to intermediate cells => small, single darkly
stained nuclei
2. Layer of Undifferentiated Basal cells.
3. Large Superficial cells => bulge easily, binucleate.
4. Flattened Urothelium of the Trigone consists of 2-3 layers
of cells.
5. Flask shaped cells = > Throughout depth of Urothelium->
Characterised by large membrane bound vescicle-> central
Dense Granule -> Help in storage of Amines. - > Wide Storage
in the Body.
Variations :
BRUNNS NEST: Bladder Biopsy samples. Proliferation of
morphologically normal basal urothelial cells-> project into the
connective tissue of Lamina Propria, frequent in the Trigone.

Vascular & Lymphatic Supply.
Arterial Supply
Anterior Trunk of Internal Iliac
Artery -> Superior Vescical,
Inferior Vescical Branch.
Obturator ARtery.
Inferior Gluteal Artery.
Uterine Artery.
Vaginal Artery.
Veinous Drainage.
form a plexus on Infero-
Lateral Surface.
Pass Backward
In the Posterior Ligaments of
the Bladder.
End in Internal Iliac Veins.
Pg 1623
Lymphatic Drainage:

Nerve Supply
Vescical Plexus.
From anterior part of Inferior Hypogastric Plexus, many
filaments passing along vescical arteries to the bladder.
Branches supply Seminal Vescical and Ductus Deferens.
Many small neurons exist among nerve fibers along the
vescicular wall.
Sympathetic Pre Ganglionic fibers are from the Lower two
thoracic and Upper two Lumbar spinal segments.
The ParaSympathetic Pre ganglionic efferrent fibers come
from 2
nd
to 4
th
sacral spinal segments. Nervi Erigentes Synapse
near or in vescical wall with post ganglionic neurons which
stimulate its Detrusor muscle. Inhibit the sphincter.

These multipolar Intramural neurons are rich in Acetyl
Cholinesterase and occur in ganglia consisting of 5-20 nerve
cell bodies.
Majority of these nerves consist of AchE and occur in
abundance throughout the muscle coat of the bladder.
Axonal Varicosities adjacent to the detrusor non striated
muscle cells possess features typical of Cholinergic Nerve
fibers which contain clustersa of small agranular vescicles
together with large granulated vescicles and small
mitochondria.

Efferent Sympathetic Nerves are motor to the
Sphincter and Inhibitor to the Detrusor
Superficial Trigonal muscles associated with Few Cholinergic
(PS) nerves, while those of the Noradrenergic (S) occur
relatively frequently.
This indicates The superficial Trigonal Muscle is of Ureteric
Origin.
In Neck of the Bladder- Male: Non striated muscle is sparsely
supplied with PS nerves but posses rich S supply (Gosling et al; 1977)
Functionally the S nerves on stimulation cause contraction of
non striated muscle in the wall of the genital tract resulting in
Seminal emission,
Concurrent S stimulation of the proximal Urethral Muscle
causes sphincteric closure of Bladder neck. Thereby,
preventing reflux of ejaculate into the bladder.
It is not known if the non striated muscle of this region plays an
active role in maintaining urinary continence.
In Female- The neck of bladder recieves relatively few
noradrenergic fibers but is richly supplied by Presumptive
Cholinergic Fibers, this is presumed to be related to absence of
a functioning Genital portion incorporated within the wall of the
female urethra
The Lamina Propria of the Fundus and Infero lateral wall of
the bladder is virtually devoid of Autonomic nerve fibers
As the urethral orifice is approached the density of nerves
unrelated to blood vessels increases.
At the trigone the Nerve Plexus extends throughout the
Lamina Propria.

Some larger diameter axons are myelinated and others lie
adjacent to the basal urothelial cells.
The Subthelial plexus of the bladder is assumed to subserve a
sensory function in the absence of any obvious Effector target
sites (Gosling & Dixon 1974)
Vescical Nerves are also associated with pain and awareness of
distention.
Pain fibers are stimulated by distention or spasm.
Found in S & PS nerves.
Hence, Presacral Neurectomy does not relieve one of Vescical
pain.
Nerve Fibers for pain are in the anterolateral white columns
and considerable relief follows a bilateral Antero Lateral
Cordectomy.
Nerve fibers mediating awareness of distention are in the
posterior column ( Fasciculus Gracilis) after anterolateral
cordectomy patient retains awareness of the need to micturate.

CLINICAL ANATOMY
Distention
Rupture
Urethral Stricture
Chronic Outlet Obstruction.
Vesical musculature Hypertrophy Trabeculated bladder

Distended bladder may be punctured just above the Pubic
Symphysis without transversing the peritoneum (Supra Pubic
Cystostomy) when bladder contains 300ml its antero lateral
surface contacts the anterior abdominal wall directly for about
7.5 cm above pubis.

Embryology
derived from Endodermal cloaca and caudal ends of
Mesonephric ducts.
Ectopia Vesciacae : Extroversion of Bladder.
Extroversion of Cloaca