Ureters and Bladder

Muscular tubes (25-30 cm long) that carry urine from kidneys to bladder

Course

• In abdomen, retroperitoneal location

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    Proximal ureters lie in perirenal space

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    Mid ureters lie over psoas muscles slightly medial to tips of L2-L5 transverse process

• In pelvis, lie anterior to sacroiliac joints crossing common iliac artery bifurcation near pelvic brim

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    Lie anterior to internal iliac vessels and course along pelvic sidewall

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    At level of ischial spines, ureters curve anteromedially to enter bladder at level of seminal vesicles (men) or cervix (women)

• Ureterovesical junction (UVJ) : Ureters pass obliquely through muscular wall of bladder for ~ 2 cm

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    Creates valve effect with bladder distension, preventing vesicoureteral reflux (VUR)

3 points of physiological narrowing

• Ureteropelvic junction

• Pelvic brim (crossing over common iliac artery)

• UVJ

Vessels, nerves, and lymphatics

• Arterial branches are numerous and variable, arising from aorta and renal, gonadal, internal iliac, vesicle, and rectal arteries

• Venous branches and lymphatics follow arteries with similar names

• Innervation

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    Autonomic from adjacent sympathetic and parasympathetic plexuses

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      Responsible for ureteral peristalsis

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    Also carry pain (stretch) receptors

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      Stone in abdominal ureter perceived as back and flank pain

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      Stone in pelvic ureter may project to scrotum or labia

• Lymphatics to external and internal iliac nodes (pelvic ureter), aortocaval nodes (abdomen)

Hollow, distensible viscus with strong, muscular wall and normal adult capacity of 300-600 mL of urine

Lies in extraperitoneal (retroperitoneal) pelvis

Peritoneum covers dome of bladder

• Reflections of peritoneum form deep recesses in pelvic peritoneal cavity

• Rectovesical pouch (between rectum and bladder) is most dependent recess in men (and in women following hysterectomy)

• Vesicouterine pouch (between bladder and uterus) and rectouterine pouch of Douglas (between rectum and uterus)

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    Rectouterine pouch most dependent in women

Bladder is surrounded by extraperitoneal fat and loose connective tissue

• Perivesical space (contains bladder and urachus)

• Prevesical or retropubic space (of Retzius) between bladder and symphysis pubis

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    Communicates superiorly with infrarenal retroperitoneal compartment

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    Communicates posteriorly with presacral space

• Spaces can expand to contain large amounts of fluid (as in extraperitoneal rupture of bladder and hemorrhage from pelvic fractures)

Bladder wall composed mostly of detrusor muscle

• Trigone of bladder: Triangular structure at base of bladder with apices marked by 2 ureteral orifices and internal urethral orifice

Vessels, nerves, and lymphatics

• Arteries from internal iliac

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    Superior vesicle arteries and other branches of internal iliac arteries in both sexes

• Venous drainage

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    Men: Vesicle and prostatic venous plexuses → internal iliac and internal vertebral veins

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    Women: Vesicle and uterovaginal plexuses → internal iliac vein

• Autonomic innervation

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    Parasympathetic from pelvic splanchnic and inferior hypogastric nerves (causes contraction of detrusor muscle and relaxation of internal urethral sphincter to permit emptying of bladder)

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    Sensory fibers follow parasympathetic nerves