Relations of the Abdominal Part of Ureter

Ureter: Muscular tube (25cm) connecting the kidneys with the urinary bladder. Begins in the abdomen, then descends in the posterior abdominal wall. the end of the common or beginning of the external iliac artery, the abdominal part ends and the pelvic part begins. The pelvic part descends along the lateral wall of the pelvis till the ischeal spine. Then it runs forward on the pelvic floor muscles and ends in the urinary bladder. Formatted: Font color: Red It is crossed by the vas deferens in male and uterine artery in females. ➢ It pierces the wall of the bladder at the superolateral angle of the trigone. Formatted: Font color: Red ➢ This oblique termination of the ureter prevents regurgitation of urine from bladder to the ureter Formatted: English (United Kingdom) L5 S1 Relations of the abdominal part of Ureter:Posterior Relation (BOTH SIDES) 1. Psoas major muscle separating the Ureter from the tips of the transverse processes of the lumbar vertebrae (2-5) 2. Genitofernoral nerve direct anterior to psoas major. 3. Termination of common or beginning of external iliac artery Anterior and medial relations: Notes: The gonadal arteries are branches of the abdominal aorta Formatted: Font color: Red Superior mesenteric artery arisesfromabdominalaortaand Formatted: Font color: Red passes to the right side hilum of kidney at L1 BUT ureter starts at L2 Note: If a patient had an obstructed Ureter, a double J catheter is used to pass the urine from the kidneys to the bladder. Constrictions of the Ureter You should be able to identify these sites on the x ray.( see the first page) Formatted: Font color: Red Arterial blood supply :Abdominal part receives branches from renal artery, abdominal aorta, gonadal and common iliac arteries. Pelvic part receives branches from vesical, middle rectal and uterine arteries (visceral branches of internal iliac) Lymphatic drainage:To lateral aortic in the abdomen, common iliac lymph nodes in the pelvis. Nerve supply: The Ureter receives sympathetic fibers from T11 – L2 segments of spinal cord. Sensory fibers from the Ureter enter the spinal cord through the same segments. Ureteric colic begins in the loin and is referred to groin, anterior aspect of the thigh and scrotum or labium majora, all through genitofemoral nerve (L1,L2) Note: Pain in the viscera is felt by the autonomic system. As a general rule: If it is covered with peritoneum, then it is transimmitted by the sympathetic and vice versa. Surface markings :The ureter begins at a point on the transpyloric plane, 5 cm from the midline It enters the bladder at the pubic tubercle Formatted: Font color: Red Formatted: Font color: Red Types of x-rays used: KUB IVU IVU 1- Intravenous urogram: a radiopaquedyeis injected in the blood, then it is filtered in the kidneys. This will show the urine flow from the kidneys to the ureters and to the bladder. Formatted: Font color: Red Note: if this x-ray doesn't show the kidneys of the patient, this might happen in case of kidney removal (nephrectomy) or a non functional kidney. 2- KUB: is used to detect stone location Formatted: Font color: Red The urinary bladder Description and Relations of the Urinary Bladder : • The empty bladder has; Apex, base, 3 surfaces (superior, right and left inferolateral) and neck . 1- Apex of the bladder: Is continuous with the median umbilical ligament which raises the peritoneum forming • median-umbilical fold.(The ligament is the remnant of the embryonic urachus). Notes: Formatted: Font color: Red Formatted: List Paragraph, Indent: Hanging: 0.25", After: 0.59", Space Before: 2.15 pt, Line spacing: Exactly 27.8 pt, Bulleted + Level: 1 + Aligned at: 0.6" + Indent at: 0.72", Tab stops: 0.59", Left The medial umbilical ligaments(2) are formed by the distal part of superior vesical artery. Formatted: Font color: Red The superior vesical artery has 2 parts: one supplies the bladder and the other forms the medial umbilical ligament.(obliterated umbilical ligament) Formatted: Font color: Red 2- Inferolateral surface: It is not covered by peritoneum. It is related to: *Body of pubis with retropubic pad of fat in the retropubic space of Retzius. *Levator ani *Obturator internus 3- Superior Surface: is covered by peritoneum and is related to: In males: Sigmoid colon, Loops if ileum In females: Vesical surface of uterus, Supravaginal part of cervix with uterovesical pouch in between Base of the bladder (fundus): Its superolateral angles receive the Ureter Note: the 2 seminal vesicles and the vas deference form the ejaculatory duct. The seminal vesicles and the vas deferens separates the rectum from the bladder 5-Neck of the bladder: It is the lowest and most fixed part of the bladder. ➢ In the male: it is continuous with the urethra at the internal ureteral meatus and rests on the upper surface of the prostate. ➢ In female: it is continuous with the urethra and rests in the pelvic fascia which surrounds the urethra. Formatted: Font color: Red Formatted: English (United Kingdom) Peritoneal Covering of the Bladder : In males, the superior surface and the superior part of its base is covered by peritoneum, In females, only the superior surface is covered by peritoneum. The peritoneum leaving the bladder is loosely attached to the suprapubic part of abdominal wall. The distended bladder lifts this peritoneum from the abdominal wall. Note: In case of suprapubic cystostomy, instruments could be introduced into the distended bladder to avoid injury of the peritoneum. Blood supply: In males: superior and inferior Formatted: Indent: Before: 0" vesical arteries. In females: superior vesical and vaginal arteries. Venous Drainage: Begins by the vesical venous plexus, embedded in the visceral fascia on the inferolateral surfaces of the bladder In males: vesical venous plexus takes venous drainage from the prostatic venous plexus. In females: it communicates with the vaginal venous plexus and receives the deep dorsal vein of the clitoris. Posteriorly: the plexus is drained by numerous vesical veins which run in the posterior ligaments of the bladder to end in the internal iliac veins. Formatted: Font color: Red Formatted: English (United Kingdom) Note: Deep dorsal vein of the penis drains in the prostatic vein, then the prostatic drains into the vesical venous plexus. Nerve supply of the bladder (derived from the Inferior hypogastric plexus): Parasympathetic efferents (pelvic splanchnic nerves) (S2 , S3 , S4 ): motor to the detrusor muscle, inhibitory to sphincter vesicae (they produce micturition). Sympathetic efferents: (L1 ,L2 ) are inhibitory to detrusor and stimulant to sphincter vesicae . Sensory afferents: Reach central nervous system through pelvic splanchnic nerves or Sympathetic fibers It record bladder distension and pain sensation. 9|Page