ANATOMY OF GENITOURINARY TRACT

Dept of Urology
Govt Royapettah Hospital and Kilpauk Medical College
Chennai
Anatomy of genitourinary tract
1

Moderators:
Professors:
• Prof. Dr. G. Sivasankar, M.S., M.Ch.,
• Prof. Dr. A. Senthilvel, M.S., M.Ch.,
Asst Professors:
• Dr. J. Sivabalan, M.S., M.Ch.,
• Dr. R. Bhargavi, M.S., M.Ch.,
• Dr. S. Raju, M.S., M.Ch.,
• Dr. K. Muthurathinam, M.S., M.Ch.,
• Dr. D. Tamilselvan, M.S., M.Ch.,
• Dr. K. Senthilkumar, M.S., M.Ch.
Dept of Urology, GRH and KMC,
Chennai.
2

KIDNEY
• Paired bean shaped, reddish-
brown retroperitoneal organs
situated in the retroperitoneum
on each side of the vertebral
column
3
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• longitudinal axes of the
kidneys are oblique
• upper poles more medial
and posterior
• Lower pole – lateral and
anterior
• Medial aspect of each
kidney is rotated
anteriorly at an angle of
approximately 30 degrees
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Relation to vertebral body
• Right kidney –
• space between the upper
border of the 1st lumbar
vertebra to the bottom of the
3rd lumbar vertebra.
• Left kidney -space
between the 12th thoracic
vertebra and the 3rd lumbar
vertebra.
• Pleural reflection
-Behind the upper pole of
both kidney
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ANTERIOR RELATION
6
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POSTERIOR RELATIONS
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RENAL VASCULATURE
Renal artery –
• aorta at the level
between the L1 and
L2 vertebrae
• Right renal artery-
long, passes posterior
to the inferior vena
cava (IVC)
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• Segmental branches of renal artery and
brodels plane
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• Right and left renal
veins lie anterior to
the right and left renal
arteries and drain into
the IVC.
• Right renal vein - 2to
4 cm
• Left renal vein - 6 to
10 cm.
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Coverings
1. Fibrous capsules
2. Perirenal/perinephric fat
3. Fascia of Gerota
Anterior – fascia of Toldt
Posterior – fascia of
Zucherkand
4.Pararenal/paranephric fat
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• The renal or Gerota’s
fascia is derived from the
intermediate stratum of the
retroperitoneal connective
tissue.
• Anterior Lamina (fascia of
toldt)
• Posterior Lamina(fascia of
Zuckerkandl)
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APPLIED ANATOMY
• Kidney tears at retroperitoneal points of
fixation –
1. Renal hilum
2. ureteropelvic junction,
• Renal artery thrombosis, renal vein
disruption, and renal pedicle avulsion
• Trauma to the anterior axillary line -
prone to damage the renal hilum and
pedicle compared to the posterior
axillary line. 15
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URETER
• 25 – 30 cm long
from renal pelvis to
trigone
• Diameter 1.5mm to
6mm
• Divided into
abdominal and pelvic
part by pelvic brim
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ureter
• proximal (upper sacroiliac
joint)
• middle (over the sacrum)
• distal (lower) segments.
International anatomic
terminology
• Abdominal part (from renal
pelvis to iliac vessels)
• Pelvic part (from iliac
vessels to the bladder)
• intramural segments
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URETER
Abdominal part
• Descends medial aspect of
psoas muscle and transverse
process of lumbar veretbra
• Left ureter
• The ureter adheres to the
sigmoid mesocolon, injury to
ureter during surgery can
occur
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Abdominal ureter
• Anterior relations
– Rt side –
• Parietal peritoneum
• Rt gonadal vessels
• 2nd & 3rd part of
duodenum
• Root of mesentry
Terminal part of ileum
– Lt side –
• Lt gonadal vessels
• Lt colic & sigmoid
vessels
• Apex of sigmoid
mesocolon
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MALE-Pelvic part
• ureter follows the
course of the internal
iliac artery and runs
along the anterior
border of the greater
sciatic notch and turns
medially at the ischial
spine
crosses vasdeferens in
front of it
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• Descends into pelvis , just
lateral to sacrum and anterior to
the internal iliac artery
• The deviate medially and course
medial to the int iliac artery and
its branches
• It pass beneath the uterine
artery ( 1.5 cm lateral to cervix)
• Then it passes thro the tunnel of
cardinal ligament ( Web or
tunnel of wertheims)
• Within the tunnel it runs
medially and anteriorly over the
vaginal fornix to enter trigone
FEMALE PELVIC URETER
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Ovarian fossa
• Very shallow depression of the
peritoneum on the lateral pelvic
sidewall
Boundaries
• Superiorly – External iliac
vessels and obturator nerve
• Anteriorly – attachement of
broad ligament to lateral pelvic
wall
• Posteroinferior - Ureter
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“Water under the bridge”
• At the level of ischial spines it
runs in the broad ligament and
crossed by the uterine vessels
running anterior to ureter.
• Here, It is 1.5 cm lateral to
cervix.
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BLADDER
• Extraperitoneal
hollow organ in
anterior pelvis
• The empty
bladder -
tetrahedral
• Full bladder -
ovoid shape.
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SURFACES OF BLADDER
• superior surface -covered
by the peritoneum
• Anteroinferiorly and
laterally- cushioned by
pelvic sidewall,perivesical
fat
• Bladder base(posterior
inferior )
- Most thickest part and
fixed
- seminal vesicles,
ampullae of the vasa
deferentia and terminal
ureter 26
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Bladder neck
• located at the internal urethral
meatus, rests 3 to 4 cm behind
the midpoint of the symphysis
pubis.
• It is firmly fixed by pubovesical
ligament .
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• It is freely movable except at the neck
that is attached by puboprostatic
ligament in male and pubovesical
ligament in female
• The muscle of the bladder wall is
called Detrusor muscle
• Trigone is triangular area where the
two ureters and urethra open into its
angles
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Urinary bladder
Apex:
 Pointed anteriorly & lies behind
the upper margin of the pubic
Symphysis.
 It is connected to the umbilicus
by Median umbilical ligament
(Remnant of urachus)
 Paucity of muscle at the point of
attachment of the urachus
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Urinary bladder
• Female
– Fundus, separated from
anterior surface of uterus
by VesicoUterine pouch.
– Below, is related to cervix
and upper vaginal wall.
– Superior surface, when
bladder is empty, uterus
rest on this.
– Inferior surface, rest on
pelvic and urogenital
diaphragm.
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Relationship of cervix
Supravaginal portion
• Anteriorly –
-Base of the bladder
-Not covered by peritoneum
• Posteriorly
- Pouch of douglus
Ureter passes within 1.5cm of the supravaginal portion
beneath the uterine artery
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Vaginal relations
Can be understood by dividing
it into 3 parts
Lower 1/3rd - Fused
• Anteriorly with urethra
• Posteriorly with perineal body
• Laterally with levator ani by fibres of
Luschka
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Middle 1/3rd
• Anteriorly – vesical neck and
trigone
• Posteriorly – Rectum
• Laterally – Levator ani
Upper 1/3rd
• Anterior – bladder and
ureter
• Posterior – Culdesac
• Lateral – cardinal ligament
of uterus 33
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Urogenital Diaphragm
• It is a triangular
musculofascial diaphragm
• Situated in the anterior part of
the perineum below pelvic
diaphragm
• Formed by the sphincter
urethrae and the deep
transverse perineal muscles,
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Superficial Perineal Pouch
potential space between the perineal membrane (superiorly) and the superficial
perineal fascia (inferiorly)
• Paired muscles of the superficial compartment
– Ischiocavernosus
– Bulbospongiosus
– Superficial transverse perineus
• Paired erectile tissue elements
– Corpora cavernosa penis or clitoris
– Corpora spongiosa
• Anteriorly -communicates freely with the potential space between the
superficial fascia of the anterior abdominal wall and the anterior abdominal
muscles.
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MALE URETHRA
• 18–20 cm long
• extends from the internal orifice in the
urinary bladder to the external meatus
Two parts.
THE ANTERIOR URETHRA - 16CM
THE POSTERIOR URETHRA -4 cm .
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Male Urethra
1. 1. Prostatic part:
• 1. Widest portion
• 2. 3 cm long
• 3. Most dilatable part
• 4.The lowermost part of the
prostatic urethra is fixed by the
puboprostatic ligaments
1. 2. Membranous part:
2. 1.Lies within urogenital
diaphragm
3. 2. 2-1.5 cm long
4. 3.shortest and least dilatable
part
5. 4.Urethral sphincter
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Male Urethra cont.,
 3. Penile part:
 It is 15.5 cm (6 inches)
 lie within corpus spongiosum
entire length
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Common penile artery
Bulbourethral artery
Cavernosal artery
Dorsal artery
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Female urethral anatomy
• 4 cm and 6mm diameter
• Neck of the bladder to the external urethral orifice
• The female urethra is oriented almost vertically in the
standing patient.
• It is fused with the anterior vaginal wall and also with the
symphysis pubis by the perineal membrane
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Actual closure of the urethra is produced
by three different systems
• The involuntary internal sphincter at the vesical neck,
• The voluntary external sphincter muscles of the urethra, and
• Mucosal coaptation produced by the urethral submucosal vascular
plexus.
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Muscles of the external sphincter
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Colles‘ Fascia
• Counterpart of Scarpa's fascia of the abdominal wall
• Laterally-Attached to the ischiopubic rami
• posteriorly - posterior edge of the urogenital
musculature.
• anatomic barrier between the urogenital spaces
anteriorly and the ischioanal fossae posteriorly.
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PENIS
• Composed of paired corpora cavernosa, each
with a proximal prolongation, the crus,
attached to the pubic arch
• Corpus spongiosum - arising at the perineal
membrane and terminating where it joins the
glans penis.
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Five layers of tissue surround the shaft of
the penis:
(1) penile skin
(2) superficial layer of the penile fascia
(3) tela subfascialis,
(4) deep layer of the penile fascia
(5) tunica albuginea
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Superficial and Deep Fascias of the
Penis
• superficial penile fascia –
• Dartos fascia
• It is continuous with adjacent layers of
superficial fascia, with the dartos muscle
of the scrotum and Scarpa’s fascia of the
lower abdomen.
• Posteriorly - Colles’ fascia, which covers
the ischiocavernosus and
bulbospongiosus muscles
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Buck’s fascia (fascia penis)
 Deep layer of penis
 Covering erectile bodies and corpus spongiosum
 Distaly upto coronal sulcus and proximaly attached
pubic rami
 A break in the pendulous or bulbous urethra is followed
by extravasation of blood or urine limited
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TUNICA ALBUGINAE
TWO LAYERS
1.Outer longitudinal
2.Inner circular
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During erection,when the tunica albuginea
becomes distended with blood, two layers
limits expansion and provides the necessary
longitudinal rigidity at full erection.
Because the tunic is then under tension, it is
subject to flexion injury, fracture or if repeated
result in a deforming scar (Peyronie’s disease)
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TUNICA ALBUGINEA
Two layers :
(1) outer longitudinal coat
(2) inner circular coat
THANK YOU
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THANK YOU
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Thank you
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Arterial supply
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• Retzius Space – retro
pubic prevesical space
– Contains loose areolar
tissue
– Cushion for anterior
bladder
– Entered by dividing the
transversalis fascia
– As far posteriorly as
iliac vessels and distal
ureter
– For open
prostatectomy, anterior
bladder and pelvic
fractures (hernia)
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Cellular Architecture
65
• 6 layers of
urothelium
• GAG coat
• Thin BM
• Thick Lamina Propria
with blood vessels
• Smooth muscle layer
• inner longitudinal,
• middle circular
• outer longitudinal
layers
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urethra
• Male urethra is a
fibromuscular canal
extending from bladder neck
to external urinary meatus
• Its length is approximately 20
cm
• It is broadly divided into three
parts
– Prostatic
– Membranous
– Spongy or penile
• Prostatic and membranous
together form posterior
urethra
• Spongy portion forms
anterior urethra
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• pars prostatica
– 3 cm is length
– Lined by transitional epithelium
– It is the widest and most dilatable part of male
urethra
• Course: Begins at the neck of the bladder ,runs
downwards and slightly forwards to end at the
posterior layer of triangular ligament(urogenital
diaphragm)
• Upon the posterior wall or floor is a narrow
longitudinal ridge, the urethral crest
(verumontanum ), formed by an elevation of the
mucous membrane and its subjacent tissue.
• it is 15- 17 mm in length&3mm in height
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• On either side of the crest is a slightly depressed fossa, the
prostatic sinus,
• the floor of which is perforated by numerous apertures, the
orifices of the prostatic ducts from the lateral lobes of the
prostate;
• the ducts of the middle lobe open behind the crest.
• At the forepart of the urethral crest, below its summit, is a
median elevation, the colliculus seminalis, upon or within
the margins of which are the orifices of the prostatic utricle
and the slit-like openings of the ejaculatory ducts.
• The prostatic utricle ( sinus pocularis ) is also called as the
uterus masculinus, as it is developed from the united lower
ends of the atrophied Müllerian ducts, and therefore
homologous with the uterus and vagina in the female
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membranous urethra
• 1.5 – 2 CM IN LENGTH
• LINED BY PSEUDO STRATIFIED COLUMNAR EPITHELIUM
• IS THE SHORTEST, LEAST DILATABLE, AND, WITH THE
EXCEPTION OF THE EXTERNAL ORIFICE, THE NARROWEST
PART OF THE CANAL
• COURSE:It extends downward and forward, with a slight anterior
concavity, between the apex of the prostate and the bulb of the
urethra, perforating the urogenital diaphragm about 2.5 cm.
below and behind the pubic symphysis
• the membranous urethra is completely surrounded by the fibers
of the Sphincter urethrae. In front of it the deep dorsal vein of the
penis enters the pelvis between the transverse ligament of the
pelvis and the arcuate pubic ligament
• The glands of cowper ( bulbo urethral glands) lie on either side of
its posterior surface
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PENILE URETHRA
• 15 CM IN LENGTH
• LINED BY PSEUDO STRATIFIED COLUMNAR EPITHELIUM
EXCEPT FOR TERMINAL 12MM , THE FOSSA
NAVICULARIS , WHICH IS LINED BY STRATIFIED
SQUAMOUS EPITHELIUM
• COURSE: extends from the termination of the membranous
portion to the external urethral orifice. Commencing below the
inferior fascia of the urogenital diaphragm it passes forward
and upward to the front of the symphysis pubis; and then, in
the flaccid condition of the penis, it bends downward and
forward
• it is dilated behind, within the bulb, and again anteriorly within
the glans penis, where it forms the fossa navicularis urethræ.
• The external urethral orifice ( orificium urethræ externum;
meatus urinarius ) is the most contracted part of the urethra; it
is a vertical slit, about 6 mm. long.
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• The lining membrane of the urethra,
especially on the floor of the cavernous
portion, presents the orifices of numerous
mucous glands and follicles situated in the
submucous tissue, and named the urethral
glands ( Littré ). Besides these there are a
number of small pit-like recesses, or
lacunæ, of varying sizes
• One of these lacunæ, larger than the rest,
is situated on the upper surface of the
fossa navicularis; it is called the lacuna 72
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73
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SPHINCTER
• INTERNAL URETHRAL SPHINCTER:
• Also known as sphincter vesicae
• Involuntary in nature
• Supplied by sympathetic nerves from lower thoracic and
upper lumbar segments
• It controls the neck of bladder and prostatic urethra above
openings of ejaculatory ducts
• EXTERNAL URETHRAL ; Also known as SPHINCTER
URETHRAE
• Voluntary in nature
• Supplied by perineal branch of pudendal nerve(S2 S3 S4)
• It controls membranous urethra and is responsible for the
voluntary holding of urine
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BLOOD SUPPLY AND LYMPHATICS
• The prostatic urethra is supplied by the
inferior vesical artery.
• The bulbourethral artery supplies the
membranous and bulbar urethra penile
urethra is supplied by the deep penile
artery, a branch of the internal pudendal
artery.
• In general, venous drainage mirrors the
arterial supply
• Lymphatics from prostatic and
membranous parts pass mostly to the
75
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Surface marking
• Morris
parellelogram
• horizontal lines-
T11 & L3 spine
vertical lines- 2.5 &
9cm from median
plane
• Hilum 5cm from
median plane,near
the
• level of transpyloric
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Posterior relation
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Anterior relation
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Urachus (Median umblical
lig.)
• Allantoic remnant
• Anchors the bladder to the anterior
abdominal wall
• There is a relative paucity of
muscle at the point of attachment of
the urachus  diverticula
formation.
• Near the umbilicus, it becomes
more fibrous and usually fuses with
one of the obliterated umblical
arteries  may be vascular in
adult life
• Cyst/ fistula/ sinus/
Adenocarcinoma
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Urethra (male)
 8 inches (20 cm) long
 Extends from neck of the bladder to external
meatus.
 It has a tortous course
 Three parts
 Prostatic urethra (1.25 inches)
 Membranous urethra (0.5 inches)
 Penile or spongy urethra(6 inches)
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• PELVIS
– Funel shaped dilatation
at upper part Formed
by union of major
calyces Passes
downwards and
medially through hilum
Capacity – 5 to 7 ml
• Abdominal part
– Passes downwards and
medially by passing
beneath the peritoneum
– Enters pelvic cavity by
crossing termination of
common iliac artery
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• At the level of ischial spines it
runs in the broad ligament and
enter the ureteric canal formed
by the cardinal
ligament,crossed by the
uterine vessels running
anterior to ureter.
• Here, It is 1.5 cm lateral to
cervix.•
• The ureter runs medially and
enter the bladder close to the
anterior vaginal wall .
• On left side it even can cross
the vaginal angle .
• Ureters while running at base
of broad ligament ,are also
very close to utero sacral
ligament.
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Urethra (male)
 External meatus is the narrowest part of the entire urethra.
 Two sphincters:
 Internal urethral sphincter (involuntary)
 External urethral sphincter (voluntary)
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• Body (or dome) and
Fundus :
- supple, mobile and highly
distensible
- capable of expanding into
abdomen
• Base of bladder not so
distensible holds orifices
(ureters and urethra) in
place
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Lymphatics
• Lateral aortic nodes at the
origin of renal arteries
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Nerve supply
Renal plexus from
coeliac plexus
Afferents – T10 –
T12
Sympathetics –
T10-
L1
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URETER
• Pair of thick walled muscular tubes which
convey urine from kidneys to the urinary
bladder , lie retroperitoneum
• DIMENSIONS Length-25 cm Diameter- 1.5-
6mmmm
• The left ureter is slightly longer than the right.
NORMAL CONSTRICTIONS
• (1) At pelviureteral junction
• (2) at brim of lesser pelvis
• (3) at passage through bladderwall
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Vessels and nerves
• Arteries, superior and inferior vesical,
middle rectal
• Veins, vesical plexus  vesical veins
internal iliac vein (communicates with
prostatic plexus)
• Lymphatics, external, internal, sacral, and
median common iliac nodes.
• Nerves. Inferior epigastric and vesical
plexus
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VENOUS SUPPLY :
* the dorsal vein of penis passes between the
inferior pubic arch and the striated urinary
sphincter to reach the pelvis
* it trifurcates into
1. central superficial branch
2. 2 lateral plexuses (plexus of santorini)
[During retropubic prostatectomy the dorsal vein complex is
best divided distally before its ramification to minimise blood
loss.]
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* The superficial branch pierces the visceral endopelvic fascia between the
puboprostatic ligaments draining
1. retropubic fat
2. anterior bladder
3. anterior prostate
* Lateral plexuses swifts down the side of the prostate receiving drainage
from prostate & rectum
*communicates with vesical plexuses on the lower part of bladder
*3-5 inferior vesical veins emerge from vesical plexuses and drains into
internal iliac veins
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Male Bladder Neck
• The large-diameter muscle fascicles replaced by much
finer fibers
• bladder neck  the detrusor muscle - three layers
• Radially oriented inner longitudinal fibers pass through
the internal meatus to become continuous with the inner
longitudinal layer of smooth muscle in the urethra.
• The middle layer forms a circular preprostatic sphincter
that is responsible for continence at the level of the
bladder neck
• The outer longitudinal fibers are thickest posteriorly
at the bladder base and attached to the apex of trigone
and prostate
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Fixation of the Urinary bladder
• True ligaments:
– Pubovesical (in female it is
directly attached)
– males -puboprostatic ligament.
– Rectovesical, from bladder to
sides of rectum and sacrum
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Fixation of urinary bladder....
• False ligaments, a group of peritoneal
folds from the bladder to the abdominal or
pelvic walls.
– 1 median ligament
– 2 medial ligament (Umblical Arteries)
– 2 lateral ligament (overlies IEA)
– 2 sacrogenital ( posterior false ligament)
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 1.5 inches (3.8 cm) long.
 Extends from neck of the bladder
to external meatus, where it opens
into the vestibule, anterior to
vagina
 External urethral sphincter
 The female lacks a well-defined
circular smooth muscle component
comparable with the sphincter of
the male.
 The muscle in this region is
arranged longitudinally and extends
into the urethral wall.
Female urethra
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Blood Supply of Urethra
Male Urethra Female Urethra
• Prostaticbranches of inferior
vesical and middle rectal
arteries
• Dorsal artery of the penis
• Arteries of the bulb of the
penis
• Internal pudendalartery
• Vaginal artery
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• Lateroconal Fascia
• anterior and posterior
laminas of the renal
fascia fuse to make a
single layer
• It separates the
anterior from the
posterior pararenal
space
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• Perirenal fat can
be distinguished by
its paler color and
finer texture
compared with that
of the pararenal fat
that lies outside the
renal fascia.
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BLOOD SUPPLY
• Upper part –renal artery
• Middle part-aorta
• Pelvic part-vesical,middle rectal or uterine
vessels
• NERVE SUPPLY
• Sympathetic- T10-L1
• Parasympathetic- S2-S4
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VASCULATURE OF BLADDER :
Vesical blood supply is through two pedicles
1. Lateral pedicle 2. Posterior pedicle
1. LATERAL PEDICLE:
- formed mainly by lateral vesical ligament in male
cardinal ligament in female
(approached from rectovesical space it lies lateral to ureter
2. POSTERIOR PEDICLE:
- formed by posterior vesical ligament in male
uterosacral ligament in female
(posteromedial to ureter)
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Urinary bladder
Base (Posterior surface):
 Superolateral angles are joined by ureters.
 Inferior angle give rise to urethra.
 Upper part of the posterior surface is covered by peritoneum.
 Lower part of the posterior surface is related to seminal vesicles and vas
deferens (males).
 Posterior surface is related to uterus and vagina (females).
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1.Superior vesical artery :
-supplies the superior part of bladder
2.Inferior vesical artery:
-supplies the lower ureter ,bladder base , prostate
and the seminal vesical in male
-in female supply the ureter ,bladder base and
vagina
3.Trigone is mainly supplied by
-vesiculo-deferential artery in male
-uterine artery in female
4.Additional supply is derived from
-obturator
-inferior gluteal
-in females-uterine and vaginal arteries
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Female neck
• At the female bladder neck, the inner
longitudinal fibers converge radially to
pass downward as the inner longitudinal
layer of the urethra.
• Middle layer not so robust
• Little adnergic innervation and is weak
108
Chennai.

UV junction
• 2 to 3 cm from the bladder,
Waldeyer fibromuscular
sheath extends
longitudinally over the
ureter and follows it to the
trigone.
• Intramural 1.5-2 cm
• The intravesical portion
lies immediately beneath
the bladder urothelium 
pliant
backed by a strong plate
of detrusor muscle
109
Chennai.

Special feature
• Trigone of the bladder:
– A smooth triangular area
above the urethral orifice.
– Posterolateral angles are
formed by the Ureteric
orifice
– Base is formed by the
interureteric ridge(Mercier)
between the orifices
– Anterior angle is at the
internal urethral orifice.
110
Chennai.

Trigone
• The muscle of trigone forms three distinct
layers:
(1)a superficial layer, derived from the
longitudinal muscle of the ureter, which
extends down the urethra to insert at the
verumontanum;
(2) a deep layer, which continues from
Waldeyer sheath and inserts at the bladder
neck;
(3) a detrusor layer, formed by the outer
longitudinal and middle circular smooth
muscle layers of the bladder wall.
111
Chennai.

112
Chennai.

ANATOMY OF GENITOURINARY TRACT

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ANATOMY OF GENITOURINARY TRACT