Genitourinary Flashcards
What veins do the right and left gonadal veins drain into?
Right: directly into IVC
Left: left renal vein
What are the narrowest parts of the ureter?
- where the ureter leaves the renal pelvis
- where the ureter enters the bladder
- pelvic brim
Describe the relationship between the ureter and the bony landmarks of the abdomen?
- The pelvis of the left kidney is about the level of Lumbar 2-3 disc and the right pelvis Lumbar body 3.
- The ureter commences at the lower part of the pelvis and runs down the tips of the transverse processes of the lumbar vertebrae.
- It runs just medial to the sacroiliac joint but usually directly over it inferiorly
- It runs across the tip of the spinous process of the pelvis and medially into the bladder
Where would you look for an undescended testes? Is it worth surgically correcting this anomaly?
- Anywhere along its normal (embryological) path on the posterior abdominal wall.
- Spermatogenesis does not occur correctly at body temperature so the testis migrates into the scrotum where the temperature is lower.
- In undescended testis correction is essential to ensure future fertility.
Where would you try to palpate lymph nodes to assess the spread of testicular cancer?
- The lymph drainage of any organ follows the arteries (but flow in the opposite direction).
- Cancer of the testis will spread to lymph nodes around the aorta where the testicular arteries arise.
What is variocele?
High pressure of venous blood in the pampiniform plexus of veins
in the scrotum cause the veins to enlarge
What does the femoral nerve supply? Where would you look for the femoral nerve?
- Femoral nerve supplies hip flexors and knee extensors
- Femoral nerve leaves L2-L4 and passes under the inguinal canal.
- It is located near the groin
How does the obtruator nerve pass from the abdomen into the thigh?
Through the obturator foramina
How do the sciatic and femoral nerves pass from the abdomen into the thigh?
- Femoral: under inguinal ligament
- Sciatic: through the greater sciatic foramen
Renal tumours can become very enlarged before they invade adjacent structures. What anatomical features explain this?
Kidneys have a thick and resilient capsule, surrounded by perinephric fat which itself is surrounded by perinephric fascia
Describe 2 common variations in the anatomy of the renal pelvis and ureter
Sometimes the ureters join together to form 1 single ureter entering the bladder but sometimes then enter separately. If there are 2 ureters there may be 2 separate kidneys on that side. If there are two complete ureters on one side the upper kidney drains normally at the trigone but the lower kidney drains abnormally higher up the bladder and does not have the valve mechanism so is prone to urine passing back up to the kidney when the bladder contracts.
What is a polar artery and why do they exist?
When the kidneys develop, they have segmental pattern with a separate artery to each part. Usually these 2 arteries join to form a single artery however, about 1/4 of people have 2 renal arteries to one kidney, usually a large renal artery and a smaller one to the inferior pole of the kidney; a polar artery. A polar artery can compress the ureter and stop urine flow.
Where would you palpate an abdominal aneurysm?
The abdominal aorta finishes just above the umbilicus so can only be felt in the upper abdomen
Why is the ureter in danger of damage during a hysterectomy?
The ureter runs immediately under the uterine artery. This artery will need to be ligated and divided to complete the hysterectomy.
What stops urine passing from the bladder back up the ureter?
- The ureter enters the bladder at unique oblique angle.
- As pressure in the bladder rises this presses on the part of the ureter which is in the bladder wall and stops urine passing back up to the kidney
A 25 year old woman involved in a car crash suffered complete transection of her spinal cord at the level of T6. Is she able to tell when her bladder is full? Does her bladder empty via muscle contraction or does it simply “overflow”? Will her bladder completely empty?
- No, the signals will not reach the brain
- The bladder will empty by muscular contraction controlled so will completely empty
Coverings of the kidneys
- Renal capsule - tough fibrous capsule
- Perirenal fat
- Renal fascia (Gerota’s fascia) encloses the kidneys and suprarenal glands
- Pararenal fat - on posterolateral aspect of the kidney
What vertebrae do the kidneys span?
T12-L3
Which kidney sits lower in the abdomen and why?
Right due to the presence of the liver
The kidneys are retroperitoneal, what does this mean?
They lay behind the peritoneum and are in contact with the posterior abdominal wall
What gland rests ontop of each kidney?
adrenal gland
What is the pouch of Morison? Why is it important?
Potential space between kidney and liver
In conditions like ascites, fluid can collect in the pouch
Describe the anterior anatomical relations to the right kidney
- Right supradrenal gland on the superior pole
- Peritoneum on the top half of anterior surface separating the right kidney from the liver.
- Descending duodenum on the centre of the anterior surface
- Right colic / hepatic flexure on the lateral part of the inferior pole
- Jejenum on the medial part of the inferior pole
Describe the anterior anatomical relations of the left kidney
- Left supradrenal gland on the upper half of the superior pole
- Stomach on the medial part of the lower half of superior pole
- Spleen on the lateral part of the lower half of superior pole
- Pancreas on the centre of the anterior surface
- Splenic flexure of descending colon on the lateral part of the inferior half
- Jejenum on the medial part of the inferior half
Posterior surface relations of both kidneys? (all boys need muscle)
A - 1 artery (subcostal)
B - 2 bones (11th and 12th ribs)
N - 3 nerves (subcostal, iliohypogastric and ilioinguinal)
M - 4 muscles (diaphragm, psoas major, Quadratus lumborum, transverses abdominis)
Describe the internal anatomy of the kidneys
- Renal cortex is the space between the medulla and the outer capsule where arterioles and venules from the renal artery and vein and glomerular capillaries perfuse the nephrons of the kidney
- Main unit of the renal medulla is the renal pyramid (8-18 renal pyramids) - pyramids are separated by renal columns
- Renal papilla open to the minor calyx
- Minor calyx join to form major calyx (usually 3, superior, middle and inferior)
- Major calyx join to form the renal pelvis
- Ureter emerges from renal pelvis and leaves through hilum
Where is EPO made in the kidneys?
renal cortex
Where does the blood supply to the kidneys come from?
Renal artery - branch from the abdominal aorta
Innervation to the kidney?
What effect will sympathetic and parasympathetic innervation have on the kidney?
Sympathetic: lower thoracic splanchnic nerves
Parasympathetic: vagus nerve
Sympathetic: triggers vasoconstriction and reduced renal blood flow = decrease urine production
Parasympathetic: vasodilation and increase blood flow to kidney = increase urine production
Where does lymph from the kidneys drain?
Lateral aortic (lumbar) lymph nodes
What is the structural unit of the kidney which filters blood and regulates blood volume, blood pressure and plasma osmolarity?
nephron
In normal circumstances, can RBC and large proteins pass through the glomerulus?
No - during injury to the kidney, they can pass and cause proteinuria and haematuria
Where is the primary site of water and salt re-absorption and glucose reabsorption in the kidney
Proximal convoluted tubule
Which part of the loop of henle is highly permeable to water but impermeable to ions?
Descending loop
The ascending loop of henle Is impermeable to water but highly permeable to ions, true or false?
true - this causes a drop in the osmolarity of fluid passing through the loop
Which cells in the kidney detect low sodium and blood pressure and release renin?
Juxtaglomerular cells
Renin causes sodium reabsorption which increased blood volume and constricts blood vessels to increase BP
ADH acts where in the kidneys to increase permeability of the tubule to water and increase water reabsorption?
DCT, this increases blood volume and blood pressure
In the bladder, which sphincter is under voluntary and which is under involuntary control?
- The internal sphincter is an involuntary muscle and keeps the bladder closed when the bladder is empty.
- External sphincter is located in the floor of the pelvis which is under voluntary control (stopping urination voluntarily)
What other structure lie behind the bladder in male and female?
- In women, bladder is infront of the vagina, uterus and rectum
- In men, bladder is infront of the rectum.
How does the spermatic cord pass from the abdomen into the scrotum?
Structures making up the spermatic cord run from the deep inguinal ring through the inguinal canal and out of the superficial inguinal ring down to the scrotum passing above and medial to the pubic tubercle as they pass down
How many layers of covering does the spermatic cord have by the time it leaves the superficial ring?
As the spermatic cord passes through the inguinal canal, it acquires a layer of tissue from each of 3 abdominal wall layers so by the time it leaves the superficial ring, the spermatic cord has 3 layers of covering
What structures are contained within the spermatic cord?
It contains structures going to and from the testes including the:
- vas deferens
- testicular artery,
- pampiniform plexus of veins
- the nerves and lymphatics of the testis
What is an inguinal hernia?
An inguinal hernia is a common problem where part of the intestine or peritoneum passes through the canal - in these males, the hernia will lie in the inguinal canal
The sac which covers the testes is called what?
Tunica vaginalis
On the posterior surface of the testes there is a coiled tube, what is this called?
epididymis
The penis body is made up of how many cylinders of erectile tissue?
3
Difference between a direct and indirect hernia?
- The inguinal canal provides a route from the abdomen to the external genitalia in both sexes and it is common for a hernia to develop through the inguinal canal
- Direct hernia: passes directly through the posterior wall of the inguinal canal
- Indirect hernia: passes along the length of the canal passing through the deep inguinal ring
Why can renal pain be felt in the gonadal area and vice versa?
- Kidney and gonads have the same nerve supply (T10-L2) pain in either organ can be felt in the dermatome for these nerves which extend from the midline at the back immediately posterior to the kidney
- Kidney pain may be felt in the loin and gonadal pain might be felt in the kidneys
What is a hydrocoel?
- The testis is partially covered by a sac of peritoneum (tunica vaginalis)
- Disease of the testis or scrotum can cause fluid to collect in the sac creating a swelling which feels fluid and transmits light when a torch is shone through it
- A very full hydrocoel might feel tense instead of fluid.
Which renal vein is longer?
Left is 3x longer than right
At what level does the aorta bifurcate into common iliac arteries?
L4
At what level is the IVC formed by the common iliac veins joining
L5
What are the 2 branches of the common iliac artery and where do they supply?
The two branches of the common iliac arteries are the internal iliac artery, supplying the pelvic area, and the external iliac, which supplies the lower limb.
The internal iliac artery supplies the caudal thigh via the caudal gluteal artery
Where is the origin and insertion point of the posts major muscle?
Origin: fascia on sides of the lumbar vertebrae and intervertebral discs and runs vertically down the sides of the spinal column.
Passes along the pelvic brim and under the inguinal ligament to enter the thigh and attach the the lesser trochanter of the femur.
What nerve lies on the anterior surface of posts major?
Genitofemoral nerve
The genitofemoral nerve branches into genital nerve and femoral nerve.
What sensation does the femoral nerve supply?
What muscle does the genital nerve supply?
The femoral branch passes under the inguinal ligament and is sensory to the inside of the thigh
The genital branch passes through the deep inguinal ring and supplies the cremaster muscle (when inside of thigh is tickled, testis retract upwards)
A nerve runs laterally to the psoas muscle and runs over iliacus and under the. inguinal ligament to supply sensation to the skin over the lateral thigh, what nerve is this?
Lateral cutaneous nerve of the thigh
What nerve runs between iliacus and psoas?
- genitofemoral
- femoral
- genital
- obturator
Femoral nerve
What are the pouches in the pelvis in male and female called?
Male: recto-vesical pouch
Female: utero-vesical pouch anterior to the uterus and recto-uterine pouch posterior to the uterus (pouch of Douglas)
If there is disease or a tumour of the left kidney, what might we see in the left testicle and why?
Left testicular vein passes into left renal vein. Disease of the left kidney can block drainage of blood from the left testicle causing veins in the scrotum to become varicose causing a varicocele
What is a psoas spasm and why might it happen?
The appendix lies over the psoas muscle and if a patient has an inflamed appendix, it can rub on the psoas causing spasm which will cause the patient to flex their hip and trying to extend the hip will cause pain.
What are the 4 surfaces of the bladder?
superior
2 lateral
base
Does the uterine artery pass over or under the ureter in a female?
uterine artery passes over (water under a bridge)
In the male, what structure passes over the ureter before it pierces the bladder wall?
Ductus deferens
In prostate cancer, metastasises can be found where and why?
Venous drainage of the prostate passes into. a. plexus of veins which lie anterior to the sacrum and communicate with veins which run up to the azygous vein in the chest.
These azygous veins communicate with veins in the vertebral bodies but the veins do not have valves meaning the blood flows up and back down during inspiration and expiration allowing tumour cells to travel up the veins and pass back down to the vertebral bodies where they attach and cause a metastasis.
Neurology of the bladder:
If there is loss of brain control over the bladder what would happen?
bladder fills, spinal cord knows bladder is full but does not reach the brain so bladder completes emptying and patient will suddenly and unexpectedly pass urine. No risk of renal failure as the bladder doesn’t overfill.
Neurology of the bladder: if there is a loss of sensation in the bladder what would happen? What is the risk associated with this?
spinal cord and patient can’t know the bladder is full as no sensation, bladder fills up and the patient continually dribbles urine with high pressure in the bladder. This rapidly progresses to kidney damage.
Neurology of the bladder: if there is a loss of spinal cord motor innervation to the bladder what would happen? What is the risk associated with this?
patient knows bladder is full but cannot empty it as there is no motor control from the spinal cord. This causes high pressure in the bladder and causes renal failure.
The uterus is typically in what position?
Ante-flexed (bent forwards)
The cervical canal communicates with the uterine cavity and vagina via what?
internal os - uterine cavity
external os - vagina
What stabilises the position of the cervix?
Levator ani muscle
Pelvic fascia
Cardinal ligaments which run from the lateral wall of the cervix to the lateral pelvic side wall
The ovaries are attached to the posterior of the broad ligament via a short mesentery know as?
mesovarium
Where does the ovary typically lie?
Position is not fixed but lies in the ovarian fossa usually (angle between internal and external iliac arteries)
Arterial blood supply to ovary is derived from where?
directly from abdominal aorta near the origin of the renal arteries
Name the male organs of reproduction (8)
paired testes epididymus ductus deferens seminal vesicles ejaculatory ducts bulbo-urethral glands prostate gland penis
The ductus deferent joins the seminal vesicle to form what?
ejaculatory duct on the back of the bladder to enter the prostate
what is the function of the seminal vesicle?
does not store spermatozoa but secretes thick alkaline fluid which forms the bulk of seminal fluid
Benign tumours of the prostate usually occur in what area? what can a benign tumour of the prostate interfere with?
median lobe (between ejaculatory ducts) and they can interfere with urination.
What are the 3 parts of the urethra in a male and which is the longest?
prostatic part - 3cm
membranous part - 1cm
spongy part - 15 cm
