Lecture 5: Kidney, Ureter, Bladder & Posterior Abdominal Wall Flashcards
Key Boney Landmarks
Anterior Sacro-Illiac Joint Illiac Crest Illiac Fossa ASIS Ischial Spine Obturator Foreamen Pubic symphysis Lesser Trochanter
Components of the Posterior Abdominal wall
- Iliacus
- Psoas Major (Ilio Psoas)
- Quadratus Lumborum
Transversus
Diaphragm
Quadratus Lumborum
Origin: Illiac Crest
Insertion: 12th Rib + L1-4 Transverse Processes
- More Posterior and Lateral than Psoas Major
Action:
a) Combined: i) Forced expiration ii) 12th rib support, bracing spine and ribs in place
b) Individually: Bend trunk to same side
Innervation: T12-L4 (Anterior Rami)
Illiacus
Origin: Illiac Fossa
Insertion: Combines and forms Common Tendon with Psoas Major –> inserts onto Femur’s Lesser Trochanter
Action: Hip flexion
Innervation: ** Femoral nerve L2-4
Psoas Major
Origin: T12, L1-5 Intervertebral discs –> forms archways/digitations –> allows vessels to enter
- Underneath Inguinal ligament
Insertion: Combines and forms Common Tendon with Illiacus –> inserts onto Femur’s Lesser Trochanter
Action:
a) Combined: Archways/Digitations ANTERIORLY attached to intervertrbal discs (T12/L1-5) –> affects spinal movement –> helps raise body from supine position
b) Hip flexion
c) Individually: Laterally bends trunk
Innervation: Lumbar Plexus L1-3 Direct branches
Aorta and IVC
Aorta: enters diaphragm at T12 –> 5x Lumbar arteries –> Bifurcates at L4 (superior to IVC bifurcation) –>
- Renal artery comes off at L1 (same as SMA) para-aorticly
- Gonadal (testicular/ovarian) artery comes off at L2
Lumbar Arteries and veins supply and drain Posterior abdominal wall
- Right C.I Artery overlaps Left C.I Vein (risk of compression)
IVC: enters right diaphragm at T8 –> 5x Lumbar veins –> Bifurcates at L5 (lower) –> Common Iliac Veins
- Venous drainage relatively more complex
Varicose Veins in Pregnant woman
Pregnant woman –> Right Common Iliac Artery (Right branch off aortic bifurcation) crosses over and compresses Left Common Iliac Vein –> No drainage in Left legs –> Left Leg Varicose Veins
Urinary system contents
Supra-renal glands –> Kidney –> Ureter –> Bladder –> urethra
- Supra renal glands technically not part of urinary system –> Deal more with Adrenalin
Location: all RETRO/INFRAperitoneal
Function of the Urinary system
- Waste removal
- Electrolyte balance
- pH balance
- BP/Volume regulation
Surface anatomy of Kidneys (and Suprarenal Glands)
Retroperitoneally (posterior to abdomen)
Superiorly sits ontop of Posterior abdominal muscles Psoas major and Quadratus Lumborum
Kidney’s Relationship with ribs: Posterior and Inferior
- Right Kidney Lower (T12) due to liver –> Left Kidney (L11/12)
Ureters –> exit kidney L1 –> Transpyloric Plance
Features of Kidneys (and Suprarenal Glands)
Red/brown
Smooth outer capsule
Kidney contains poles (Upper and Lower)
Hilum of each kidney: Renal Vein + Renal Artery branches + Renal Pelvis + (Lymphatics and ANS)
- Posterior to Hila vessels: Renal Pelvis + Ureters (at Ilium)
Suprarenal glands are encased in similar fascial layers
Kidney padding
Kidneys conduct essential functions –> Surrounded and protected from trauma –> with Fat pads:
- PERInephric fat (near kidney)
- PARAnephric fat (outside kidney)
- B/w Peri and para nephric fat pads is RENAL FASCIA
Renal Fascia
Separates Peri and Para nephric fat pads
Extends over IVC, Aorta –> connects with other side –> Blends with Psoas Major Fascia
Pathological relevance: Renal Fascia –> Both Left and Right kidneys within same fascial compartment –> allows diseases to spread Left Right
Internal Structure of Kidney
Capsule –> Cortex (glomerular. Smooth glandular tissue) –> Medulla (medullary rays, LOD, CD) –> Renal papilla –> Minor Calyces –> Major Calyces –> Renal pelvis –> Ureter
Differentiation b/w Kidneys’ Cortex and Medulla
Poor differentiation b/w Smooth Glandular tissue of cortex vs Medullar tissue –> Pathology/Something is wrong
Relations of the Right Kidney
Anterior: Suprarenal gland, Under Liver, 2 Duodenum (anterior medial), Hepatic Flexure (of colon)
Posterior: Diaphragm, Psoas, Quadratus Lumborum, Transversus abdominus, Rib 12 (relatively lower), SUBCOSTAL nerve (T12 Spinal nerve)
Relations of the Left Kidney
Anterior: Suprarenal gland, Spleen (anterior and superior), Stomach, Pancreas (splenorenal ligament), Jejunum, Splenic Flexure of Colon
Posterior: Diaphragm, Psoas, Quadratus Lumborum, Transversus Abdominus, Ribs 11 and 12 (relatively higher as spleen > liver), SUBCOSTAL nerve (T12 Spinal nerve)
Blood Supply of the Kidneys
L1 Renal arteries and veins
Veins Anterior to Arteries –> avoids risk of compression against Posterior abdominal wall –> Spilt into septal banches
Arteries –> bifurcate into Anterior and Posterior branches –> enter Hilum of Kidneys –> segmental branches
Blood Supply of the Supra-renal gland
- Branch from abdominal aorta
- Phrenic Artery
- Suprarenal artery
Structures relative to Left Renal Artery
Vertically Ontop of LRA: SMA
Vertically Underneath LRA: Anterior Aorta
Horizontally Underneath LRA: Splenic vein + Body of pancreas
General Notes on Kidney Blood, Nerve and Lymph
General Notes:
Veins anterior to arteries. Vessels come off para-aortically at L1
Arterial Summary of Kidney Blood, Nerve and Lymph
Arterial:
Renal arteries off laterally at L1 –> anterior branches –> segmental branches
- double renal arteries not uncommon, embriologically multiple arteries fuse, therefore some may not have been obliterated out
Aorta located on left side of body –> RIGHT renal Artery 3x Longer –> in order to supply kidney from opposite side
Venous Summary of Kidney Blood, Nerve and Lymph
Venous:
Renal veins off laterally at L1
IVC located on Right side of body –> Left Renal vein 3x longer –> in order to drain kidney from opposite side
Left Renal vein runs Vertically Posterior to SMA, Vertically Anterior to Abdominal Aorta, Horizontally INFERIOR to Splenic Vein + Body of Pancreas
Nervous Summary of Kidney Blood, Nerve and Lymph
Nervous: Renal plexus - Sympathetic = complicated - Parasympathetic = Vagus nerve (Cranial nerve 10) Referred pain --> FLANK pain
Lymphatic Summary of Kidney Blood, Nerve and Lymph
(Lymphatics follow arteries) –> **Para-aortic nodes L1
- Located Posteriorly, on the side
Ureters
Smooth muscle tube
Urine propelled through ureter via:
1. smooth muscle contractions
2. GFP Filtration Pressure from Glomerulus
~25cm
Exits Kidneys at L1/Hilus (same level of entering arteries) –> Runs on surface of Psoas Major
Radiologically: Roughly in line with processes of Lumbar spine
At Anterior Sacro-Iliac Joint –> Ureter Crosses bifurcation of Common Illiac artery on respective side –> continues along ileum on pelvis’ lateral wall –> towards Ischial Spine –> Enters Trigone at bladder’s Inferior surface (enters obliquely. tries to control flow)
Most common place for ureter’s Kidney Stone to lodge
Narrowest part due to constriction of surround structures –> when ureter is at Anterior Sacro-Iliac Joint –> is crossing Bifurcation of Common Iliac arteries
3x Constrictions of Ureters
- PUJ: Junction of the Renal Pelvis –> Ureter (Pelvo-Urteric Junction
- Anterior Sacro-Iliac Joint –> where ureters cross bifurcation of aorta into Common Iliac arteries (Pelvic Brim)
- Inferior Bladder’s Trigone (Ureter enters obliquely) (tries to control flow)
- -> All 3x sites (PUJ, Anterior SIJ, Trigone) common places of kidney stone/ renal calculus obstruction
Ureter’s Blood and Nerve supply in 1/3s
Superior 1/3 (proximal) –> Middle 1/3 –> Inferior 1/3 (distal)
Arterial: Renal artery –> Gonadal (testicular/ovarian) artery –> Superior Vesicular(bladder) artery (branch of Internal Iliac)
Venous: Renal vein –> Gonadal (testicular/ovarian) vein –> Superior Vesicular (bladder) artery (branch of Internal Iliac)
Nervous: Renal Plexus (sup+mid 1/3) –> Hypogastric Plexuses (controls pelvic contents/urogenital)
Ureter’s Pain referral and Lymphatic supply
- Pain referred to L1 and 2 Dermatomes (Suprapubic regions)
- Lymphatics (Lateral aortic L1 Iliac nodes) –> variable due to variable supply
“vesicular”
bladder
- Hence Inferior 1/3 of both ureter’s arterial supply and venous drainage = Superior Vesicular Artery/Vein (from Internal Iliac branch)
Bladder
Infraperitoneal: Partial peritoneal covering –> Stuck against the pubic bones (various ligaments helping to do so)
Transitional epithelium and rugae
Apex of bladder = Posterior to Pubic Symphisis
When Bladder located in midpubic region –> bladder fills -> rises to suprapubic region (decreased sensation’s large filling leads to increased chance of UTI urinary tract infections)
Dextrusor muscle : Smooth muscle coat
Sphincter Vesicae Smooth muscle sphincter at neck of bladder
Bladder’s smooth muscle coat
Dextrusor muscle
Bladder’s smooth muscle sphincter
Sphincter Vesicae (Vesicae = vesicular = bladder)
- located at neck of bladder
Internal sphincter of bladder, Prior to ureter’s involuntary control
Sensation of bladder with position and age
Standing/Elderly –> Decreased sensation of bladder –> Bladder fills to large levels (2L) w/o realising/emptying –> Bladder distends into suprapubic region –> Urinary Tracts
Trigone
Smooth muscle area, at Base/back of bladder
- Mucous membrane
-NO rugae
Superiorly: 2x ureters enter
–> Interuteric bar/crest b/w 2x ureters = BASE = Less mobile –> easily irritated
Inferiorly: 1x urethra exits = APEX
Blood and nerve of the Bladder
Arterial:
2x superior and 1x inferior Vesicular artery from each side (branches off internal illiac)
-Note: Male Inferior vesicular artery –> tends to be Vaginal artery in females
Venous:
Vesicular plexus –> drains into Internal Illiac Vein
Nervous:
ANS –> Inferior Hypogastric Plexus (located in sacral area)
a) Sympathetic: Sacral splanchnic nerves S2-4 (L1-2 fibres)
- Note: Pain referred to Supra-pubic region due to L1-2 Dermatomes
b) Parasympathetic: Pelvic Splanchnic nerves
Gender variation of Bladder arteries
Bladder arteries: 2x Superior + 1x Inferior vesicular artery
Males: Inferior vesicular arteries
Females: Vaginal artery
Bladder Pain referral
Pain referred to Suprapubic region (L1-2 Dermatomes)
