Ureter, Urinary Bladder, Urethra

Question 1

Where is the ureter located?

Answer 1

Retroperitoneal from renal pelvis down to bladder and attached to the posterior abdominal wall

Question 2

Anatomical Course of Ureter

Descends along anterior surface of ____

First step

Answer 2

Descends along anterior surface of psoas major

L2-L5

Question 3

Anatomical Course of Ureter

Crosses the ____ at level of ____ to enter pelvic cavity

Second step

Answer 3

Crosses the pelvic brim at level of sacroiliac joints to enter pelvic cavity

Question 4

Anatomical Course of Ureter

Descend along ____

Third step

Answer 4

Descend along lateral pelvic walls

Question 5

Anatomical Course of Ureter

Turn anteromedially at the level of ____ to travel transversely towards bladder

Fourth step

Answer 5

Turn anteromedially at the level of ischial spines to travel transversely towards bladder

Question 6

Anatomical Course of Ureter

Pierces lateral aspect of bladder walls in ____ manner

Fifth step

Answer 6

Pierces lateral aspect of bladder walls in oblique manner

Creates a one-way valve preventing backflow of urine

Question 7

Name the 3 constrictions of the ureter

Answer 7

1. Ureteropelvic junction
2. Pelvic inlet (where ureters cross the iliac vessels)
3. Vesico-ureteric junction (narrowest - entrance to bladder)

Question 8

Clinical significance of constrictions

Answer 8

Common sites of obstruction by calculi

Question 9

Ureteral Pain

What does ureteral pain result from?

Answer 9

Strong peristaltic waves of contraction pass down ureter in attempt to pass stone onward -> Smooth muscle spasms causes colicky pain

Question 10

Ureteral Pain

How does ureteral pain come about? (spinal cord)

Answer 10

Afferent nerve fibers of renal pelvis and ureter enter spinal cord at segments T11, T12, L1 and L2 -> Pain referred to corresponding dermatomal distribution along flank, loin and groin

Question 11

Ureteral Pain

Ureter lies in close proximity to the ____ nerve and pain is referred along ____ branch of the nerve -> Pain over tip of penis (male) and labia major (female)

Answer 11

Ureter lies in close proximity to the genitofemoral nerve and pain is referred to genital branch of the nerve -> Pain over tip of penis (male) and labia major (female)

Question 12

Ureteral Pain

Ureter lies in close proximity to the ____ nerve and pain is referred along ____ branch of the nerve -> Pain over front of thighs

Answer 12

Ureter lies in close proximity to thegenitofemoral nerve and pain is referred along femoral branch of the nerve -> Pain over front of thighs

Question 13

Urinary bladder is a ____ and ____ organ

Answer 13

Urinary bladder is a hollow and distensible organ

Question 14

Where is the urinary bladder located?

Answer 14

On floor of pelvic cavity, inferior to peritoneum and posterior to pubic bones

Question 15

Urinary bladder expands ____ into abdomen when full

Answer 15

Urinary bladder expands superiorly into abdomen when full

Question 16

Male Urinary Bladder

Upper part of posterior surface is covered by ____

Answer 16

Upper part of posterior surface is covered by peritoneum

Question 17

Male Urinary Bladder

Lower part of posterior surface separated from the ____ by ____ , seminal vesciles and the rectovesical fascia

Answer 17

Lower part of posterior surface separated from the rectum by vasa deferens, seminal vesicles and the rectovesical fascia

Question 18

Male Urinary Bladder

Neck of bladder rests upper surface of ____

Answer 18

Neck of bladder rests upper surface of prostate

Question 19

Female Urinary Bladder

Posterior surface separated from ____ by ____

Answer 19

Posterior surface separated from rectum by vagina

Question 20

Female Urinary Bladder

Superior surface related to ____

Answer 20

Superior surface related to uterovesical pouch

Question 21

Female Urinary Bladder

Neck of bladder rests directly on upper surface of ____

Answer 21

Neck of bladder rests directly on upper surface of urogenital diaphragm

no prostate

Question 22

Internal features of bladder

What is the muscle in the urinary bladder?

Answer 22

Detrusor (smooth muscles)

Question 23

Function of detrusor muscle

Answer 23

Contracting in response to signals from nervous system and empty bladder when necessary

Question 24

What is the neck of the bladder formed by?

Answer 24

Convergence of the fundus and 2 inferolateral surfaces

Question 25

# Internal features of bladder When bladder is empty, the walls of it have a series of ridges, thick mucosal folds known as ____ that allow for ____ of bladder

Answer 25

When bladder is empty, the walls of it have a series of ridges, thick mucosal folds known as **rugae** that allow for **expansion** of bladder ## Footnote *Only seen when bladder is empty*

Question 26

# Internal features of bladder What is the trigone of the bladder?

Answer 26

Smooth triangular region on base of internal urinary bladder and is seen in between 2 ureteric orifices/openings and internal urethral orifice ## Footnote *No rugae even when urinary bladder is empty (always smooth)*

Question 27

What are the layers of the bladder wall?

Answer 27

- Mucosal - transitional epithelium - Lamina propria - Submucosa - Detrusor muscle - Peritoneum

Question 28

Function of submucosa of urinary bladder

Answer 28

Provides support and elasticity to the bladder

Question 29

What are the 2 key functions of the urinary bladder?

Answer 29

1. Temporary storage of urine 2. Assist in expulsion of urine

Question 30

What is the maximum capacity of the urinary bladder?

Answer 30

About 500ml

Question 31

What can cause urinary retention?

Answer 31

Obstruction distal to bladder neck - Benign Prostatic Hyperplasia - Bladder stone (cystolithiasis) - Large blood clot (haematuria) - Urethral structures

Question 32

Where are the 2 sphincters located and what are their names?

Answer 32

Urethra Internal and External urethral sphincter

Question 33

Sphincters are ____ muscles that open and close passages in the body to regulate flow of substances such as ____ through the body

Answer 33

Sphincters are **circular** muscles that open and close passages in the body to regulate flow of substances such as **bile, urine and feces** through the body

Question 34

What forms the internal urethral sphincter?

Answer 34

Circular muscle fibres at base of bladder becomes thickened

Question 35

Where is the internal urethral sphincter located?

Answer 35

Bladder neck

Question 36

Internal urethral sphincters are ____ muscle fibers under ____ control

Answer 36

Internal urethral sphincters are **smooth** muscle fibers under **autonomic** control

Question 37

Function of internal urethral sphincters in males and females

Answer 37

Maintains urinary continence - controls release of urine into urethra

Question 38

Function of internal urethral sphincters in males

Answer 38

Prevents seminal regurgitation during ejaculation

Question 39

External urethral sphincters are ____ muscle under ____ control

Answer 39

External urethral sphincters are **skeletal** muscle under **voluntary/somatic** control

Question 40

Which nerve is the external urethral sphincter innervated by?

Answer 40

Pudendal nerve (S2-4) ## Footnote *Provides voluntary control over micturition*

Question 41

What are the blood supplies of the bladder?

Answer 41

- Superior vesical - Inferior vesical - Obturator - Uterine arteries (female)

Question 42

Lymph of urinary bladder mostly drains into ____ nodes and a few from superolateral surface drains into ____ nodes

Answer 42

Lymph of urinary bladder mostly drains into **internal iliac** nodes and a few from superolateral surface drains into **external iliac** nodes

Question 43

Veins of bladder do not follow arteries but form a plexus that converges on ____ plexus in groove between ____ and ____ which drains backwards across the pelvic floor into the ____ veins

Answer 43

Veins of bladder do not follow arteries but form a plexus that converges on **vesico-prostatic** plexus in groove between **bladder** and **prostate** which drains backwards across the pelvic floor into the **internal iliac** veins

Question 44

Which nervous system regulates function of bladder?

Answer 44

Autonomic nervous system

Question 45

Sensory pathway of bladder

Answer 45

Afferent nerve fibers from bladder wall to CNS and signals to the brain the need to urinate when bladder becomes full ## Footnote *bladder contains stretch receptors to detect bladder filling*

Question 46

What is the sympathetic nerve that innervates the bladder?

Answer 46

Hypogastric nerve (L1-L2)

Question 47

Function of sympathetic innervation of bladder

Answer 47

- Inhibits contraction of detrusor muscle - Contracts internal urethral sphincters which closes -> Urinary retention

Question 48

What is the parasympathetic nerve that innervates the bladder?

Answer 48

Pelvic splanchnic nerve (S2-4)

Question 49

Function of parasympathetic innervation of bladder

Answer 49

- Stimulate contraction of detrusor muscles - Inhibit action of internal urethral sphincter -> Micturition

Question 50

What is the somatic nerve that innervates the bladder?

Answer 50

Pudendal nerve (S2-4)

Question 51

Function of somatic innervation of bladder

Answer 51

Controls external urethral sphincter -> voluntary control over micturition

Question 52

# Micturition reflex in infants When bladder reaches its micturition threshold, stretch receptors on bladder wall send signals to ____ via the ____ nerves. Interneurons within spinal cord relays signals to ____ which causes ____ of detrusor muscle and ____ of internal urethral sphincter and ____ of urination -> ____ spinal reflex

Answer 52

When bladder reaches its micturition threshold, stretch receptors on bladder wall send signals to **S2, S3 and S4** via the **pelvic splanchnic** nerves. Interneurons within spinal cord relays signals to **parasympathetic efferent fibres** which causes **contraction** of detrusor muscle and **relaxation** of internal urethral sphincter and **initiation** of urination -> **primitive** spinal reflex

Question 53

# Micturition reflex in adults Facilitated and inhibtied by ____ and subject to ____

Answer 53

Facilitated and inhibtied by **higher brain centers** and subject to **voluntary facilitation and inhibition**

Question 54

# Micturition reflex in adults What is the simple stretch reflex inhibited by in adults?

Answer 54

Activity of cerebral cortex until the time and place for micturition are favourable

Question 55

# Micturition reflex in adults What happens when it is not convenient to urinate?

Answer 55

CNS sends back an inhibitory signal to keep sphincters closed and prevent voiding

Question 56

# Micturition reflex in adults Inhibitory fibres pass downwards with ____ to ____ of spinal cord to innervate ____ nerve

Answer 56

Inhibitory fibres pass downwards with **corticospinal tracts** to **S2-4** of spinal cord to innervate **pudendal** nerve

Question 57

# Micturition reflex in adults Spinal cord through ____ nerves signals detrusor muscle of bladder to ____ and internal urethral sphincter to ____ . Voluntary ____ of external urethral sphincter closes urethra and micturition follows.

Answer 57

Spinal cord through **pelvic splanchnic** nerves signals detrusor muscle of bladder to **contract** and internal urethral sphincter to **relax** . Voluntary **relaxation** of external urethral sphincter closes urethra and micturition follows.

Question 58

Function of urethra

Answer 58

Vessel responsible for transporting urine from bladder to external opening in the perineum

Question 59

Difference of urethra between males and females

Answer 59

- Female: Short (3-4cm) - Males: Long (15-20cm)

Question 60

Why are females more susceptible to UTI?

Answer 60

1. Shorter urethra -> easier for pathogens to enter and infect urinary tract 2. Urethral proximity to anus -> bacteria from large intestine often cause UTI -> proximity allows bacteria to easily access urethra

Question 61

What are the 3 types of bladder dysfunction due to spinal cord injury?

Answer 61

1. Atonic bladder 2. Automatic bladder 3. Autonomous bladder

Question 62

When does atonic bladder occur?

Answer 62

Spinal shock - Immediately after spinal injury and may last for a few days to several weeks

Question 63

Atonic bladder: Bladder becomes greatly ____ and overflows. Bladder wall muscle is ____, internal sphincter muscle tightly ____ and external sphincter muscle ____

Answer 63

Atonic bladder: Bladder becomes greatly **distended** and overflows. Bladder wall muscle is **relaxed**, internal sphincter muscle tightly **contracted** and external sphincter muscle **relaxed**

Question 64

Which spinal cord lesion does automatic reflex bladder occur at?

Answer 64

Cord lesion above level of parasympathetic outflow (S2-4) - Injury above T12

Question 65

If injury above T12: disrupts brain's ability to control bladder but ____ remains intact

Answer 65

If injury above T12: disrupts brain's ability to control bladder but **reflex arc** remains intact

Question 66

Automatic Bladder: Bladder fills and empties ____ Afferent signals unable to reach brain and patient has no awareness of bladder filling -> Loss of descending control over ____ and no ____ control over urination

Answer 66

Automatic Bladder: Bladder fills and empties **automatically** Afferent signals unable to reach brain and patient has no awareness of bladder filling -> Loss of descending control over **exernal urethral sphincter** and no **voluntary** control over urination

Question 67

Which spinal cord lesion does autonomous reflex bladder occur at?

Answer 67

Sacral segments - Injury below T12

Question 68

If injury below T12: damaged ____ outflow to bladder and ____ does not function

Answer 68

If injury below T12: damaged **parasympathetic outflow** to bladder and **spinal reflex** does not function ## Footnote *detrusor muscle paralysed and cannot contract*

Question 69

Autonomous bladder: Bladder fills to capacity and ____ Continual ____ occurs once bladder is full and bladder may be partially emptied by manual compression of lower part of anterior abdominal wall => recurrent ____ and back-pressure effects on ____ and ____

Answer 69

Autonomous bladder: Bladder fills to capacity and **overflows** Continual **dribbling** occurs once bladder is full and bladder may be partially emptied by manual compression of lower part of anterior abdominal wall => recurrent **UTI** and back-pressure effects on **ureters** and **kidneys**