Anatomy of Upper & Lower Urinary Tract.pptx

ANATOMY
UPPER AND LOWER
URINARY TRACT
Dr. NDAYISABA CORNEILLE
CEO of CHG
MBChB,DCM,BCSIT,CCNA
Supported BY

By the end of the presentation, we should be able to
describe the:
 Anatomical features of the kidneys and the tracts:
position, extent, relations, hilum, peritoneal
coverings.
 Internal structure of the kidneys:
Cortex, medulla and renal sinus.
 The vascular segments of the kidneys.
 The blood supply and lymphatics of the kidneys .
Objectives
Dr Ndayisaba Corneille
2

KIDNEYS
 Its main function is to excrete
most of the waste products of
metabolism
 It control the water and electrolyte
balance of the body
 It maintain acid-base balance of
the blood
 The waste products leave the
kidneys as urine, which passes
down the ureters to the urinary
bladder
 The urine leaves the body
through the urethra
3

KIDNEYS
 Kidneys are reddish brown
in color
 Lie behind the peritoneum of
the posterior abdominal wall
 It lie high up on either side
of the vertebral column
 Are largely under cover of
the costal margin
 The right kidney lies slightly
lower than the left due to the
large size of right lobe of the
liver
4

 Kidneys are retroperitoneal
paired organs.
 Each kidney lies , on the
posterior abdominal wall,
lateral to the vertebral
column
 In the supine position, the
kidneys extend from
approximately T12 to L3.
 The right kidney is slightly
lower than the left kidney
because of the large size of
the right lobe of the liver.
 With contraction of the
diaphragm during
respiration, both kidneys
move downward in a
vertical direction (high of
one vertebra, 1 inch, 2.5
cm).
POSITION OF THE KIDNEYS
5

• The kidney is a reddish brown,
bean-shaped organ with the
dimensions 12 x 6 x 3cm.
• Although they are similar in size and
shape, the left kidney is slightly
longer and more slender than the
right kidney, and nearer to the
midline.
• Each kidneys has:
Convex upper & lower ends.
Convex lateral border.
Convex medial border at both
ends, but its middle shows a
vertical slit called the hilum.
Internally the hilum extends into a large
cavity called the renal sinus.
Hilum
Renal
sinus
Color, Shape & Dimensions
Renal sinus
6

HILUM & RENAL SINUS
• The hilum transmits, from
anterior to posterior, the
renal vein, renal artery &
the ureter (VAU).
• Lymph vessels &
sympathetic fibers also
pass through the hilum.
• The renal sinus contains
the upper expanded part of
the ureter called the renal
pelvis.
• Perinephric fat is continues
into the hilum and the sinus
and surrounds all these
structures.
V
A
U
7

COVERINGS
1. Fibrous capsule:
Is closely adherent to its
surface
2. Perirenal fat:
covers the fibrous capsule.
3. Renal fascia:
Condensation of areolar
connective tissue that lies
outside the Perirenal fat
and encloses the kidney
and the suprarenal gland.
4. Pararenal fat:
Lies external to the renal
fascia, is part of the
retroperitoneal fat.
The last 3 structures support the
kidneys and hold it in position on
the posterior abdominal wall.
8

THE KIDNEYS
 The Nephron
 Consists of renal tubule and renal corpuscle
 Renal tubule
 Long tubular passageway
 Begins at renal corpuscle
10

THE KIDNEYS
 The Nephron
 Renal corpuscle
 Spherical structure consisting of:
 Glomerular capsule (Bowman’s capsule)
 Cup-shaped chamber
 Capillary network (glomerulus)
11

A frontal section of the left
kidney
Renal columns
Renal medulla
Renal cortex
Ureter
Hilum
Renal
pyramids
Renal sinus
Renal pelvis
Major calyx
Minor calyx
Renal papilla
Renal lobe
Fibrous
capsule
12

THE KIDNEYS
 Blood Supply to the Kidneys
 Kidneys receive 20%–25% of total cardiac
output
 1200 mL of blood flows through kidneys each
minute
 Kidney receives blood through renal artery
13

ANTERIOR RELATIONS OF
THE KIDNEYS
 RIGHT KIDNEY
 Suprarenal gland
 Liver,
 Second part of the
duodenum,
 Right colic flexure
 Coils of small intestine
 LEFT KIDNEY
 Suprarenal gland,
 Spleen,
 Stomach,
 Pancreas (body),
 Left colic flexure,
 Descending colon
 Coils of jejunum
14

RIGHT KIDNEY
Diaphragm,
Costodiaphragmatic recess of the
pleura,
Twelfth rib & last intercostal
space,
Psoas major
Quadratus lumborum,
Transversus abdominis muscle
Subcostal nerve (T12)
Iliohypogastric nerve (L1)
Ilioinguinal nerve (L1)
LEFT KIDNEY
Same as the right except it
is higher it reaches up to the
11th rib.
Posterior Relations of the
Kidneys
16

BLOOD SUPPLY
 The renal artery arises from
the aorta at the level of the
second lumbar vertebra
 Each renal artery divides
into five segmental arteries
that enter the hilum of the
kidney, four infront and one
behind the renal pelvis
 Lobar artery arise from each
segmental artery, one for
each renal pyramid
17

SEGMENTAL BRANCHES &
VASCULAR SEGMENTS OF
KIDNEYS
• Each kidney has 5
segmental
branches and is
divided into 5
vascular
segments:
1. Apical.
2. Caudal.
3. Anterior Superior.
4. Anterior Inferior.
5. Posterior.
1
5
2
3
4
5
4
3
2
1
18

BLOOD SUPPLY
 Each lobar artery gives two
or three interlobar arteries
 The interlobar arteries run
toward the cortex on each
side of the renal pyramid
 Interlobar arteries give the
arcuate arteries at the
junction of the cortex and
medulla
 The arcuate arteries give
several interlobular arteries
 Afferent glomerular
arterioles arise as branches
of interlobular arteries
19

BLOOD SUPPLY
• Abdominal aorta
• Renal artery
• Segmental
arteries
• lobar arteries
• Interlobar arteries
• Arcuate arteries
• Interlobular
arteries
• afferent glomerular
arterioles
 Inferior vena
cava
 Renal vein
 Interlobar veins
 Arcuate veins
 Interlobular
veins
20

A sectional view, showing major
arteries and veins
Interlobar
veins
Renal
vein
Renal
artery
Adrenal
artery
Segmental
artery
Interlobar
arteries
Cortical
radiate
arteries
Cortical
radiate
veins
Cortex
Medulla
Arcuate
veins
Arcuate
arteries
21

Circulation in a single renal lobe
Cortical radiate vein
Cortical radiate artery
Arcuate artery
Arcuate vein
Renal
pyramid
Glomerulus
Afferent
arterioles
Cortical
nephron
Juxtamedullary
nephron
Interlobar vein
Interlobar artery
Minor calyx
22

A flowchart of renal circulation
Renal vein Renal artery
Segmental arteries
Interlobar arteries
Arcuate arteries
Cortical radiate arteries
Afferent arterioles
Glomerulus
Efferent
arteriole
Peritubular
capillaries
Interlobar veins
Arcuate veins
Cortical radiate veins
Venules
NEPHRONS
23

VEINS, LYMPH,
NERVE SUPPLY
 Renal vein emerges from the
hilum in front of the renal
artery and drains into the IVC
 Left renal vein is longer than
the right renal vein
 Lateral aortic lymph nodes lie
around the origin of the renal
artery
 Renal sympathetic plexus:
afferent fibers that travel
through the renal plexus
enter the spinal cord in the
10th, 11th, and 12th thoracic
nerves
24

URETERS
 The two ureters are muscular
tubes that extend from the
kidneys to the posterior
surface of the urinary bladder
 The urine is propelled along
the ureter by peristaltic
contractions
 Each ureter measures about
25 cm long
 Each ureter has three
constrictions along its course,
 1- Where the renal pelvis
joins the ureter,
 2- As it crosses the pelvic
brim,
 3- Where it pierces the
bladder wall ( intra-mural
25

URETER
 The renal pelvis is the
funnel-shaped expanded
upper end of the ureter
 It lies within the hilum of the
kidney and receives the
major calyces
 It enters the pelvis by
crossing the bifurcation of
the common iliac artery in
front of the sacroiliac joint
 It runs downward & forward
on the lateral wall of the
pelvis to enter the lateral
angle of the bladder
26

RELATIONS, RIGHT URETER
 Anterior:
 Duodenum,
 Terminal part of the ileum,
 Right colic vessels,
 Iliocolic vessels,
 Right testicular or ovarian
vessels, and the
 Root of the mesentery.
 Posterior:
 Right psoas muscle,
 Bifurcation of the right
common iliac artery
27

RELATIONS, LEFT URETER
 Anterior:
 Sigmoid colon,
 Sigmoid mesocolon,
 Left colic vessels,
 Left testicular or
ovarian vessels
 Posterior:
 Left psoas muscle,
 Bifurcation of left
common iliac artery
28

BLOOD SUPPLY
 Upper end is supplied
by the renal artery
 Middle portion by
(gonadal) testicular or
ovarian artery
 In the pelvis is supplied
by the superior vesical
artery
 The lymph drains to the
lateral aortic nodes and
the iliac nodes
29

NERVE SUPPLY
 Renal, testicular (or
ovarian), and hypogastric
plexus (in the pelvis)
 Afferent fibers travel with
the sympathetic nerves
and enter the spinal cord
in the first and second
lumbar segments
30

URINARY BLADDER
SHAPE:
 It has the shape of three-sided pyramid
placed on one of its angles, with the apex
of pyramid is directed forward & its base
is directed backward
SITE:
 It lies behind the body of pubis & is
separated from it by the retropubic space
31

Upper Surface
Inferolateral surface
Inferolateral surface
Apex
Neck
32

MALE PELVIS
33

MALE PELVIS
34

BASE OF MALE BLADDER
35

FEMALE PELVIS
36

FEMALE PELVIS
37

URINARY BLADDER
RETROPUBIC SPACE:
 It is a space filled with extraperitoneal
fatty tissue continuous with that of lower
part of anterior abdominal wall
 It accomodates distention of urinary
bladder
 In case of rupture of urinary bladder,
urine may escape upward into the
anterior abdominal wall
38

URINARY BLADDER
APEX:
 Is directed forward
 Is related to upper border of symphysis
pubis
 Is connected to umbilicus by the median
umbilical ligament (obliterated part of
urachus)
39

URINARY BLADDER
BASE (POSTERIOR SURFACE):
 Is directed backward
 Its superolateral angles receive the ureters
 In male:
1. Its upper part is covered by peritoneum
2. It is related to vasa deferentia & seminal
vesicles separating it from rectum
 In female:
1. It has no peritoneal covering
2. It is related to vagina
40

URINARY BLADDER
SUPERIOR SURFACE:
 Is covered by peritoneum in both sexes
 In male: it is related to sigmoid colon &
loops of ileum
 In female: it is related to the uterus
separating it from sigmoid colon & loops
of ileum
41

URINARY BLADDER
INFEROLATERAL SURFACES:
 Are related to retropubic fat separating
them from:
1. Body of pubis
2. Levator ani
3. Obturator internus
42

URINARY BLADDER
NECK:
 Is the lowest & most fixed part
 Lies behind symphysis pubis
 Is continuous with urethra
 In male:
1. It rests on upper surface of prostate
2. Anteriorly: it is attached to puboprostatic ligament
3. Posteriorly: it is related to beginning of ejaculatory
ducts
 In female:
1. Anteriorly: it is attached to pubovesical ligament
2. Posteriorly: it is related to anterior wall of vagina
43

URINARY BLADDER
LIGAMENTS:
1. Median umbilical ligament
2. Puboprostatic (pubovesical) ligament:
 Forms the floor of retropubic space
 In male: is called “puboprostatic” &
extends from body of pubis to prostatic
fascia & neck of bladder
 In female: is called “pubovesical” &
extends from body of pubis to neck of
bladder
44

INTERIOR OF URINARY BLADDER
45

INTERIOR OF URINARY BLADDER
 The mucous membrane forms folds (rugae)
that disappear when the bladder is
distended
 TRIGONE:
1. A triangular area in the base of bladder,
bounded by the 2 ureteric orifices & the
internal urethral orifice
2. Its mucous membrane is elastic, more
vascular & more sensitive
 UVULA VESICA: is an elevation
immediately behind internal urethral orifice
produced by the underlying median lobe of
prostate
46

URINARY BLADDER
Distended Empty
47

URINARY BLADDER
CAPACITY:
 Is about 300 ml with a maximum capacity
of 500 ml
 Distended bladder:
 Is circular in shape
 Bulges upward into abdominal cavity
 Removes peritoneum form lower part of
anterior abdominal wall & becomes into
direct contact with it
48

URINARY BLADDER IN CHILD
 It is an abdominal
organ even when
empty
 It begins to enter the
enlarging pelvis at
six years of age
 It is not entirely a
pelvic organ till after
puberty
Median sagittal section of
a new-born female child
Dr Ndayisaba Corneille 49

URINARY BLADDER
ARTERIAL SUPPLY:
 Superior & inferior vesical arteries
VENOUS DRAINAGE:
 Veins from the vesical venous plexus that
drain into the internal iliac vein
LYMPHATIC DRAINAGE:
 Into internal & external iliac lymph nodes
50

URINARY BLADDER
 NERVE SUPPLY: by the inferior
hypogastric plexuses
1. Parasympathetic fibers: from S2,3,4
motor to detrusor muscle (muscle
coat of bladder) & inhibitory to
internal urethral sphincter, produce
micturation
2. Sympathetic fibers: from first &
second lumbar ganglia
3. Ascending sensory fibers: carry
sensation of fullness (distention) &
pain sensation
51

PELVIC PART OF URETER
 Crosses the front of
bifurcation of
common iliac artery
to reach the pelvis
 Descends downward
& backward, along
the lower border of
internal iliac artery,
crossing (from
above downward):
1. External iliac artery
& vein
2. Obturator nerve,
artery & vein
 Curves forward &
medially

IN MALE
 It is crossed
anteriorly by
vas deferens

IN FEMALE
 It passes below
the root of
broad
ligament,
lateral to lateral
fornix of
vagina & is
crossed
superiorly by
the uterine
artery

PELVIC PART OF URETER
TERMINATION:
 It reaches the posterosuperior angle of
bladder
 It runs an oblique course of about 2 cm
through the wall of bladder before it
opens into its lumen (intramural part of
ureter). This part forms a valve-like
mechanism that prevents reflux of urine
into the ureter when bladder is distended
55

MALE URETHRA
 About 8 inches (20cm)
long
 Extends from the neck
of bladder to the
external urinary meatus
on the tip of the glans
penis
 Divided into three
parts:
 Prostatic
 Membranous
 Penile
56

Prostatic urethra
 Length=3 cm
 Widest & most dilatable
 Extends from neck of
bladder inside prostate
gland
 Structures openings into
prostatic urethra:
 Ejaculatory ducts
 Ducts of prostate gland
Membranous urethra
 Length=1 cm
 Surrounded by external
urethral sphincter
 Penile (spongy) urethra
 Length=16 cm
 narrowest part of whole urethra
 Extends inside penis & opens
externally through external
urethral orifice
58

FEMALE URETHRA
 Extends from neck
of urinary bladder
to open externally
through the
external urethral
orifice (anterior to
the vaginal
opening)
 Has only urinary
function
59

DIURETICS
 Diuretics are medicines that increase the
amount of urine that is produced.
 People who have high blood pressure might be
prescribed diuretics to decrease the blood
volume.
 Alcohol is a diuretic and this is what
contributes to the symptoms of a hangover.
The best way to prevent a hangover after
drinking is to consume a lot of water before
you go to bed.
 Caffeine is also a diuretic, so coffee, energy
drinks, and regular Coca-cola are diuretics.
 You should drink one cup of water for every
cup of those beverages to prevent
dehydration.
60

PROBLEMS
 URETHRITIS = infection and inflammation of the
urethra
 PYELITIS= infection of the renal calyxes
 CYSTITIS = infection of the urinary bladder.
 CHOLEOCYTITIS = infection of the gall bladder
 Nephritis: inflammation of the nephrons.
 Hydronephritis: excess fluid in the nephron.
61

PROBLEMS
 KIDNEY STONES
 Develop in the renal pelvis
 Stones are made out of a variety of things: uric
acid, calcium, cystine (an amino acid), or
cholesterol.
 They keep growing.
62

KIDNEY STONES
 They can block the ureter, causing the kidney to
enlarge. As the kidney stretches, the capsule
stretches, causing excruciating pain in cycles of
hours. As pressure builds up from fluid
accumulating around the stone, urine can pass,
and the kidney stone moves down the urethra
slowly.
 Symptomatic kidney stones may be pea sized or
larger (up to 1 ½ inches).
 They get stuck in three places:
 Renal pelvis
 In the ureter as it bends over the common iliac artery
 In the urinary bladder at the trigone.
63

KIDNEY FAILURE
 Things can happen to the kidney that can lead to
kidney failure: infection, excess proteins, pH
change, and blood pressure drops.
 Treatment for kidney failure is DIALYSIS, which
removes blood, send it through a filter, and returns
it without the wastes. It is done three times a week,
six hours a day. Ideally, they need a kidney
transplant because the kidney has other functions
as well.
 The brain, heart, and kidney are the only three
organs in the body that have to get oxygen to
sustain life.
64

WHO IS MOST LIKELY TO GET RENAL FAILURE?
 Kidney or Liver Disease
 Diabetes
 High Blood Pressure
 Heart Failure
 Obesity
 Bone Marrow Transplant
 Heart or Belly Surgery
65

MICTRUITION
 A reflex action, which in toilet trained
individuals is controlled by higher centers in
the brain
 Is a function of parasympathetic nervous
system
 Reflex inititated when volume of urine
reaches 300ml leading to stimulation of
stretch receptors
67

URINARY INCONTINENCE
 An involuntary leakage of urine. Usually a
problem of women.
 Has severe psychological and social
repurcussions
 Can lead to depression, breakdown of
marriages, sleep disturbances, social
withdrawal, suicididal tendencies
 Can occur in different forms
68

TYPES OF INCONTINENCE
 Urge incontinence
 Functional incontinence
 Stress incontinence
 Structural incontinence
 Bed wetting
69

URGE INCONTINENCE
 Involunatary leakage of urine while feeling
the urge to go to the toilet.
 Caused by an overexcitable bladder.
 Presence of small volumes of urine in the
bladder triggers mictruition.
 Can follow spinal shock
70

STRESS INCONTINENCE
 Involuntary leakage of small drops of urine
during laughing, coughing, shouting,
sneezing, singing
 Common in women following child birth
 Can be due to weak levator ani muscles
 Can occur in men following prostatectomy
 Overweight and menopause are
predisposing factors
71

FUNCTIONAL INCONTINENCE
 Due to a functional disability that prevents a
patient from accessing the toilet.
 Causes include deafness, blindness, severe
illness, limb defects, language barrier
 The bladder becomes so full and finally gives
way
72

STRUCTURAL INCONTINENCE
 Due to presence of an identifiable structural
abnormality with the urinary system.
 Causes include bladder trauma, urinary tract
infections, prostatitis, urethritis, kidney
stones
73

BED WETTING
 Involuntary leakage of urine during sleep
 Can occur during day time or night time or
both
Causes
 Genetics: if both parents are bed wetters,
chances are 80% for children
 Anxiety, stress, delayed physical
development
 Decreased ADH production at night
74

MANAGEMENT
 Bladder training
 Pelvic exercises
 Moisture absorbents: pampers
 Catheters
 Moisture alarms
 Counselling
 Drugs: desmopressin
 Vaginal tampoons and slings
75

URINARY RETENTION
 Failure to pass urine. Usually very painfull.
 Mainly a problem of men
 Causes includes: kidney stones, bladder
trauma, tumors, urethral strictures, phimosis,
circumcision, urethral valves, spinal cord
injuries
 Mgt: catherisation and treatment of the cause
76

By
DR NDAYISABA CORNEILLE
MBChB,DCM,BCSIT,CCNA
Contact us:
amentalhealths@gmail.com/
ndayicoll@gmail.com
whatsaps :+256772497591
/+250788958241
77

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