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Dr. Florencia T. Belmonte | July 02, 2015 | GYNECOLOGY

FEMALE URINARY TRACT AND GENITAL TRACT

RELATIONSHIP
Close
relationship,
anatomically
and
embryologically related
Inductive influence of embryologic urinary tract on
developing genital system; the urinary system has
to develop and induce the development of the
genital tract.
10% of infants with GUT abnormality are mirrored
by defects in other system
Both develop from intermediate mesoderm
Both develop from urogenital ridge
o Urogenital Ridge: bulge produced by
each cord at dorsal side of coelom

EMBRYOLOGY
DAY 8 to 9
This also corresponds to Implantation events.
The embryonic disk is very small and is still
developing.
The amniotic cavity and the stalk are also
noticeable they become thinner later on and
become the umbilical cord
The yolk sac provides nutrition initially but will also
degenerate.

DAY 8 to 9

Note:

Important Component: Coelomic Cavity, the

mesoderm, its outpouching provides the
urogenital ridge
Urogenital Ridge comes from the intermediate
mesoderm, and is the origin of the genitourinary
system
A portion of the urogenital ridge becomes the
urinary system

DEVELOPMENT OF THE RENAL SYSTEM

-

am. - amniotic cavity

b.c. - blood clot, at the site of initial implantation
b.s. - body-stalk, or connective stalk later forming the placental
cord region with placental blood vessels
ect. - embryonic ectoderm that will contribute to embryonic and
placental membrane development
ent. - entoderm (endoderm), this was the historic term for what
we today call endoderm that will contribute to embryo
development
mes. - mesoderm, consisting of both embryonic mesoderm (in
the trilaminar embryonic disc) and extraembryonic mesoderm
(outside the trilaminar embryonic disc)
m.v. - maternal vessels, spiral arteries that have been opened
at their ends
tr. - trophoblast, relative to the embryonic disc the outer
syncitiotrophoblast and inner cytotrophoblast layers that will
contribute to placental development
u.e. - uterine epithelium, the epithelial layer that lines the
unerus
u.g. - uterine glands, the glands that secrete nutrients to
support the initial growth both before and after implantation
y.s. - yolk-sac, the endoderm lined and extraembryonic
mesoderm covered cavity that will contribute to the
gastrointestinal tract, blood and blood vessels

Nephrogenic Cord
Portion of urogenital ridge; origin of urinary system
Longitudinal mass of mesoderm on each side of
primitive aorta
Gives rise to 3 successive sets of increasingly
advanced urinary structure; each more caudal to
its predecessor
a. Pronephros 1st kidney, rudimentary,
non-funcitonal
b. Mesonephros middle kidney
c. Metanephros definitive kidney,
functional
Note:

Urethra, vagina, and the rectum are very close to

each other in the adult anatomy because of their
embryonic basis and relation to the cloaca. They
try to form exits and linkages to the cloaca that
will later allow expulsion of wastes urine and
feces.

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Genital System
Genetic sex is determined at fertilization
Early genital sex indistinguishable between 2
sexes (indifferent stage)
Indifferent Stage:
o Both male and female gonads with prominent
cortical and medullary regions
o Dual sets of genital ducts
o Similar appearing external genitalia

Early in embryonic life, two (2) sets of paired genital ducts

develop in each sex, the WOLFFIAN DUCTS and the
MULLERIAN DUCTS:
-

Wolffian Ducts
o Develops into male organs
o Also known as the mesonephric ducts
Mullerian Ducts
o Develops into female organs
o Also known as the paramesonephric ducts

Early in embryonic life, three (3) sets of excretory ducts and

tubules develop bilaterally, the PRONEPHROS,
MESONEPHROS, and METANEPHROS:
- Pronephros
o First of the ducts to form; most cranial
o Forms at the fourth week after conception
o They have NO excretory function in
humans
o Eventually regress
- Mesonephros
o Function briefly before regressing
o Transient excretory organ
o Grows caudally and form excretory
channel into primitive cloaca and the
outside world
o Serves as starting point in development of
metanephros, the definitive kidney
o Has a duct: the mesonephric duct
(Wolffian duct) that ultimately forms the
efferent ductules of the testes

The development of the urinary system is separate, but

interdependent on the development of the genital system.
The formation, however, of the urinary system (specifically
the development of the mesonephros) precedes that of the
genital system.

Metanephros
o Ultimately develop into the adult kidney
o Inductive role in the development of the
paramesonephric duct or mullerian duct
o Ureteric buds (sprouting from distal
mesonephric ducts) initiate development
of metanephros

Ureteric Bud
Urogenital Sinus (The urogenital sinus will form
the vaginal plate later on)
Ureteric Bud
Wolffian Duct
Mullerian Tubercle
Mesenchyme

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Kidneys
Initially lie in pelvis; subsequently ascend to
permanent location, rotating 90% in the process
More caudal portion of embryo grows away from
kidney
Blood supply:
o initially middle sacral, common iliac arteries
o later higher branches of aorta
Previous vessels regress
Bladder and Urethra
Dilation of opening to fetal exterior forms cloaca
(the cloaca should be pierced to form an exit)
Cloaca partitioned by mesenchymal urorectal
septum into:
o Anterior urogenital sinus
o Posterior rectum
Urogenital Sinus
Superior Portion: Bladder, urethra
Surrounding Mesenchyme: muscular and
serosal layer
Inferior Portion: Phallic or definitive urogenital
sinus which will start the development of the
vagina. For the male it will be the external
reproductive organs.
Others
Distal mesonephric ducts with attached ureteric
buds incorporated to posterior bladder wall area to
become bladder trigone
Allantois which becomes the vestigial
diverticulum of hindgut; losses lumen and
becomes a fibrous band called urachus or
median umbilical ligament

Ureteric Buds
Extend cranially; penetrate portion of nephrogenic
cord metanephric blastema
Branch sequentially, each growing tip covered by
metanephric blastema (forms nephrons
functional units)
Become: collecting duct system of kidney and
ureters
Collecting ducts of kidney include: collecting
tubules, major and minor calyces, renal pelvis
Note:

Again, the development of primitive tissue

separate but interdependent on inductive
influence from each other.
Neither can develop without the other.

CLINICAL CORRELATION
In very young infants, stimulation of the abdomen
causes contraction of the abdominal muscles,
pulling the median umbilical ligament.
When you stimulate the umbilical area for the
baby, sometimes the baby urinates. This is
because the median umbilical ligament connects
the umbilicus to the bladder.
Failure of the urachus to close can result to certain
pathologies.
If the urachus is partially patent becomes
urachal cyst
If completely patent forms a urinary fistula to
umbilicus
In a C-section, the median umbilical ligament
should be identified to avoid inadvertent injury.
When you do a C section, this is the ligament that
you will find. It is thicker. So you always have to
check because if you inadvertently stitch it, the
patient will come to you with a complaint of a cyst
or if you are not aware of the allantois it may
become more fistulas (more urine coming out) the
patient might blame you for the procedure so you
must always avoid it during the surgery.

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DEVELOPMENT OF THE REPRODUCTIVE SYSTEM

Reproductive System
- Starts on the 5th and 6th week
Indifferent Stage stage of reproductive
development when the fetal sex cannot
be determined
- Gonads (testes and ovaries) develop from:
Coelomic epithelium
Inner mesenchyme tissue
Primordial germ cells
- Thickening of ventromedial surface of urogenital
ridge forms genital ridge
Mullerian Ducts
- Mullerian ducts fuse to form the sinusal duct
- The sinusal duct then develops into the
uterovaginal canal, giving rise to the uterus
and vagina

*Pictures A-D show the progressive development of the

uterovaginal canal. The fusion of the Mullerian ducts
give rise to the uterus and the vagina, with the two
superior ends tapering into the uterine/Fallopian tubes.
The mesonephric ducts (Wolffian ducts) regress.

*Diagram of the relative position of the genital tract in

relation with the urinary tract.

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Descent/Regress
- Mesonephric duct grows caudally
- Connects to the sinus ridge
- Paramesonephric duct on each side uniting on
the lower portion
Clinical Correlation
- Gender is not apparent until 12th week of
embryonic life (at this time, the fetal sex may be
determined through ultrasound)
o Genetic sex may be determined as early
as conception/time of fertilization
o Visualization of the genitalia may only be
done at 12th week of life through
ultrasonography (CLUE: 12th week = 3rd
month = 3 = S.E.X. has three letters)
- Depends on elaboration of TDY (Testis
Determining
Factor)
and
subsequently
androgen of developing gonads.
- Female development basic development path
not requiring estrogen but absence of
testosterone
Internal Reproductive Organs
- Primordial germ cells migrate from yolk sac
to posterior body wall mesenchyme at
approximately 10th thoracic level (T10)
- Primordial germ cells induce cell proliferation
in adjacent mesonephros and coelemic
epithelium forming pair of genital ridges medial
to mesonephros
- Gonadal development dependent on these sex
cords; otherwise gonads degenerate

*The pictures above show the pattern of migration of the

primordial germ cells (cells that will give rise to the sex
cord). Primordial germ cells originate from the YOLK
SAC, specifically in the junction of the hindgut (posterior
intestinal tract) and the allantois. The germ cells migrate
through the gut and up the dorsal mesentery, and finally
into the genital ridge.
In the 6th week, the primordial germ cells
invade the genital ridges. The ridges
proliferate, forming the primitive sexual cords
which will become the seminiferous tubules in
the male and the medullary cords in the
female.

Mullerian Ducts
- or Paramesonephric ducts
- Form lateral to mesonephric ducts
- Grow caudally and medially to fuse in the midline
- Contact urogenital at region of posterior urethra
at thickening (sinusal tubercle)
- Subsequent development dependent on
presence or absence of TDY
TESTIS-DETERMINING FACTOR ON Y
CHROMOSOME (TDY)
- Encoded in Y chromosome, elaborate by somatic
sex cord cells
- Causes:
Degeneration of gonadal cortex
Differentiation of medullary region of
gonad into Sertoli cells
- Sertoli cells secrete glycoprotein AMH (antimullerian hormone) Male development
Note:

The development of the sex is dependent on the

presence
of
TESTOSTERONE.
When
testosterone is present, the embryo will be a male.
When testosterone is absent, the embryo will be a
female.

AMH (Anti-Mullerian Hormone)

- Causes regression of paramesonephric duct
system into male embryo so there will be no
formation of a uterus
- Signal for differentiation of Leydig cells from
surrounding mesenchyme after being produced by
the TDY
- Leydig cells produce testosterone and 5-alpha
reductase
Hydrotestosterone
Responsible for evolution of mesonephric duct
system into vas deferens, epididymis, ejaculatory
duct, seminal vesicle
At puberty, leads to spermeogenesis, changes in
primary and secondary sex characteristics

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Dihydrotestosterone results in development of

male external genitalia, prostate, bulbourethral
glands

Without TDY
Medulla regresses
Cortical sex cords break up into isolated cell
clusters (primordial follicles)
Germ cell differentiate into oogonia, enter 1st
meiotic division as primary oocytes
Development arrested until puberty
Without AMH
Mesonephric duct system degenerates
Remnants of mesoovarium seen in of adult
women: epoophoron/paraophoron or gartners
duct cyst (along lateral wall of uterus)
Paramesonephric duct system develops
Paramesonephric Duct System
Inferior fused portion become uterovaginal canal;
later become epithelium and glands of uterus and
upper vagina
o Hysterectomy cutting off at the connection of
the uterus and vagina because during the
developmental period, they are actually
disconnected
Surrounding mesenchyme differentiate and
become endometrial stroma and myometrium
Cranial unfused portion open into coelomic (future
peritoneal) cavity and become fallopian tube
Fusion of paramesonephric ducts bring together 2
folds of peritoneum and become broad ligament
which covers the surface of the uterus
Broad ligament divides pelvic cavity into:
o Posterior rectouterine pouch
o Anterior vesicouterine pouch or cul de sac
Upper portion will become fallopian tube, open into
the coelemic cavity

*Seen in this picture is the suspensory ligament of the

ovary which then continues to become the round
ligament. Prior to hysterectomy, the round ligament is
clamped, cut, and then ligated. This then is supported to
prevent vaginal prolapse.
Vagina
Forms on 3rd month of embryonic life
Endodermal tissue of sinusal tubercle proliferates
forming inferior 20% of vagina
Most inferior portion of uterovaginal canal
becomes occluded by solid core of tissue (vaginal
plate)
Vaginal Plate
Origin unclear
Elongates in next 2 months and canalize thru
process of central desquamation
Peripheral cells become vaginal epithelium
Mesoderm of uterovaginal canal become
fibromuscular wall of vagina

Accessory Genital Glands

Outgrowths from urethra (paraurethral or Skenes)
Definitive urogenital sinus (greater vestibular or
bartholins)
It is important to examine and palpate for these
glands during the pelvic examination.
o Bartholin Cysts:
Marsupialization done to prevent
vaginal dryness among women
Technique:
Once the patient is properly anesthetized, a
thorough bimanual examination should be
performed. This helps the surgeon determine the
borders and extent of the cyst or abscess. Once
properly prepped and draped, the bladder is
drained with a straight catheter. A Foley catheter
can be placed at the discretion of the surgeon.

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The labia are retracted digitally and the introitus is

exposed so that the entire surgical field is
visualized. If local anesthetic is to be used, it is
applied to the area immediately surrounding the
cyst with care taken not to enter or puncture the
cyst wall.
A 1.5- to 2-cm vertical incision is then made over
the mucosa just distal to the hymenal ring and on
the wall of the gland at the cyst site. Care must be
taken to ensure that the opening into the gland is
sufficient to promote adequate drainage. Any
bleeding noted can be controlled with sponges or
suction.
The wall of the gland is then incised and the cyst
contents are evacuated. This can be
accomplished with gentle expression or with
irrigation. At this point, cultures of the fluid are
obtained and sent to the lab.
If marsupialization did not work, excision is done

Ovaries and Gubernaculum

Ovaries in thoracic region and descend to pelvis
under control of ligamentous cord (gubernaculum)
o For the testes, they descend even
lower.
Gubernaculum attached to ovary superiorly and
fascia in future vagina inferiorly and to
paramesonephric ducts at point of superior fusion;
divides into 2 separate structures
More proximal ovarian ligament; distal round
ligament
External Genitalia
5th embryonic life: folds of tissue on each side of
cloaca meet anteriorly in midline forming genital
tubercle
Cloaca divided by urorectal septum and form
perineum
Cloacal folds: anterior urogenital folds; posterior
anal folds

2-Genital Tubercle
3-Cloacal Folds
4-Cloacal Membrane
5-Urethral Folds
6-Anal Folds
7-Urogenital Orifice
8-Perineum
9-Anal Orifice
10-Genital Swelling

Note:

Hysterectomy should not be done too low,

because the vagina would become shorter.
Another case is when a female patient is
discovered to have testes inside; the patient
should still be reared as a girl. Chromosomal
analysis is done, and the testes should be
removed because these might develop into a
tumor. A vaginal opening is also created in case
the patient is already about to become sexually
active. Also check for any signs of imperforate
hymen.

Genital Tubercle
Enlarges; in female embryos become clitoris;
urogenital folds become labia minora
In males, becomes penis; urogenital folds fuse to
enclose penile urethra
Without androgens, remain unfused, become labia
minora
Definitive urogenital sinus gives rise to vaginal
vestibule, which opens, into urethra, vagina,
vestibular glands
*In Africa, they usually circumcise the prepuce of the
clitoris and fuse the labia minora, only putting a little hole
for the urine to pass through. When the lady is married and
ready for sexual contact, the doctor would unfuse the labia
minora. The purpose of this might probably be to protect
the hymen of the female.
*Inflammation can cause labial fusion or labial adhesion
CLINICAL CORRELATION
Renal Problems
Renal Agenesis: metanephric blastema not
induced to form nephrons
Unilateral renal agenesis with absence of
abnormalities of fallopian tubes
Various Malformations
Improper fusion of paramesonephric ducts
Incomplete or failure of development of 1
paramesonephric duct
Absence or incomplete canalization of vaginal
plate
Includes:
o Uterus Didelphys double uterus, double
vagina; double uterus, single vagina
Fusion is not complete so the
canalization in the middle cannot
occur properly
This results to a weak uterus.
Sometimes, this leads to a poor
pregnancy.
Patients
would
usually lose their babies in their
4th month of gestation or longer.
Metroplasty
(also
called
uteroplasty or hysteroplasty) is
the procedure done.

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Other uterine malformations:

o Bicornuate Uterus
o Bicornuate Uterus with Rudimentary
Horn
o Septate Uterus
o Unicornuate Uterus

Genital System
True Hermaphroditism: have both ovarian and
testicular tissue
Pseudohermaphroditism: genetic sex indicates
one gender but external genitalia has
characteristics of the other gender

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