8.

01 Anatomy Practical Session Urinary System

Learning Objectives
Describe the location and relationships of the kidneys, its features and neurovascular supply
Describe the course of the ureters and their relationships in the abdomen and pelvis
Understand the significance of the constrictions along the ureter and the relationship
Describe the location of the bladder, internal and external features and neurovascular supply
Explain the relationship of the filling bladder to the anterior abdominal wall
Understand the differences in course and relationships of the male and female urethra
ACTIVITY 1
1. Prosections. Identify the kidneys in situ and the renal vessels. What is more anterior, the renal
artery or vein? Is an accessory renal artery present? Identify the left suprarenal and left gonadal
veins draining into the left renal vein. The 5 vascular segments of the kidneys are supplied by
end arteries. What are end arteries and what is the implication of blockage of an end artery?
2. Posterior relations of the kidneys. Identify the muscles upon which the kidneys lie:
diaphragm, psoas major, quadratus lumborum and aponeurosis of transversus abdominis. Note
that the right kidney is slightly lower, the superior poles are closer together and the anterior
surfaces face anterolaterally. Compare the movement of an enlarged left kidney to an enlarged
spleen? What is the relationship of the lower ribs to each kidney? Explain why posterior
surgical access to a kidney may sometimes cause a pneumothorax on that side.
3. Isolated kidneys external features. Identify the poles, surfaces, borders and hilum of each
kidney. Find the renal artery, renal vein and renal pelvis and determine to which side the
kidney belongs.
4. Kidneys - internal features. Identify on models and sectioned kidneys, the capsule, cortex,
renal columns, pyramids, renal papillae, minor and major calyces and renal pelvis.
Differentiate the renal hilum (vertical slit on medial surface through which structures pass)
from the renal sinus (space deep to hilum containing the calyces, vessels and nerves).
ACTIVITY 2
Anterior relationships of the kidneys. Identify the structures related anteriorly to each kidney

(answers on last page)

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2.

Course of the ureters. Identify where the renal pelvis narrows to become the ureter. Observe
the ureters descending almost vertically on psoas major muscle. What is the relationship to the
peritoneum here? The ureters cross the pelvic brim at the bifurcation of the common iliac
artery and at first pass laterally and posteriorly on the wall of the pelvic cavity to the level of
the ischial spine, then pass forward and medially towards the bladder. The ureters pass
obliquely through the wall of the bladder; verify this on prosections. Describe the three sites of
constriction where a ureteric stone will most commonly lodge. Describe the nature of pain and
pattern of pain referral of ureteric colic.
Relationships of ureters in pelvis of males and females.
On male models and prosections, note the ureters passing under the ductus (vas) deferens just
before reaching the bladder. On female models and prosections trace the ureter as it passes
posterior to the ovary (in nulliparous females), below the uterine artery and lateral to the fornix
of the vagina. One ureter may be more closely related to the vagina than the other as the uterus
is usually deviated to one side. Why is the relationship of the ureters to the uterine artery and to
the ovarian vessels important to keep in mind during hysterectomy and ovariectomy
(oophorectomy) respectively?

ACTIVITY 3
1. Bladder - relations. Review the relationships of the bladder: the retropubic space separating
the bladder from pubic symphysis and fascia over levator ani and obturator internus muscles;
coils of intestines above the bladder and, in addition, the body of uterus above the empty
female bladder. Posterior to the female bladder: the cervix of uterus and vagina. Posterior to the
male bladder from lateral to medial: the seminal vesicles, ampulla of ductus (vas) deferens and
rectum. Below the bladder in the male: prostate gland. How are the bladder and its associated
peritoneum related to the anterior abdominal wall when the bladder fills?
2. Bladder - features. Identify external features: superior surface, inferolateral surfaces, apex,
base (fundus), neck of bladder, ureters passing to the superolateral base of the bladder. What is
the advantage of the oblique passage of the ureters through the bladder wall? Identify internal
features: trigone bounded by the slit-like ureteric orifices (and joined by an interureteric crest)
and the internal urethral orifice, rugae (mucosal folds) in an empty bladder but smooth mucosa
at the trigone. The detrusor muscle fibres are arranged in a criss-cross arrangement. When
these muscle fibres undergo hypertrophy in chronic urethral obstruction, a trabeculated or
open-weave appearance may be visible on the internal surface, often with pockets that may
retain urine and provide a medium for bacterial proliferation. This may be evident on bladders
of individuals with benign prostatic hypertrophy.
3. Female urethra. Identify internal and external urethral orifices and internal and external
urethral sphincters (sphincter vesicae and sphincter urethrae respectively). Which of these
sphincters is under voluntary control? Note the length, direction and relationships of the female
urethra. How would the catheter be oriented during urethral catheterization?
4. Male urethra. Identify: internal and external urethral orifices and prostatic, membranous and
spongy or penile parts of the urethra. A pre-prostatic part extends from the internal urethral
orifice to prostate and is surrounded by the internal urethral sphincter (sphincter vesicae).
Identify the external urethral sphincter. If possible in the prostatic urethra, identify the urethral
crest with seminal colliculus (verumontanum) and prostatic sinuses (see Wilson bottle 338). The
urethra in the male has two almost right angle turns. How is the urethra catheterized in the
male? What is the: a) narrowest part of the urethra; b) least distensible part; and c) most
distensible part and what empties into this region at ejaculation?
5. Micturition. What spinal cord levels are involved in voluntary and involuntary control of the
bladder and micturition?
a) sympathetic innervation
b) parasympathetic innervation
c) voluntary control of sphincter urethrae (via pudendal nerve)

ACTIVITY 4
1. Plain abdominal X-ray. Look for soft tissue shadows of the renal parenchyma. Fat
surrounding the kidney helps to outline its margins, but gas in overlying intestines may obscure
it. Note that the medial border of the kidney is close and parallel to the lateral border of the
shadow of psoas major.
The ureters are not visible on plain radiographs, however calculi may lodge in the ureter and if
they are radio-opaque, may be visible. On radiographs, the course of the ureters follow a line
from the tips of the transverse process of L2 to L5 to the sacroiliac joint, then laterally along
the anterior margin of the greater sciatic notch to the ischial spine, from which point it runs
medially to the bladder. Ureteric stones usually lodge at the points of constriction and if the
stone is radioopaque, may be seen at (1) junction of the renal pelvis and ureter: tip of L2 TP,
(2) narrowing at pelvic brim: overlies SI joint on radiograph and (3) at the entrance to the
bladder: just medial to ischial spine on radiograph.
2. Intravenous urograms (IVU)/ Intravenous pyelograms (IVP). Urograms (pyelograms) are
used to check the function of the kidney, as the demonstration of radio-opacity in the urinary
system depends on the kidneys ability to receive, filter, concentrate and secrete organically
based iodine compounds.
i) Nephrogram Phase of IVU (IVP).
These are taken one minute after intravenous injection of an iodine-based contrast medium.
Dye is found in the renal parenchyma of a well-functioning kidney. This makes one aware of
how quickly the kidneys act to excrete substances from the bloodstream. The outlines of the
kidneys are well demonstrated by this technique. Radio-opacity of the kidney tissue depends on
the amount of contrast medium that reaches the kidney.
ii) Urogram (Pyelogram) Phase of IVU (IVP).
These are later films of the nephrogram and demonstrate the collecting system. The radioopacity demonstrated by this technique depends on the kidneys ability to concentrate urine. A
greater radio-opacity may be achieved if fluid intake is restricted. On the intravenous
pyelograms, note the increased radio-opacity of the kidney parenchyma, minor and major
calyces, renal pelvis, ureters and bladder.
3. Retrograde urograms / pyelograms. In these x-rays a catheter is introduced via the urethra
and bladder into each ureteric orifice. Contrast medium is injected to show the collecting
system. This technique involves the risks of introduced infection, mechanical damage and
damage produced by overfilling; it is consequently less commonly used than the IVP. On the
retrograde pyelograms, identify catheters and parts of the collecting system. Why is there an
absence of radio-opacity in the renal parenchyma?
ACTIVITY 5
Prior to leaving the session, complete the practice spot test created by your tutors.
Discuss the answers as required.
Key to Identification exercise.
1. suprarenal glands
2. spleen
3. stomach
4. pancreas
5. colon
6. jejunum
7. jejunum (jejunoileum)
8. colon
9. duodenum (second or descending part)
10. liver