1. Kidney and Urinary Tract Anatomy

Question 1

The kidneys, adrenal glands and the abdominal portion of each ureter lie along the ____ abdominal wall from roughly ____

Answer 1

posterior

T12 to L3

Question 2

Kidneys, ureters and adrenals are ____ RETROPERITONEAL
viscera, lying outside the
____

Answer 2

primary

peritoneal sac

Question 3

The kidneys lie obliquely in the ____ gutters, surrounded by fat and ____

Note how difficult the kidneys are to ____ on physical examination

Answer 3

paravertebral
fasciae
palpate

Question 4

Renal fascia
(anterior layer)

Renal fibrous capsule
Encloses the renal ____

Renal fascia
(posterior layer)
aka Gerota’s fascia
– connective-tissue fascial sac that enclose the ____fat, portions of the abdominal aorta and ____ close to the kidney, and the proximal ureter; subdivided into a ____ anterior layer and a ____ posterior layer

Answer 4

parenchyma
perirenal
inferior vena cava
thin
thicker

Question 5

Within the capsule
of renal fascia, each kidney is surrounded by
____

Answer 5

perirenal fat

Question 6

Surrounding the capsule of renal fascia is abundant ____

Answer 6

pararenal fat

Question 7

Both perinephric and paranephric fat cushion and protect the ____, which do not benefit from much protection by elements of the ____

Answer 7

kidneys

rib cage

Question 8

Both ____ attachments of the diaphragm and ____ abdominal muscles lie ____ to each kidney and its associated fat and fasciae

Answer 8

posterior
posterior
posterior

Question 9

Anterior relations of the kidney

Answer 9

YA

Question 10

Branches of the abdominal aorta arise and distribute in three planes

1. ____ branches arise anteriorly and supply the ____and digestive glands
   
   2. ____ visceral branches arise bilaterally and supply the ____ (i.e. kidneys, adrenals & gonads)
2. ____ parietal branches arise posteriorly and supply the ____ and posterior abdominal wall

Answer 10

unpaired
GI tract
paired
primary retroperitoneal viscera
paired
diaphragm

Question 11

The left and right renal arteries arise most commonly at the ____ level of the spine

Answer 11

L1-L2

Question 12

The renal arteries lie ____ to, and normally obscured by the left and right renal ____

The right renal artery normally passes posterior to the ____ to reach the right kidney

Answer 12

posterior
veins
inferior vena cava

Question 13

Renal vessels course bilaterally to enter each kidney through an indentation called the ____, the entrance to a fat filled cavity called the ____

• The kidneys actually lie \_\_\_\_ to the sagittal plane

Answer 13

renal hilum
renal sinus
oblique

Question 14

Like the lung, each kidney has a HILUM medially through which vasculature passes to and from the organ
• Renal artery from the ____
• Renal vein to the ____

Answer 14

aorta

renal vein

Question 15

Within the renal hilum, each renal artery divides into ____ and ____branches

Within the ____, segmental branches arise from these vessels
- Each of these supplies a distinct ____ segment of the organ and lacks peripheral ____ (they are ____)

Answer 15

renal hilum
anteroir
posterior
vascular
anastomoses
end-arteries

Question 16

… thus obstruction of a segmental artery leads to death of that ____ of the kidney

Answer 16

segment

Question 17

Interlobar and Arcuate arteries ascend to the ____ via cortical extensions called the ____ (C]

Answer 17

renal cortex

renal columns

Question 18

The renal cortex contains ____, the initial blood filtering components of the nephron, at the interface between the renal ____ and the ____ of the urinary tract

Answer 18

renal corpuscles
blood vessels
excretory portion

Question 19

____
contain the structures of the nephron responsible for maintaining the salt and water balance of the blood, including ____ and descending limbs of the renal tubules and ____ leading to the ____

Answer 19

medullary pyramids
ascending
collecting ducts
renal papillae

Question 20

Urine draining from the papilla at the apex of each pyramid (P) fills the____ embedded in the ____ packing the ____

Answer 20

minor calyces
fat
renal sinus

Question 21

In turn, each
____ CALYX
receives
urine drained from 2-3 ____

Answer 21

major

minor calyces

Question 22

At the hilum, the
____
receives urine from the major calyces

And funnels it into the ____

The ____ is indistinct

Answer 22

renal pelvis
ureter
ureteropelvic junction

Question 23

Smooth muscle in the ____, pelvis and ____ undergoes ____ contraction to move urine

Answer 23

calyces
ureter
peristaltic

Question 24

Initially pelvic organs, the kidneys “____” along the posterior abdominal wall
via ____ and ____

Note the simultaneous descent of the ____ (testis or ovary)

Answer 24

ascend
differential growth
migration
gonad

Question 25

____ or supernumerary renal arteries are common, reflecting the ascent of the kidney during development without regression of all earlier, more ____ vessels However, ____ by such a vessel is possible

Answer 25

accessory caudal ureteral compression

Question 26

Normal variation in the anatomy of kidney and ureter • Physical migration superiorly x growth of posterior abdominal wall x elongation of spine.... = variation in anatomy of kidney and ureter • Left pic: • Right kidney has failed to ascend -- literally hung up in pelvis • ***Insert radio (next slide) • Referred to as a pelvic kidney. • Top right: horseshoe kidney result of anomaly in development • Left and right kidney fail to ____ from common primordial mass • Even though development remain connected here across the ____ • The presence here of isthmus connecting left and right helps ____ how far the kidneys can ascend! • Restrained from further movement by ____ (level of L3)

Answer 26

separate midline ascend inferior mesenteric artery

Question 27

The URETERS Smooth muscular tubes extending from the ____ to the posterior surface of the ____ The abdominal portion of each ureter descends the posterior abdominal wall anterior to the ____ muscle in proximity to the ____ vessels before crossing the ____ artery and vein and entering the true ____

Answer 27

renal pelvis urinary bladder PSOAS MAJOR gonadal external iliac pelvis

Question 28

Ureteric smooth muscle is arranged in a spiraling configuration of ____ and ____ layers to propel urine toward the bladder Several drops of urine are transported by peristaltic contractions at intervals of ____ seconds

Answer 28

circular longitudinal 12-20

Question 29

Obstruction of the ureter at any of three points of constriction by ____ may produce ____ proximal to the site of the blockage, with reflux of urine into the kidney leading to ____ of the renal pelvis

Answer 29

ureteric calculi hydronephrosis inflammation

Question 30

NEPHROLITHIASIS. URETEROLITHIASIS and VESICOLITHIASIS Entry of a stone into the ureter leads to powerful contraction of smooth muscle in the wall in an effort to expel the stone producing the sharp pain of ____ Four main types of stones: • Calcium oxalate: Most ____; formed when calcium combines with ____ in the urine. Inadequate calcium and ____ intake may contribute to stone formation. • Uric acid: Another common type. Foods such as organ ____ and shellfish have high concentrations of purines; high purine intake leads to a higher production of ____, which may form stones. • Struvite: Less common; caused by ____ in the upper urinary tract. • Cystine: Rare; tend to run in ____

Answer 30

``` ureteral colic common oxalate fluid meats purine infections families ```

Question 31

The referred pain of such stones is experienced | “____”

Answer 31

loin to groin

Question 32

``` The ureters have a complex blood supply with ____ between branches of the following arteries: • ____ • ____ • ____ • ____ ```

Answer 32

``` anastomoses renal gonadal iliac vesicular ```

Question 33

____ | PELVIC portion of ureter

Answer 33

intravenous pyelogram

Question 34

No matter one’s sex, in considering the pelvic portion of the ureter, the “____” always runs under a “____” • Male: Before ureter reaches bladder it passes inferior to ____ (ductus deferens) • Smooth muscular tube conveying sperm from testis epididymis to elements ejaculatory system (posterior to urinary bladder) • Female: pelvic portion of ureter passes under the ____ • Supplies uterus and is critical for delivering blood to organ (periods ew - endometrial lining ripens) should the need for raising an embryo parasite arise

Answer 34

water bridge vas deferens uterine artery

Question 35

The ____ portion of the ureters pass obliquely though the muscular wall of the urinary bladder in an ____direction... ...forming a one-way “____” in which the internal pressure of the filling bladder causes the intramural passage to ____, preventing the possibility of ____ and ____

Answer 35

``` intramural inferomedial flap valve collapse urinary reflux retrograde flow ```

Question 36

The urinary bladder is a hollow, distensible pelvic organ in the adult, varying in size, shape, position and relationships according to the ____ of its contents and the state of neighboring ____ It is an abdominal organ, even when empty, in the very young, becoming an organ of the true pelvis only after ____ That said, the full bladder may ascend as high as the ____ in some adults!

Answer 36

volume viscera puberty umbilicus

Question 37

The urinary bladder is a ____ organ

Answer 37

subperitoneal

Question 38

he organ may be ruptured as a result of certain | ____

Answer 38

pelvic fractures

Question 39

The bladder drains into the ____ in both sexes

Answer 39

urethra

Question 40

``` The fundus (base) of the bladder lies posteriorly (facing the ____) ``` The two inferolateral surfaces: • Meet anteriorly at the ____ deep to the pubis • Meet inferiorly at the ____

Answer 40

rectum apex neck

Question 41

URINARY BLADDER (Lateral view) - apex - neck - fundus - body

Answer 41

YA

Question 42

The walls of the bladder feature ____ layers of tissue; the middle of which is comprised of smooth muscle - mucosa - ____ - adventitia

Answer 42

three | detrusor

Question 43

The mucosa is fixed only at the ____, where contraction of the detrusor in micturition helps close the ____

Answer 43

trigone | ureteric orifices

Question 44

At the neck of the bladder, smooth muscle fibers continuous with the detrusor encircle the ____

Answer 44

internal urethral orifice

Question 45

In the male, these fibers form an “____” ____ aka sphincter vesicae

Answer 45

anatomical | internal urethral sphincter

Question 46

In the female, the internal urethral sphincter is described as more of a “____” sphincter Constriction of sphincter vesicae in both sexes enables the bladder to fill with and ____ urine, but in males… The internal urethral sphincter contracts during ____ to prevent ____ ejaculation (ejaculatory reflux)

Answer 46

physiological retain ejaculation retrograde

Question 47

... as the male bladder drains urine into the ____... … which also receives a mixture of ____ and ____ fluid from the ejaculatory ducts

Answer 47

prostatic urethra sperm seminal

Question 48

The ____ and ____prostate surround the upper prostatic urethra Site of ____ The PERIPHERAL PROSTATE - site of most ____ elements.. ... is most susceptible to the formation of ____

Answer 48

``` central periurethral BPH glandular prostatic adenocarcinoma ```

Question 49

``` The male urethra features four distinct parts: • ____ • ____ • ____ • ____ (spongy) ``` The membranous portion is surrounded by the fibers of the ____ (aka sphincter urethrae)

Answer 49

``` prostatic membranous bulbar penile external urethral sphincter ```

Question 50

Internal urethral sphincter • ____ • ____ muscle • ____ ``` EXTERNAL URETHRAL SPHINCTER surrounds the membranous urethra • ____ • ____ muscle • ____ fibers from LMN's in the ventral horn of S2-4 maintain ____ contraction via branches of the ____ ```

Answer 50

involuntary smooth GVE ``` voluntary skeletal GSE tonic pudendal nerve ```

Question 51

____ is a component of the “urogenital diaphragm” in both sexes Sphincter vesicae - prevents ____ Sphincter urethrae - main provider of ____

Answer 51

sphincter urethrae retrograde ejaculation tonic continence

Question 52

In contrast, the ____ female urethra is more ____ than that of the male, containing considerable ____ tissue as well as smooth muscle, easing ____ and cystoscopy

Answer 52

shorter distensible elastic catheterization

Question 53

The shorter FEMALE urethra passes through the “urogenital diaphragm” where it is encircled by ____ and opens into the vestibule just anterior to the vaginal orifice URINARY TRACT INFECTIONS Females are more vulnerable due to the shorter urethra and exposure to pathogens during sexual activity among other factors, possibly leading to ... • ____ (bladder inflammation) • ____ (kidney infection) Note that some of the musculature of the female “UG diaphragm” surrounds the ____ as well as the urethra

Answer 53

sphincter urethrae cystitis pyelonephritis vaginal canal

Question 54

URINARY STRESS INCONTINENCE May result not only from decreased function of the ____ and other ____ floor muscles but from weakening of the ____ and related condensations of connective tissues of the pelvic floor (____), involuntary loss of urine with increased____.

Answer 54

``` sphincter urethrae pelvic pubovesical ligaments endopelvic fasciae thoracoabdominal pressure ```

Question 55

Innervation of the bladder is by the ____, consisting of the anterior component of the ____

Answer 55

vesical plexus | inferior hypogastric plexus

Question 56

Preganglionic sympathetics from ____ synapse in the ____ ganglion or cross the pelvic brim in the ____ plexus to synapse in ganglia in the ____ plexus Postganglionic sympathetics facilitate constriction of the ____ (internal sphincter) permitting the bladder to fill and and preventing retrograde ejaculation. Some of these fibers inhibit contraction of the ____ but this appears to be a minor function

Answer 56

T11-L2 inferior mesenteric superior hypogastric inferior hypogastric sphincter vesicae detrusor

Question 57

Pelvic splanchnics convey ____ fibers from ____ to the ____ plexus. These fibers synapse on ____ ganglia in the plexus and on the walls of the ____ Postganglionic parasympathetics facilitate emptying of the bladder by: • Inducing contraction of the ____ • Inducing relaxation of the ____ (internal sphincter)

Answer 57

``` preganglionic parasympathetic S2-4 inferior hypogastric terminal bladder ``` detrusor sphincter vesicae

Question 58

Inferior hypogastric plexus also carries ____ FIBERS from pelvic viscera GVA fibers accompanying sympathetics carry ____ sensations from the ____ and bladder GVA fibers accompanying parasympathetics respond to distension of the ____ and convey a sense and awareness of ____

Answer 58

``` visceral afferent pain ureter bladder fullness ```

Question 59

Afferent pathways for conscious bladder sensations Note: The urethra enjoys some ____ afferent innervation, hence the “____” sensation on urination associated with certain infectious and inflammatory processes

Answer 59

somatic | burning

Question 60

MICTURITION ``` • The process by which urine flows from the bladder into the ____ • Micturition is mediated by the micturition or ____ reflex. • The reflex is facilitated by : – ____ nerves – ____ nerves – ____ (via the ____nerve) • The reflex has two components: – ____ stage – urinary continence – ____ stage - voiding ```

Answer 60

``` urethra vesical parasympathetic sympathetic somatic pudendal filling emptying ```

Question 61

FILLING stage – Stretch receptors in the wall of the bladder innervated by visceral ____ in the ____ nerves respond to the accumulation of urine and the degree of stretch of the bladder wall – A bladder storage center is activated in the CNS, which stimulates ____ nerves to inhibit the ____ to allow the bladder to continue to stretch AND keep the ____ contracted – As the bladder fills, the walls of the bladder compress the ____, preventing reflux of urine – At or near a micturition threshold, conscious perception of bladder fullness is appreciated via ____ – Pain fibers which accompany ____ elements in the pelvis are stimulated by bladder fullness and refer pain over the ____dermatomes

Answer 61

``` afferents pelvic splanchic sympathetic detrusor sphincter vesicae ureteric orifices pelvic splanchics sympathetic T11-L1 ```

Question 62

EMPTYING stage Once the micturition threshold is reached and a CNS micturition center is activated: – ____ facilitate contraction of the ____, raising pressure within the bladder as the ____ is raised, creating a funnel at the internal urethral orifice – The urethra is ____ – The sphincter vesicae and sphincter urethrae are ____, THE LATTER BY INHIBITION OF ____ NEURONS – Urine passes through the length of the urethra – In both sexes, the diaphragm and abdominal muscles ____ to increase intrapelvic pressure on the bladder, ____ the flow of urine – In the male, ____ contracts to expel urine from the penile urethra

Answer 62

``` pelvic splanchnics detrusor trigone dilated relaxed somatic motor contract accelerating bulbospongiosus ```

Question 63

As the micturition reflex may be volitionally controlled following “____” we must consider the role of ____in deciding where and when to void urine like a switch turning continence off! When activated by afferent inputs, including from ____, the ____, a collection of neurons located in the ____, is thought to relax the sphincters and contract the detrusor to ____ urination. The process requires: 1) ____ bladder sensation 2) assessment and integration of ____, emotional, and ____ aspects, that it is safe, appropriate, and comfortable to micturate, 3) release of the ____ micturition reflex, and 4) adequate ____ function to relax the ____ and pelvic floor muscles These SUPRASPINAL CENTERS permit you to ____ AND ____ Does lack of adequate cortical input = "____?"

Answer 63

toilet training supraspinal control center prefrontal cortex pontine mictuirition center (PMC) initiate ``` conscious environmental social bulbospinal sensorimotor sphincter urethrae ``` start stop shy bladder