Lecture 5: Kidney, Ureter, Bladder & Posterior Abdominal Wall

Question 1

Key Boney Landmarks

Answer 1

Anterior Sacro-Illiac Joint
Illiac Crest
Illiac Fossa
ASIS
Ischial Spine
Obturator Foreamen
Pubic symphysis
Lesser Trochanter

Question 2

Components of the Posterior Abdominal wall

Answer 2

1. Iliacus
2. Psoas Major (Ilio Psoas)
3. Quadratus Lumborum
   Transversus
   Diaphragm

Question 3

Quadratus Lumborum

Answer 3

Origin: Illiac Crest
Insertion: 12th Rib + L1-4 Transverse Processes
- More Posterior and Lateral than Psoas Major
Action:
a) Combined: i) Forced expiration ii) 12th rib support, bracing spine and ribs in place
b) Individually: Bend trunk to same side
Innervation: T12-L4 (Anterior Rami)

Question 4

Illiacus

Answer 4

Origin: Illiac Fossa
Insertion: Combines and forms Common Tendon with Psoas Major –> inserts onto Femur’s Lesser Trochanter
Action: Hip flexion
Innervation: ** Femoral nerve L2-4

Question 5

Psoas Major

Answer 5

Origin: T12, L1-5 Intervertebral discs –> forms archways/digitations –> allows vessels to enter
- Underneath Inguinal ligament
Insertion: Combines and forms Common Tendon with Illiacus –> inserts onto Femur’s Lesser Trochanter
Action:
a) Combined: Archways/Digitations ANTERIORLY attached to intervertrbal discs (T12/L1-5) –> affects spinal movement –> helps raise body from supine position
b) Hip flexion
c) Individually: Laterally bends trunk
Innervation: Lumbar Plexus L1-3 Direct branches

Question 6

Aorta and IVC

Answer 6

Aorta: enters diaphragm at T12 –> 5x Lumbar arteries –> Bifurcates at L4 (superior to IVC bifurcation) –>
- Renal artery comes off at L1 (same as SMA) para-aorticly
- Gonadal (testicular/ovarian) artery comes off at L2
Lumbar Arteries and veins supply and drain Posterior abdominal wall
- Right C.I Artery overlaps Left C.I Vein (risk of compression)
IVC: enters right diaphragm at T8 –> 5x Lumbar veins –> Bifurcates at L5 (lower) –> Common Iliac Veins
- Venous drainage relatively more complex

Question 7

Varicose Veins in Pregnant woman

Answer 7

Pregnant woman –> Right Common Iliac Artery (Right branch off aortic bifurcation) crosses over and compresses Left Common Iliac Vein –> No drainage in Left legs –> Left Leg Varicose Veins

Question 8

Urinary system contents

Answer 8

Supra-renal glands –> Kidney –> Ureter –> Bladder –> urethra
- Supra renal glands technically not part of urinary system –> Deal more with Adrenalin
Location: all RETRO/INFRAperitoneal

Question 9

Function of the Urinary system

Answer 9

1. Waste removal
2. Electrolyte balance
3. pH balance
4. BP/Volume regulation

Question 10

Surface anatomy of Kidneys (and Suprarenal Glands)

Answer 10

Retroperitoneally (posterior to abdomen)
Superiorly sits ontop of Posterior abdominal muscles Psoas major and Quadratus Lumborum
Kidney’s Relationship with ribs: Posterior and Inferior
- Right Kidney Lower (T12) due to liver –> Left Kidney (L11/12)
Ureters –> exit kidney L1 –> Transpyloric Plance

Question 11

Features of Kidneys (and Suprarenal Glands)

Answer 11

Red/brown
Smooth outer capsule
Kidney contains poles (Upper and Lower)
Hilum of each kidney: Renal Vein + Renal Artery branches + Renal Pelvis + (Lymphatics and ANS)
- Posterior to Hila vessels: Renal Pelvis + Ureters (at Ilium)
Suprarenal glands are encased in similar fascial layers

Question 12

Kidney padding

Answer 12

Kidneys conduct essential functions –> Surrounded and protected from trauma –> with Fat pads:

1. PERInephric fat (near kidney)
2. PARAnephric fat (outside kidney)
   - B/w Peri and para nephric fat pads is RENAL FASCIA

Question 13

Renal Fascia

Answer 13

Separates Peri and Para nephric fat pads
Extends over IVC, Aorta –> connects with other side –> Blends with Psoas Major Fascia
Pathological relevance: Renal Fascia –> Both Left and Right kidneys within same fascial compartment –> allows diseases to spread Left Right

Question 14

Internal Structure of Kidney

Answer 14

Capsule –> Cortex (glomerular. Smooth glandular tissue) –> Medulla (medullary rays, LOD, CD) –> Renal papilla –> Minor Calyces –> Major Calyces –> Renal pelvis –> Ureter

Question 15

Differentiation b/w Kidneys’ Cortex and Medulla

Answer 15

Poor differentiation b/w Smooth Glandular tissue of cortex vs Medullar tissue –> Pathology/Something is wrong

Question 16

Relations of the Right Kidney

Answer 16

Anterior: Suprarenal gland, Under Liver, 2 Duodenum (anterior medial), Hepatic Flexure (of colon)
Posterior: Diaphragm, Psoas, Quadratus Lumborum, Transversus abdominus, Rib 12 (relatively lower), SUBCOSTAL nerve (T12 Spinal nerve)

Question 17

Relations of the Left Kidney

Answer 17

Anterior: Suprarenal gland, Spleen (anterior and superior), Stomach, Pancreas (splenorenal ligament), Jejunum, Splenic Flexure of Colon
Posterior: Diaphragm, Psoas, Quadratus Lumborum, Transversus Abdominus, Ribs 11 and 12 (relatively higher as spleen > liver), SUBCOSTAL nerve (T12 Spinal nerve)

Question 18

Blood Supply of the Kidneys

Answer 18

L1 Renal arteries and veins
Veins Anterior to Arteries –> avoids risk of compression against Posterior abdominal wall –> Spilt into septal banches
Arteries –> bifurcate into Anterior and Posterior branches –> enter Hilum of Kidneys –> segmental branches

Question 19

Blood Supply of the Supra-renal gland

Answer 19

1. Branch from abdominal aorta
2. Phrenic Artery
3. Suprarenal artery

Question 20

Structures relative to Left Renal Artery

Answer 20

Vertically Ontop of LRA: SMA
Vertically Underneath LRA: Anterior Aorta
Horizontally Underneath LRA: Splenic vein + Body of pancreas

Question 21

General Notes on Kidney Blood, Nerve and Lymph

Answer 21

General Notes:

Veins anterior to arteries. Vessels come off para-aortically at L1

Question 22

Arterial Summary of Kidney Blood, Nerve and Lymph

Answer 22

Arterial:
Renal arteries off laterally at L1 –> anterior branches –> segmental branches
- double renal arteries not uncommon, embriologically multiple arteries fuse, therefore some may not have been obliterated out
Aorta located on left side of body –> RIGHT renal Artery 3x Longer –> in order to supply kidney from opposite side

Question 23

Venous Summary of Kidney Blood, Nerve and Lymph

Answer 23

Venous:
Renal veins off laterally at L1
IVC located on Right side of body –> Left Renal vein 3x longer –> in order to drain kidney from opposite side
Left Renal vein runs Vertically Posterior to SMA, Vertically Anterior to Abdominal Aorta, Horizontally INFERIOR to Splenic Vein + Body of Pancreas

Question 24

Nervous Summary of Kidney Blood, Nerve and Lymph

Answer 24

Nervous:
Renal plexus
- Sympathetic = complicated
- Parasympathetic = Vagus nerve (Cranial nerve 10)
Referred pain --> FLANK pain

Question 25

Lymphatic Summary of Kidney Blood, Nerve and Lymph

Answer 25

(Lymphatics follow arteries) --> **Para-aortic nodes L1 | - Located Posteriorly, on the side

Question 26

Ureters

Answer 26

Smooth muscle tube Urine propelled through ureter via: 1. smooth muscle contractions 2. GFP Filtration Pressure from Glomerulus ~25cm Exits Kidneys at L1/Hilus (same level of entering arteries) --> Runs on surface of Psoas Major Radiologically: Roughly in line with processes of Lumbar spine At Anterior Sacro-Iliac Joint --> Ureter Crosses bifurcation of Common Illiac artery on respective side --> continues along ileum on pelvis' lateral wall --> towards Ischial Spine --> Enters Trigone at bladder's Inferior surface (enters obliquely. tries to control flow)

Question 27

Most common place for ureter's Kidney Stone to lodge

Answer 27

Narrowest part due to constriction of surround structures --> when ureter is at Anterior Sacro-Iliac Joint --> is crossing Bifurcation of Common Iliac arteries

Question 28

3x Constrictions of Ureters

Answer 28

1. PUJ: Junction of the Renal Pelvis --> Ureter (Pelvo-Urteric Junction 2. Anterior Sacro-Iliac Joint --> where ureters cross bifurcation of aorta into Common Iliac arteries (Pelvic Brim) 3. Inferior Bladder's Trigone (Ureter enters obliquely) (tries to control flow) - -> All 3x sites (PUJ, Anterior SIJ, Trigone) common places of kidney stone/ renal calculus obstruction

Question 29

Ureter's Blood and Nerve supply in 1/3s

Answer 29

Superior 1/3 (proximal) --> Middle 1/3 --> Inferior 1/3 (distal) Arterial: Renal artery --> Gonadal (testicular/ovarian) artery --> Superior Vesicular(bladder) artery (branch of Internal Iliac) Venous: Renal vein --> Gonadal (testicular/ovarian) vein --> Superior Vesicular (bladder) artery (branch of Internal Iliac) Nervous: Renal Plexus (sup+mid 1/3) --> Hypogastric Plexuses (controls pelvic contents/urogenital)

Question 30

Ureter's Pain referral and Lymphatic supply

Answer 30

- Pain referred to L1 and 2 Dermatomes (Suprapubic regions) | - Lymphatics (Lateral aortic L1 Iliac nodes) --> variable due to variable supply

Question 31

"vesicular"

Answer 31

bladder - Hence Inferior 1/3 of both ureter's arterial supply and venous drainage = Superior Vesicular Artery/Vein (from Internal Iliac branch)

Question 32

Bladder

Answer 32

Infraperitoneal: Partial peritoneal covering --> Stuck against the pubic bones (various ligaments helping to do so) Transitional epithelium and rugae Apex of bladder = Posterior to Pubic Symphisis When Bladder located in midpubic region --> bladder fills -> rises to suprapubic region (decreased sensation's large filling leads to increased chance of UTI urinary tract infections) Dextrusor muscle : Smooth muscle coat Sphincter Vesicae Smooth muscle sphincter at neck of bladder

Question 33

Bladder's smooth muscle coat

Answer 33

Dextrusor muscle

Question 34

Bladder's smooth muscle sphincter

Answer 34

Sphincter Vesicae (Vesicae = vesicular = bladder) - located at neck of bladder Internal sphincter of bladder, Prior to ureter's involuntary control

Question 35

Sensation of bladder with position and age

Answer 35

Standing/Elderly --> Decreased sensation of bladder --> Bladder fills to large levels (2L) w/o realising/emptying --> Bladder distends into suprapubic region --> Urinary Tracts

Question 36

Trigone

Answer 36

Smooth muscle area, at Base/back of bladder - Mucous membrane -NO rugae Superiorly: 2x ureters enter --> Interuteric bar/crest b/w 2x ureters = BASE = Less mobile --> easily irritated Inferiorly: 1x urethra exits = APEX

Question 37

Blood and nerve of the Bladder

Answer 37

Arterial: 2x superior and 1x inferior Vesicular artery from each side (branches off internal illiac) -Note: Male Inferior vesicular artery --> tends to be Vaginal artery in females Venous: Vesicular plexus --> drains into Internal Illiac Vein Nervous: ANS --> Inferior Hypogastric Plexus (located in sacral area) a) Sympathetic: Sacral splanchnic nerves S2-4 (L1-2 fibres) - Note: Pain referred to Supra-pubic region due to L1-2 Dermatomes b) Parasympathetic: Pelvic Splanchnic nerves

Question 38

Gender variation of Bladder arteries

Answer 38

Bladder arteries: 2x Superior + 1x Inferior vesicular artery Males: Inferior vesicular arteries Females: Vaginal artery

Question 39

Bladder Pain referral

Answer 39

Pain referred to Suprapubic region (L1-2 Dermatomes)