The bladder’s normal capacity lies at 500mL, but strong urinary urgency occurs already with 300 mL.

In patients with voiding dysfunctions after surgery, up to 2000mL can collect.

The urinary bladder is located in the lesser pelvis behind the symphysis. An empty bladder does not extend with its superior pole beyond the symphysis; a full bladder can be palpated up to 3 cm above the symphysis.

Superior

peritoneum

small intestinal loops

uterus (depending on location)

Anterior

pubis

peritoneum

when bladder is full: anterior abdominal wall

Inferior

uterine cervix

vagina

urethra

pelvic floor (levator ani)

obturator internus

Posterior

uterine cervix and isthmus

vagina

ureter

Lateral. Peritoneum, runs into the broad ligament of the uterus.

Fig. 15.2 Fascial attachments of the organs in the lesser pelvis.

Fig. 15.3 Topography of the male lesser pelvis.

Superior

peritoneum

intestinal loops

Anterior

pubis

peritoneum

when bladder is full: anterior abdominal wall

Inferior. Prostate gland.

Posterior

vas deferens

seminal vesicle

rectum

ureter

peritoneum

small intestinal loops

Fig. 15.4 Ligaments of the bladder, frontal view.

Fig. 15.5 Ligaments of the bladder, sagittal view.

Lateral

peritoneum

levator ani

obturator internus

Retropubic space (Retzius space):

Located between the pubic bone/abdominal wall and the urinary bladder, bordered caudally by the pubovesical ligament and medially by the median umbilical ligament.

peritoneum (anterior, lateral, and in men also posterior attachment)

median umbilical ligament (with urachus)

medial umbilical ligament (obliterated umbilical artery)

pubovesical ligament (with muscle fibers from the bladder), corresponds to the puboprostatic ligament

connective tissue of the lesser pelvis

Fig. 15.6 Ligaments of the bladder, side view, in the male body.

Fig. 15.7 Ligaments of the bladder, in the male body (view from the front).

Branches of the internal iliac artery, e.g.:

inferior vesical artery

internal pudendal artery

obturator artery

vesical venous plexus (anastomoses to the prostatic and vaginal venous plexus)

internal iliac vein

Internal and external iliac nodes.

sympathetic nervous system from L1 to L2 via the intermesenteric plexus and hypogastric nerves to the inferior hypogastric plexus and vesical plexus

sacral parasympathetic nervous system (S2–S4) via the inferior hypogastric plexus and vesical plexus

Maximal time: 3–5p.m.

Minimal time: 3–5a.m.

The ureter is 25–30cm long and approximately 5mm thick.

There are three physiologic bottlenecks where kidney stones are most likely to get impacted:

1. Transition from the renal pelvis into the ureter.
   
2. Sharp bend by the common/external iliac artery.
   
3. Passage into the urinary bladder (= narrowest point).

The ureter runs caudal on top of the psoas major, passes across the bifurcation of the common iliac artery (left) or the external iliac artery (right) as it enters the lesser pelvis, and then descends further caudally along the lateral wall of the pelvis near the peritoneum.

Fig. 15.8 Location of the ureter.

Roughly at the level of the ischiadic spine, it changes its course medially and anteriorly in the direction of the urinary bladder. Slightly above the seminal vesicle, it reaches the posterior lateral wall of the bladder, where it is crossed by the vas deferens. Here, the vas deferens lies closer to the peritoneum than the ureter. Continuing on, the ureter crosses the bladder diagonally from posterolat-eral to anteromedial.

Roughly at the level of the ischiadic spine, it changes its course medially and anteriorly in the direction of the urinary bladder. It initially lies in the base of the broad ligament of the uterus, and then it is crossed by the uterine artery. In its continued path, it proceeds at a distance of about 1–2cm away from the supravaginal part of the uterine cervix. Right in front of the urinary bladder, it lies on top of the anterior and lateral vaginal vault. Entry into the urinary bladder takes place diagonally, as in the male body.

See “Location”; in addition:

peritoneum

psoas fascia

genitofemoral nerve

inferior vena cava (right)

duodenum (right)

testicular/ovarian vessel

right colic artery

ileocolic artery

inferior mesenteric artery or left colic artery

root of the mesentery

root of the sigmoid mesocolon

adipose capsule of the kidney

peritoneum

retro- and extraperitoneal connective tissue

Fig. 15.9 Topographic relationships of the ureter.

The arterial supply is provided by branches of the arteries in its vicinity:

renal artery

abdominal aorta

testicular/ovarian artery

common iliac artery

internal iliac artery

inferior vesical artery

uterine artery

testicular/ovarian vein

internal iliac vein

vesical plexus

internal/communal/external iliac nodes

lumbar nodes

renal lymph nodes

sympathetic nervous system from T10 to L1 via the lesser and lowest splanchnic nerves and the lumbar splanchnic nerves 1 and 2 to the celiac plexus, aorticorenal ganglion, renal plexus, and posterior renal ganglion

vagus nerve (via the celiac plexus)

sacral parasympathetic system (S2–S4) via the superior hypogastric plexus to the renal plexus

The urinary bladder moves together with the sacrum and uterus: during inhalation posteriorly and superiorly and during exhalation anteriorly and inferiorly.

Another movement results when the bladder is filled with urine and then voided.

During the expiratory phase, we see a movement postero-superiorly, and during the inspiratory phase in the opposite direction.

Urine reaches the bladder in portions. The peristaltic contraction of the ureter opens and closes the opening of the ureter.

The ureter penetrates the urinary bladder diagonally. As a result, the internal pressure of the bladder keeps the entrance of the ureter closed except for during peristaltic waves. This mechanism prevents a reflux of urine.

The pelvic floor becomes limp, and the bladder consequently shifts lower, its neck assuming a funnel shape.

Urine enters the urethra up to the inner sphincter, the detrusor muscle of the bladder contracts (innervated parasympathetically), and the funnel shape is reinforced. The sphincter opens.

The urethra muscles and the external sphincter become limp.

To conclude micturition, the pelvic floor as well as the internal and external sphincter contract, and the neck of the bladder loses its funnel shape.

Definition. Infection of the upper urinary tract due to pathogenic organisms.

Causes. Highly virulent organisms coinciding with a weakened state of defense.

Precipitating factors include:

stricture of the urinary tract, e.g., prostatic hyperplasia

vesicoureteral reflux

neurogenic disturbance of bladder voiding

calculi

diabetes mellitus

immunosuppressive therapy

Clinical

dysuria

pollakiuria

subfebrile temperatures