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Common Urological Problems

Female Pelvic Viscera

  • - Female Urology & Urogynecology - Anatomy of Pelvic Support
  • Jun 19, 2010
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  • Viewed: 17045
  
Tags: | bladder | clitoris | cystocele | enterocele |

Lower Urinary Tract
The bladder is comprised of the body and the trigone and normally serves to store urine at low pressures and effectively contract to urinate (7). The bladder is composed of an inner transitional epithelium, a multilayer muscular wall, and an outer serosal covering.  The exact dimensions and configuration of the bladder vary considerably depending on degree of distention, prolapse, or other pathology. The bladder base and urethra rest on the anterior vaginal wall (1). The bladder is an extraperitoneal organ covered by peritoneum at the dome superiorly and posteriorly. 

The peritoneum then reflects onto the anterior vagina and uterus, forming the vesicouterine pouch, and continues over the posterior uterus and onto the rectum, creating the rectouterine space or pouch of Douglas (Fig. 10) (3). The peritoneum in the rectouterine space may herniate into the posterior vagina, resulting in an enterocele.

The ureter is a continuation of the renal collecting system and transports urine from the kidney to the bladder (8). The ureter courses inferiorly and medially; below the inferior border of the sacrum, the ureter is referred to as the lower, distal, or pelvic ureter.

The position of the distal ureter can be affected by bladder distention or significant prolapse, and it is susceptible to injury during pelvic reconstruction. The ureter crosses anterior to the common iliac vessels at the bifurcation medial to the ovarian vessels. The course of the ureter is retroperitoneal and runs deep to the base of the broad ligament before traveling through the cardinal ligament, where the ureter passes underneath the uterine artery (Fig. 11) (3). The ureter is located in the anterior vaginal wall before entering the bladder and is usually 1.5 cm superolateral to the cervix (1).

Fig. 10. Peritoneal cleavage planes. (From ref. 3.)Peritoneal cleavage planes

The female urethra is approx 4 cm in length and extends from the bladder neck to the external urethral meatus (1). As mentioned, the midportion of the urethra is attached to the inferior pubis by the pubourethral ligaments. The ligaments divide the urethra into proximal and distal halves; the external sphincter is just distal to the ligaments.

The urethra is typically divided into three portions: proximal, mid, and distal. The proximal urethra is responsible for passive continence. The midportion, which contains the rhabdosphincter, is responsible for passive and active continence.  The distal one-third is principally a conduit and, if damaged or resected, usually does not have an impact on continence. The epithelium of the urethra varies proximal to distal, transitional to non-keratinized squamous epithelium, respectively. Many small glands communicate with the urethra and may be a source of urethral diverticula.

The urethra is bordered laterally by two small labia, which contain minor vestibular glands. The Skene ducts open on the inner aspect of these labia and when inflamed can be palpated on the distal anterior vaginal wall as a suburethral mass (3).

The mechanism of continence is multifactorial. Innate properties of the urethra provide a measure of control. The urethral epithelium has many infoldings, which result in a mucosal seal (Fig. 12).

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