1
Q
Describe the general structure of the kidney.
What is its peritoneal relation?
Size and shape.?
A
retroperitoneal organ
- 120 - 200g
- 10 - 12cm long, 5-6cm wide, 4cm thick
2 different types of structures:
- urine formation: nephrons + uriniferous tubules
- urine collection: renal calyces + renal pelvis
2
Q
What are the functions of the kidney?
A
- homeostasis of bodily fluids (amount, osmolarity, pH, ion concentration)
∽ 180l primary urine filtered out of the blood/day - excretion of metabolic end products (urine)
1.5 - 2l final urine formed/day - endocrine function (renin-angiotensin, vit D3, erythropoietin)
3
Q
1 - 5
A
1) extremitas superior
2) extremitas inferior
3) hilum renale
4) sinus renalis
5) pyramidis renalis
4
Q
6 - 10
Another name for #8.
A
6) capsula fibrosa
7) capsula adiposa
8) fascia renalis (= GEROTA)
9) medulla renalis
10) cortex renalis
5
Q
11 - 13
A
11) papilla renalis
12) columna renalis
13) lobus renalis
6
Q
What is a floating kidney?
What are other names?
A
loss of capsula adiposa → hypermobility of the kidney which descends into the pelvis
- other names:
nephroptosis, nephroptosia, renal ptosis, renal descensus, renal prolapse
7
Q
Which structures can be found in the cortex?
A
radii medullares (= medullary rays) = continuation of medullary substance
cortex corticis = contains radii medullares
labyrinthus corticis = area btw radii medullares
8
Q
What are the projections of the kidney?
A
in fossa lumbalis
- right: Th12 → L3
- left: Th11 → L3
- hilum: L2
⇒ left kidney moves (2-3 cm) during deep inspiration
9
Q
What are the boundaries of the kidney?
- laterally - medially
- cranially
- dorsally
A
laterally:
- 6) m. transversus abdominis
medially:
- 8) m. psoas major
cranially:
- diaphragm
- suprarenal gll.
dorsally:
- 7) m. quadratus lumborum
- n. subcostalis
- n. iliohypogastricus
- n. ilioinguinalis
10
Q
What are the ventral boundaries of the kidney?
Differentiate btw right/left.
A
right:
- 1) right lobe of the liver
- 2) pars descendens duodeni
- 3) flexura coli dextra
- 4) loops of small intestine
left:
- 6) stomach
- 7) spleen
- 9) pancreas
- 10) flexura coli sinistra
- 11) radix mesocolica
- 12) loops of small intestine
11
Q
What are the dorsal relations of the kidney clinically relevant?
A
contact to n. ilioinguinalis + n. iliohypogastricus explains why pain can spread up to the inguinal region in case of renal diseases
12
Q
Explain the segmentation of the kidney.
A
5 segments
- segm. superius
- segm. anterius superius
- segm. anterius inferius
- segm. inferius
- segm. posterius
⇒ correspond to the arterial supply via a. renalis
13
Q
What is the microscopic unit of the kidney?
Describe it.
A
nephron
- renal corpuscle
- glomerulus
forms together with renal tubule the uriniferous tubule
14
Q
List some genetic abnormalities of the kidney.
A
- additional kidneys
- horseshoe kidney = fused kidneys
- renal aplasia = one kidney is missing
- renal hypoplasia = underdevelopment of one kidney
15
Q
Explain the vasculature of the kidney
A
arterial supply:
- a. renalis dex./sin.
- type I r. principalis ant./post.
* *type II** r. principalis ant./post./inf. - aa. interlobulares
- aa. arcuatae
- aa. corticales radiatae (= aa. interlobulares)
- arteriolae afferentes
drainage: beginning at glomerulus
- arteriolae efferentes
- vasa recta/peritubular cap.
- vv. corticales radiatae
- vv. arcuatae interlobulares
- vv. renales
- IVC
16
Q
What are clinically important abberations of the renal vasculature?
A
- accessory renal aa.: persisting branches of aorta that didn’t redevelop during fetal dev., esp. important in case of surgeries
- abberant renal aa.: aa. don’t enter through hilum, but through sup./inf. pole
17
Q
What is important abt v. renalis sin.?
Why is it clinically important?
A
3 tributaries:
- v. suprarenalis
- v. testicularis/ovarica
- v. phrenica inf.
⇒ cancer in the left renal v. can cause reflux into v. testicularis → dilation of scrotum (= varicocele)
18
Q
What innervates the kidneys?
A
sympathetic innervation via plexus renalis
19
Q
What are calices renalis?
Differentiate.
A
drain urine from papilla renalis into pelvis renalis
- major
- minor
20
Q
What are the 2 shapes of the pelvis renalis?
A
type depends on calices renalis
volume: 3 - 8ml
- branching: minor calices open consistently into major which eventually open into pelvis renalis
- ampullary: minor and major calices open into pelvis renalis
21
Q
What are the 2 ways for X-ray examinations to investigate the pelvis renalis?
A
- urogram: iodid containing contrast material injected intravenously, eventually excreted by kidney
- retrograde pyelogram: contrast material injected into ureters via a catheter
22
Q
Which structures are connected by the ureter?
What are its 3 points of constriction?
A
pelvis renalis → urinary bladder
- exit from pelvis renalis
- crossing of a. iliaca communis/externa when entering the lesser pelvis
- wall of urinary bladder
23
Q
Why are the points of constriction of the ureter clinically relevant?
A
⇒ renal colic = type of abdominal pain commonly caused by kidney stones, often wavelike in phases
24
Q
What are the parts of the ureter?
A
- pars abdominalis in retroperitoneal space
- pars pelvica in lesser pelvis
- pars intramuralis in wall of urinary bladder
25
Explain the crossings of the ureter.
**_over - under - over - under_**
1. over **n. genitofemoralis**
2. under **a./v. testicularis/ovarica**
3. over **a. iliaca communis** (left)/**externa** (right)
4. under **ductus deferens** (male)/**a. uterina** (female)
26
What is important during a uterectomy?
**a. uterina** is close to ureter → injury/ligation of ureter can lead to **loss of kidney**
27
Which vessels supply and drain the ureter?
_supply:_
* *pars abdominalis:* **a. renalis, aorta abdominalis, a. testicularis/ovarica, a. iliaca communis**
* *pars pelvica:* **a. iliaca interna, a. vesicalis inf.** (in females also often a. uterina)
_drainage:_
→ **v. testicularis** → **v. iliaca int.** → **plexus venosus vesicalis**
28
Which structures form the bladder, vesica urinaria?
What is its peritoneal relation?
How much volume can it contain, when does usually the urge to void appear?
**subperitoneal organ**
* apex, corpus, fundus
* **trigonum vesicae** + 2 ostia ureteris (+ plica interureterica) + 1 ostium urethrae internum
* *in males:* uvula vesicae
capacity = 500ml, urge to void at 300 ml
29
Which structures surround the urinary bladder?
* __**paravesicular adipose tissue**
* anteriorly **spatium retropubicum** (**RETZIUS**)
* posteriorly *in males* **excavatio rectovesicalis**
* in female*s **excavatio vesicouterina**
_additionally posteriorly located in males from medial to lateral *(cf. picture*):_
1. **ductus deferens**
2. **gl. vesiculosa**
3. **ureter**
30
Why is the spatium retropubicum clinically relevant?
distended urinary bladder can be punctuated superiorly to symphysis pubica → **suprapubic catheter**
31
Which structures attach to the vesica urinaria?
Differentiate btw genders.
* *both genders:* **lig. umbilicale medianum** (obliterated urachus, connects to umbilicus)
* *males:* **ligg. puboprostatica** (1 on each side)
* *females:* **ligg. pubovesicalia** (1 on each side)
32
Explain the structure of the wall of the vesica urinaria?
_from inside to outside_
1. **mucosa**
2. **m. detrusor vesicae**
3. **tunica serosa** (where overlied by peritoneum)
33
Which vessels supply/drain the vesica urinaria?
Innervation.
_supply:_
* **aa. vesicales sup./inf.** (from a. iliaca int.)
_drainage:_
* __**plexus venosus vesicalis** → vv. vesicales → v. iliaca int.
_innervation:_
* *parasymp:* **plexus hypogastricus inf.** → contract m. detrusor vesicae → micturition
34
Explain the macroscopical structure of the female urethra.
Supply/drainage/innervation?
Clinical relevance?
from **ostium urethrea internum** (bladder) to **ostium urethrae externum**
* 3 - 5cm long
* closed by **m. sphincter urethrae ext.**
* supply/drainage/innervation are the same as for the bladder
⇒ **cystitis** (inflammation of the bladder) much more common in females due to short urethra
35
What is micturition?
Explain the process.
urination
_closure of bladder/urethra by_
* **smooth m. sphincter urethrae int.**, innervated symphathetically
* **striated m. sphincter urethrae ext.**, innervated by n. pudendus → voluntary
_micturition_
1. relaxation of **pelvic diaphragm** → lowering of bladder
2. contraction of **m. detrusor vesicae**
3. relaxation of **m. sphincter urethrae int./ext.**
36
What seperates cavitas pelvis from cavitas abdominalis?
How is it subdivided?
seperated by **apertura pelvis superior** demarcated by linea terminalis
_subdivision in craniocaudal direction_
* **cavitas peritonealis pelvis** bounded by peritoneum inferiorly
* **spatium extraperitoneale pelvis** bounded by pelvic diaphragm
* **regio urogenitalis** (ant.) = spatium perinei sup./prof.
* *regio analis** (post.) = fossa ischioanalis
37
What are the contents of cavitas pelvis?
Differentiate btw male/female.
_both:_
* vesica urinaria
* ureters
* rectum
_male:_
* **gll. vesiculosae**
* **ductus deferentes**
* **prostate**
_female:_
* **uterus**
* **vagina**
* **ovaria**
* **tubae uterinae**
38
Where is plica rectovesicalis/rectouterina?
Which structures does it contain?
lat. folds bounding excavatio rectovesicalis/rectouterina (= **DOUGLAS pouch)**
⇒ contains **plexus hypogastricus inf.** (+ **lig. rectouterium** in females)
39
Explain the peritoneal relations in cavitas peritonealis of females.
2 pouches are formed instead of just 1 since peritoneum reflects on superior surface of vesica urinaria to cover uterus + adnexa → **intraperitoneal** → **lig. latum**
⇒ **excavatio vesicouterina** (ant.) + **excavatio rectouterina** (post.) = **DOULGAS pouch**
40
What are the parts of lig. latum?
What does it contain?
_parts:_
* **mesometrium** attaches at uterus
* **mesosalpinx** covers tuba uterina
* **mesovarium** covers ovaries
_add. contents:_
* a. ovarica
* a. uterina
* lig. ovarii proprium
* lig. teres uteri
* paracervical ganglion
*for more information cf. ...genital system*
41
Which structures are connected by parametrium?
8 ligg. (each side 4)
_laterally:_ **cervix + pelvis** = **paracervix**
* **lig. cardinale (MACKENRODT)**
* continues caudally as **paracolpium**
* contains branches of **a./v. uterina**
_ventrally:_ **cervix + canalis inguinalis/bladder**
* **lig. vesicouterinum**
* **lig. teres uteris**
_dorsally:_ **cervix + sacrum**
* **lig. sacrouterinum**
42
Why is the Douglas pouch clinically relevant?
only **seperated by thin tissue layers** from post. wall of vagina
→ Douglas abscesses can be removed
→ uterus, ovaries, tubae uterinae can be examined via endoscopy
43
What is the name of the fascia that seperates prostate from rectum?
fascia rectoprostatica
(= **DENON-VILLIER)**
44
Which mm. form the diaphragma pelvis?
What is their common function?
How do you call the opening that is formed by one of the 2 mm.?
Both are innervated by ... ?
**m. levator ani** + **m. ischiococcygeus
⇒** form hiatus levatorius for passage of urethra (+ vagina)
→ support pelvic/abdominal viscera + provide continence
_both:_ innervated by **plexus sacralis** (S3/4)
45
#1 - 3
Origin, insertion, innervation.
**m. levator ani**
* *ORIGIN:*
* **m. pubococcygeus/-rectalis: ramus sup.
* m. iliococcygeus: arcus tendineus m. levatorius (fascia of m. obturator int.)
* *INSERTION:***
* m. pubo-/iliococcygeus: sacrum, coccyx
* m. puborectalis forms sling around rectum
* *INNERVATION:*
* **plexus sacralis** (S3/4)
* m. puborectalis _also_ by **n. pudendus**
46
#4
Origin, insertion, innervation
**m. ischiococcygeus**
* *ORIGIN:* spina ischiadica, lig. sacrospinale
* *INSERTION:* coccyx
* *INNERVATION:* **plexus sacralis** (S3/4)
47
What might be the reason for pelvic floor insufficiency?
What are consequences?
multiple vaginal births
→ descensus/prolapse of bladder (= **cystocele**), rectum (= **rectocele**)
→ **incontinence**
48
#1 - 5
1) pubic bone
2) ischium
3) membrana obturatoria
4) m. obturator int.
5) membrana perinei
49
#6 - 10
6) vesica urinaria
7) prostate
8) urethra - pars prostatica
9) urethra - pars intramuralis
10) urethra - pars membranacea
50
#11 - 15
11) urethra - pars spongiosa
12) m. sphincter urethrae ext.
13) m. levator ani
14) fossa ischioanalis
15) peritoneum
51
#16 - 20
What is formed by #17?
Another 2 names for #20.
16) corpus spongiosum
17) corpus cavernosum → crura of penis
18) m. ischiocavernosus
19) m. bulbospongiosus
20) fascia perinei profunda (= **GALLAUDET**), investing layer of perineal fascia
52
#21 - 25
Another 2 names for #22. What is it continuous with?
What does #25 partially form?
21) skin
22) fascia perinei superficialis (= **COLLES**), membraneous layer of perineal fascia → continuous w/ fascia penis sup., tunica DARTOS
23) spatium superficiale perinei
24) spatium profundum perinei
25) m. transversus profundus (part of **urogential diaphragm**)
53
#26 - 29
26) trigonum vesicae
27) ostium uteris
28) saccus subcutaneus perinei
29) paracystium
54
What are the contents of spatium profundum perinei?
Differentiate btw male/female.
_male:_
* **urethra**
* **gll. bulbourethrales** (**COWPER**)
* **m. transversus profundus**
_female:_
* **vagina w/ urethra**
* **smooth m.** instead of m. transversus profundus
55
What are the contents of spatium superficiale perinei?
Differentiate btw male/female.
_female:_
* **gl. vestibularis maj.** (**BARTHOLIN**)
* **gll. vestibulares min.** ∽ correspond to Cowper's glands
_both_:
* **erectile tissues**
* **canalis pudendalis (ALCOCK)** containing:
* n. pudendus
* a. + v. pudenda int.
56
What are the contents of fossa ischioanalis?
* **canalis pudendalis** (ALCOCK) containing
* n. pudendus
* a. + v. pudenda int.
* **a. + v + n. rectalis inf.**
57
What are the boundaries of fossa ischioanalis?
* *base:* **skin**
* *apex:* **m. levator ani, m. obturator int.**
* *med:* **m. sphincter ani ext., m. levator ani**
* *lat:* **tuber ischiadicum, m. obturator int.**
* *ventr:* **COLLES fascia**
* *dors:* **m. gluteus max., lig. sacrotuberale**
58
Why is saccus subcutaneus perinei clinically relevant?
**infections in this region can spread** to ant. abdominal wall, scrotum/labiae majorae
59
Which n. innervates ALL perineal mm.?
**n. pudendus**
| (= "shame" nerve)
60
What is a pudendal nerve block?
**local anesthesia technique** used in an obstretic procedure to anasthesize the perineum during labor
→ e.g. lidocaine injected through inner wall of vagina in direction of spina ischiadica
61
What is due to its location a common site for anal fistulas?
**fossa ischioanalis**
62
#1 - 5
1) ischium
2) pubis
3) membrana obturatoria
4) m. obturator int.
5) membrana perinei
63
#6 - 10
Another name for #10.
6) vagina
7) cervix
8) fornix lat.
9) vestibulum vaginae
10) ostium uteri (= ext. os)
64
#11 - 15
Another 2 names for #15
11) m. levator ani
12) m. sphincter urethrae ext.
13) m. compressor urethrae
14) peritoneum
15) lig. cardinale (**MACKENRODT**), lig. cervicale lat.
65
#16 - 20
Which structure is formed by #18?
16) labia min.
17) labia maj.
18) corpus spongiosum (both form bulbus vestibuli)
19) m. bulbospongiosus
20) corpus cavernosum clitoridis
66
#21 - 26
Another 2 names for #22, 23.
#24 is the remnant of which embryological structure?
21) m. ischiocavernosus
22) fascia perinei profunda, investing layer of per. fascia (**= GALLAUDET**)
23) fascia perinei superficialis, membraneous layer of per. fascia (= **COLLES**)
24) lig. teres uteri (= remnant of gubernaculum)
25) spatium perinei profundum
26) spatium perinei superficiale
67
What is an episiotomy?
surgical incision of perineum/post. vag. wall to **enlarge opening for baby during labor**
OTHERWISE: perineal tear can rupture m. levator ani, m. sphincter ani int./ext.
68
Since in some books more add. mm. are considered part of m. sphincter urethrae ext., list them.
* **m. compressor urethrae** = adjacent to original m. sphincter urethrae ext.
* **m. sphincter urethrovaginalis** = adjacent to vagina
Anatomy II
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