Applied Anatomy of the

Genitourinary Tract
Howard B. Goldman MD FACS
Glickman Urologic and Kidney Institute
Lerner College of Medicine
Cleveland Clinic
Cleveland, Ohio

Skeletal

Skeletal Anatomy

Ribs
Vertebral Bodies
Pelvis

Skeletal

Ribs
Ribs 6-10 connected by cartilaginous
costal arch
Ribs 11 and 12 not joined

Costal groove - intercostal vessels and nerve

on inner inferior surface
Netter 171, 231

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Skeletal

Vertebral Bodies
T 11-12, L 1-5, Sacrum, Coccyx

Spinal Nerves
Spinal nerves named for vertebral body just
above its foramen of exit
Spinal cord terminates at L1-2
Nerves continue as cauda equina

Skeletal

Lumbar cord is at T11 - L 1

vertebral levels

Sacral cord is at L 1-2 vertebral

levels
Netter 149

Skeletal
Pelvis
Innominates - ilium
- ischium - Paired

- pubis

Sacrum
Netter 231

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Skeletal
Pelvic Foramina
Within bone - 1. Obturator foramen
Formed by ligaments - sacrotuberous
(ischial tuberosity to
sacrum / coccyx)
- sacrospinous (ischial
spine to lower sacrum)
- 2. Greater sciatic foramen
- 3. Lesser sciatic foramen
Netter 331

Skeletal
Division of Pelvis
False pelvis - bowl shaped
- formed by iliac fossa
- in contact with
intraperitoneal contents
True pelvis - entered directly through a
low midline incision
Arcuate line of ilium - part of what
divides true from false pelvis
Hinman 10.2

Musculature

Abdominal Wall
Skin and Sub Q
Musculature
Anterior abdominal wall
Anterolateral abdominal wall
Posterior abdominal wall
Pelvis

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Musculature Skin and Subcutaneous
fascia
Camper’s fascia - loose layer of fatty tissue
beneath skin
Scarpa’s fascia - deep to Camper’s
- superior/lateral - blends with Camper’s
- inferior - fuses with fascia of thigh
- medially - continuous with Colle’s
Colle’s fascia - continuous with Scarpa’s and dartos
- till posterior edge of UG diaphragm
Dartos fascia - superfical layer of penis & scrotum
- continuous with Colle’s and Scarpa’s
Netter 354

Musculature
Anterior Abdominal Wall
Rectus Muscle - from pubic crest to ribs 5, 6, 7
Aponeurosis of ext. and int. oblique and transversus
abdominus
Rectus Sheath
above arcuate line
anterior - ext/int oblique
posterior - int/transversus
below arcuate line - anterior all

Arcuate line = 2/3 distance from

pubis to umbilicus
Netter 232, 233, 234

Musculature
Anteriolateral Abdominal Wall
External oblique - fibers run caudal/medial
- free inferior border is the inguinal ligament
- portion continues as external spermatic fascia
Internal oblique - upper fibers run cranially
- lower fibers run medially
- form part of conjoined tendon
- portion continues as cremaster muscle
Transversus abdominus - fibers run medially
- lowest fibers form conjoined tendon
Intercostals - external/internal
- connect ribs
Netter 232, 233, 234

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 Musculature
Posterior Abdominal Wall
Outer Layer - Latissimus dorsi
- External oblique
Middle layer - Internal oblique
- Serratus posterior inferior
- Sacrospinalis
Inner layer - Quadratus lumborum
- Iliacus
Innermost layer - Psoas
- Diaphragm Hinman 8.5b

Musculature

Posterior Abdominal Wall - outer layer

Latissimus dorsi - Triangular shaped

- Covers most of lower back
External oblique
Petit’s triangle - Lat. Dorsi, ext. obl., iliac crest

Netter 237

Musculature

Posterior Abdominal Wall - middle layer

Internal Oblique
Serratus Posterior Inferior
Sacrospinalis

Netter 237

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 Musculature

Posterior Abdominal Wall -

inner and innermost layers

Inner layer - Quadratus lumborum

- Iliacus
Innermost layer - Psoas
- Diaphragm

Netter 246

Musculature

Layers of a Flank Incision

Posteriorly - Latissimus dorsi
- ? Serratus posterior inferior

Anterolaterally - External oblique

- Internal oblique
*(neurovascular bundle)*
- Transversus abdominus (+/- rib)
- Transversalis fascia
- Thoracolumber fascia
- Pararenal connective tissue/fat
- Gerota’s fascia
- Perirenal fat
- Kidney

Netter 237, Hinman 8.5B

Musculature

Layers of Anterior Subcostal or

Chevron Incision
External oblique
Internal oblique & rectus
Transversus abdominus
Transversalis fascia
Parietal peritoneum
Netter 235

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 Musculature

Stratum of Retroperitoneal
Tissue
Outer Layer - Investment of body wall
muscles (endopelvic fascia,
transversalis fascia)

* Intermediate - Investment of GU tract

organs
Inner - Investment of intestinal tract
(Denonvillier’s fascia)

Musculature
Pelvic Musculature
Iliacus
Psoas
Obturator internus
Piriformis
Coccygeus
Levator ani - puborectalis Arise from arcus
pubococcygeus tendineus and
iliococcygeus pubis

Netter 246, 333, 335

Obturator

Obturator Foramen

Has assumed importance with the

advent of transobturator
approaches to midurethral sling
placement in women

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 Obturator

Obturator Foramen

Obturator internus muscle

Obturator membrane
Obturator externus muscle
Obturator nerves and vessels in
superiolateral portion of foramen

Adductors

Adductor muscles encountered in

transobturator sling

Adductor brevis
Adductor longus
Gracilis

Musculature

Perineum and UG Diaphragm

Male and female almost the same
- only proportions change

Urogenital triangle - R and L ischial

tuberosities to symphysis pubis

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 Musculature
Perineum
Superficial - superficial transverse
perineal muscles
- ischiocavernosus muscles
- bulbospongiosus muscles
- perineal body
- external anal sphincter
[Bartholin’s glands (F)]

Netter 352, 356, 357

Musculature
Perineum
Deep - deep transverse perineal
muscles
- levator ani
- perineal body
- membranous urethra (M)/ext.
urethral sphincter (F)
[Cowpers glands (M)]

Netter 352, 356, 357

Vascular

Vascular Anatomy
Arterial - abdominal
- pelvic
Venous
Lymphatic

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Vascular
Arterial - Abdominal Aortic Branches (1)
Inferior Phrenic - superior suprarenals (adrenal)
Celiac Trunk - common heptic
- gastroduodenal
- right gastroepipoic (stomach &
omentum) *(best for pedicle of
omentum)
- splenic
-left gastroepiploic (stomach &
omentum)
- left gastric
Middle Suprarenals - (adrenal)
Lumbars - 4 pairs Netter 247, 282

Vascular
Abdominal Aortic Branches (2)
Superior Mesenteric - middle colic (transverse colon)
- right colic (ascending colon)
- intestinal arteries (jejunum & ileum)
- ileocolic (distal ileum, appendix,
cecum)
Renal - inferior suprarenals (adrenal)
- renal divisions (kidney)
Gonadal - (testis/ovary)
Inferior mesenteric - left colic (descending colon)
- sigmoid (sigmoid)
- rectal (rectum)

[Bifurcation]
Netter 286, 287

Vascular
Arterial - Pelvis (1)
Common Iliacs
Divide at junction of L5 and sacrum
External iliac - inferior epigastric (medial)
- deep circumflex (lateral)
- passes beneath inguinal ligament
- becomes femoral artery
Internal iliac (Hypogastric) - most of pelvic arterial
supply
Posterior - iliolumbar, lateral sacral
- superior gluteal (gluteal muscles)
* [If ligating hypogastrics - distal to posterior division ]

Netter 372, 373

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 Vascular
Arterial - Pelvis (2)

Internal Iliac - Anterior Division

- Obturator
- Umbilical
- obliterated umbilical
- superior vesical(bladder)
- (Vaginal/uterine [near ureter])*
* - inferior vesical (bladder/prostate)
* - internal pudendal - leaves pelvis through
Alcock’s canal
- penile
- perineal Netter 373, 374

Vascular

Veins
In most cases parallel arteries
Exceptions - left gonadal and adrenal veins
empty into left renal vein
In many cases multiple veins (plexuses)
accompany single arteries

Netter 248

Vascular

Lymphatics (1)
Retroperitoneal (testis/kidney)
1 - Left paraortic
2 - Interaortocaval
3 - Right paracaval
Left testis tumors metastasize to 1 and 2
Right testis tumors may metastasize to all
Hinman 3.4, Campbells 2-11, 2-12

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 Vascular
Lymphatics (2)

Pelvic (prostate/bladder)
Internal/external iliac
Obturator

Inguinal (scrotum/penis)
Superficial - external to
fascia lata
Deep - along femoral vessels
Netter 249

Neuro

Neuroanatomy
Somatic - Motor and Sensory
Thoracic
Lumbar
Sacral
Autonomic

Neuro

Thoracic

- Intercostals 6-12
- Abdominal wall

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 Neuro
Lumbar plexus
- Iliohypogastric - S - lower abdomen, pubis
- M - lower abdominal wall
- Ilioinguinal - S - upper thigh, base of penis, upper scrotum
- travels in inguinal canal
- Lateral femoral cutaneous - S - ant/lat upper leg
- Genitofemoral - S - cord, scrotum, ant. thigh
- M -cremaster and dartos muscles
- Femoral - S - anter/med leg
- M - psoas, iliac, knee extensors
- Obturator - M - thigh adductors
- Sciatic - S/M - posterior thigh and lower leg
Netter 462, 463 Hinman 4.11, 4.12

Neuro

Lumbar plexus - cautions !

- Genitofemoral - lies directly atop psoas - don’t injure in
psoas hitch
- Femoral - hidden by body of psoas proximally
- may be injured by retractors
- loss of knee extension and ant/med
thigh sensation
- Obturator - may be injured during pelvic LAD
- loss of thigh adduction
- Sciatic - passes posterior to sacrospinous ligament
- may be injured during SSF
- exaggerated lithotomy may stretch

Neuro

Sacral plexus
- Sciatic - see above
- Posterior femoral cutaneous
- perineal branch - S - perineum &
posterior scrotum
- Pudendal nerve - perineal
- post. scrotal
- dorsal nerve of penis/ clitoris
- Nervi erigente - to autonomic plexus (parasympathetic)

Netter 381

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 Neuro
Autonomic
(much more detailed than current presentation)
Celiac & Superior mesenteric plexus
- adrenal/kidney/upper ureter

Superior hypogastric - largely sympathetic - lumbar roots

- seminal emission
- bladder neck closure
continue as hypogastric nerves (symp)
combine with pelvic nerves & erigente
(parasymp)
Inferior hypogastric (pelvic) plexus - lateral to rectum
Netter 322, 387

Neuro

Inferior hypogastric (pelvic) plexus

Midpoint at tip of seminal vesicles
Multiple prostatic/rectal/vesical blood vessels penetrate
Prostatic innervation
Neurovascular bundles - cavernous nerves

Inguinal Canal
Contains - Males - spermatic cord plus
- Females - round ligament plus

3 Sides - anterior - external oblique fascia

- posterior - transversus abd and
transversalis fascia
- inferior - inguinal ligament
Hesselbach’s triangle
borders - inferior epigastrics
- margin of rectus muscle
- inguinal ligament

Indirect hernia - lateral to triangle

Direct hernia - through triangle
Netter 243

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 Femoral triangle
Base - inguinal ligament
Lateral - sartorius
Medial - adductor longus
Floor - iliopsoas and pectineal muscles

Femoral triangle - contents - (NAV)

Lateral - femoral nerve
femoral artery
Medial - femoral vein
- covered by fascia lata
- opening in fascia lata - fossa ovalis through which
superficial vessels and saphenous vein emerge
- sentinal node (Cabana) jxn. of saph vein and super. ext.
pudendal vein (penile Ca)
- fascia lata divides deep and superficial nodes

Netter 466, 244

Adrenal

Adrenal
Arterial supply - superior - inferior phrenic
- medial - from aorta
- inferior - from renals
Venous drainage - left - to left renal vein
- right - short vein to IVC
2 distinct sections - adrenal cortex (G, F, R)
- adrenal medulla
Within Gerota’s fascia

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 Kidney
Kidneys - Anatomic Relations
Anterior
Right Left
Adrenal Adrenal Liver
Spleen Duodenum
Stomach Colon
Pancreas
Jejunum
Colon
Posterior Right Right &
Left Left Rib 12,
Diaphragm Rib 11 Transversus
abdominus fascia
Quadratus lumborum, Psoas Campbells 2-25

Kidney

Gerota’s Fascia
1. Intermediate stratum
2. Perinephric fat is within
3.Anterior = Toldt’s; Posterior = Zuckerkandl’s
Laterally/Superiorly - Fused
Medially - Fused over great vessels but contiguous with
contralateral side
Inferiorly - open potential space

Kidney

Renal Pedicle - VAP

Anterior Vein
Artery
Posterior Pelvis
- At L 1-3
- Below take off of SMA

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 Kidney
Renal Vasculature
- Main renal artery
- Segmental arteries (5)
- Interlobar arteries
- Arcuate arteries
- Interlobular arteries
- Afferent arteriole
Netter 315

Kidney

Segmental Branches - end arteries

Posterior (1st branch) - prior to hilum
Apical
Upper Anterior
Middle
Lower

Avascular plane - separates anterior

branches from posterior
- posterior to convex border
Hinman 12.34

Kidney

Veins in Kidney
- Accompany arteries
- Intercommunicate
Right renal vein - short to IVC
Left renal vein - receives adrenal and
gonadal V.
- crosses anterior to aorta,
posterior to SMA

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 Kidney
Microanatomy
Cortex - nephrons
Medulla - collecting ducts
Nephron - afferent arteriole (from interlobular)
glomerulus (filtration) prox. conv. tubule
efferent arteriole loop of Henle
distal conv. tubule

collecting tubule

Netter 317

Kidney

Renal Collecting System

- typically 7-9 papillae (tip of pyramid)
- each papilla cupped by a minor calyx
(may have more than one papilla
per minor calyx)
- minor calyces connected by necks,
infundibulae, to form 2 or 3 major
calyces
- major calyces coalesce to form renal pelvis

Netter 313

Ureter
Ureters 22 - 30 cm long
Relations
Psoas in retroperitoneum
Crosses iliac vessels near iliac bifurcation
Pelvis
Females Males
* behind ovary behind vas
* behind uterine artery (* sites of injury deferens
* cervix at hysterectomy)
* vaginal wall
Netter 320

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 Ureter

Ureters - blood supply

Multiple feeding branches
renal artery gonads
upper ureteral supply is medial aorta
iliacs
(uterine) lower ureteral supply is lateral
vesical arteries
After reaching ureter -longitudinal anastamosing
plexuses
Campbells 2-46

Ureter
Ureteral Caliber
3 areas of narrowing *
* UPJ - 2mm
Abdominal - 10mm
* Iliacs - 4mm
Pelvic - 4-6mm
* UVJ - 3-4mm
Campbells 2-47

Bladder

Bladder - Innervation
Sympathetic -T 10 - L 2
- hypogastric N. (trigone, BN)
Parasympathetic - S 2-4
- pelvic N. - (bladder body)
Somatic - S 2
- pudendal N. (external sphincter)

Hinman 13.35, 13.36

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 Bladder

Bladder - Vasculature
Superior vesical pedicle - superior vesical artery
(from internal iliac)
obliterated umbilical artery
from same branch
Inferior vesical pedicle - inferior vesical artery
(usually from internal iliac
or internal pudendal)

Hinman 13.33

Bladder

Bladder - relations
- Adults - pelvic organ children - more abdominal
- Covered superiorly by peritoneum
- Posterior - males - rectum; females - vagina
- Anterior - potential space to pubis - space of Retzius

- 3 muscular layers - outer longitudinal

- middle circular
- inner longitudinal
- trigone - ureteric musculature to vesical neck
Netter 342

Prostate
Prostate
Vitals - Weight - 18 grams
Length - 3-4 cm
Width - 4 cm
Depth - 2 cm
Relations - Anterior-space of
Retzius/puboprostatic ligaments
- Anterolateral-endopelvic fascia
- Lateral-fatty tissue/levator ani/NVB
- Posterior-Denonvilliers
fascia/rectum
- Superior-bladder/seminal vesicles
- Inferior-urogenital diaphragm
Netter 358

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 Prostate

Prostate - Zonal Anatomy

Transitional zone - 5 - 10% of normal vol.
- gives rise to BPH Primarily
- 20% of CAP proximal
Central zone - 20% of normal volume to veru.
- surrounds ejaculatory ducts
- 1-5 % of CAP
Peripheral zone - 75 % of normal volume
- 70 % of CAP

Campbells 3-28

Prostate
Prostate - Vascular
Arterial - inferior vesical
- prostatic branch
- urethral branches
- perpendicular to urethra near BN
- turn parallel to urethra
- supply BPH adenoma
- capsular branches
- part of NVB
- gives off rami to prostate
Venous - prostatic plexus (Santorini’s)
- inflow from deep dorsal vein of penis
- drains primarily to internal iliac
- communicates with vertebral veins -
(Batson’s plexus ) Netter 374

Prostate

Prostate - Neural/Lymphatic

Innervation - via inferior hypogastric plexus

- both sympathetic (hypogastric)
and parasympathetic (pelvic)

Lymphatic drainage - primary - internal iliac

chain

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 Prostate

Seminal Vesicals
5 cm in length
Fuses with ampulla of vas to form
ejaculatory ducts

Vasa Deferentia
Arises from tail of epididymis
Posterior to cord vessels
Leaves internal ring and runs extraperitoneally
Passes above ureter
Dilated terminal vas = Ampulla
Blood supply - vesiculodeferential artery
- a branch of superior vesical
Innervation - from inferior hypogastric (pelvic)
plexus - mostly sympathetic

Netter 358

Urethra
Urethra

Male
Prostatic posterior
Membranous
Bulbar
Penile anterior
Glanular

Anterior urethra - within corpus spongiosum

- openings of multiple small glands

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 Urethra

Urethra
Blood supply - dual supply

- internal pudendal artery

- common penile A
- bulbourethral artery
- dorsal artery - terminates at glans
- circumflex branches

Campbell’s 3-38

Urethra
Urethra - Female
- 4 cm long
- Many small glands
- distally grouped to form Skene’s
glands
- Mucosa/submucosa form cushion to
increase closure pressure

- Anterior to vaginal tissues

Female pelvic floor

Female pelvic floor

Prevents abdominal/pelvic organs from falling out
Controls storage and evacuation of feces
Allows conception and parturition

Two components
Viscerofascial layer – connective tissue
endopelvic fascia
Muscular layer – levator ani muscle

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 Female pelvic floor
Viscerofascial layer
Cardinal ligaments apex
Uterosacral ligaments apex
Pubocervical fascia bladder/pelvic side walls
Prerectal fascia rectum/pelvic side walls
Pubovisceral muscles
Levator ani - from pubis to coccyx – sling like
Pubococcygeous – connects immobile structures
-little contribution to support
Puborectalis – attached to lateral vaginal walls
-penetrates rectal wall
Illeococcygeous – horizontal sheet
Female pelvic floor

Pelvic floor prolapse

Cystocoele – bladder prolapse
Enterocoele – apical prolapse
frequently with bowel
Rectocoele – rectal prolapse

Penis

Penis
Paired Corpora Cavernosa
- Attached proximally (via crura) to pubic
arch
- Distal 3/4 closely apposed
- Distally evaginate glans

Corpus Spongiosum
- Encloses urethra
- Terminates to join glans

Netter 356

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Penis
Penis
Corpora Cavernosa
- Enclosed by tunica albuginea
- Filled with erectile tissue - vascular spaces
- Divided by septum
distally vascular spaces communicate
- Buck’s fascia surrounds corporal bodies
dorsal nerves/arteries/vein within Buck’s
- dartos fascia surrounds Buck’s
Corpus Spongiosium
- Enclosed by tunica albuginea and Buck’s
- Minimal vascular communication with corpora
cavernosa
Netter 355

Penis
Penis - Arterial Supply
- Internal pudendal artery
- penile artery (via Alcock’s canal)
- cavernosal arteries - corp. cavernosa
- bulbourethral - spongiosum
- dorsal artery - cavernosal branches
- circumflex
- glans
- femoral artery
- external pudendal arteries
- superficial penile arteries
( supplies shaft skin)

Campbell 3-38

Penis
Penis - Venous Return
Superficial - superficial veins join
- superficial dorsal vein
saphenous vein
Intermediate - glans, c. spong. distal 2/3 c. cavern
- retrocoronal plexus
- circumflex veins
- deep dorsal vein
- prostatic plexus
Deep - prox 1/3 c. cavern, bulb
- cavernous v. internal pudendal
- bulbar v. prostatic plexus
- crural v. both of above
Hinman 16.31

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 Penis

Penis - Innervation
Somatic
Pudendal nerve (via Alcock’s canal)
dorsal nerve of penis
Autonomic
Inferior hypogastric (pelvic) plexus
cavernous nerves

Testis
Testis and Epididymis
4 - 5 cm in length
Volume - 30 cc
Covered by tunica albuginea
Arterial supply -testicular artery ( from aorta)
- vasal artery (from sup. vesical A.)
Venous return - pampiniform plexus
gonadal vein
right IVC
left renal vein
Netter 362

Testis

Testis and Epididymis

Seminiferous tubules
- rete testis
- efferent ductules
- convoluted epididymal duct
- ductus deferens
Cranial portion of epididymis - globus major/head
Caudal portion of epididymis - globus minor/tail

Netter 362

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 Testis

Scrotal Layers
(Testis)
Tunica albuginea
Tunica Vaginalis (visceral)
Tunica Vaginalis (parietal)
Internal spermatic fascia
Cremasteric muscle and fascia
External spermatic fascia
Dartos muscle
Scrotal skin

Netter 362

Scrotal Blood Supply

Laterally – inferior external pudendal
artery – off of femoral artery (external iliac)
Medially – superficial perineal artery –
branch of internal pudendal artery (internal
iliac)

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