BMS305& BMS205

Kidney and ureter, pelvic joints,

muscles, and ligaments

Prof.Dr.Mona Attia
Professor of in Galala University
Faculty of Medicine, Spring 2024
Galala University

gu.edu.eg
 G A L A L A U N I V E R S I T Y T H E F U T U R E S T A R T S H E R E

Lec 14/4
BMS305& BMS205
Kidney and ureter, pelvic joints, muscles, and ligaments

Prof.Dr.Mona Attia
Professor of in Galala University

T H E F U T U R E S T A R T S H E R E
4/12/2024
 Intended learning outcomes
Kidney and ureter
1-Describe the site, size, shape, coverings,
relations, and surface anatomy of right and Pelvic joints, muscles, and ligaments
left kidneys. 1. Define the true and false pelvis.
2-Identify arrangement of structures in 2. Differentiate between the male and female pelvis.
the hilum of kidney.
3. Describe the pelvic joints (type, articulations,
3-Discuss blood supply, renal vascular ligaments, and movements).
segments, lymphatic drainage, and
nerve supply of the kidney. 4. Discuss the attachments, nerve supply and action
of muscles forming the walls and floor of the
4-Describe the length, parts, relations,
pelvis.
and blood supply of the ureter.
5- Correlate the anatomical sites of
ureteric constriction with its clinical
significance.
 The site, size, shape, Kidney

Each kidney is bean shaped

• It is about 12cm long, 6cm breadth & 3cm
thick. It has 2 surfaces, 2 borders and 2 poles.

Site, on the posterior abdominal wall

(retroperitoneal). On each side of the vertebral column
The right kidney lies in a lower position than the
left one.Supra renal gland lies on the upper pole
of each kidney.
Coverings of the kidney: coverings from inside to
outside:1- Fibrous capsule: This surrounds the kidney and is
Closely applied to its outer surface. 2-Perirenal fat: covers
the fibrous capsule.3-Renal fascia: connective tissue that lies
outside the perirenal fat and encloses the kidneys and suprarenal glands;
it is continuous laterally with the fascia transversalis. 4-Pararenal fat:
lies external to the renal fascia and is often in large quantity. It forms part
of the retroperitoneal fat.
The perirenal fat, renal fascia, and pararenal fat support the
kidneys and hold them in position on the posterior abdominal
wall
Posterior relations of the right and left kidneys
Right kidney left kidney Anterior relations of right and left kidneys
- 11th and 12th ribs -12th rib Right kidney left kidney
- diaphragm - Right suprarenal gland - left suprarenal gland
- psoas major muscle - right lobe of liver - stomach
- qudratus lumborum muscle - 2nd part of duodenum - spleen
- subcostal nerve and vessels - right colic flexure - pancreas
- iliohypogastric nerve - coils of jejunum - left colic flexure
- ilioinguinal nerve - coils of jejunum
 surface anatomy of right and left kidneys
• They extend from the level of the 12th thoracic vertebra to
the level of the 3rd lumbar vertebra
• The left kidney lies in an upper position than the right
because of its relation to the liver.
- The left kidney reaches up to the 11th rib
- The right kidney reaches up to the 11th space
• They lie sloping in the para-vertebral gutters so that the
hilum faces somewhat forwards as well as medially,They lie
obliquely with their upper poles nearer to the median plane than the
lower ones.
The hilum is a vertical slit in the medial concave border
of each kidney that
is bounded by thick lips of renal substance. The hilum
extends into a large cavity called the renal sinus. The
hilum transmits, from the front
backward, the renal vein, two branches of the renal
artery, the ureter,. Lymph vessels and sympathetic
fibers .
 ❑ longitudinal section Kidney
❑It is composed of an outer cortex and inner medulla.
❑The medulla consists of conical masses called renal

pyramids (10 to 18), the base of which are directed

towards the renal cortex while their apices (renal
papillae) are directed towards the renal sinus.
❑Minor calyx surrounds one or more renal papillae.

❑The minor calyces (10 to 12 in number) unit to form 2

or 3 major calyces, which unite together forming the

renal pelvis inside the renal sinus.
❑Sinus of the kidney is a central recess within the hilum

of the kidney, which contains renal vessels and pelvis

❑Cortical tissue extends between the pyramids to

form the renal columns.

❑Each pyramid with its covering cortex forms a renal

lobe.
 There is a network of blood vessels throughout the kidneys.
• The kidneys receive blood from the aorta via the renal arteries.
An outline of the pathway of blood through the
kidneys is as follows
1-Renal artery 2-Segmental arteries
3-Lobar arteries 4- Interlobar arteries
5-Arcuate arteries 6- interlobular arteries
7- Afferent arterioles (Arteries = Afferent)
7-Glomerulus (capillaries) 8- Efferent arterioles (Exit
vein = Efferent)
9-Peritubular capillaries 10- Interlobular veins
11- Arcuate veins 12- Interlobar veins 13-Renal vein

Lymph Drainage
Lymph drains to the lateral aortic lymph nodes around the
origin of the renal artery.

Nerve Supply
The nerve supply is the renal sympathetic plexus. The afferent fibers that
travel through the renal plexus enter the spinal cord in the 10th, 11th, and
12th thoracic nerves.
•(Nephron):1- Bowman’s capsule to 2-proximal convoluted Building unit of the kidney
tubule 3- loop of Henle, 4- Distal convoluted tubules,
• 5- Collecting tubules, which open at the tip of the pyramid
by the papilla into minor calyx to a major calyx to
pelvis of the ureter.

Each nephron begins

by a renal corpuscle
formed of Bowman’s
capsule clasps a
glomerulus.
The glomerulus is a
tuft of capillaries
made by an efferent and
afferent arterioles. About
1.3 million in each
kidney
The renal vascular segments

Renal artery usually gives into

5 segmental based on the
distribuation of five segmental
branches of renal artery ,each
kidney is divided into five
vascular segment
•Apical/ superior
•Upper anterior
•Middle anterior
•Caudal/ inferior
•posterior
Ureter: Abdominal, Pelvic, Intramural parts
The two ureters are muscular tubes that extend from the kidneys
to the posterior surface of the urinary bladder.

The ureter emerges from the hilum of the kidney and runs
vertically downward behind the parietal peritoneum
Each ureter measures about 10 in. (25 cm) long and resembles the
esophagus (also 10 in. long) in having three constrictions along
its course: where 1- the renal pelvis joins the ureter2-it is kinked as
it crosses the pelvic brim, and where3- it pierces the bladder wall.

The Renal pelvis of ureter: is the funnel-

shaped expanded upper end of the ureter. It
lies within the hilum of the kidney and
receives the major calyces
 Figure 7.63 Posterior abdominal wall showing the kidneys
Ureter and the ureters in situ.

Blood Supply: The arterial supply :

1-Upper end, the renal artery;
2-Middle portion, the testicular or ovarian artery; and
in the 3-Pelvis, the superior vesical artery.
Venous blood drains: into veins that correspond to the
arteries.

Lymph Drainage
The lymph drains to the lateral aortic nodes
and the iliac nodes.
Nerve Supply is the renal, testicular (or ovarian), and
hypogastric plexuses (in the pelvis).
Afferent fibers travel with the sympathetic nerves
and enter the spinal cord in the first and second
lumbar segments.
Relations, Left Ureter
Anteriorly: 1-The sigmoid colon and sigmoid mesocolon,
the2- left colic vessels, and 3-the left testicular or ovarian
vessels
Posteriorly: 1-The left psoas muscle, which separates it
from the lumbar transverse processes, and 2-the
bifurcation of the left common iliac artery.
Medially: The inferior mesenteric vein
Relations, Right Ureter
Anteriorly: 1-The duodenum, the 2-terminal part of the ileum,
3-the right colic and ileocolic vessels, 4-the right testicular or
ovarian vessels, and 5-the root of the mesentery of the small
intestine.
Posteriorly:1- The right psoas muscle, which separates it from the
lumbar transverse processes, and 2- the bifurcation of the right
common iliac artery
 Pelvic part of the ureter
❑Course and relations:
▪ It enters the pelvic :
- Opposite the sacroiliac joint. Crossing infront of the bifurcation
of common iliac artery
1- From the pelvic brim to the ischial spine:

◘ In female forms the posterior border of ovarian fossa

2- From the ischial spine to the urinary bladder:

◘ In male: It is crossed by the vas deferens.

◘ In female: It passes closely lateral to the upper end of
vagina is crossed by the uterine artery from lateral to
medial.

3-Intramural part of the ureter:

- It runs a very oblique course through the bladder
wall to open at the supero-lateral angle of the trigone.
 In female:
It passes closely lateral to the upper end of vagina Pelvic part of the ureter
Here, it is crossed by the uterine artery from lateral to
medial on its way to the broad ligament.
From the ischial spine to the urinary bladder:
At the ischial spine the ureter changes its direction to run
forwards and medially on the floor of the pelvis to reach
the postero-superior angle of the urinary bladder .
Ureteric Stones
There are three sites of anatomic narrowing of the ureter
where stones may be arrested, namely, the pelviureteral
junction, the pelvic brim, and where the ureter enters the
bladder
❖ The term pelvis is applied to the skeletal ring
formed by the two hip bones, the sacrum and the
coccyx
❖It provides a strong stable connection between the
trunk and the lower limbs
❖Bones of the pelvis
1. Hip bones form the anterior and lateral walls
2. Sacrum and coccyx form the posterior wall

1. Define the true and false pelvis.

• Pelvic cavity is divided into two

parts by the pelvic brim
•The pelvic brim is formed of the
sacral promontory posteriorly, the
ileo-pectineal lines laterally and the
symphysis pubis anteriorly
•The greater (false) pelvis is located
above pelvic brim. The lesser (true)
pelvis is located below it
 1. Define the true and false pelvis.

Greater
Pelvis(False
Pelvis) It is bounded
by:
LESSER PELVIS (TRUE PELVIS): • Posteriorly by the
The true pelvis has an inlet, an outlet and a lumbar vertebrae
cavity which is enclosed by the pelvic and base of the
Walls :Pelvic inlet:Boundaries Anteriorly: sacrum.On each
symphysis pubis Posteriorly: sacral promontory side by the iliac
On each side: pubic crest, pecten pubis, fossa and iliacus
arcuate line and linea terminalis ( anterior
muscle.Anteriorly by
border of ala of sacrum).Pelvic
the anterior abdominal
outlet:Boundaries Anteriorly: lower border of
wall. it is considered
symphysis pubis
as a part of the
Posteriorly: tip of coccyxOn each side: ischial
abdominal cavity
tuberosity, sacrotuberous ligament and side
of pubic arch
 Ligaments of the pelvis

Figure 8.2 Right half of the pelvis showing the pelvic inlet, Figure 8.4 Right half of the pelvis
pelvic outlet, and sacrotuberous and sacrospinous ligaments. showing the pelvic walls.
Sacrospinous ligament:

From the ischial

spine to the lateral
margins of sacrum
and coccyx.

It is the degenerated
dorsal part of
coccygeus muscle

It lies ventral to the

sacrotuberous
Ligaments of the pelvis

Sacrotuberous ligament:

Superior

Inferior
 Differences Between the Female and Male Pelvis
The Female
The Male
1-The bones smaller, lighter,
1-The bones larger, heavy, and thinner
and thicker
2-Inlet is transversely
2-Inlet heart-shaped oval
3-outlet is smaller inverted 3-outlet is larger, everted
ischial tuberosities. ischial tuberosities
4-The cavity is narrow, 4-The cavity is wider,
long shallower

5-The subpubic angle( 5-The subpubic angle( pubic

pubic arch) is small arch) is larger

6-the greater sciatic notch 6-the greater sciatic notch is

is narrow wider
7- Sacrum is shorter and wider
7- Sacrum is longer and narrow
8-Obturator foramen is oval or
8-Obturator foramen is rounded triangular
The false pelvis is shallow in
the female
and deep in the male.
The pelvic cavity is roomier in
the female than in the male,
the distance between the inlet
and the outlet is much shorter in
female.

Figure 8.13 A. Pelvic inlet, pelvic outlet, diagonal conjugate, and

axis of the pelvis. B. Some of the main differences between the
female and the male pelvis.
 JOINTS OF THE PELVIS

A. Lumbosacral Joint.
B. Sacroiliac Joint.
C. Sacrococcygeal Joint.
D. Pubic Symphysis:

A. Lumbosacral Joint
■Is the joint between vertebra
L5 and the base of the sacrum,
joined by an intervertebral
disk and supported by the
iliolumbar ligaments.
 B. Sacroiliac Joint
■Is a synovial joint of an irregular plane type between the
articular surfaces of the sacrum and ilium.■ Is covered by
cartilage and is supported by the anterior, posterior, and
interosseous sacroiliac ligaments. Transmits the weight
of the body to the hip bone.

Movements
A small but limited amount of movement is possible at the
sacroiliac joints.
In older people, the synovial cavity disappears and the joint
becomes fibrosed.
Their primary function is to transmit the weight of the
body from the vertebral column to the bony pelvis.
The nerve supply :is from branches of the sacral spinal
nerves.
Sacroiliac Joint Disease
The sacroiliac joint is innervated by the lower lumbar and
sacral nerves so that disease in the joint can produce low
back pain and pain referred along the sciatic nerve
(sciatica).
 JOINTS OF THE PELVIS
C. Sacrococcygeal Joint
■ Is a cartilaginous joint between the sacrum and

coccyx, reinforced by the anterior, posterior, and lateral

sacrococcygeal ligaments.Movements Extensive flexion
and extension are possible at this joint.

D. Pubic Symphysis: Is a cartilaginous or

fibrocartilaginous joint between the pubic
bones in the median plane,Movements
Almost no movement is possible at this joint.

A. Horizontal section through the pelvis

showing the sacroiliac joints and the
symphysis pubis.
•It lies between pelvic inlet and outlet PELVIC CAVITY
•It is short curved canal with its concavity
directed anteriorly
•Its posterior wall is longer than its anterior
wall

•Walls of pelvic cavity: 1-Anteriorly& inferiorly; symphysis pubis and pubic rami
•2-Posteriorly; anterior surface of sacrum and coccyx, piriformis muscle and parietal pelvic fascia
•3-On each side; ilium and ischium, sacrotuberous ligament, sacrospinous ligament , obturator
membrane and obturator internus muscle and fascia
•4-Inferiorly: PELVIC CAVITY
•The floor of pelvis divides it into main pelvic cavity above and
perineum below
•It supports the pelvic viscera and is considered the pelvic
diaphragm
•It is traversed by urethra, vagina and rectum in female
•It is formed by the levator ani and coccygeus muscles

OBTURATOR INTERNUS
• Origin:
• From inner margin of obturator
foramen
•From inner surface of obturator
membrane
•From an area of hip bone above
and behind the obturator membrane
 OBTURATOR INTERNUS, inserion

The muscle fibres converge to form a

tendon which comes out of the lesser
sciatic notch
•It passes laterally and forwards to be
inserted into the medial surface of the
greater trochanter of femur
•Nerve supply: nerve to obturator internus (L5, S1,2)
•Action: lateral rotation of the thigh

Origin:
PIRIFORMIS
• From the anterior surface of the
middle 3 pieces of sacrum

• Insertion:
• It comes out through the greater
sciatic foramen and is inserted
into top of greater trochanter of
femur
•
 PIRIFORMIS

Nerve supply: from ventral rami of 1st&

2nd sacral nerves
Action: lateral rotation of the hip joint.
 LEVATOR ANI MUSCLE
Origin:
Anteriorly: from pelvic surface of
body of pubis
Posteriorly: from inner surface of
ischial spine
Inbetween: from white line (
tendinous arch) formed by
thickening of obturator fascia

Insertion:
• The muscles of both sides meet together
forming greater part of floor of pelvis
•The fibres are divided morphologically into 2
parts :
-Pubococcygeus
- Iliococcygeus
 Obturator
Internus

Origin of levator
ani Rectum

Anal canal

Middle fibers or Pubo-

rectalis
 -Pubococcygeus

Obturato
r
Internus
Origin of
levator ani
Rectum Pubococcygeus : it is the anterior part that arises from body of pubis and
Anal canal anterior ½ of white line
Its fibres form 3 functional parts:1- levator prostate or sphincter vagina: these
Middle fibers fibres pass across the sides of prostate in male or side of vagina in female and
or Pubo-rectalis
inserted into perineal body2- Puborectalis: these are the intermediate fibres that
form a sling around the anorectal junction3-Pubococcygeus proper: these are
the posterior fibres that are attached to the tip of coccyx and anococcygeal
raphe
• The puborectalis thus forms a U-shaped puborectal sling, the
tonus of which is responsible for maintaining the anorectal angle.
This part plays a major role in maintaining fecal continence.
Iliococcygeus Iliococcygeus:
•It is the posterior part of levator ani that arises from
posterior ½ of white line and ischeal spine
•The fibres are inserted into the side of last 2
segments of coccyx and anococcygeal raphe

Action:1- the two sides form an efficient muscular sling that

supports and maintains the pelvic viscera in position.
2-They resist the rise in intrapelvic pressure during the straining and
expulsive efforts of the abdominal muscles (as occurs in coughing).
3-They also have an important sphincter action on the
anorectal junction, and, 4- in the female, they serve also as a
sphincter of the vagina.

Nerve supply(S4). From the roots of the sacral Plexus

and Pudendal nerve (S2,3,4):
1-While performing a pelvic exenteration, the 2. A 49-year-old woman has a large mass
surgical oncologist notices a fractured or ruptured on the pelvic brim. Which of the following
boundary of the pelvic inlet. Which of the structures is most likely compressed by this
following structures is most likely damaged? mass when crossing the pelvic brim?
(A) Promontory of the sacrum (A) Deep dorsal vein of the penis
(B) Anterior–inferior iliac spine (B) Uterine tube
(C) Inguinal ligament (C) Ovarian ligament
(D) Iliac crest (D) Uterine artery
(E) Arcuate pubic ligament (E) Lumbosacral trunk

3-Which of the following statement describes 4-Which of the following describes the anterior
the kidney? relations of right kidney?
(A) Its triangular in shaped. (A) left suprarenal gland
(B) Its intra peritoneal organ. (B) stomach.
(C)The right one lies lower than the left. (C) pancreas.
(D) Lies on the pelvis. (D) left colic flexure.
(E) Supra renal gland lies on its lower pole. (E) 2nd part of duodenum .
5-Which of the following describes the ureter?
(A) Its fibrous tubes. 6-Which of the following related to the pelvic part of
(B) About 20 in.. the ureter?
(C) Having four constrictions . ▪A- It enters the pelvic ,Opposite the Sacrococcygeal joint.
(D) Emerges from the hilum of the kidney . ▪B- Crossing infront of the bifurcation of common iliac artery.
(E)Lies infront the parietal peritoneum. ▪C- In female forms the anterior border of ovarian fossa.
▪D-In male: It is crossed by the testicular A.
▪E- In female: It is crossed by the ovarian A.

7-Which of the following statement describes greater pelvis(False Pelvis)?

A- Posteriorly: the sacral vertebrae.
B-Lateral:ischial tuberosity,
C- Anteriorly: lower border of symphysis pubis
D- Has an inlet, an outlet.
E- It is considered as a part of the abdominal cavity.

1-Mentions the action and nerve supply of pireformis?

2-Writs the part of levator ani muscle?
3- Mentions the action of levator ani muscle?
4- Mentions the action and nerve supply of obturator internus? Thank you
Mona.Attia@
Gu.edu.eg