Renal and urology
Anatomy of the lower
urinary tract
Anand K Patel
Christopher R Chapple
Abstract
The lower urinary tract consists of the bladder and urethra and in males
also includes the prostate. These organs are involved in the involuntary
storage of urine produced in the upper urinary tract and the voluntary
expulsion of urine at an appropriate time and place. Functional disor-
ders such as overactive bladder, urinary incontinence and bladder out-
let obstruction secondary to prostatic enlargement are common, as are
bladder and prostate carcinoma. A thorough knowledge of the relevant
anatomy is vital to understand the pathophysiological mechanisms and
appropriate management of these conditions. There are considerable
variations in the anatomy of the male and female urinary tract and
this review of the anatomy highlights these differences, in addition to
providing a comprehensive description of the histology, vasculature and
innervations of the lower urinary tract organs.
Keywords anatomy; bladder; innervations; ­ lymphatic drainage;
prostate; urethra; urinary tract; vasculature
The lower urinary tract (LUT) consists of the bladder and ­urethra,
and in males also includes the prostate. There are considerable
differences in the anatomy of the LUT in males and females
owing to the differences in pelvic anatomy and sexual function.
Urinary bladder
Function
The urinary bladder is a hollow muscular organ with two
­principal functions.
• To act as a low-pressure reservoir for the storage of urine.
Urine is produced in the kidneys and transported to the blad-
der via the ureters. The capacity of the bladder in the adult is
­approximately 500 ml.
• To expel the urine at high pressure at an appropriate time and
under voluntary control via the urethra.
Anand K Patel MB ChB MRCS is a Urological Research Fellow in the
Department of Urology Research, Sheffield Teaching Hospitals NHS
Trust, Royal Hallamshire Hospital, Sheffield, UK. Conflicts of interest:
none declared.
Christopher R Chapple BSc MD FRCS is visiting Professor of Urology at
Sheffield Hallam University and Consultant Urological Surgeon at the
Royal Hallamshire Hospital, Sheffield, UK. His clinical and research
interests are in functional and reconstructive urology and pharmacology
of the lower urinary tract. Conflicts of interest: none declared.
SURGERY 26:4
These functions of the bladder convert the low-pressure continu-
ous production of urine in the kidneys into intermittent volun-
tary voiding.
Anatomy
Being a highly distensible organ, the anatomical position of
the bladder varies depending on the degree of distension. The
empty bladder is an entirely extraperitoneal pelvic organ and lies
behind the symphysis pubis in the shape of a flattened tetrahe-
dron (three-sided pyramid).
Anterior: the apex of the tetrahedron points anteriorly towards
the superior edge of the pubic symphysis (Figure 1). The median
umbilical ligament (remnant of the obliterated fetal urachus)
anchors the apex of the bladder to the umbilicus and runs up
the midline of the abdominal wall in the median umbilical fold
of peritoneum. Beneath the apex and adjacent to the inferolateral
surfaces of the bladder is the retropubic space of Retzius. This
space contains loose fatty tissue and the pubovesical ligaments,
which extend from the inferior pubic bones to the bladder neck.
Superior: the superior surface is covered by peritoneum upon
which the sigmoid colon and small intestine usually rest. In
females the anterverted uterus lies against the posterosuperior sur-
face (Figure 2). With increasing distension the bladder rises in the
shape of a dome, well above the symphysis pubis, and becomes
an abdominal organ which can be palpated and percussed in the
suprapubic region. As the bladder distends the parietal perito-
neum is stripped upwards from behind the rectus abdominus; thus
access to the bladder (such as for suprapubic catheter insertion) is
possible without violating the peritoneal cavity.
Inferolateral: the two inferolateral surfaces are supported by the
levator ani.
Posterior: in males the triangular base faces posteriorly towards
the rectum. Only the uppermost part of the posterior surface is
covered by visceral peritoneum, forming the rectovesical pouch.
Below this level the ductus deferens and seminal vesicles are
adherent to the posterior surface, and the space between the
bladder and rectum contains Denonvilliers’ rectovesical fascia.
In females the base is united with the anterior vaginal wall and
the upper part of the cervix, with no peritoneum intervening.
Bladder neck and trigone: the lowest part of the bladder where
the inferolateral surfaces meet the base is the bladder neck. In
the male the bladder neck lies directly on the prostate, whereas
in the female the bladder neck and urethra lie in the connective
­tissue of the anterior vaginal wall. The lowest part of the neck
is the triangular trigone. The two ureters each insert obliquely
into the bladder postero-inferiorly, approximately 5 cm apart.
The oblique external insertions are an important antireflux
­mechanism. On the interior surface of the bladder the outlets of
the ureters (ureteric orifices) are approximately 2.5 cm apart in
the empty bladder (up to 5 cm apart in the distended ­bladder).
The three angles of the trigone are the ureteric orifices and infe-
riorly the internal urethral orifice (bladder outlet). The ­superior
trigonal border forms an interureteric ridge, which is readily
identifiable endoscopically. The trigone is histologically and
127 © 2008 Published by Elsevier Ltd.
 Renal and urology

Median sagittal section of male pelvis showing the lower urinary tract

Ureteric ridge
Bladder wall
Peritoneum
Ureteric orifice

Rectum

Urachus
Rectovesical pouch

Bladder apex

Retropubic space of Retzius

Trigone
Pubic symphysis Bladder neck
Seminal vesicle
Ejaculatory tract
Penile urethra
Denonvilliers’ fascia

Prostate
Corpus cavernosum

Membranous urethra

Glans penis

Perineal membrane
Bulbar urethra
External urethral meatus
Corpus spongiosum
Scrotum Bulb of corpus spongiosum
Navicular fossa

Figure 1

embryologically different from the rest of the bladder and contains
a rich plexus of neuronal tissue; it is also the least mobile part of
the bladder and is firmly adherent to the underlying muscle.
Histology
The bladder is composed of three distinct layers.
Serosa: an outer adventitial connective tissue layer.
Detrusor muscle: a middle smooth muscle layer, comprising
interlacing muscle fibres running randomly in all directions.
Only close to the internal urethral meatus do the fibres orien-
tate themselves into three specific layers (inner – longitudinal,
middle ­circumferential, outer – longitudinal).
Urothelium: an innermost lining composed of transitional cell
epithelium provides an elastic barrier that is impervious to urine.
Immediately beneath this lies a suburothelial layer which is
­metabolically active.
Vasculature
Arterial: the arterial supply is primarily from the superior, ­middle
and inferior vesical arteries which arise from the ­ hypogastric
(anterior) trunk of the internal iliac artery. Small branches also
arise from the obturator and inferior gluteal arteries, and in
females also from the uterine and vaginal arteries, to provide a
contribution to the lower bladder.
Venous: a plexus of veins surround the bladder and in the
male form a vesicoprostatic plexus between the bladder and
the prostate, which empties into the hypogastic (internal iliac)
veins.
Lymphatic: occurs into the paravesical, hypogastric (internal
iliac), external iliac and common iliac lymph nodes.
Nerve supply
Sympathetic nerves originate from the T10–L2 spinal level, via
the hypogastric nerve. They relax the detrusor smooth muscle
and contract the smooth muscle of the involuntary sphincteric
mechanisms at the bladder neck/prostate.
Parasympathetic nerves originate from the S2–S4 level (spi-
nal micturition centre), via the pelvic nerve. They contract
the detrusor muscle and relax the involuntary sphincteric
­mechanisms.

SURGERY 26:4 128 © 2008 Published by Elsevier Ltd.

 Renal and urology
Median sagittal section of female pelvis showing the lower urinary tract
Fallopian tube
Ovary
Peritoneum
Urachus
Vesico-uterine pouch
Pubic symphysis
Retropubic space
of Retzius
External urethral sphincter
Labia
External urethral orifice
Figure 2
Sympathetic and parasympathetic pathways both also supply
afferent innervation regarding bladder fullness and the presence
of any noxious stimuli (e.g. chemical, cold).
Prostate
Function
The prostate is a fibromuscular (30%) and glandular (70%)
organ. It is ovoid in shape (walnut sized) and is normally broader
than it is long, with its longest edge usually being approximately
4 cm. The normal prostate weighs approximately 20 g and pro-
duces about 30% of the volume of seminal fluid; much of the
remainder is produced by the seminal vesicles. In addition, the
most proximal part of the urethra, the prostatic urethra, traverses
the entire length of the organ from the base to the apex.
Anatomy
The prostate lies entirely behind the pubic symphysis and is
enclosed within a true capsule of strong connective tissue. Out-
side this is a layer of pelvic fascia forming a ‘false capsule’.
Superior: the base of the prostate is the superior surface of the
organ and is fused to the neck of the bladder.
SURGERY 26:4
Vertebrae
Recto-uterine pouch
(of Douglas)
Bladder lumen
Bladder neck
Rectum
Urethra Anus
Vagina
Inferior: the rounded apex is the lowest surface of the prostate.
The urethra emerges inferiorly from the base as the membranous
urethra.
Anterior: the anterior surface is in the retropubic space of
Retzius and is connected to the pubic bones by the puboprostatic
­ligaments.
Inferolateral: the prostate is cradled by the pubococcygeal part
of the levator ani.
Posterior: the posterior surface is separated from the lower rec-
tum by the two layers of Denonvilliers’ fascia. This surface is
readily palpable per rectum. The seminal vesicles and the vas
deferens join to form the ejaculatory ducts; these ducts pierce the
prostate superoposteriorly (where the prostate and bladder fuse)
and pass obliquely through the gland (Figure 3).
Prostatic urethra: this is 2.5–4 cm in length and is closer to the
anterior surface of the prostate. The proximal part of the prostatic
urethra is surrounded by smooth muscle, which is continuous with
the longitudinal detrusor smooth muscle of the bladder neck, and
prevents retrograde transport of semen during ejaculation and is
129 © 2008 Published by Elsevier Ltd.
 Renal and urology
Posterior view of bladder and prostate, showing
relationships between adherent structures
Body of bladder
Ampulla of
vas deferens
Ureter
Prostate Seminal vesicle
Membranous urethra
Figure 3
also responsible for continence at the level of the bladder neck. A
midline projection called the urethral crest is present on the poste-
rior surface of the urethral lumen and runs for most of the length
of the prostatic urethra. The prostatic glands drain into the urethra
on either side of the urethral crest. The verumontanum forms a
rounded eminence at the midline of the urethral crest. The ejacula-
tory ducts open on the verumontanum.
Zones: originally the prostate was divided descriptively into lobes,
but it is now conventional to describe it in terms of zones.
• The transitional zone makes up 5–10% of the prostate and
surrounds the distal half of the prostatic urethra. Benign prostatic
hyperplasia tends to occur in this zone and may cause occlusion
of the prostatic urethra, with subsequent voiding dysfunction.
• The central zone comprises 25% of the gland and is cone
shaped. It surrounds the ejaculatory ducts from the bladder base
to the verumontanum.
• The peripheral zone comprises the rest of the gland, the
bulk of which is the posterior and lateral aspects of the gland.
­Approximately 70% of prostatic carcinomas occur in the periph-
eral zone and may lead to a detectable abnormality on digital
rectal examination.
Lobes: formerly, the prostate was classified as consisting of
lobes, although these did not correspond to histologically defined
structures. The two lateral lobes are separated by a median sul-
cus which is palpable rectally. A median lobe (between the two
ejaculatory ducts) may protrude into the bladder neck and act as
a valve, causing obstruction during voiding.
Vasculature
Arterial: principally from the prostatic branch of the inferior
­vesical artery, with some smaller branches from the middle rectal
(haemorrhoidal) and internal pudendal vessels.
Venous: the periprostatic plexus of veins lies between the true and
the false capsules of the prostate; these join the vesicoprostatic
SURGERY 26:4
plexus between the bladder and the prostate. Some of the venous
drainage occurs to the valveless vertebral veins (of Bateson),
explaining the early spread of prostatic carcinoma to the vertebrae.
Lymphatics: primarily to the internal iliac and obturator nodes.
Nerve supply
Parasympathetic: pelvic splanchnic nerves, promoting prostatic
secretion.
Sympathetic: inferior hypogastric plexus; smooth muscle con-
traction during ejaculation.
Histology
Beneath the true capsule are circularly orientated smooth muscle
fibres and collagenous tissue, forming an involuntary sphincter.
Deep to this layer is the prostatic stroma of connective and elastic
tissues, smooth muscle fibres and epithelial glands. The prostatic
urethra is lined with transitional epithelium.
Male urethra
Function
The total length of the male urethra is approximately 20 cm and it
is composed of four sections; the short prostatic and membranous
sections form the ‘posterior’ urethra and the longer (approximately
15 cm) bulbar and penile sections form the ­‘anterior’ urethra. The
anterior urethra is entirely enclosed within the ­corpus spongiosum
and is sometimes termed the ‘spongy’ ­urethra.
Anatomy
Prostatic urethra: this is 3–4 cm in length and passes down-
wards through the prostate as described above.
Membranous urethra: after emerging inferiorly from the apex
of the prostate, the prostatic urethra becomes the membranous
­urethra. This part of the urethra is approximately 2 cm in length
and traverses the urogenital diaphragm in the deep perineal
pouch. The membranous urethra is surrounded by the ­ striated
external urethral sphincter and is the narrowest part of the
urethra (after the external urethral meatus). The membranous
­urethra pierces the perineal membrane approximately 2.5 cm
behind the pubic symphysis.
Bulbar urethra: at the inferior surface of the perineal membrane
the corpus spongiosum is enlarged as a ‘bulb’. Having pierced
the perineal membrane the urethra enters this bulb and immedi-
ately changes direction almost 90° degrees from downwards to
forwards.
Penile urethra: at the root of the penis the urethra becomes
the penile (pendulous) urethra. The urethra continues to pass
through the corpus spongiosum on the ventral aspect of the penis.
The urethra opens externally at the external urethral meatus at
the tip of the glans penis. Immediately proximal to the external
urethral meatus is a short dilated area called the navicular fossa.
A mucosal fold (lacuna) present in the roof of the navicular fossa
may catch the tip of a catheter, and so during catheterization it is
useful always to aim the catheter to the floor (ventral) surface of
130 © 2008 Published by Elsevier Ltd.
 Renal and urology

the urethra initially and to keep in mind the 90° change of direc-
tion in the bulbar urethra (Figure 4).
Vasculature
Arterial: multiple branches from adjacent vessels supply the
­urethra as it traverses the prostate, urogenital diaphragm and the
corpus spongiosum. The penile urethra is chiefly supplied by the
internal pudendal arteries.
Venous: urethral and penile drainage is to the internal pudendal
vein.
Lymphatic: drainage occurs to the internal iliac (hypogastric)
and common iliac lymph nodes.
Nerve supply
Somatic nerves originate from the S2–S4 level (Onuf’s nucleus),
via the pudendal nerve and provide voluntary control of the
external urethral sphincter.
Histology
The urethra is lined by transitional epithelium except in the distal
glans penis, where it is lined by stratified squamous epithelium.
Sphincter mechanisms
A continuation of the circular smooth muscle fibres from the
detrusor forms the involuntary internal urethral sphincter at the
level of the bladder neck and proximal urethra. This mechanism
is sometimes termed the pre-prostatic sphincter, and is important
in preventing retrograde ejaculation of semen and in maintaining
urinary continence. This sphincter is often injured during blad-
der neck or prostatic surgery, frequently resulting in retrograde
ejaculation. However, incontinence occurs less commonly owing
to the presence of the voluntary external urethral sphincter,
composed of striated muscle, which surrounds the membranous
­urethra and is a further powerful anti-incontinence mechanism.
Female urethra
Function
The female urethra is much shorter than the male urethra and is
usually only about 4 cm in length.
Anatomy
The urethra passes below the pubic symphysis embedded in the
anterior vaginal wall. It curves slightly forward during its course
from the bladder neck (internal urethral meatus) to the external
urethral meatus.

Frontal schematic showing bladder base and entire length of the urethra

Bladder

Ureteric orifice
Trigone

Internal urethral
meatus Prostatic urethra
Verumontanum
Prostate
Orifice of
Urogenital ejaculatory duct
diaphragm Membranous urethra

Perineal membrane
External urethral sphincter

Bulb of corpus spongiosum Bulbar urethra

Penile urethra

Corpus cavernosum

Glans penis
Navicular fossa

External urethral meatus

Figure 4

SURGERY 26:4 131 © 2008 Published by Elsevier Ltd.

 Renal and urology
Vasculature
Arterial: superiorly from branches of the inferior vesical and
vaginal arteries; inferiorly from branches of the internal puden-
dal arteries.
Venous: urethral drainage is to the internal pudendal vein via
the vesical plexus.
Lymphatic: drainage occurs from the deeper portions of the ure-
thra to the internal iliac (hypogastric) nodes, and from the super-
ficial portions to the inguinal and subinguinal nodes.
Nerve supply
Somatic nerves originate from the S2–S4 level (Onuf’s nucleus),
via the pudendal nerve and provide voluntary control of the
external urethral sphincter.
Sympathetic fibres from the inferior hypogastric plexus contract the
smooth muscle involved in involuntary sphincteric mechanisms.
Parasympathetic fibres from the pelvic nerve relax the involun-
tary sphincteric mechanisms.
Histology
The epithelial lining of the urethra is transitional or pseudostrati-
fied proximally, and in the distal urethra is non-keratonized
SURGERY 26:4
stratified squamous epithelium. A number of periurethral glands,
including the glands of Skene, are embedded in the submucosa
and empty into the floor of the urethra. The submucosa also
contains a number of venous spaces which may have a role in
maintaining continence by ensuring that the urethral epithelium
is apposed and therefore ‘watertight’.
Sphincter mechanisms
A longitudinal layer of smooth muscle, continuous with the inner
longitudinal layer of detrusor muscle, surrounds the submucosa.
Surrounding this is a thicker layer of circular smooth muscle,
which is also continuous with the external detrusor muscle at the
bladder neck. These smooth muscle layers form the involuntary
urethral sphincter; however, the involuntary urethral mechanism
at the bladder neck is poorly developed compared with that in the
male. Surrounding the involuntary muscle in the middle third of
the urethra is the circular voluntary striated muscle, which forms
the external urethral sphincter. This external sphincter is horseshoe
shaped, and is thicker at the sides and ventrally. In contrast to
those in males, the involuntary bladder neck and voluntary exter-
nal sphincters are not distinct structures and both sphincters are
much less powerful in females. The weaker sphincter mechanisms
coupled with the much shorter urethra may predispose to urinary
incontinence. In addition, the urethra, sphincters and their inner-
vation along with the pelvic floor muscles may be injured during
childbirth, further predisposing women to urinary incontinence. ◆
132 © 2008 Published by Elsevier Ltd.