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Smith & Tanagho’s

General Urology
NINETEENTH EDITION
Edited by
Jack W. McAninch, MD, FACS, FRCS(E)(Hon)

Professor of Urology
University of California School of Medicine
Chief, Department of Urology
San Francisco General Hospital
San Francisco, California
Tom F. Lue, MD, FACS, ScD (Hon)

Department of Urology
University of California School of Medicine
New York Chicago San Francisco Athens London Madrid Mexico City
Milan New Delhi Singapore Sydney Toronto
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Contents
Contributors vii 10 Laparoscopic Surgery 149
Preface xi
David B. Bayne, MD, MPH;
J. Stuart Wolf, Jr., MD, FACS;
1 Anatomy of the Genitourinary Tract 1
Marshall L. Stoller, MD; & Thomas Chi, MD
Emil A. Tanagho, MD; &
Tom F. Lue, MD, ScD (Hon), FACS 11 Robotic Surgery in Urology 167
Maxwell V. Meng, MD, MPH
2 Embryology of the Genitourinary System 17
Emil A. Tanagho, MD; Hiep T. Nguyen, MD; 12 Urinary Obstruction & Stasis 177
& Michael DiSandro, MD
Marshall L. Stoller, MD; &
3 Symptoms of Disorders of the
Genitourinary Tract 31
13 Vesicoureteral Reflux 191
Benjamin N. Breyer, MD, MAS, FACS
Thomas W. Gaither, MD, MAS; &
Hillary L. Copp, MD, MS
4 Physical Examination of the
Genitourinary Tract 41
14 Bacterial Infections of the
Maxwell V. Meng, MD, MPH; & Genitourinary Tract 201
Emil A. Tanagho, MD
Mary K. Wang, MD; &
Hillary L. Copp, MD, MS
5 Urologic Laboratory Examination 49
Anobel Y. Odisho, MD, MPH; 15 Specific Infections of the
Sima P. Porten, MD, MPH; & Genitourinary Tract 229
Kirsten L. Greene, MD, MS
Emil A. Tanagho, MD; &
Christopher J. Kane, MD, FACS
6 Radiology of the
Urinary Tract 63
16 Sexually Transmitted Infections 243
Daniela Franz, MD; Scott Gerst, MD; &
Hedvig Hricak, MD, PhD Kristin Madden, PharmD;
Amanda B. Reed-Maldonado, MD, FACS;
& John N. Krieger, MD
7 Vascular Interventional Radiology 107
Ryan Kohlbrenner, MD; & Roy L. Gordon, MD 17 Urinary Stone Disease 259
Marshall L. Stoller, MD
8 Retrograde Instrumentation of
the Urinary Tract 117
18 Injuries to the Genitourinary Tract 291
9 Percutaneous Endourology and
Ureterorenoscopy 129 19 Urothelial Carcinoma: Cancers of the
Bladder, Ureter, and Renal Pelvis 309
David B. Bayne, MD, MPH;
Joachim W. Thüroff, MD; Badrinath R. Konety, MD, MBA; &
Rolf Gillitzer, MD; & Thomas Chi, MD Peter R. Carroll, MD, MPH
iii

iv Contents
20 Renal Parenchymal Neoplasms 329 31 Disorders of the Adrenal Glands 509

Anobel Y. Odisho, MD, MPH; & Michelle L. McDonald, MD; &
Kirsten L. Greene, MD, MS Christopher J. Kane, MD, FACS
21 Cancer of the Prostate Gland 351 32 Disorders of the Kidneys 521

Matthew R. Cooperberg, MD, MPH; David B. Bayne, MD, MPH;
Samuel L. Washington III, MD; & Jack W. McAninch, MD, FACS, FRCS(E)(Hon); &
Peter R. Carroll, MD, MPH Thomas Chi, MD
22 Genital Tumors 377 33 Diagnosis of Medical Renal Diseases 539

Sima P. Porten, MD, MPH; & Brian K. Lee, MD; & Flavio G. Vincenti, MD
Joseph C. Presti, Jr., MD
34 Acute Kidney Injury and Oliguria 551
23 Urinary Diversion and
Brian K. Lee, MD; & Flavio G. Vincenti, MD
Bladder Substitutions 391
Maxwell V. Meng, MD, MPH; 35 Chronic Kidney Disease and
Susan Barbour, RN, MS, WOCN; & Renal Replacement Therapy 557
Peter R. Carroll, MD, MPH
Brian K. Lee, MD; &
Flavio G. Vincenti, MD
24 Systemic Therapy of Urologic Tumors 407
Vadim S. Koshkin, MD; & Eric J. Small, MD 36 Renal Transplantation 563
John M. Barry, MD
25 Immunotherapy in
Urologic Malignancies 415
37 Disorders of the Ureter and
Arpita Desai, MD; & Eric J. Small, MD Ureteropelvic Junction 571
Barry A. Kogan, MD
26 Radiotherapy of
Urologic Tumors 421
38 Disorders of the Bladder, Prostate,
Yun Rose Li, MD, PhD; and Seminal Vesicles 585
Alexander R. Gottschalk, MD, PhD; &
Mack Roach III, MD Samuel L. Washington III, MD; &
Katsuto Shinohara, MD
27 Neurophysiology and Pharmacology
of the Lower Urinary Tract 453 39 Male Sexual Dysfunction 605
Karl-Erik Andersson, MD, PhD Amanda B. Reed-Maldonado, MD, FACS; &
Tom F. Lue, MD
28 Neurogenic Bladder 473
40 Women’s Sexual Health 631
Anne M. Suskind, MD, MS, FACS
Alan W. Shindel, MD, MAS; &
Tami S. Rowen, MD, MS
29 Urodynamics 485
Anne M. Suskind, MD, MS, FACS 41 Disorders of the Penis and
Male Urethra 645
30 Urinary Incontinence 499
Benjamin N. Breyer, MD, MAS, FACS; &
Tom F. Lue, MD, FACS, ScD (Hon); & Jack W. McAninch, MD, FACS, FRCS(E)(Hon)
Emil A. Tanagho, MD

Contents v
42 Disorders of the Female Urethra 659 46 Genital Gender-Affirming Surgery:

Patient Care, Decision Making, and
Donna Y. Deng, MD, MS
Surgery Options 747
43 Disorders of Sex Development 671 Maurice M. Garcia, MD, MAS
Laurence S. Baskin, MD
47 History and Physical Examination in
Pediatric Urology 769
44 Male Infertility 703
Michael DiSandro, MD
Thomas J. Walsh, MD, MS; &
James F. Smith, MD, MS
48 Introduction to Clinical
Research Design 781
45 The Aging Male 735
June M. Chan, ScD; David Tat, DO; &
James F. Smith, MD, MS; Stacey Kenfield, ScD
Bogdana Schmidt, MD, MPH; &
Thomas J. Walsh, MD, MS Index 793

Contributors
Karl-Erik Andersson, MD, PhD June M. Chan, ScD
Institute for Regenerative Medicine Program Director, Genitourinary Cancer Epidemiology and
Wake Forest University School of Medicine Population Sciences
Winston Salem, North Carolina Department of Urology
UCSF School of Medicine
Susan Barbour, RN, MS, WOCN San Francisco, California
Palliative Care Services
UCSF School of Medicine Thomas Chi, MD
San Francisco, California Associate Professor and Katzman Endowed Professor in
Clinical Urology
John M. Barry, MD Department of Urology
Professor of Urology and Professor of Surgery UCSF School of Medicine
Division of Abdominal Organ Transplantation San Francisco, California
Organ Health and Science University
Portland, Oregon Matthew R. Cooperberg, MD, MPH
Associate Professor
Laurence S. Baskin, MD Department of Urology
Chief of Pediatric Urology Helen Diller Family Comprehensive Cancer Center
University of California Children’s Medical Center UCSF School of Medicine
UCSF School of Medicine San Francisco, California
Attending Urologist Hillary L. Copp, MD, MS
Children’s Hospital Oakland Associate Professor of Urology and Pediatric Urology
Oakland, California Fellowship Director
Benioff Children’s Hospital
David B. Bayne, MD, MPH UCSF School of Medicine
Endourology Fellow San Francisco, California
UCSF School of Medicine Donna Y. Deng, MD, MS
San Francisco, California Neurourology Lead, Kaiser Permanente Northern
California
Benjamin N. Breyer, MD, MAS, FACS Medical Director, Kaiser NorCal Regional Spina Bifida
Associate Professor and Vice Chair Program
Department of Urology Associate Fellowship Director, Female Pelvic Medicine
UCSF School of Medicine Reconstructive Surgery, Kaiser East Bay/UCSF
San Francisco, California Oakland, California
Peter R. Carroll, MD, MPH Arpita Desai, MD

Professor Clinical Instructor
Ken and Donna Derr-Chevron Endowed Chair in Department of Genitourinary Medical Oncology
Prostate Cancer Helen Diller Family Comprehensive Cancer Center
Department of Urology UCSF School of Medicine
UCSF School of Medicine San Francisco, California
vii

viii Contributors
Michael DiSandro, MD Kirsten L. Greene, MD, MS

Professor of Urology Professor and Chair
Department of Urology Department of Urology
UCSF School of Medicine University of Virginia
San Francisco, California Charlottesville, Virginia
Daniela Franz, MD Hedvig Hricak, MD, PhD

Department of Diagnostic and Interventional Radiology Chair
Klinikum rechts der Isar Department of Radiology
Munich Technical University Memorial Sloan-Kettering Cancer Center
Munich, Germany Professor of Radiology
Cornell University
Thomas W. Gaither, MD, MAS New York, New York
Urology resident
University of California Christopher J. Kane, MD, FACS
Los Angeles, California Dean of Clinical Affairs
UC San Diego School of Medicine
Maurice M. Garcia, MD, MAS CEO, UC San Diego Health Physician Group
Associate Professor of Urology and Anatomy (Adjunct) La Jolla, California
Departments of Urology and Anatomy
UCSF Medical Center Stacey A. Kenfield, ScD
San Francisco, California Associate Professor
Director, Cedars-Sinai Transgender Surgery and Department of Urology
Health Program UCSF School of Medicine
Division of Urology San Francisco, California
Cedars-Sinai Medical Center
Los Angeles, California Barry A. Kogan, MD
Professor, Surgery and Pediatrics
Scott Gerst, MD Falk Chair in Urology
Associate Attending Physician Albany Medical College
Department of Radiology Albany, New York
Memorial Hospital, Memorial Sloane-Kettering
Cancer Center Ryan Kohlbrenner, MD
New York, New York Assistant Professor of Interventional Radiology
Departments of Radiology and Biomedical Imaging
Rolf Gillitzer, MD UCSF School of Medicine
Clinical Director San Francisco, California
Johannes Gutenberg University Medical Center Mainz Badrinath R. Konety, MD, MBA
Mainz, Germany Associate Dean for Innovation
Roy L. Gordon, MD Director of the Institute for Prostate and Urologic Cancers
Professor of Interventional Radiology University of Iowa
Department of Radiology Iowa City, Iowa
San Francisco, California Vadim S. Koshkin, MD
Assistant Clinical Professor
Alexander R. Gottschalk, MD, PhD Genitourinary Medical Oncologist
Professor of Radiation Oncology Departments of Hematology and Oncology
Director of CyberKnife UCSF School of Medicine
Departments of Radiation and Oncology San Francisco, California

Contributors ix
John N. Krieger, MD Anobel Y. Odisho, MD, MPH

Professor of Urology Assistant Professor
University of Washington School of Medicine Department of Urologic Oncology
Seattle, Washington UCSF School of Medicine
Brian K. Lee, MD
Professor of Medicine Sima P. Porten, MD, MPH
The Connie Frank Kidney Transplant Center Assistant professor
UCSF School of Medicine Department of Urology
San Francisco, California UCSF School of Medicine
Yun Rose Li, MD, PhD
Resident Physician Joseph C. Presti, Jr., MD
Departments of Radiation and Oncology Lead for Urologic Oncology
UCSF School of Medicine Kaiser Permanente Northern California
San Francisco, California Oakland, California
Tom F. Lue, MD, FACS, ScD (Hon) Amanda B. Reed-Maldonado, MD, FACS
Professor of Urology Chief, Male Reproductive Urology
Emil Tanagho Endowed Chair in Clinical Urology Department of Urology
Department of Urology Tripler Army Medical Center
UCSF School of Medicine Honolulu, Hawaii
Mack Roach III, MD
Kristin Madden, PharmD Professor of Radiation Oncology and Urology
Pharmacist Department of Urology
Department of Veterans Affairs UCSF School of Medicine
San Antonio, Texas San Francisco Comprehensive Cancer Center
Jack W. McAninch, MD, FACS, FRCS(E)(Hon)
Professor of Urology Tami S. Rowen, MD, MS
UCSF School of Medicine Assistant Professor
San Francisco, California Departments of Obstetrics, Gynecology, and
Reproductive Sciences
Michelle L. McDonald, MD UCSF School of Medicine
Urologist San Francisco, California
San Diego, California
Bogdana Schmidt, MD, MPH
Maxwell V. Meng, MD, MPH Urologic Oncology Fellow
Professor Stanford University Medical Center
Department of Urology Stanford, California
San Francisco, California Alan W. Shindel, MD, MAS
Associate Professor
Hiep T. Nguyen, MD Department of Urology
Associate Professor University of California
Surgery and Urology Davis, California
Harvard Medical School and Children’s Hospital
Boston, Massachusetts

x Contributors
Katsuto Shinohara, MD David Tat, DO

Professor Infectious Disease Specialist
Helen Diller Family Chair in Clinical Urology Moses H. Cone Memorial Hospital
Department of Urology Greensboro, North Carolina
San Francisco, California Joachim W. Thüroff, MD
Professor
Eric J. Small, MD Department of Urology
Professor of Medicine and Urology University Medical Center
Urologic Oncology Program and Program Member, Mannheim, Germany
Comprehensive Cancer Center
UCSF School of Medicine Flavio G. Vincenti, MD
San Francisco, California Professor of Medicine
The Connie Frank Kidney Transplant Center
James F. Smith, MD, MS UCSF School of Medicine
Associate Professor San Francisco, California
Director, Male Reproductive Health
Departments of Urology, Obstetrics, Gynecology, and Thomas J. Walsh, MD, MS
Reproductive Sciences Associate Professor
UCSF School of Medicine Department of Urology
San Francisco, California University of Washington School of Medicine
Seattle, Washington
Professor of Urology Mary K. Wang, MD
Department of Urology Childrens’ Urology
UCSF School of Medicine Austin, Texas
Samuel L. Washington, III, MD
Anne M. Suskind, MD, MS, FACS Urologic Oncology Clinical Fellow
Associate Professor of Urology, Obstetrics, Gynecology, and Department of Urology
Reproductive Sciences UCSF School of Medicine
Director, Neurourology, Female Pelvic Medicine & San Francisco, California
Reconstructive Surgery
UCSF School of Medicine J. Stuart Wolf, Jr., MD, FACS
San Francisco, California Professor, Department of Surgery and Perioperative Care
Dell Medical School
Emil A. Tanagho, MD The University of Texas at Austin
Professor of Urology Austin, Texas

Preface
Smith & Tanagho’s General Urology, nineteenth edition, provides the updated information for the understanding, diagnosis,
and treatment of urological diseases in a concise and well-organized format. The book is up-to-date, to the point, and readable.
Medical students will find this book useful because of its concise, easy-to-follow format, and its breadth of information on
common urological diseases. Residents, as well as practicing physicians in urology, family practice, or general medicine, will find
it an efficient and current reference, particularly because of its emphasis on diagnosis and treatment.
This nineteenth edition has been thoroughly updated with clinical information and current references. The reader will find
that this edition is written in an uncomplicated, straightforward manner that provides relevant clinical information and guide-
lines for diagnosis and management of urologic conditions. Chapters on immunotherapy in urologic malignancies, radiotherapy
of urologic tumors, urinary incontinence, and vascular interventional radiology have all undergone extensive revision. For
this current edition, we have added two chapters on the timely topic of gender dysphoria and introduction to clinical research
design.
Many illustrations and figures have been modernized and improved with added color. The classic fine anatomic drawings
demonstrate well the important clinical findings.
This book has been one of the leading sources of information for students, trainees, and urologists around the world. In addi-
tion to English, this book has been published in many other foreign languages, like Chinese, French, Greek, Italian, Japanese,
Korean, Portuguese, Russian, Spanish, and Turkish.
We greatly appreciate the patience and efforts of our McGraw-Hill staff, the expertise of our contributors, and the support
of our readers.
Jack W. McAninch, MD, FACS, FRCS(E) (Hon)

San Francisco, California, January 2020
xi

1
1
Anatomy of the
Genitourinary Tract
Emil A. Tanagho, MD; & Tom F. Lue, MD, ScD (Hon), FACS
Urology deals with diseases and disorders of the adrenal ▶▶Blood Supply
gland, the male genitourinary tract, and the female
urinary tract. These systems are illustrated in Figures 1–1 A. Arterial
and 1–2. Each adrenal gland receives three arteries: one from the infe-
rior phrenic artery, one from the aorta, and one from the
ADRENALS renal artery.
B. Venous
▶▶Gross Appearance
A. Anatomy Blood from the right adrenal gland is drained by a very short
vein into the vena cava; the left adrenal vein terminates in the
Each kidney is capped by an adrenal gland, and both left renal vein.
organs are enclosed within Gerota’s (perirenal) fascia.
Each adrenal gland weighs 4–5 g. The right adrenal is tri- ▶▶Lymphatics
angular in shape; the left is more rounded and crescentic.
The average dimensions are 3 cm width, 5 cm length, and The lymphatic vessels accompany the suprarenal vein and
1 cm thickness. Each gland is composed of a cortex, chiefly drain into the lumbar lymph nodes.
influenced by the pituitary gland, and a medulla derived
from chromaffin tissue (Avisse et al, 2000; O’Donoghue KIDNEYS
et al, 2010).
B. Relations A. Anatomy
Figure 1–2 shows the relationships between the adrenals and The kidneys lie along the borders of the psoas muscles and
other organs. The right adrenal lies between the liver and are therefore obliquely placed. The position of the liver
the vena cava. The left adrenal lies close to the aorta and is causes the right kidney to be lower than the left (Figures 1–2
covered on its lower surface by the pancreas. The spleen lies and 1–3). The adult kidney weighs between 125 and 170 g in
superior and lateral to it. men and 115 and 155 g in women. It is about 10–12 cm long,
5–7 cm wide, and 3–5 cm thick.
The kidneys are supported by the perirenal fat (which is
▶▶Histology enclosed in the perirenal fascia), the renal vascular pedicle,
The adrenal cortex, which makes up 85% of the mass, is com- abdominal muscle tone, and the general bulk of the abdomi-
posed of three distinct layers: the outer zona glomerulosa, the nal viscera (Rusinek et al, 2004). Variations in these factors
middle zona fasciculata, and the inner zona reticularis. The permit variations in the degree of renal mobility. The aver-
medulla lies centrally and is made up of polyhedral cells with age descent on inspiration or on assuming the upright posi-
hormone-containing granular cytoplasm. These chromaf- tion is 4–5 cm. Lack of mobility suggests abnormal fixation
fin cells are accompanied by a small number of sympathetic (eg, perinephritis), but extreme mobility is not necessarily
ganglion cells. pathologic.
McAninch_CH01_p001-p016.indd 1 07/02/20 9:58 AM

2 SMITH & TANAGHO’S GENERAL UROLOGY
▲▲Figure 1–1. Anatomy of the male genitourinary tract. The upper tract and midtract have urologic function only.
The lower tract has both genital and urinary functions.

ANATOMY OF THE GENITOURINARY TRACT CHAPTER 1 3
▲▲Figure 1–2. Relations between the kidneys, ureters, and bladder (anterior aspect).
On longitudinal section (Figure 1–4), the kidney is seen gastrointestinal symptoms that accompany kidney diseases
to be made up of an outer cortex, a central medulla, and the (Glassberg, 2002).
internal calices and pelvis. The cortex is homogeneous in
appearance. Portions of it project toward the pelvis between ▶▶Histology
the papillae and fornices and are called the columns of A. Nephron
Bertin. The medulla consists of numerous pyramids formed
by the converging collecting renal tubules, which drain into The functioning unit of the kidney is the nephron, which is
the minor calices at the tip of the papillae. composed of a tubule that has both secretory and excretory
functions (Figure 1–4). The secretory portion is contained
largely within the cortex and consists of a renal corpuscle and
B. Relations
the secretory part of the renal tubule. The excretory portion of
Figures 1–2 and 1–3 show the relationships between the this duct lies in the medulla. The renal corpuscle is composed
kidneys and adjacent organs and structures. Their intimacy of the vascular glomerulus, which projects into Bowman’s cap-
with intraperitoneal organs and the autonomic innervation sule, which, in turn, is continuous with the epithelium of the
that they share with these organs explain, in part, some of the proximal convoluted tubule. The secretory portion of the renal

▲▲Figure 1–3. Relations between the kidneys (posterior aspect). The dashed lines represent the outline of the kidneys,
where they are obscured by overlying structures.
tubule is made up of the proximal convoluted tubule, the loop of the posterior surface. The anterior branch supplies both
of Henle, and the distal convoluted tubule. upper and lower poles as well as the entire anterior surface.
The excretory portion of the nephron is the collecting The renal arteries are all end arteries.
tubule, which is continuous with the distal end of the ascend- The renal artery branches further divide into interlobar
ing limb of the convoluted tubule. It empties its contents arteries, which travel in the columns of Bertin (between the
through the tip (papilla) of a pyramid into a minor calyx. pyramids) and then arch along the base of the pyramids
(arcuate arteries). These arteries then divide as interlobular
B. Supporting Tissue arteries. From these vessels, smaller (afferent) branches pass
to the glomeruli. From the glomerular tuft, efferent arterioles
The renal stroma is composed of loose connective tissue and
pass to the tubules in the stroma.
contains blood vessels, capillaries, nerves, and lymphatics.
B. Venous
▶▶Blood Supply (Figures 1–2, 1–4, and 1–5)
The renal veins are paired with the arteries, but any of them
A. Arterial
will drain the entire kidney if the others are tied off.
Usually there is one renal artery, a branch of the aorta that Although the renal artery and vein are usually the sole blood
enters the hilum of the kidney between the pelvis, which vessels of the kidney, accessory renal vessels are common and
normally lies posteriorly, and the renal vein. It may branch may be of clinical importance if they are so placed so as to com-
before it reaches the kidney, and two or more separate arter- press the ureter, in which case hydronephrosis may result.
ies may be noted (Budhiraja et al, 2010). In duplication of the
pelvis and ureter, it is common for each renal segment to have
its own arterial supply. ▶▶Nerve Supply
The renal artery divides into anterior and posterior The renal nerves derived from the renal plexus accompany
branches. The posterior branch supplies the midsegment the renal vessels throughout the renal parenchyma.

▲▲Figure 1–4. Anatomy and histology of the kidney and ureter. Upper left: Diagram of the nephron and its blood supply.
(Courtesy of Merck, Sharp, Dohme: Seminar. 1947; 9[3].) Upper right: Cast of the pelvic caliceal system and the arterial
supply of the kidney. Middle: Renal calices, pelvis, and ureter (posterior aspect). Lower left: Histology of the ureter. The
smooth-muscle bundles are arranged in both spirally and longitudinally. Lower right: Longitudinal section of kidney
showing calices, pelvis, ureter, and renal blood supply (posterior aspect).

▲▲Figure 1–5. (A) The posterior branch of the renal artery and its distribution to the central segment of the posterior
surface of the kidney. (B) Branches of the anterior division of the renal artery supplying the entire anterior surface of the
kidney as well as the upper and lower poles at both surfaces. The segmental branches lead to interlobar, arcuate, and
interlobular arteries. (C) The lateral convex margin of the kidney. Brödel’s line, which is 1 cm from the convex margin, is
the bloodless plane demarcated by the distribution of the posterior branch of the renal artery.

▶▶Lymphatics
The lymphatics of the kidney drain into the lumbar lymph
nodes.
CALICES, RENAL PELVIS, AND URETER
A. Anatomy
1. Calices—The tips of the minor calices (8–12 in number)

are indented by the projecting pyramids (Figure 1–4). These
calices unite to form two or three major calices that join to
form the renal pelvis (Sozen et al, 2008).
2. Renal pelvis—The pelvis may be entirely intrarenal or
partly intrarenal and partly extrarenal. Inferomedially, it
tapers to join the ureter.
▲▲Figure 1–6. Anatomy and relations between the
3. Ureter—The adult ureter is about 30 cm long, varying ureters, bladder, prostate, seminal vesicles, and vasa
in direct relation to the height of the individual. It follows a deferentia (anterior view).
rather smooth S curve. Areas that stones are often impacted
are (a) at the ureteropelvic junction, (b) where the ureter
crosses over the iliac vessels, and (c) where it courses through helical and longitudinal smooth-muscle fibers. They are not
the bladder wall. arranged in discrete layers. The outermost adventitial coat is
composed of fibrous connective tissue.
B. Relations
▶▶Blood Supply
1. Calices—The calices are intrarenal and are intimately A. Arterial
related to the renal parenchyma.
The renal calices, pelvis, and upper ureters derive their blood
2. Renal pelvis—If the pelvis is partly extrarenal, it lies along supply from the renal arteries; the midureter is fed by the
the lateral border of the psoas muscle and on the quadratus internal spermatic (or ovarian) arteries. The lowermost por-
lumborum muscle; the renal vascular pedicle is just anterior tion of the ureter is served by branches from the common
to it. The left renal pelvis lies at the level of the first or second iliac, internal iliac (hypogastric), and vesical arteries.
lumbar vertebra; the right pelvis is a little lower.
3. Ureter—On their course downward, the ureters lie on the B. Venous
psoas muscles, pass medially to the sacroiliac joints, and then The veins of the renal calices, pelvis, and ureters are paired
swing laterally near the ischial spines before passing medi- with the arteries.
ally to enter the base of the bladder (Figure 1–2). In females,
the uterine arteries are closely related to the juxtavesical por-
tion of the ureters. The ureters are covered by the posterior
▶▶Lymphatics
peritoneum; their lowermost portions are closely attached to The lymphatics of the upper portions of the ureters as well
it, while the juxtavesical portions are embedded in vascular as those from the pelvis and calices enter the lumbar lymph
retroperitoneal fat (Koff, 2008). nodes. The lymphatics of the midureter pass to the internal
The vasa deferentia, as they leave the internal inguinal iliac (hypogastric) and common iliac lymph nodes; the lower
rings, sweep over the lateral pelvic walls anterior to the ureteral lymphatics empty into the vesical and hypogastric
ureters (Figure 1–6). They lie medial to the latter before join- lymph nodes.
ing the seminal vesicle and penetrating the base of the pros-
tate to become the ejaculatory ducts. BLADDER
▶▶Histology (Figure 1–4) ▶▶Gross Appearance

The walls of the calices, pelvis, and ureters are composed of The bladder is a hollow muscular organ that serves as a res-
transitional cell epithelium under which lies loose connec- ervoir for urine. In women, its posterior wall and dome are
tive tissue (lamina propria). External to these are a mixture of invaginated by the uterus. The adult bladder normally has

a capacity of 400–500 mL. The wall of the bladder is about ▶▶Blood Supply
3–5 mm in thickness; it is thinner when it is distended.
A. Arterial
A. Anatomy The bladder is supplied by the superior, middle, and inferior
When empty, the adult bladder lies behind the pubic sym- vesical arteries, which arise from the anterior trunk of the
physis and is largely a pelvic organ. In infants and children, internal iliac (hypogastric) artery, and by smaller branches
it is situated higher (Berrocal et al, 2002). When it is full, it from the obturator and inferior gluteal arteries. In females,
rises well above the symphysis and can readily be palpated the uterine and vaginal arteries also send branches to the
or percussed. When overdistended, as in acute or chronic bladder.
urinary retention, it may cause the lower abdomen to bulge
visibly. B. Venous
Extending from the dome of the bladder to the umbilicus Surrounding the bladder is a rich plexus of veins that ulti-
is a fibrous cord, the median umbilical ligament, which rep- mately empties into the internal iliac (hypogastric) veins.
resents the obliterated urachus. The ureters enter the bladder
posteroinferiorly in an oblique manner and at these points ▶▶Nerve Supply
are about 5 cm apart (Figure 1–6). The orifices, situated at
the extremities of the crescent-shaped interureteric ridge that The bladder receives innervation from sympathetic and
forms the proximal border of the trigone, are about 2.5 cm parasympathetic nervous systems. The sensory afferent of
apart. The trigone occupies the area between the ridge and the bladder originates from both subepithelial nerve endings
the bladder neck. and nerve fibers between detrusor muscle bundles (Andersson,
The internal sphincter, or bladder neck, is not a true cir- 2010; Birder et al, 2010; McCloskey, 2010).
cular sphincter but a thickening formed by interlaced and
converging muscle fibers of the detrusor as they pass distally ▶▶Lymphatics
to become the smooth muscle component of the urethra. The lymphatics of the bladder drain into the vesical, external
iliac, internal iliac (hypogastric), and common iliac lymph
B. Relations nodes.
In males, the bladder is related posteriorly to the seminal
vesicles, vasa deferentia, ureters, and rectum (Figures 1–7 PROSTATE GLAND
and 1–8). In females, the uterus and vagina are interposed
between the bladder and rectum (Figure 1–9). The dome ▶▶Gross Appearance
and posterior surfaces are covered by peritoneum; hence, in
A. Anatomy
this area, the bladder is closely related to the small intestine
and sigmoid colon. In both males and females, the bladder is The prostate is a fibromuscular and glandular organ lying just
related to the posterior surface of the pubic symphysis, and, inferior to the bladder (Figures 1–6 and 1–7). The normal
when distended, it is in contact with the lower abdominal prostate weighs about 20 g and contains the posterior urethra,
wall. which is about 2.5 cm in length. It is supported anteriorly by
the puboprostatic ligaments and inferiorly by the urogenital
diaphragm (Figure 1–6). The prostate is perforated posteri-
▶▶Histology (Figure 1–10) orly by the ejaculatory ducts, which pass obliquely to empty
The mucosa of the bladder is composed of transitional epi- through the verumontanum on the floor of the prostatic ure-
thelium. Beneath it is a well-developed submucosal layer thra just proximal to the striated external urinary sphincter
formed largely of connective and elastic tissues. The mucosa (Figure 1–11).
may be considered as a single functional unit that consists The prostate can be subdivided into two ways: by lobe
of the epithelial layer, basement membrane, and lamina pro- or by zone. The lobe classification is often used in cystoure-
pria. Physical or chemical stress on the bladder elicits releases throscopic examinations and consists of five lobes: anterior,
of multiple factors that modulate afferent and efferent nerve posterior, median, right lateral, and left lateral. The zone clas-
activities (Fry and Vahabi, 2016). External to the submu- sification is often used in pathology. McNeal (1981) divides
cosa is the detrusor muscle that is made up of a mixture of the prostate into four zones: peripheral zone, central zone
smooth-muscle fibers arranged at random in a longitudi- (surrounds the ejaculatory ducts), transitional zone (sur-
nal, circular, and spiral manner without any layer formation rounds the urethra), and anterior fibromuscular zone (Myers
or specific orientation except for proximity to the internal et al, 2010) (Figure 1–12). The segment of urethra that tra-
meatus, where the detrusor muscle assumes three definite verses the prostate gland is the prostatic urethra. It is lined
layers: inner longitudinal, middle circular, and outer longitu- by an inner longitudinal layer of muscle (continuous with
dinal (John et al, 2001). a similar layer of the vesical wall). Incorporated within the

▲▲Figure 1–7. (A) Anatomic relationship between the bladder, prostate, prostatomembranous urethra, and root of
the penis. (B) Histology of the testis. Seminiferous tubules lined by supporting basement membrane for the Sertoli and
spermatogenic cells. The latter are in various stages of development. (C) Cross sections of the testis and epididymis.
(Images [A] and [C] reproduced with permission from Walsh PC, Campbell MF: Campbell’s Urology, 6th ed. Philadelphia, PA:
Saunders; 1992.)

▲▲Figure 1–8. Top: Relations between the bladder, prostate, seminal vesicles, penis, urethra, and scrotal contents.
Lower left: Transverse section through the penis. The paired upper structures are the corpora cavernosa. The single
lower body surrounding the urethra is the corpus spongiosum. Lower right: Fascial planes of the lower genitourinary
tract. (After Wesson.)
prostate gland is an abundant amount of smooth muscula- separated from the rectum by the two layers of Denonvilliers’
ture derived primarily from the external longitudinal bladder fascia, serosal rudiments of the pouch of Douglas, which
musculature. This musculature represents the involuntary once extended to the urogenital diaphragm (Raychaudhuri
smooth muscle sphincter of the posterior urethra in males. and Cahill, 2008) (Figure 1–8).
B. Relations ▶▶Histology (Figure 1–10)

The prostate gland lies behind the pubic symphysis. Located The prostate consists of a thin fibrous capsule under
closely to the posterosuperior surface are the vasa deferentia which lie circularly oriented smooth-muscle fibers and
and seminal vesicles (Figure 1–7). Posteriorly, the prostate is collagenous tissue that surrounds the urethra (involuntary

▲▲Figure 1–9. Anatomy and relations of the bladder, urethra, uterus and ovary, vagina, and rectum.
▲▲Figure 1–10. Left: Histology of the prostate. Epithelial glands embedded in a mixture of connective and elastic tissue
and smooth muscle. Right: Histology of the bladder. The mucosa is transitional cell in type and lies on a well-developed
submucosal layer of connective tissue. The detrusor muscle is composed of interlacing longitudinal, circular, and spiral
smooth-muscle bundles.

▲▲Figure 1–11. Section of the prostate gland shows the

prostatic urethra, verumontanum, and crista urethralis,
in addition to the opening of the prostatic utricle and
the two ejaculatory ducts in the midline. Note that the
prostate is surrounded by the prostatic capsule, which
is covered by another prostatic sheath derived from the
endopelvic fascia. The prostate is resting on the genitouri-
nary diaphragm. (Reproduced with permission from Walsh
PC, Campbell MF: Campbell’s Urology, 6th ed. Philadelphia,
PA: Saunders; 1992.) ▲▲Figure 1–12. Anatomy of the prostate gland. Prostatic
adenoma develops from the periurethral glands at the
site of the median or lateral lobes. The posterior lobe,
however, is prone to cancerous degeneration. (Adapted
sphincter). Deep in this layer lies the prostatic stroma,
with permission from McNeal JE: The zonal anatomy of the
composed of connective tissues and smooth-muscle fibers
prostate. Prostate 1981;2(1):35–49.)
in which are embedded the epithelial glands. These glands
drain into the major excretory ducts (about 25 in number),
which open chiefly on the floor of the urethra between
the verumontanum and the vesical neck. Just beneath ▶▶Lymphatics
the transitional epithelium of the prostatic urethra lie the The lymphatics from the prostate drain into the internal iliac
periurethral glands. (hypogastric), sacral, vesical, and external iliac lymph nodes
(Saokar et al, 2010).
▶▶Blood Supply
A. Arterial SEMINAL VESICLES
The arterial supply to the prostate is derived from the inferior
vesical, internal pudendal, and middle rectal (hemorrhoidal) ▶▶Gross Appearance
arteries. The seminal vesicles lie just cephalic to the prostate under
the base of the bladder (Figures 1–6 and 1–7). They are about
B. Venous 6 cm long and quite soft. Each vesicle joins its corresponding
vas deferens to form the ejaculatory duct (Kim et al, 2009).
The veins from the prostate drain into the periprostatic The ureters lie medial to each, and the rectum is contiguous
plexus, which has connections with the deep dorsal vein of with their posterior surfaces.
the penis and the internal iliac (hypogastric) veins.
▶▶Histology
▶▶Nerve Supply The mucous membrane is pseudostratified. The submu-
The prostate gland receives a rich innervation from the sym- cosa consists of dense connective tissue covered by a thin
pathetic and parasympathetic nerves of the inferior hypogas- layer of muscle that, in turn, is encapsulated by connective
tric plexus. tissue.

▶▶Blood Supply EPIDIDYMIS

The blood supply of the seminal vesicles is similar to that of
the prostate gland. ▶▶Gross Appearance
A. Anatomy
▶▶Nerve Supply The upper portion of the epididymis (globus major) is con-
The nerve supply is mainly from the sympathetic nerve nected to the testis by numerous efferent ducts from the testis
plexus. (Figure 1–7). The epididymis consists of a markedly coiled
duct that, at its lower pole (globus minor), is continuous with
▶▶Lymphatics the vas deferens. An appendix of the epididymis is often seen
on its upper pole; this is a cystic body that in some cases is
The lymphatics of the seminal vesicles are those that serve
pedunculated, but in others, it is sessile.
the prostate.
B. Relations
SPERMATIC CORD
The epididymis lies posterolateral to the testis and is nearest
▶▶Gross Appearance to the testis at its upper pole. Its lower pole is connected to
the testis by fibrous tissue. The vas lies posteromedial to the
The two spermatic cords extend from the internal ingui- epididymis.
nal rings through the inguinal canals to the testicles
(Figure 1–7). Each cord contains the vas deferens, the
internal and external spermatic arteries, the artery of
▶▶Histology
the vas, the venous pampiniform plexus (which forms The epididymis is covered by serosa. The ductus epididy-
the spermatic vein superiorly), lymph vessels, and nerves midis is lined by pseudostratified columnar epithelium
(Jen et al, 1999). The entire cord contents are enclosed in throughout its length.
investing layers of thin fascia. A few fibers of the cremaster
muscle insert on the cords in the inguinal canal (Bhosale ▶▶Blood Supply
et al, 2008; Kim et al, 2009). A. Arterial
▶▶Histology The arterial supply to the epididymis comes from the internal
spermatic artery and the artery of the vas (deferential artery).
The fascia covering the cord is formed of loose connective
tissue that supports arteries, veins, nerve, and lymphatics. B. Venous
The vas deferens is a small, thick-walled tube consisting of an
internal mucosa and submucosa surrounded by three well- The venous blood drains into the pampiniform plexus, which
defined layers of smooth muscle encased in a covering of becomes the spermatic vein.
fibrous tissue. Above the testes, this tube is straight. Its proxi-
mal 4 cm tends to be convoluted. ▶▶Lymphatics
The lymphatics drain into the external iliac and internal iliac
▶▶Blood Supply (hypogastric) lymph nodes.
A. Arterial
TESTIS
The external spermatic artery, a branch of the inferior epigas-
tric, supplies the fascial coverings of the cord. The internal ▶▶Gross Appearance
spermatic artery passes through the cord on its way to the
testis. The deferential artery is close to the vas. A. Anatomy
The average testicle measures about 4 × 3 × 2.5 cm
B. Venous (Figure 1–7). The volume can be measured by an orchidom-
The veins from the testis and the coverings of the spermatic eter or by a formula with ultrasonic measurement (length ×
cord form the pampiniform plexus, which, at the internal width × height × 0.71). The average volume is 18 mL (rang-
inguinal ring, unites to form the spermatic vein. ing from 12 to 30 mL). The testicle has a dense fascial cov-
ering called the tunica albuginea testis, which, posteriorly,
is invaginated somewhat into the body of the testis to form
▶▶Lymphatics the mediastinum testis. This fibrous mediastinum sends
The lymphatics from the spermatic cord empty into the fibrous septa into the testis, thus separating it into about
external iliac lymph nodes. 250 lobules.

The testis is covered anteriorly and laterally by the visceral SCROTUM

layer of the serous tunica vaginalis, which is continuous with
the parietal layer that separates the testis from the scrotal ▶▶Gross Appearance
wall (Bidarkar and Hutson, 2005). A small amount of fluid
normally exists within the tunica vaginalis sac. At the upper Beneath the corrugated skin of the scrotum lies the dartos
pole of the testis is the appendix testis, a small pedunculated muscle. Deep to this are the three fascial layers derived from
or sessile body similar in appearance to the appendix of the the abdominal wall at the time of testicular descent. Beneath
epididymis. these is the parietal layer of the tunica vaginalis (Kim et al,
2007).
B. Relations The scrotum is divided into two sacs by a septum of con-
nective tissue. The scrotum not only supports the testes but
The testis is closely attached posterolaterally to the epididy- also, by relaxation or contraction of its muscular layer, helps
mis, particularly at its upper and lower poles (Klonisch et al, to regulate their temperature.
2004).
▶▶Histology
▶▶Histology (Figure 1–7) The dartos muscle, under the skin of the scrotum, is nonstri-
Each lobule contains one to four markedly convoluted ated. The deeper layer is made up of connective tissue.
seminiferous tubules, each of which is about 60 cm long.
These ducts converge at the mediastinum testis, where ▶▶Blood Supply
they connect with the efferent ducts that drain into the A. Arterial
epididymis.
The seminiferous tubule has a basement membrane con- The arteries to the scrotum arise from the femoral, internal
taining connective and elastic tissue. This supports the semi- pudendal, and inferior epigastric arteries.
niferous cells that are of two types: (1) Sertoli (supporting)
cells and (2) spermatogenic cells. The stroma between the B. Venous
seminiferous tubules contains connective tissue in which the The veins are paired with the arteries.
interstitial Leydig cells are located.
▶▶Lymphatics
▶▶Blood Supply The lymphatics drain into the superficial inguinal and subin-
The blood supply to the testes is closely associated with that guinal lymph nodes.
to the kidneys because of the common embryologic origin of
the two organs. PENIS AND MALE URETHRA
A. Arterial
The arteries to the testes (internal spermatics) arise from the The penis is composed of two corpora cavernosa and the
aorta just below the renal arteries and course through the corpus spongiosum, which contains the urethra. The corpus
spermatic cords to the testes, where they anastomose with spongiosum enlarges distally and forms the glans penis. Each
the arteries of the vasa deferentia that branch off from the corpus is enclosed in a fascial sheath (tunica albuginea), and
internal iliac (hypogastric) artery. all three corpora are surrounded by a thick fibrous envelope
known as Buck’s fascia. A covering of skin, devoid of fat, is
B. Venous loosely wrapped these bodies. The prepuce forms a hood
The blood from the testis returns in the pampiniform plexus over the glans.
of the spermatic cord. At the internal inguinal ring, the Beneath the skin of the penis (and scrotum) and extend-
pampiniform plexus forms the spermatic vein. ing from the base of the glans to the urogenital diaphragm is
The right spermatic vein enters the vena cava just below Colles’ fascia, which is continuous with Scarpa’s fascia of the
the right renal vein; the left spermatic vein empties into the lower abdominal wall (Figure 1–8).
left renal vein. The proximal ends of the corpora cavernosa are attached
to the pelvic bones just anterior to the ischial tuberosities.
The ischiocavernosus muscles insert into the lateral surface
▶▶Lymphatics of the tunica albuginea at the proximal corpora cavernosa.
The lymphatic vessels from the testes pass to the lumbar Occupying a depression of their ventral surface in the midline
lymph nodes, which, in turn, are connected to the medias- is the corpus spongiosum, which is connected proximally to
tinal nodes. the undersurface of the urogenital diaphragm, below which

lies the urethral bulb. This portion of the corpus spongiosum FEMALE URETHRA
is surrounded by the bulbospongiosus muscle.
The suspensory ligament of the penis arises from the linea ▶▶Gross Appearance
alba and pubic symphysis and inserts into the fascial covering
of the corpora cavernosa. The adult female urethra is about 4 cm long and 8 mm in
diameter. It is slightly curved and lies beneath the pubic sym-
physis just anterior to the vagina.
▶▶Histology
A. Corpora and Glans Penis ▶▶Histology
The corpora cavernosa, the corpus spongiosum, and the The epithelial lining of the female urethra is squamous in
glans penis are composed of smooth muscles, intracaverno- its distal portion and pseudostratified or transitional in the
sal struts (corpus cavernosum only), and endothelium-lined remainder. The submucosa is made up of connective and
sinusoids. The sympathetic and parasympathetic (as well as elastic tissues and spongy venous spaces. Embedded in it are
the nonadrenergic, noncholinergic [NANC]) nerve termi- many periurethral glands, which are most numerous distally;
nals are often seen around the vessels and near the smooth the largest of these are the periurethral glands of Skene that
muscles. open on the floor of the urethra just inside the meatus.
External to the submucosa is a longitudinal layer of
B. Urethra smooth muscle continuous with the inner longitudinal
layer of the bladder wall. Surrounding this is a heavy layer
The urethral mucosa that traverses the glans penis is formed
of circular smooth-muscle fibers extending from the exter-
of squamous epithelium. Proximal to this, the mucosa is tran-
nal vesical muscular layer. This constitutes the involuntary
sitional in type. Underneath the mucosa is the submucosa that
internal urethral sphincter. Distal to this is the external stri-
contains connective and elastic tissue and smooth muscle. In
ated (voluntary) sphincter surrounding the middle third of
the submucosa are the numerous glands of Littre, whose ducts
the urethra composed of smooth and striated muscles within
connect with the urethral lumen. The urethra is surrounded by
the midurethra (Ashton-Miller and Delancey, 2009; Morgan
the vascular corpus spongiosum and the glans penis.
et al 2009; Thor and de Groat, 2010).
▶▶Blood Supply ▶▶Blood Supply

A. Arterial The arterial supply to the female urethra is derived from the
The penis and urethra are supplied by the internal pudendal inferior vesical, vaginal, and internal pudendal arteries. Blood
arteries. Each artery divides into a cavernous artery of the from the urethra drains into the internal pudendal veins.
penis (which supplies the corpora cavernosa), a dorsal artery
of the penis, and the bulbourethral artery. These branches ▶▶Lymphatics
supply the corpus spongiosum, the glans penis, and the ure- Lymphatic drainage from the external portion of the urethra
thra. Accessory pudendal arteries originate from inferior is to the inguinal and subinguinal lymph nodes. Drainage
vesical, obturator, or other arteries may also supply the penis from the deep urethra is into the internal iliac (hypogastric)
(Henry et al, 2017). lymph nodes.
B. Venous BIBLIOGRAPHY
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17
2
Embryology of the
Genitourinary System
Emil A. Tanagho, MD; Hiep T. Nguyen, MD;

& Michael DiSandro, MD
At birth, the genital and urinary systems are related only in nearby primary nephric duct as it grows caudally to join
the sense that they share certain common passages. Embryo- the cloaca (Figure 2–1). This primary nephric duct is now
logically, however, they are intimately related. Because of the called the mesonephric duct. After establishing their con-
complex interrelationships of the embryonic phases of the nection with the nephric duct, the primordial tubules elon-
two systems, they are discussed here as five subdivisions: gate and become S-shaped. As the tubules elongate, a series
the nephric system, the vesicourethral unit, the gonads, the of secondary branches increase their surface exposure,
genital duct system, and the external genitalia. thereby enhancing their capacity for interchanging material
with the blood in adjacent capillaries. Leaving the glomeru-
NEPHRIC SYSTEM lus, the blood is carried by one or more efferent vessels that
soon break up into a rich capillary plexus closely related to
The nephric system develops progressively as three distinct
the mesonephric tubules. The mesonephros, which forms
entities: pronephros, mesonephros, and metanephros.
early in the 4th week, reaches its maximum size by the end
of the second month.
▶▶Pronephros
The pronephros is the earliest nephric stage in humans, and ▶▶Metanephros
it corresponds to the mature structure of the most primitive
The metanephros, the final phase of development of the
vertebrate. It extends from the 4th to the 14th somites and
nephric system, originate from both the intermediate meso-
consists of 6–10 pairs of tubules. These open into a pair of
derm and the mesonephric duct. Development begins in the
primary ducts that are formed at the same level, extend cau-
5–6-mm embryo with a budlike outgrowth from the meso-
dally, and eventually reach and open into the cloaca. The pro-
nephric duct as it bends to join the cloaca. This ureteral bud
nephros is a vestigial structure that disappears completely by
grows cephalad and collects mesoderm from the nephro-
the 4th week of embryonic life (Figure 2–1).
genic cord of the intermediate mesoderm around its tip. This
mesoderm with the metanephric cap moves, with the grow-
▶▶Mesonephros ing ureteral bud, more and more cephalad from its point of
The mature excretory organ of the larger fish and amphib- origin. During this cephalic migration, the metanephric cap
ians corresponds to the embryonic mesonephros. It is becomes progressively larger, and rapid internal differentia-
the principal excretory organ during early embryonic life tion takes place. Meanwhile, the cephalic end of the ureteral
(4–8 weeks). It, too, gradually degenerates, although parts bud expands within the growing mass of metanephrogenic
of its duct system become associated with the male repro- tissue to form the renal pelvis (Figure 2–1). Numerous out-
ductive organs. The mesonephric tubules develop from the growths from the renal pelvic dilatation push radially into
intermediate mesoderm caudal to the pronephros shortly this growing mass and form hollow ducts that branch and
before pronephric degeneration. The mesonephric tubules rebranch as they push toward the periphery. These form the
differ from those of the pronephros in that they develop a primary collecting ducts of the kidney. Mesodermal cells
cuplike outgrowth into which a knot of capillaries is pushed. become arranged in small vesicular masses that lie close to
This is called Bowman’s capsule, and the tuft of capillaries the blind end of the collecting ducts. Each of these vesicular
is called a glomerulus. In their growth, the mesonephric masses will form a uriniferous tubule draining into the duct
tubules extend toward and establish a connection with the nearest to its point of origin.

▲▲Figure 2–1. Schematic representation of the development of the nephric system. Only a few of the tubules of the
pronephros are seen early in the 4th week, while the mesonephric tissue differentiates into mesonephric tubules that
progressively join the mesonephric duct. During this time, the first sign of the ureteral bud from the mesonephric duct is
seen. At 6 weeks, the pronephros has completely degenerated and the mesonephric tubules start to do so. The ureteral
bud grows dorsocranially and has met the metanephrogenic cap. At the 8th week, there is cranial migration of the differ-
entiating metanephros. The cranial end of the ureteric bud expands and starts to show multiple successive outgrowths.
(Data from several sources.)
As the kidney grows, increasing numbers of tubules are the ends of the anterior pronephric tubules; (4) this pronephric
formed in its peripheral zone. These vesicular masses develop duct serves subsequently as the mesonephric duct and as such
a central cavity and become S-shaped. One end of the S gives rise to the ureter; (5) the nephric duct reaches the cloaca
coalesces with the terminal portion of the collecting tubules, by independent caudal growth; and (6) the embryonic ureter
resulting in a continuous canal. The proximal portion of the is an outgrowth of the nephric duct, yet the kidney tubules dif-
S develops into the distal and proximal convoluted tubules ferentiate from adjacent metanephric blastema.
and into Henle’s loop; the distal end becomes the glomeru-
lus and Bowman’s capsule. At this stage, the undifferentiated
mesoderm and the immature glomeruli are readily visible on ▶▶Molecular Mechanisms of Renal and
microscopic examination (Figure 2–2). The glomeruli are
Ureteral Development
fully developed by the 36th week or when the fetus weighs The kidney and the collecting system originate from the
2500 g (Osathanondh and Potter, 1964a, b). The metaneph- interaction between the mesonephric duct (Wolffian duct)
ros arises opposite the 28th somite (fourth lumbar segment). and the metanephric mesenchyme (MM). The uretic bud
At term, it has ascended to the level of the first lumbar or (UB) forms as an epithelial outpouching from the meso-
even the twelfth thoracic vertebra. This ascent of the kidney nephric duct and invades the surrounding MM. Reciprocal
is due not only to actual cephalic migration but also to differ- induction between the UB and MM results in branching
ential growth in the caudal part of the body. During the early and elongation of the UB from the collecting system and in
period of ascent (7th–9th weeks), the kidney slides above the condensation and epithelial differentiation of MM around
arterial bifurcation and rotates 90°. Its convex border is now the branched tips of the UB. Branching of the UB occurs
directed laterally, not dorsally. Ascent proceeds more slowly approximately 15 times during human renal development,
until the kidney reaches its final position. generating approximately 300,000 and 1 million nephrons
Certain features of these three phases of development must per kidney (Nyengaard and Bendtsen, 1992).
be emphasized: (1) the three successive units of the system This process of reciprocal induction is dependent on the
develop from the intermediate mesoderm; (2) the tubules at all expression of specific factors. Glial cell-derived neurotrophic
levels appear as independent primordia and only secondarily factor (GDNF) is the primary inducer of ureteric budding
unite with the duct system; (3) the nephric duct is laid down (Costantini and Shakya, 2006). GDNF interacts with sev-
as the duct of the pronephros and develops from the union of eral different proteins from the MM (eg, Wt1, Pax2, Eyal,

EMBRYOLOGY OF THE GENITOURINARY SYSTEM CHAPTER 2 19
▲▲Figure 2–2. Progressive stages in the differentiation of the nephrons and their linkage with the branching collecting
tubules. A small lump of metanephric tissue is associated with each terminal collecting tubule. These are then arranged
in vesicular masses that later differentiate into a uriniferous tubule draining into the duct near which it arises. At one
end, Bowman’s capsule and the glomerulus differentiate; the other end establishes communication with the nearby
collecting tubules.
Six1, Sall1) and from the UB itself (Pax2, Lim1, Ret) result- termination and tubule maintenance (hepatocyte growth fac-
ing in outgrowth of the UB (reviewed by Shah et al, 2004). tor, transforming growth factor-α, epidermal growth factor
Proper activation of the Ret/GDNF signaling pathway in receptor) (reviewed by Shah et al, 2004). BMP7, SHH, and
the tip of UB epithelium appears to be essential in the pro- Wnt11 produced from the branching ureteric bud induce the
gression of branching morphogenesis (reviewed by Michos, MM to differentiate. These factors induce the activation of
2009). B-catenin and Gata3 are important regulators of Ret Pax2, α-8-integrin, and Wnt4 in the renal mesenchymal cells,
expression, and correct activity of Ret is regulated by posi- resulting in condensation of the MM and the formation of
tive (Wnt11 from MM) and negative (Sprouty1 from the UB) pretubular aggregate and primitive renal vesicle (reviewed by
feedback signaling. Additional specific factors are required for Burrow, 2000). With the continued induction from the UB
(1) early branching (eg, Wnt4 and Wnt11, fgf 7–10); (2) late and the autocrine activity of Wnt4, the pretubular aggregates
branching and maturation (bmp2, activin); and (3) branching differentiate into comma-shaped bodies. Platelet-derived

growth factor α-β and vascular endothelial growth factor ureter and is most commonly associated with an accessory
expression are required for initiating the migration of endo- ureteral bud in a duplicated system, but it also can be seen in
thelial cells into the cleft of the comma-shaped bodies to a single system. The migration and insertion of the ureteric
form rudimentary glomerular capillary tufts (reviewed by bud into the bladder depend on Ret gene activity and Ret
Burrow, 2000). Wt1 and Pod1 may have important functions gene expression and is mediated by the action of the retinoic
in the regulation of gene transcription necessary for the dif- acid and Gata3 gene (Schultza, 2016).
ferentiation of podocytes (Ballermann, 2005).
Fibroblast growth factors (FGF) are also important for
VESICOURETHRAL UNIT
early metanephric development, especially the receptors
Fgfr1 and Fgfr2. A loss of both these receptors leads to kid- The blind end of the hindgut caudal to the point of origin of
ney agenesis. Other signaling proteins include Six1 and Sall1. the allantois expands to form the cloaca, which is separated
Six1 is a homeobox protein essential for early kidney devel- from the outside by a thin plate of tissue (the cloacal mem-
opment. Sall1 is a transcription factor that is important for brane) lying in an ectodermal depression (the proctodeum)
the development of the metanephros. Lack of Sall1 leads to under the root of the tail. At the 4-mm stage, starting at the
renal agenesis (Krause, 2015). cephalic portion of the cloaca where the allantois and gut
meet, the cloaca progressively divides into two compartments
by the caudal growth of a crescentic fold, the urorectal fold.
ANOMALIES OF THE NEPHRIC SYSTEM
The two limbs of the fold bulge into the lumen of the cloaca
Failure of the metanephros to ascend leads to an ectopic kidney. from either side, eventually meeting and fusing. The division
An ectopic kidney may be on the proper side but low (simple of the cloaca into a ventral portion (urogenital sinus) and a
ectopy) or on the opposite side (crossed ectopy) with or with- dorsal portion (rectum) is completed during the 7th week.
out fusion. Failure to rotate during ascent causes a malrotated During the development of the urorectal septum, the cloacal
kidney. Fusion of the paired metanephric masses leads to vari- membrane undergoes a reverse rotation, so that the ectoder-
ous anomalies—most commonly a “horseshoe” kidney. mal surface is no longer directed toward the developing ante-
The ureteral bud from the mesonephric duct may bifur- rior abdominal wall but gradually is turned to face caudally
cate, causing a bifid ureter at various levels depending on and slightly posteriorly. This change facilitates the subdivision
the time of the bud’s subdivision. An accessory ureteral bud of the cloaca and is brought about mainly by development of
may develop from the mesonephric duct, thereby forming the infraumbilical portion of the anterior abdominal wall and
a duplicated ureter, usually meeting the same metaneph- regression of the tail. The mesoderm that passes around the
ric mass. Rarely, each bud has a separate metanephric mass, cloacal membrane to the caudal attachment of the umbilical
resulting in supernumerary kidneys. cord proliferates and grows, forming a surface elevation, the
If the double ureteral buds are close together on the meso- genital tubercle. Further growth of the infraumbilical part
nephric duct, they open near each other in the bladder. In of the abdominal wall progressively separates the umbilical
this case, the main ureteral bud, which is the first to appear cord from the genital tubercle. The division of the cloaca is
and the most caudal on the mesonephric ducts, reaches the completed before the cloacal membrane ruptures, and its two
bladder first. It then starts to move upward and laterally and parts therefore have separate openings. The ventral part is the
is followed later by the second accessory bud as it reaches the primitive urogenital sinus, which has the shape of an elon-
urogenital sinus. The main ureteral bud (now more cranial gated cylinder and is continuous cranially with the allantois;
on the urogenital sinus) drains the lower portion of the kid- its external opening is the urogenital ostium. The dorsal part
ney. The two ureteral buds reverse their relationship as they is the rectum, and its external opening is the anus.
move from the mesonephric duct to the urogenital sinus. Traditionally, it is believed that the urogenital sinus
This is why duplicated ureters always cross (Weigert–Meyer receives the mesonephric ducts. The caudal end of the meso-
law). If the two ureteral buds are widely separated on the nephric duct distal to the ureteral bud (the common excre-
mesonephric duct, the accessory bud appears more proximal tory duct) is progressively absorbed into the urogenital sinus.
on the mesonephric duct and therefore ends in the bladder By the 7th week, the mesonephric duct and the ureteral bud
more distal than usual, with an ectopic orifice lower than the have independent opening sites. This introduces an island of
normal one. This ectopic orifice could still be in the bladder mesodermal tissue amid the surrounding endoderm of the
close to its outlet, in the urethra, or even in the genital duct urogenital sinus. As development progresses, the opening
system (Figure 2–3). A single ureteral bud that arises more of the mesonephric duct (which will become the ejaculatory
proximal than normal on the mesonephric duct can also end duct) migrates downward and medially. The opening of the
in a similar ectopic location, although this is less common. ureteral bud (which will become the ureteral orifice) migrates
Lack of development of a ureteral bud results in a solitary upward and laterally. The absorbed mesoderm of the meso-
kidney and a hemitrigone. The ureteral bud may also develop nephric duct expands with this migration to occupy the area
or migrate into the bladder, abnormally leading to a uretero- limited by the final position of these tubes (Figure 2–3).
cele. A ureterocele is a cystic dilation of the distal intramural This will later be differentiated as the trigonal structure,

▲▲Figure 2–3. Development of the ureteral bud from the mesonephric duct and the relationship of both to the urogenital
sinus. The ureteral bud appears at the 4th week. The mesonephric duct distal to this ureteral bud is gradually absorbed
into the urogenital sinus, resulting in separate endings for the ureter and the mesonephric duct. The mesonephric tissue
that is incorporated into the urogenital sinus expands and forms the trigonal tissue.
which is the only mesodermal inclusion in the endodermal supported by more recent studies that suggest the trigone is
vesicourethral unit. formed mostly from bladder smooth muscle and less so from
More recent studies suggest an alternative path of devel- the ureters. Condensation of myoblasts in the region between
opment (reviewed by McInnes and Michaud, 2009). The the openings of the ureters and Wolffian ducts at 12 weeks of
right and left common excretory ducts appear to undergo gestation gives rise to the trigone, as a single circular muscu-
gradual programmed cell death; the elimination of the com- lar layer and the muscles from the distal ureters cross midline
mon excretory ducts brings the distal ureters into immediate to form the interureteral fold (Oswald et al, 2006).
contact with the urogenital sinus epithelium. Concurrently, The urogenital sinus can be divided into two main seg-
the ureters undergo a 180° rotation around the axis of the ments. The dividing line, the junction of the combined
mesonephric duct (also known as the Wolffian duct). The Müllerian ducts with the dorsal wall of the urogenital sinus, is
distal segment of the ureters then also undergoes apoptosis. an elevation called Müller’s tubercle, which is the most fixed
As a result, this process generates a new ureteral connection reference point in the whole structure and is discussed in a
point in the urogenital sinus region that will give rise to the subsequent section. The segments are as follows:
bladder, while the Wolffian duct remains in the region giving 1. The ventral and pelvic portion forms the bladder, part of
rise to the urethra. Further growth of the bladder and ure- the urethra in males, and the whole urethra in females.
thra moves the ureteral orifices cranially, while those to the This portion receives the ureter.
Wolffian ducts move caudally. This pattern of development is

2. The urethral, or phallic, portion receives the mesonephric The part of the urogenital sinus caudal to the opening of
and the fused Müllerian ducts. This will be part of the ure- the Müllerian duct forms the vaginal vestibule and contrib-
thra in males and forms the lower fifth of the vagina and utes to the lower fifth of the vagina in females (Figure 2–5).
the vaginal vestibule in females. In males, it forms the inframontanal part of the prostatic
During the 3rd month, the ventral part of the urogenital urethra and the membranous urethra. The penile urethra
sinus starts to expand and forms an epithelial sac whose apex is formed by the fusion of the urethral folds on the ventral
tapers into an elongated, narrowed urachus. The pelvic por- surface of the genital tubercle. In females, the urethral folds
tion remains narrow and tubular; it forms the whole urethra remain separate and form the labia minora. The glandular
in females and the supramontanal portion of the prostatic urethra in males is formed by canalization of the urethral
urethra in males. The splanchnic mesoderm surrounding the plate. The bladder originally extends up to the umbilicus,
ventral and pelvic portion of the urogenital sinus begins to where it is connected to the allantois that extends into the
differentiate into interlacing bands of smooth-muscle fibers umbilical cord. The allantois usually is obliterated at the level
and an outer fibrous connective tissue coat. By the 12th week, of the umbilicus by the 15th week. The bladder then starts to
the layers characteristic of the adult urethra and bladder are descend by the 18th week. As it descends, its apex becomes
recognizable (Figure 2–4). stretched and narrowed, and it pulls on the already obliterated
▲▲Figure 2–4. Differentiation of the urogenital sinus in males. At the 5th week, the progressively growing urorectal
septum separates the urogenital sinus from the rectum. The former receives the mesonephric duct and the ureteral
bud. It retains its tubular structure until the 12th week, when the surrounding mesenchyme starts to differentiate into
the muscle fibers around the whole structure. The prostate gland develops as multiple epithelial outgrowths just above
and below the mesonephric duct. During the 3rd month, the ventral part of the urogenital sinus expands to form the
bladder proper; the pelvic part remains narrow and tubular, forming part of the urethra. (Reproduced with permission
from Tanagho EA, Smith DR: Mechanism of urinary continence. I. Embryologic, anatomic and pathologic considerations, J Urol.
1968 Nov;100(5):640–646.)

▲▲Figure 2–5. Differentiation of the urogenital sinus and the Müllerian ducts in the female embryo. At 9 weeks, the
urogenital sinus receives the fused Müllerian ducts at Müller’s tubercle (sinovaginal node), which is solidly packed with
cells. As the urogenital sinus distal to Müller’s tubercle becomes wider and shallower (15 weeks), the urethra and fused
Müllerian duct will have separate openings. The distal part of the urogenital sinus forms the vaginal vestibule and the
lower fifth of the vagina (shaded area), and that part above Müller’s tubercle forms the urinary bladder and the entire
female urethra. The fused Müllerian ducts form the uterus and the upper four-fifths of the vagina. The hymen is formed at
the junction of the sinovaginal node and the urogenital sinus.
allantois, now called the urachus. By the 20th week, the blad- anterior lobe tubules are large and show multiple branches,
der is well separated from the umbilicus, and the stretched they gradually contract and lose most of the branches. They
urachus becomes the middle umbilical ligament. continue to shrink so that at birth, they show no lumen and
appear as small, solid embryonic epithelial outgrowths. In
contrast, the tubules of the posterior lobe are fewer in num-
PROSTATE ber yet larger, with extensive branching. These tubules, as
The prostate develops as multiple solid outgrowths of the they grow, extend posterior to the developing median and lat-
urethral epithelium both above and below the entrance of the eral lobes and form the posterior aspect of the gland, which
mesonephric duct. These simple tubular outgrowths begin to may be felt rectally.
develop in five distinct groups at the end of the 11th week and Prostate development results from complex interaction
are complete by the 16th week (112-mm stage). They branch between urogenital sinus epithelium and mesenchyme in
and rebranch, ending in a complex duct system that encoun- the presence of androgens (reviewed by Cunha et al, 2004,
ters the differentiating mesenchymal cells around this seg- and Thomson, 2008). Early in development, the androgen
ment of the urogenital sinus. These mesenchymal cells start receptors are solely expressed in the urogenital sinus mesen-
to develop around the tubules by the 16th week and become chyme. Under the influence of androgen, the mesenchyme
denser at the periphery to form the prostatic capsule. By the induces epithelial bud formation, regulates the growth and
22nd week, the muscular stroma is considerably developed, branching of epithelial bud, promotes differentiation of a
and it continues to increase progressively until birth. secretory epithelium, and specifies differential expression
From the five groups of epithelial buds, five lobes are eventu- of prostatic secretory proteins. Genome-wide analyses have
ally formed: anterior, posterior, median, and two lateral lobes. revealed critical molecular events in prostate development.
Initially, these lobes are widely separated, but later they meet, These include Nkx3.1, Sox, and homeobox genes for ductal
with no definite septa dividing them. Tubules of each lobe do morphology development; sonic hedgehog, fibroblast growth
not intermingle with each other but simply lie side by side. factor and the Wnt5a gene for bud development; and bone
The anterior lobe tubules begin to develop simultaneously morphogenic protein and notch genes for branching (Meeks,
with those of the other lobes. In the early stages, although the 2011). Other factors such as activin A serve to inhibit ductal

branching in order to maintain tissue homeostasis and regu- mesonephros is converted into a gonadal mesentery known
lated growth in the prostate. as the mesorchium. The cells of the germinal epithelium
grow into the underlying mesenchyme and form cordlike
ANOMALIES OF THE VESICOURETHRAL UNIT masses. These are radially arranged and converge toward the
mesorchium, where a dense portion of the blastemal mass
Failure of the cloaca to subdivide is rare and results in a
is also emerging as the primordium of the rete testis. A net-
persistent cloaca. Incomplete subdivision is more frequent,
work of strands soon forms that is continuous with the testis
ending with rectovesical, rectourethral, or rectovestibular
cords. The latter also split into three to four daughter cords.
fistulas (usually with imperforate anus or anal atresia).
These eventually become differentiated into the seminifer-
Failure of descent or incomplete descent of the blad-
ous tubules by which the spermatozoa are produced. The rete
der leads to a urinary umbilical fistula (urachal fistula),
testis unites with the mesonephric components that will form
urachal cyst, or urachal diverticulum depending on the
the male genital ducts, as discussed in a subsequent section
stage and degree of maldescent.
(Figure 2–6).
Development of the genital primordia in an area more
If the gonad develops into an ovary, it (like the testis) gains
caudal than normal can result in formation of the corpora
a mesentery (mesovarium) and settles in a more caudal posi-
cavernosa just caudal to the urogenital sinus outlet, with the
tion. During the 9th week the internal blastema differentiates
urethral groove on its dorsal surface. This defect results in
in the into a primary cortex beneath the germinal epithelium
complete or incomplete epispadias depending on its degree.
and a loose primary medulla. A compact cellular mass bulges
A more extensive defect results in bladder exstrophy. Failure
from the medulla into the mesovarium and establishes the
of fusion of urethral folds leads to various grades of hypospa-
primitive rete ovarii. At 3–4 months of age, the internal cell
dias. This defect, because of its mechanism, never extends
mass becomes young ova. A new definitive cortex is formed
proximal to the bulbous urethra. This is in contrast to epi-
from the germinal epithelium as well as from the blastema
spadias, which usually involves the entire urethra up to the
in the form of distinct cellular cords (Pflüger’s tubes), and a
internal meatus.
permanent medulla is formed. The cortex differentiates into
ovarian follicles containing ova.
GONADS
Genetically, in the presence of a Y chromosome, SRY (as
Most of the structures that make up the embryonic genital sys- known as testis determining factor [TDF]) induces the upreg-
tem have been taken over from other systems, and their read- ulation of Sox9 in the undifferentiated gonad (reviewed by
aptation to genital function is a secondary and relatively late Sekido, 2010). This in turn upregulates the expression of FGF9
phase in their development. The early differentiation of such and increases PGD2 synthesis, both helping to maintain Sox9
structures is therefore independent of sexuality. Furthermore, expression. Sox9 directs the differentiation of cells into Sertoli
each embryo is at first morphologically bisexual, possessing all cell by activating several downstream genes such as Amh,
the necessary structures for either sex. The development of one Cbln4, FGF9, and Ptgds. In the absence of a Y chromosome
set of sex primordia and the gradual involution of the other are and SRY, Rspo1 is upregulated in the undifferentiated gonads
determined by the sex of the gonad. (reviewed by Nef and Vassalli, 2009). Rspo1 is required for
The sexually undifferentiated gonad is a composite struc- Wnt4 expression, and together they activate β-catenin, which,
ture. Male and female potentials are represented by specific in turn, suppresses the formation of the testis cords by inhibit-
histologic elements (medulla and cortex) that have alterna- ing Sox9 and FGF9. A second pathway involving the upregu-
tive roles in gonadogenesis. Normal differentiation involves lation of Foxl2 also serves to inhibit Sox 9 and FGF9 activity,
the gradual predominance of one component. contributing to the development of the ovary.
The primitive sex glands appear during the 5th and 6th New genetic data on human sex determination from
weeks within a localized region of the thickening known as modern gene sequencing will create opportunities for the
the urogenital ridge (this contains both the nephric and the development of mechanistic models and should lead to
genital primordia). At the 6th week, the gonad consists of better understanding of this complex process (reviewed by
a superficial germinal epithelium and an internal blastema. Bashamboo, 2017).
The blastemal mass is derived mainly from proliferative
ingrowth from the superficial epithelium, which comes loose ▶▶Descent of the Gonads
from its basement membrane.
A. Testis
During the 7th week, the gonad begins to assume the
characteristics of a testis or ovary. Differentiation of the In addition to its early caudal migration, the testis later leaves
ovary usually occurs somewhat later than differentiation of the abdominal cavity and descends into the scrotum. By the
the testis. 3rd month of fetal life, the testis is located retroperitoneally
If the gonad develops into a testis, the gland increases in in the false pelvis. A fibromuscular band (the gubernacu-
size and shortens into a more compact organ while achiev- lum) extends from the lower pole of the testis through the
ing a more caudal location. Its broad attachment to the developing muscular layers of the anterior abdominal wall

▲▲Figure 2–6. Transformation of the undifferentiated genital system into the definitive male and female systems.

to terminate in the subcutaneous tissue of the scrotal swell- the 4-mm stage) joins the ventral part of the cloaca, which
ing. The gubernaculum also has several other subsidiary will be the urogenital sinus. This duct gives rise to the ureteral
strands that extend to adjacent regions. Just below the bud close to its caudal end. The ureteral bud grows cranially
lower pole of the testis, the peritoneum herniates as a and meets metanephrogenic tissue. The part of each meso-
diverticulum along the anterior aspect of the gubernacu- nephric duct caudal to the origin of the ureteric bud becomes
lum, eventually reaching the scrotal sac through the ante- absorbed into the wall of the primitive urogenital sinus so
rior abdominal muscles (the processus vaginalis). The testis that the mesonephric duct and ureter open independently.
remains at the abdominal end of the inguinal canal until the This is achieved at the 15-mm stage (7th week). During this
7th month. It then passes through the inguinal canal behind period, starting at the 10-mm stage, the Müllerian ducts start
(but invaginating) the processus vaginalis. Normally, it to develop. They reach the urogenital sinus relatively late—at
reaches the scrotal sac by the end of the 8th month. the 30-mm stage (9th week); their partially fused blind ends
producing the elevation called Müller’s tubercle. Müller’s
B. Ovary tubercle is the most constant and reliable point of reference
in the whole system.
In addition to undergoing an early internal descent, the ovary If the gonad starts to develop into a testis (17-mm stage,
becomes attached through the gubernaculum to the tissues 7th week), the Wolffian duct will start to differentiate into
of the genital fold and then attaches itself to the developing the male duct system, forming the epididymis, vas deferens,
uterovaginal canal at its junction with the uterine (fallopian) seminal vesicles, and ejaculatory ducts, when the Müllerian
tubes. This part of the gubernaculum between the ovary and duct proceeds toward its junction with the urogenital sinus
uterus becomes the ovarian ligament; the part between the and immediately starts to degenerate. Only its upper and
uterus and the labia majora becomes the round ligament lower ends persist, the former as the appendix testis and the
of the uterus. These ligaments prevent extra-abdominal latter as part of the prostatic utricle.
descent, and the ovary enters the true pelvis. It eventually lies If the gonad starts to differentiate into an ovary (22-mm
posterior to the uterine tubes on the superior surface of the stage, 8th week), the Müllerian duct system forms the uter-
urogenital mesentery, which has descended with the ovary ine (fallopian) tubes, uterus, and most of the vagina. The
and now forms the broad ligament. A small processus vag- Wolffian ducts, aside from their contribution to the urogeni-
inalis forms and passes toward the labial swelling, but it is tal sinus, remain rudimentary.
usually obliterated at full term.
MALE DUCT SYSTEM
GONADAL ANOMALIES
The gonad may either (1) not develop (agenesis), (2) develop ▶▶Epididymis
incompletely (hypogenesis), (3) develop incorrectly (dysgen- Because of the proximity of the differentiating gonads and the
esis), or (4) develop correctly, but then suffer an embryologic nephric duct, some of the mesonephric tubules are retained
injury (eg, intrauterine torsion). Supernumerary gonads are as the efferent ductules, and their lumens become continu-
rare. The commonest anomaly involves descent of the gonads, ous with those of the rete testis. These tubules, together with
especially the testis. Retention of the testis in the abdomen or the part of the mesonephric duct into which they empty, will
arrest of its descent at any point along its natural pathway form the epididymis. Each coiled ductule makes a conical
is called cryptorchidism, which may be either unilateral or mass known as the lobule of the epididymis. The cranial end
bilateral. If the testis does not follow the main gubernacular of the mesonephric duct becomes highly convoluted, com-
structure but follows one of its subsidiary strands, it will end pleting the formation of the epididymis. This is an example of
in an abnormal position, resulting in an ectopic testis. direct inclusion of a nephric structure into the genital system.
Failure of union between the rete testis and mesonephros Additional mesonephric tubules, both cephalad and caudal
results in a testis separate from the male genital ducts (the to those that were included in the formation of the epididy-
epididymis) and azoospermia. mis, remain as rudimentary structures, that is, the appendix
of the epididymis and the paradidymis.
GENITAL DUCT SYSTEM
Alongside the indifferent gonads, there are, early in embry- ▶▶Vas Deferens, Seminal Vesicles, and
Ejaculatory Ducts
onic life, two different yet closely related ducts. One is pri-
marily a nephric duct (Wolffian duct), yet it also serves as a The mesonephric duct caudal to the portion forming the
genital duct if the embryo develops into a male. The other epididymis forms the vas deferens. Shortly before this duct
(Müllerian duct) is primarily a genital structure from the joins the urethra (urogenital sinus), a localized dilatation
start. (ampulla) develops, and the saccular convoluted structure
Both ducts grow caudally to join the primitive urogenital that will form the seminal vesicle is evaginated from its wall.
sinus. The Wolffian duct (known as the pronephric duct at The mesonephric duct between the origin of the seminal

vesicle and the urethra forms the ejaculatory duct. The whole tubes (fallopian tubes, oviducts) are the cephalic two-thirds
mesonephric duct now achieves its characteristic thick of the Müllerian ducts (Figure 2–6).
investment of smooth muscle, with a narrow lumen along
most of its length. ANOMALIES OF THE GONADAL DUCT SYSTEM
Both above and below the point of entrance of the meso-
Nonunion of the rete testis and the efferent ductules can
nephric duct into the urethra, multiple outgrowths of ure-
occur and, if bilateral, causes azoospermia and sterility.
thral epithelium mark the beginning of the development of
Failure of the Müllerian ducts to approximate or to fuse com-
the prostate. As these epithelial buds grow, they meet the
pletely can lead to various degrees of duplication in the geni-
developing muscular fibers around the urogenital sinus,
tal ducts. Congenital absence of one or both uterine tubes or
and some of these fibers become entangled in the branch-
of the uterus or vagina occurs rarely.
ing tubules of the growing prostate and become incorporated
Arrested development of the infratubercular segment of
into it, forming its muscular stroma (Figure 2–4).
the urogenital sinus leads to its persistence, with the urethra
and vagina having a common duct to the outside (urogenital
FEMALE DUCT SYSTEM sinus).
The Müllerian ducts, which are a paired system, are seen
alongside the mesonephric duct. It is not known whether EXTERNAL GENITALIA
they arise directly from the mesonephric ducts or separately During the 8th week, external sexual differentiation begins
as an invagination of the celomic epithelium into the paren- to occur. Not until 3 months, however, do the progressively
chyma lateral to the cranial extremity of the mesonephric developing external genitalia attain characteristics that can
duct, but the latter theory is favored. The Müllerian duct be recognized as distinctively male or female. During the
develops and runs lateral to the mesonephric duct. Its open- indifferent stage of sexual development, three small protu-
ing into the celomic cavity persists as the peritoneal ostium berances appear on the external aspect of the cloacal mem-
of the uterine tube (later it develops fimbriae). The other brane. In front is the genital tubercle, and on either side of the
end grows caudally as a solid tip and then crosses in front of membrane are the genital swellings.
the mesonephric duct at the caudal extremity of the meso- With the breakdown of the urogenital membrane (17-mm
nephros. It continues its growth in a caudomedial direction stage, 7th week), the primitive urogenital sinus achieves a
until it meets and fuses with the Müllerian duct of the oppo- separate opening on the undersurface of the genital tubercle.
site side. The fusion is partial at first, so there is a tempo-
rary septum between the two lumens. This later disappears,
leaving one cavity that will form the uterovaginal canal. The
MALE EXTERNAL GENITALIA
potential lumen of the vaginal canal is completely packed The urogenital sinus opening extends on the ventral aspect
with cells. The solid tip of this cord pushes the epithelium of the genital tubercle as the urethral groove. The primitive
of the urogenital sinus outward, where it becomes Müller’s urogenital orifice and the urethral groove are bound on either
tubercle (33-mm stage, 9th week). The Müllerian ducts fuse side by the urethral folds. The genital tubercle becomes elon-
at the 63-mm stage (13th week), forming the sinovaginal gated to form the phallus. The corpora cavernosa is indicated
node, which receives a limited contribution from the uro- in the 7th week as paired mesenchymal columns within the
genital sinus (this contribution forms the lower fifth of the shaft of the penis. By the 10th week, the urethral folds start
vagina). to fuse from the urogenital sinus orifice toward the tip of the
The urogenital sinus distal to Müller’s tubercle, originally phallus. At the 14th week, the fusion is complete and results
narrow and deep, shortens, widens, and opens to form the in the formation of the penile urethra. The corpus spongio-
floor of the pudendal or vulval cleft. This results in separate sum results from the differentiation of the mesenchymal
openings for the vagina and urethra and brings the vaginal masses around the formed penile urethra.
orifice to its final position nearer the surface. At the same The glans penis becomes defined by the development of a
time, the vaginal segment increases appreciably in length. circular coronary sulcus around the distal part of the phallus.
The vaginal vestibule is derived from the infratubercular seg- The urethral groove and the fusing folds do not extend
ment of the urogenital sinus (in males, the same segment will beyond the coronary sulcus. The glandular urethra develops
form the inframontanal part of the prostatic urethra and the as a result of canalization of an ectodermal epithelial cord that
membranous urethra). The labia minora are formed from the has grown through the glans. This canalization reaches and
urethral folds (in males they form the pendulous urethra). communicates with the distal end of the previously formed
The hymen is the remnant of the Müllerian tubercle. The penile urethra. During the 3rd month, a fold of skin at the
lower fifth of the vagina is derived from the portion of the base of the glans begins growing distally and, 2 months later,
urogenital sinus that combines with the sinovaginal node. surrounds the glans. This forms the prepuce. Meanwhile, the
The remainder of the vagina and the uterus are formed from genital swellings shift caudally and are recognizable as scrotal
the lower (fused) third of the Müllerian ducts. The uterine swellings. They meet and fuse, resulting in the formation of

the scrotum, with two compartments partially separated by Michos O: Kidney development: From ureteric bud formation
a median septum and a median raphe, indicating their line to branching morphogenesis. Curr Opin Genet Dev 2009;19:
of fusion. 484–490.
Mcinnes RR, Michaud JL: Plumbing in the embryo: Development
defects of the urinary tracts. Clin Genet 2009;75:307–317.
FEMALE EXTERNAL GENITALIA
Nef S, Vassalli JD: Complementary pathways in mammalian female
Until the 8th week, the appearance of the female external geni- sex determination. J Biol 2009;8:74.
talia closely resembles that of the male genitalia except that the Nyengaard JR, Bendtsen TF: Glomerular number and size in relation
urethral groove is shorter. The genital tubercle, which becomes to age, kidney weight, and body surface in normal man. Anat Rec
bent caudally and lags in development, becomes the clitoris. As 1992;232(2):194–201.
in males (albeit on a minor scale), mesenchymal columns differ- Oswald J et al: Reevaluation of the fetal muscle development of the
entiate into corpora cavernosa, and a coronary sulcus identifies vesical trigone. J Urol 2006;176(3):1166–1170.
the glans clitoridis. The most caudal part of the urogenital sinus Reddy PP, Mandell J: Prenatal diagnosis: Therapeutic implications.
Urol Clin North Am 1998;25:171.
shortens and widens, forming the vaginal vestibule. The urethral
folds do not fuse but remain separate as the labia minora. The Sekido R: SRY: A transcriptional activator of mammalian testis deter-
mination. Int J Biochem Cell Biol 2010;42(3):417–420.
genital swellings meet in front of the anus, forming the posterior
Shah MM et al: Branching morphogenesis and kidney disease.
commissure, while the swellings enlarge and remain separated Development 2004;131(7):1449–1462.
on either side of the vestibule and form the labia majora.
Stephens FD: Embryopathy of malformations. J Urol 1982;127:13.
Stephens FD: Congenital Malformations of the Urinary Tract. Prae-
ANOMALIES OF THE EXTERNAL GENITALIA ger, New York, 1983.
Absence or duplication of the penis or clitoris is very rare. Tanagho EA: Embryologic development of the urinary tract. In: Ball
More commonly, the penis remains rudimentary or the cli- TP (ed): AUA Update Series. American Urological Association,
Philadelphia, 1982.
toris shows hypertrophy. These anomalies may be seen alone
Tanagho EA: Developmental anatomy and urogenital abnormalities.
or, more frequently, in association with differences of sex
In: Raz S (ed): Female Urology. 2nd ed. Saunders, Philadelphia,
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penis and scrotum are relatively rare anomalies. Thomson AA: Mesenchymal mechanisms in prostate organogenesis.
Failure or incomplete fusion of the urethral folds results Differentiation 2008;76(6):587–598.
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ment is also anomalous in cases of epispadias and exstrophy Review for practicing urologist. Urology 1975;6:139.
(see preceding discussion).
Anomalies of the Nephric System

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31
3
Symptoms of Disorders of
the Genitourinary Tract
In the workup of any patient, the history is of paramount General malaise may be noted with tumors, chronic
importance; this is particularly true in urology. It is neces- pyelonephritis, or renal failure. The presence of many of
sary to discuss here only those urologic symptoms that are these symptoms may be compatible with human immunode-
apt to be brought to the physician’s attention by the patient. ficiency virus (HIV; see Chapter 17).
It is important to know not only whether the disease is acute
or chronic but also whether it is recurrent, since recurring LOCAL AND REFERRED PAIN
symptoms may represent acute exacerbations of chronic
disease. Two types of pain have their origins in the genitourinary
Obtaining the history is an art that depends on the skill organs: local and referred. The latter is especially common.
and methods used to elicit information. The history is only Local pain is felt in or near the involved organ. Thus, the
as accurate as the patient’s ability to describe the symptoms. pain from a diseased kidney (T10–T12, L1) is felt in the cos-
This subjective information is important in establishing an tovertebral angle and in the flank in the region of and below
accurate diagnosis. the 12th rib. Pain from an inflamed testicle is felt in the gonad
itself.
SYSTEMIC MANIFESTATIONS Referred pain originates in a diseased organ but is felt at
some distance from that organ. The ureteral colic (Figure 3–1)
Symptoms of fever and weight loss should be sought. The
caused by a stone in the upper ureter may be associated with
presence of fever associated with other symptoms of urinary
severe pain in the ipsilateral testicle; this is explained by the
tract infection may be helpful in evaluating the site of the
common innervation of these two structures (T11–T12).
infection. Simple acute cystitis is essentially an afebrile dis-
A stone in the lower ureter may cause pain referred to the
ease. Acute pyelonephritis or prostatitis is apt to cause high
scrotal wall; in this instance, the testis itself is not hyperes-
temperatures (≤40°C [104°F]), often accompanied by violent
thetic. The burning pain with voiding that accompanies
chills. Infants and children who have acute pyelonephritis
acute cystitis is felt in the distal urethra in females and in the
may have high temperatures without other localizing symp-
glandular urethra in males (S2–S3).
toms or signs. Such a clinical picture, therefore, invariably
Abnormalities of a urologic organ can also cause pain in
requires bacteriologic study of the urine.
any other organ (eg, gastrointestinal, gynecologic) that has a
A history of unexplained attacks of fever occurring even
sensory nerve supply common to both (Figures 3–2 and 3–3).
years before may otherwise represent asymptomatic pyelo-
nephritis. Renal carcinoma sometimes causes fever that may
reach 39°C (102.2°F) or more. The absence of fever does not ▶▶Kidney Pain (Figure 3–1)
by any means rule out renal infection, for it is the rule that Typical renal pain is felt as a dull and constant ache in the
chronic pyelonephritis does not cause fever. costovertebral angle just lateral to the sacrospinalis muscle
Weight loss is to be expected in the advanced stages of and just below the 12th rib. This pain often spreads along
cancer, but it may also be noticed when renal insufficiency the subcostal area toward the umbilicus or lower abdominal
due to obstruction or infection supervenes. In children who quadrant. It may be expected in the renal diseases that cause
have “failure to thrive” (low weight and less than average sudden distention of the renal capsule. Acute pyelonephritis
height for their age), chronic obstruction, urinary tract infec- (with its sudden edema) and acute ureteral obstruction (with
tion, or both should be suspected. its sudden renal back pressure) both cause this typical pain.

▲▲Figure 3–1. Referred pain from kidney (dotted areas) and ureter (shaded areas).
It should be pointed out, however, that many urologic renal The physician may be able to judge the position of a ure-
diseases are painless because their progression is so slow that teral stone by the history of pain and the site of referral. If the
sudden capsular distention does not occur. Such diseases stone is lodged in the upper ureter, the pain radiates to
include cancer, chronic pyelonephritis, staghorn calculus, the testicle, since the nerve supply of this organ is simi-
tuberculosis, polycystic kidney, and hydronephrosis due to lar to those of the kidney and upper ureter (T11–T12).
chronic ureteral obstruction. With stones in the midportion of the ureter on the right side,
the pain is referred to McBurney’s point and may therefore
▶▶Ureteral Pain (Figure 3–1) simulate appendicitis; on the left side, it may resemble diver-
ticulitis or other diseases of the descending or sigmoid colon
Ureteral pain is typically stimulated by acute obstruction (pas-
(T12, L1). As the stone approaches the bladder, inflamma-
sage of a stone or a blood clot). In this instance, there is back
tion and edema of the ureteral orifice ensue, and symptoms
pain from renal capsular distention combined with severe col-
of vesical irritability such as urinary frequency and urgency
icky pain (due to renal pelvic and ureteral muscle spasm) that
may occur. It is important to realize, however, that in mild
radiates from the costovertebral angle down toward the lower
ureteral obstruction, as seen in the congenital stenoses, there
anterior abdominal quadrant, along the course of the ureter.
is usually no pain, either renal or ureteral.
In men, it may also be felt in the bladder, scrotum, or testicle.
In women, it may radiate into the vulva. The severity and col-
icky nature of this pain are caused by the hyperperistalsis and ▶▶Vesical Pain
spasm of this smooth-muscle organ as it attempts to rid itself The overdistended bladder of the patient in acute urinary
of a foreign body or to overcome obstruction. retention causes agonizing pain in the suprapubic area. Other

SYMPTOMS OF DISORDERS OF THE GENITOURINARY TRACT CHAPTER 3 33
▲▲Figure 3–2. Diagrammatic representation of autonomic nerve supply to gastrointestinal and genitourinary tracts.

▲▲Figure 3–3. Diagrammatic representation of sensory nerves of gastrointestinal and genitourinary tracts.

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Title: A summer journey in the west
Author: Eliza R. Steele
Release date: September 25, 2023 [eBook #71725]
Language: English
Original publication: NYC: John. S. Taylor, and Co, 1841
Credits: Chuck Greif and the Online Distributed Proofreading Team

at https://www.pgdp.net (This file was produced from
images generously made available by The Internet Archive)
*** START OF THE PROJECT GUTENBERG EBOOK A SUMMER

JOURNEY IN THE WEST ***
LETTER I., II., III., IV., V., VI., VII., VIII., IX., X., XI.
Numerous typographical errors have been corrected.—Etext
transcriber.
A SUMMER JOURNEY IN THE WEST.
A
SUMMER JOURNEY
BY
Mrs. STEELE.
NEW-YORK.
PUBLISHED BY JOHN S. TAYLOR,
145 Nassau Street.
SUMMER JOURNEY IN THE

WEST.
BY MRS. STEELE,
AUTHOR OF HEROINES OF SACRED HISTORY.
“I write that which I have seen”—Le Baum.
NEW YORK:
JOHN S. TAYLOR, AND CO.
(Brick Church Chapel, 145 Nassau-St.)
1841.
Entered according to the Act of Congress, in the year 1841, by

JOHN S.
TAYLOR & CO.
in the Clerk’s Office of the District Court for the
Southern District of New York.
P R E FA C E .
This little book assumes to be nothing more than a note book of all that
passed before the observation of the author, during a summer tour of four
thousand miles, through the great lakes; the prairies of Illinois; the rivers
Illinois, Mississippi, and Ohio; and over the Alleghany mountains to New
York. Since she has been ‘urged by friends to print,’ the author has added to
her notes and letters, some little information regarding the western States, in
hopes her book may be of use to future tourists and emigrants, who will
here find an account of the distances, prices, and conveyances, throughout
the author’s route. Anxious to guard against errors, information acquired
upon the road, has been compared with the best Gazeteers. Accuracy, in a
newly settled country, is difficult, and accounts differ much; still the author
trusts the traveller who may honor her by taking her book for his guide, will
not be far mis-led.
New York, May, 1841.
A SUMMER JOURNEY.
“I write that which I have seen”—Le Baum.
LETTER I.
June 14th, 1840.
My dear E.—The variety of scenes which have passed before my eyes
since I last beheld you, and the crowd of new ideas acquired thereby, have
not obliterated your Shaksperian adieu from my mind:
“Think on thy Proteus, when thou haply see’st

Some rare note-worthy object in thy travels,”
were your last words—in consequence of this desire, I hereby send you all I
deem note-worthy. With what delight did I find myself once more upon the
Hudson! Although so often seen, to me it is still lovely, for custom cannot
stale its beauties. I pass along this river as through a gallery of cabinet
pictures. The sunny vista and romantic glen of Gainsborough—the
frowning cliff and murderous dell of Rosa—the Dutch cottage of Teniers—
the Italian villa and graceful trees of classic Weir—cattle, as if just sprung
from out a Berghman and grouped upon the shore, or standing ‘in the cool
translucent wave,’ their ‘loose train of amber-dropping hair,’ not being
‘braided with lilies,’ but occupied in flapping the flies away!—all these, and
many more are placed side by side before me as I float along.
You have never seen this famed stream, and I will therefore describe it to
you minutely. Mine will not be ‘notes by the way,’ nor ‘crayoning,’ nor
‘pencil sketches,’ but perfect Daguerrotype likenesses of all I see.
With a bold rush our steamboat was free of the wharf and out into the
stream. Ascend now to the upper deck with me and you will obtain a fine
view of the city of New York and its noble bay. Upon one side lies the city
with its mass of houses, churches, and vessels; beyond is Long Island.
Observe what a pretty back ground is Staten Island: its numerous white
buildings show well against the green elevated ridge behind them; then turn
your eye to the opposite side and you will behold New Jersey, with its
pretty city, and villages, and churches; and in the center of all this is the
glassy water covered with steamboats, brigs, ships of war, and vessels of all
sizes, and dotted with pretty fortress islets. Hoboken with its neat church
and romantic colonade are passed, and the rugged cliffs of Weehawken rise
upon our left as we ascend the river. These cliffs are the commencement of
the Palisade rocks, which soon retreat into the interior to arise again above.
Bull’s Ferry (worthy of a better name,) next appears, with Fort Lee, pretty
rural retreats, whose white houses, churches, and fences, are pencilled as
with white chalk upon the river’s green and sloping bank.
From the east side, turret and spire have passed away, and villages and
country seats adorn the shores until we arrive at Spuyten Duyvel creek,
rendered famous by the redoubtable Van Corlear, who swore he would pass
it in spigt den Duyvel; and also as being the boundary line of Manhattan
Island. To a hasty observer, the shores beyond this are as lonely and wild as
if we were hundreds of miles from any city; but if you will fix your eyes
steadily upon the woodlands which line the river banks, you will catch
glimpses, between the trees, of Grecian portico, Yankee piazza, or Dutch
gable, telling of many a summer haunt of the city’s ‘tired denizen.’
Upon the west side the Palisade commences, a perpendicular wall, or to
speak more scientifically, ‘a columnar escarpement,’ from three to eight
hundred feet high, and two miles broad, thus continuing for twenty miles
along the New Jersey side of the river. As you dabble in geology, I must not
forget to tell you these rocks are of the trap formation, passing into green
stone. Under it are layers of slate, sandstone, and grey limestone, much of
which is used in the city and its neighborhood. Sloops were lying at the foot
of the rocks, as we passed, taking in their load of sandstone flagging, or
roofing slate for the use of the citizens. These sloops, which carry masts
sixty or seventy feet high, show the height of these cliffs, as when seen
anchored below them they appear like skiffs. A few stone-cutters have
erected cottages upon the rocks, which might be taken for children’s houses.
Shrubbery is seen in some spots, while a green fringe of trees is waving
from the summit. These rocks have stood the brunt of that mighty torrent
which wise men tell us once rushed over the country from the north-west,
as if some lake had burst its barrier—for bowlders washed from the
Palisades are seen in various parts of Manhattan Island and Long Island. To
the alluvium brought down by this flood, we are indebted for Manhattan
Island and Staten Island. What a pity ‘wise saws’ are out of fashion, or I
could lengthen my epistle by telling what ‘modern instances’ these islands
are, of the ‘good’ brought down by ‘ill winds.’
As we are both now tired of these Palisades, it is very pretty of them to
retire as they do, into the country, making a fine back ground to the rich
land lying upon the river’s bank, adorned with several picturesque townlets.
These are Nyack, reclining upon a verdant slope; Haverstraw, nestled under
a high, green promontory; and Tappan, which ought to have been first
mentioned. This is, however, but the ‘landing’ of the town of that name,
lying a few miles in the interior, and whose ‘heavens’ ought to be ‘hung
with black,’ for the sake of the talented and unfortunate Andre, whose silver
cord was here untimely loosed.
The river swells out into a broad lake, called Tappan sea, which ought to
be spelled Tap-pann Zee. The west side I have described, except that from
these towns the ground rises into an elevated green ridge of Haverstraw, and
then descends gracefully to the water, ending in a low level spot, covered
with a rich velvet sward, dotted with groups of oaks, and evergreens, among
which a silver rivulet winds its happy way. This is very prettily called
Grassy Point.
Upon our right hand we have smooth, lawn-like slopes, over which the
buildings of Yonkers, Tarrytown, and Dobbs’ Ferry (harmonious sounds,)
are straggling, or reposing in graceful groups upon every gentle swell. Sing
Sing, with its long range of prisons, is before us; so called, I suppose, that
the inhabitants of those abodes may have something cheerful about them. It
is a lovely spot commanding a beautiful view of the river scenery—so
lovely that I am almost tempted to be wicked, that I may be ordered to
reside there, and sit like a Naiad sing singing upon a
“diamond rock,
Sleeking her soft alluring lock.”
That is all very well, you will say, when the rock is already cut out for you
to sit upon; but where one is obliged to hew out one’s own rock, as do these
woful sing-singers, it would be as well to abandon the place to the heroes
who there do congregate. They quarry a white granular limestone which is
used as building material. The antique Dutch church looks very well, seated
upon an eminence; and Wolfert’s Roost, with its Dutch points and gables,
the residence of the celebrated Irving, is another interesting object upon this
shore.
Look behind you quickly, if you would take a last farewell of Staten
Island, whose dark outline has, until now, filled up the back ground,
although we are thirty miles from it. As we turn towards the narrow outlet
between Stoney and Verplanck’s Points, the Palisades are sweeping around
to the east, and rapidly shoving in their side scene between us and the
Island. Now it is gone, and the Narrows are fast being covered, through
which you might, if your eyes could see so far, descry the green ocean and
its gallant barks. The river now seems a lake behind us, upon whose bright
bosom a fleet of vessels, like a flock of birds, are skimming, and ducking,
or reposing upon the water. Two Points defend the entrance to the
Highlands: Stony Point on the west, a bold rocky promontory, formed of
fine horneblend granite rock, and surmounted by a light-house; Verplanck’s
on the east presents a small village, containing a pretty fanciful hotel, and
some lordly dwellings upon the elevated ground above. These are now
behind us, and we find ourselves in the Grand Pass of the Highlands.
Beautiful creations they are—high, green cones, sweeping gradually down
to the water’s edge, where they sometimes appear a verdant precipice nearly
two thousand feet high; or projecting their spurs into the river, and crossing
each other so that the Hudson must wind hither and thither to follow the
tortuous path between them. Various lights give new beauties to these hills.
It is pleasant when the sun shines broad and bright upon them, to penetrate
with your eye their green recesses, or endeavor to distinguish whether those
bushes on the summit are indeed trees or no; and again when a cloud
passes, running rapidly over the surface, the effect is very beautiful. As we
were near the centre of the Pass, the sun was obscured, and a heavy shower
clothed every thing with gloom.—Through the sombre light they seemed
like giant mastadon or mammoth of olden times, couching down upon each
side, musing upon the changes which have taken place upon this diluvial
earth. The rain has ceased, and the mist has all retired into the mountain
caves, save on one spot near the summit, where it lowering stands, like one
of Ossian’s ghosts, whose wont it is, he tells us, to ‘fly on clouds, and ride
on winds.’ Or, it may be the wandering spirit of some red warrior who has
perished on these shores, and now haunts the scene of his former triumphs.
Upon a promontory jutting out from the river, are situated the Military
Schools of West Point. It is a summer’s day well spent to ramble over that
pretty spot. If you care not for the Schools, nor to see the orderly young
cadets, you may admire the monument dedicated to Kosciusco, or walk in
his garden as they call the spot where he used to ‘sit on rocks’ and muse
upon the sweets of Liberty—or you may climb up to that ruined fortress
crowning the summit of the mountain which overhangs the Point. From
thence you have a fine view of all the rugged, cultivated, wild, adorned and
varied country for miles around—and of that broad silver stream bearing
upon its waters many a graceful vessel. The dusky peaks and dells, and
undulations of the several mountains around are here distinctly seen.
The Dunderberg, where is the thunder’s home, raises its frowning head
at the right, followed by Bare Mountain, Sugar Loaf, Bull’s Hill, Crow’s
Nest, Butter Hill, Breakneck Hill, and many others bearing designations
equally euphonius. Among these hills, beside West Point, are many spots
famous in the history of our country. Do not be afraid, I am not going to
begin ‘In the year 17—’ nor tell of the iron chain which bound Anthony by
the nose to the Fort opposite; nor arouse your indignation by pointing to the
chimneys of Arnold’s house; nor make you sad by speaking again of Andre;
nor arouse your patriotism by relating the deeds here done in times of old.
Let the past be by-gones; and turn to the present whose sun is shining down
upon the pretty village of Cold Spring opposite to us, and upon that
romantic white chapel dedicated to ‘Our Lady of Cold Spring,’ which is so
tastefully perched upon a rock washed by the Hudson’s waters. At West
Point is a depot of fossil enfusoria, and sulphur has also been found.
Shooting out of the Highland Pass, we find ourselves in a broad expanse of
water, presenting some of the prettiest views to be seen upon the river.
Seated upon the elevations of the left bank are many towns; Newburgh
being the most conspicuous as it is the largest: and it is built upon a high
cliff of argillaceous slate, thus displaying its numerous houses and churches
to advantage. The opposite shore presents a beautiful green mountain wall,
the highest peak of which is 1689 feet above the river. At its foot reposes
the smiling town of Fishkill.
I must not linger thus by the way. Remember I have four thousand miles
to travel and the summer is passing. Imagine then to yourself a broad and
beautiful river, skirted with cultivated country with often a mountainous
back ground, and rich with ‘summer’s green emblazoned field’—and
wafting upon its waters river-craft of all forms, from the lazy whaler
returning after a four year’s cruise, to the little pleasure yacht. There are
many towns on this river, one of which, Poughkeepsie, is rendered famous
as being the place where Washington, Hamilton, Jay and Chancellor
Livingston met, to compose the Constitution of the United States. The city
of Hudson is agreeably situated upon the summit of a slaty cliff
commanding a view of the Catskill mountains, and the town of Athens on
the opposite bank of the river. Imagine, scattered like gems upon the
borders of the stream, pretty villas of Grecian, Gothic and nondescript
styles, the homes of the Livingstons, Dewitts, Ellisons, Verplancks, Van
Renselears, Schuylers, and other gentlemen of taste and wealth. I saw
nothing of those Dutch elves and fays which the genius of Irving has
conjured up, among the dells and rocks of the Hudson—those creatures are
unfortunately out of fashion; and one might as well look for them as for
high heeled shoes. Perhaps they will come in with the ancient modes. If I
thought so, I would immediately order hoop, train, cushion, buckle, high
heel, and all the odious costume which rendered my ancestresses so
hideous. Alas I fear the ‘mincing dryades’ with high crowned hats, are all
departed—and no more—
“On the tawny sands and shelves,

Trip the pert fairies, and the dapper elves.”
Albany appears at great advantage seated upon a side hill, presenting a

mass of imposing buildings surmounted by many a tall steeple, and
crowned by the Capitol and City Hall, from whose gilded dome the evening
sunbeams are brightly streaming.
I have said nothing about my gallant bark, nor my company—the first a
large and rapid steamboat, arranged with satin cushioned and canopied
saloons—the latter a mixture of all countries and sexes.
But we are at the wharf and I must put up my papers. Adieu.
LETTER II.
June 15th, 1840.
My dear E.—We shall of course remain in Albany during the Sabbath
for the pleasure of worshipping that kind Friend, who has showered upon us
the blessings we are now enjoying. In the morning we walked to the church
of a Baptist clergyman, Mr. W——h, who has been long celebrated as a
very interesting preacher. This church is a handsome marble structure,
surmounted by a dome, and adorned by a colonade of pillars in front. The
lecture room is below, and we ascended to the chapel, a neat apartment with
a good pulpit and commodious seats. Mr. W. sprang from an obscure
station, being a mechanic, and therefore could only obtain a common
education. What he is, he has made himself, or rather was made by the Holy
Spirit; for we all know how religion refines and elevates the intellect of
man, as well as his affections. After his conversion he rapidly improved,
and now one is astonished at the beauty and purity of his language. He is
not an animated preacher, nor does his forte lie in arousing a sinner; but he
shows forth the truth and beauty of religion, and expounds the Gospel
doctrines with a power and grace, and clearness, which fascinate the hearer.
This church is always crowded by the elite of Albanian society of all sects,
and by the strangers who are in the city.
In the afternoon we attended service in an old Dutch church, one of the
oldest in the city. It is built of brick, and boasts two spires which give it a
singular appearance. The interior is richly fitted up, with gilded chandeliers
and many comforts and elegant conveniences. Here we found ourselves
surrounded by the old Dutch families, whose fathers emigrated from
Holland and settled themselves here; among them were the family of the
Patroon. I looked around with pleasure upon the sober benevolent faces of
the congregation, for I have always felt a very kindly sentiment toward our
Dutch brethren. The peaceful, even tenor of their lives; their contented
spirit, their industry and integrity entitle them to our most ‘golden
opinions.’ The Rev. Mr. Y——, who officiates here, is an able, solid,
preacher, well versed in the fundamental truths of christianity.
I am happy to say, the people of this city, are a very moral and religious
people. This applies also to the ‘first society’—which is a singularity in city
history. Beneath their influence theatres, dissipation, and extravagance
cannot thrive. Already I seem to breathe freer, although so little distant from
New York; whose atmosphere, rank with foreign luxuries, is like a hot
house over-crowded by fragrant exotics; stifling us with perfume.
We admire this city, which however we have only been able to see in our
odds and ends of time. Its situation is very fine, it contains many handsome
buildings, and it is generally kept very neat. A broad street through the
centre leads up to a pretty square, surrounded by several imposing buildings
—the Capitol occupies a fine position here; it is of dark stone, with a neat
marble portico supported by four ionic columns. The City Hall on the
opposite side of the square, is a noble edifice, built of white marble from
the quarries of Sing Sing, surmounted by a gilded dome. The view from this
dome is beautiful; embracing the city at your feet—green hilly country,
dotted with country seats and towns, among which is the city of Troy—the
noble Hudson, winding among this country and a back ground of
mountains. The new State Hall is a pretty building—the Exchange, is a
huge mass of granite, giving one a great idea of the extent of business
which requires so large a structure for its merchants.
What a different place is this to the town which stood upon this two
hundred years since. Then the only public building was a quaint old Dutch
church, with painted glass windows; adorned with the coat of arms of those
ancient worthies, who, clad in trunk hose and steeple crowned hats, sat
demurely below. There are but few of the ancient Dutch houses left, and
these are daily falling before the yankee spirit of improvement—which
improvement by the bye sometimes merely amounts to alteration. At this
city is the southern termination of the great Erie Canal.
LETTER III.
June 17th, 1840.
My dear E.—We arose at an early hour, and after looking into some of
the public buildings we returned to breakfast, This dispatched, we drove to
the rail road depot, an ugly building at the head of State Street where we
alighted and stood in a large barn-like apartment, among men and trunks
and boys—the latter screaming, Albany Argus’—‘Evening Journal!’—and
among all sorts of confusion, until we were seated in the cars. Soon
however, two fine horses, to whom I render my thanks, dragged us out of
the barn into open day—up through the square, over the hill, to the
Locomotive Depot, giving us on the way many sweet little back views of
Albany and its pretty country and river, and the round tops of the Catskills
in the blue distance beyond. The snort of a steampipe, and perfume of
grease and smoke, announced the vicinity of our locomotive; and, as if to
show off its paces, the engineer whirled the hideous thing back and forth
before our—at least my—nil admirari eyes. Our horses were unhitched—
the engine attached, and away we rushed, leaving our fine steeds gazing
after us with tears in their eyes, to see themselves outdone by a great tea-
kettle.
There are many pretty villas along the road; breathing places for the
heated citizens below, which I would describe to you; but dashing along at
sixteen miles an hour speed I can only catch a glimpse of white pillar and
portico when the next minute we are three miles away. You must expect no
description of the country when I am on a rail road, for the scenery is all
blurred, like a bad lithograph. I only saw groups of pine trees rushing past
and several bright dots which I suppose meant wild flowers when we came
in sight of Schenectady, an antique dutch town. Before entering it I was
struck by the vision of two immense tarred ropes walking deliberately
beside our car, and discovered we were upon an inclined plain, descending
which, cars of stone were brought up at the other end of our ropes. Our
steam horse was once more exchanged for one of flesh and we set off upon
a jog trot. Near the city we passed a canal basin in which lay several canal
boats, for the Erie Canal passes through here. We entered the city, crossed
the end of a long street filled with bright looking shops, where people and
horses were frisking about in the morning air,—when another large depot
received us in its barn-like expanse. The Ballston and Saratoga train entered
at the other end, and you may imagine the charming confusion as the people
of both trains jumped in and out the carriages, marched and counter
marched until they had settled down into their several seats.
We were not suffered long to look upon this pleasant picture, for at 9
o’clock we were on our way to Utica. We could see but little of
Schenectady while passing through it, but it looked well at a distance. Upon
an eminence above the town stands Union College a fine building of grey
stone.
Schenectady is an Indian name spelt by them Schan-naugh-ta-da;
meaning ‘the Pine Plains,’ a fitting name, for the pine is universal here.
This town has been the property of many different nations—the Mohawk,
the French, the Dutch, and the English having each in succession ruled its
destinies.
After leaving the town, we entered at once the glorious valley of the
Mohawk which runs nearly westerly, and whose course we followed eighty
miles to Utica. There may be lovelier vallies in the world, but certainly not
another like this, for it is unique in its kind. Imagine a long green valley
covered with rich farms—through its centre a bright transparent river,
having a rail road on one bank and a canal on the other; while a range of
hills frame in the picture on each side. So straight is this valley, that canal,
river, and rail road run parallel, and within sight of each other nearly all the
way.
It was one of June’s sweetest mornings when we passed the shores of the
pretty Mohawk, and I was never weary of gazing down into its smiling face,
as we glided along; or of watching the lazy canal boat dragging its rich
freight at the foot of those soft green hills opposite; or, of peeping out the
coach at the rugged cliffs, which reared their bare heads far above our road.
There are many little villages on this route, where we stopped to refresh
ourselves, or to fill the engine. The first was Amsterdam a small Dutch
settlement. Near this place stands a handsome stone edifice which is
renowned in the annals of New York as the residence of Grey Johnson and
his brother Sir William, the dreamer. At these towns there are hotels, and at
other spots refreshment houses, built at the road side, where you are
allowed a few minutes to rest. You are shown into large rooms set out with
long narrow tables, bearing loads of coffee, oysters, cakes, pies, fruit
lemonade, etc.,—you pile your plate with good things, stir around your
coffee or tea, when tingle! goes the bell ‘all aboard!’ rings in your ears, and
you have just time to put your 25 cents into the attendants hands and
yourself in a car when puff! and away you go. Some of these towns are
pretty, as St Johns, Fonda, Canajoharie, Herkimer, and many others.—What
hungry people these travellers are! at every refreshment station the tables
were crowded and at the signal they rushed into the cars each with a cake or
pie, or apple, to finish at his leisure. We may say with Horace,
‘At Fundi we refused to bait.’
One would imagine he was speaking of our little Fonda, which is here
pronounced as Horace spells it. It was named after the celebrated Col.
Fonda.
Fort Plain is a pretty place on the other bank of the river; here I longed to
‘stay one turn’ to hammer a specimen from the encrinal lime-rock which is
found there. The little falls of the Mohawk is a delightful place. The river
here forces its way through a rocky country and falls over successive ledges
of rock in pretty cascades. The beauty of the scene does not consist in
altitude, but in number and variety of these saults; and the foaming river
rushing over its rocky bottom or winding around its tiney islets, and in the
towering cliffs around it. The village is seated upon each side of the river,
connected by a handsome marble aqueduct leading to the canal basin, and
by a neat bridge for carriages. The scene as we approached was very pretty.
You see a frame work of rugged cliffs, enclosing a noisy rushing river with
numerous cascades, its shores crowned with white buildings, and spanned
by a noble bridge; the canal boat is seen creeping at the foot of the hills
opposite, while the steeples, court house and hotels, are peeping from the
trees which cover the sloping bank at our right. Perched upon every jutting
point and grouped around the shores were many shanties occupied by the
children of Erin who have kindly volunteered to make our rail roads and
canals.
When the train stopped before the hotel, instead of the usual sound of
‘Newspapers,’ or ‘Nuts,’ or ‘Apples to sell,’ I heard young voices asking if
we wanted some diamonds! Surprised, I looked out and beheld several little
girls holding up small boxes containing Quartz Crystals. We of course
became purchasers, and found among them some very perfect and pure.
‘Where do you find these?’ I asked. ‘Oh, all among the cliffs ma’am,’ she
answered in the Hibernian tongue—‘and if its stop ye wud, I’d show ye to
the diamond holes where I often dig up the ful of my pocket.’ We observed
this was a large town, having several churches, dwellings, a handsome court
house, and many large manufacturers. Geologists tell us this was one shore
of that lake of which the highlands were the southern boundary. How it
came to wear through these hills and run away to the sea no one can ever
know. The rocks here are limestone, principally; but I observed there was
with it some fine granite. There was an old man among our passengers, who
had lived here ‘when all this was a wilderness.’ He amused us with some
stories of past times; one of which I think interesting enough to tell you.
Here it is to fill up the page.
During the War of Independence there were two brothers, who, although
they were brothers, could not think alike; they joined opposite sides in the
war. It happened while the Division under Gen. Herkimer was destitute of
arms, ammunition and clothing, he heard of the approach of the English
troops. Fight he could not; fly he would not; and he was seeking some
stratagem to better his situation, when fortunately, for him, the English
brother having strayed too near his camp was taken up as a spy. The
brothers, who had been long separated met once more; but it was a bitter
meeting, for one was a prisoner and condemned to die. In spite of their
different sentiments they loved each other. The prisoner earnestly entreated
his brother, who was the General’s Aid, to use all the influence in his power
to save his life. The Aid was conscious he could not succeed unless he
made the ‘worse appear the better reason;’ for his brother had been fairly
captured as a spy, and in consequence of some bloody deeds of the enemy,
his life was to be forfeited. With a heavy heart and darkened brow he
entered the General’s tent.
‘I know what you would ask ere you speak’ said his commander. ‘I have
expected you and have determined upon my course. You come to ask your
brother’s life—it is your’s upon one condition.’ ‘Name it! I am not afraid to
agree to any thing my General may propose!’ ‘I require you to go over to
the enemy as a deserter—tell them exactly of our numbers; for I have learnt
they do not imagine we are so strong; conceal the state of our arms and
provisions; and if I am not much mistaken, they will immediately withdraw
when they know how large is our force. You are then to find your way back
again as you can. When you return your brother shall be free.’
For one moment the Aid hesitated. To appear as a deserter—to act the
spy—to deceive even an enemy, was adverse to his open noble nature—
there was also danger of discovery when returning, which would lead to
disgrace and death.
‘Well young man! what is your determination?’ asked the General. ‘I
will go, and trust in heaven and in you.’ He sought the enemy’s camp, was
imprisoned as a spy—but his feigned tale procured his liberation. The
enemy retreated before so large a force, which they could have conquered if
they had known their distressed condition. It was many months ere the Aid
rejoined his General. His brother was released, and after a parting full of
sorrow they separated never to meet again.
We arrived at Utica at three o’clock, and repaired immediately to
Baggs’s hotel. Here we found an excellent dinner, just ready, which to
hungry travellers is a cheering sight. As I promised to put down our
expenses, we pay $3,75 each, from Albany to Utica, eighty miles. We here
concluded to leave the train, and spend a few days at the celebrated Trenton
falls. After partaking a very nice dinner at Bagg’s hotel, we entered a neat
carriage for Trenton falls, 14 miles north of Utica. The drive is a pretty one,
and up hill all the way. We arrived at dark at a small inn in a forest, and
were obliged to defer our visit to the cascade until the next morning.
After breakfast we walked out to visit the falls. Our way was through a
deep forest breathing forth sweet fragrance in the early morning air.
Suddenly, in the midst of the woods, we found ourselves upon the brink of a
precipice, one side of a narrow chasm two hundred feet deep, while, too far
below to be heard, a mountain torrent was rushing and foaming over the
rock. A range of five ladder stairways led down the steep,—and as we thus
hung over the water, we felt very much like some of Shakespear’s samphire
gatherers, and thought what a ‘dreadful trade’ was hunting waterfalls.
Safely down, we found a narrow ravine, so filled with the roaring torrent,
that there was scarcely room for a pathway beside it. Part of the way a chain
was inserted into the rock that we might, by holding upon it, pass the
boiling whirlpool, if our nerves are strong enough to command our hands
and feet—so scrambling, climbing, swinging, we contrived to reach the
uppermost cascade, which is two miles from the last one. This stream,

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Smith & Tanagho’s General Urology

19th Edition Jack W. Mcaninch

Life-Span Development, 19th Edition John W. Santrock

Campbell Walsh Wein Handbook of Urology 1st Edition

A Death in Live Oak A Jack Swyteck Novel 19th Edition

General, Organic, & Biological Chemistry, 5th Edition

Black Light The Menagerie Black Light Series Book 26

Ethical Judgments 1st Edition Stephen W. Smith

Campbell-Walsh Urology 12th Edition Review, 3e (Mar 2,

Principles of General, Organic, & Biological Chemistry

Smith & Tanagho’s

Jack W. McAninch, MD, FACS, FRCS(E)(Hon)

Tom F. Lue, MD, FACS, ScD (Hon)

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eBook conversion by codeMantra

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20 Renal Parenchymal Neoplasms 329 31 Disorders of the Adrenal Glands 509

21 Cancer of the Prostate Gland 351 32 Disorders of the Kidneys 521

22 Genital Tumors 377 33 Diagnosis of Medical Renal Diseases 539

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42 Disorders of the Female Urethra 659 46 Genital Gender-Affirming Surgery:

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Peter R. Carroll, MD, MPH Arpita Desai, MD

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Michael DiSandro, MD Kirsten L. Greene, MD, MS

Daniela Franz, MD Hedvig Hricak, MD, PhD

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John N. Krieger, MD Anobel Y. Odisho, MD, MPH

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Katsuto Shinohara, MD David Tat, DO

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Jack W. McAninch, MD, FACS, FRCS(E) (Hon)

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CALICES, RENAL PELVIS, AND URETER

1. Calices—The tips of the minor calices (8–12 in number)

▶▶Histology (Figure 1–4) ▶▶Gross Appearance

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B. Relations ▶▶Histology (Figure 1–10)

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▲▲Figure 1–11. Section of the prostate gland shows the

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▶▶Blood Supply EPIDIDYMIS

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The testis is covered anteriorly and laterally by the visceral SCROTUM

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▶▶Blood Supply ▶▶Blood Supply

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Emil A. Tanagho, MD; Hiep T. Nguyen, MD;