3 2001 Book StructureandFunctionoftheBladderNeck

Advances in Anatomy
Embryology and Cell Biology
Vol. 159
Editors
F. Beck, Melbourne B. Christ, Freiburg
W. Kriz, Heidelberg W. Kummer, GieBen
E. Marani, Leiden R. Putz, Munchen
Y. Sano, Kyoto T. H. Schiebler, Wurzburg
G. C. Schoenwolf, Salt Lake City
K. Zilles, Dusseldorf
Springer-Verlag Berlin Heidelberg GmbH
w. Dorschner J.-U. Stolzenburg
J. Neuhaus
Structure and
Function of
the Bladder Neck
With 36 Figures and 1 Table

anda CD-Rom
t Springer
WOLFGANG DORSCHNER, MD
JENS-UWE STOLZENBURG, MD
JOCHEN NEUHAUS, PhD
Klinik und Poliklinik fUr Urologie
Universitătsklinikum Leipzig AOR
Stephanstrasse Il
04103 Leipzig, Germany
e-mails:
dorw@medizin.uni-Ieipzig.de
stolj@medizin.uni-Ieipzig.de
neuj@medizin.uni-Ieipzig.de
ISSN 0301-5556
Library of Congress-Cataloging-in- Publication- Data

Dorschner, W. (Wolfgang), 1942-
Structure and function of the bladder neck / W. Dorschner, J.-U. Stolzenburg,
J. Neuhaus. p.cm. - (Advances in anatomy, embryology, and cell biology,
VoI. 159)
Includes bibliographical references and index.
Additional material to this book can be downloaded from http://extras.springer.com
ISBN 978-3-540-67998-1 ISBN 978-3-642-56879-4 (eBook)
DOI 10.1004/978-3-642-56879-4
1. B1adder-Histology. 1. Stolzenburg, J.-U. (Jens-Uwe), 1964- II. Neuhaus,

J. (Jochen), 1958- III. Title. IV. Series
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"Any physician, whether he uses remedies or his hands, is noth-
ingwithout the exact knowledge ofthe external and internal parts
of man. It is by no means sufficient to acquaint himself superfi-
cially with the form, location and interplay of the various forms
of the unfathomable organism. Therefore, the physician who
takes the revision ofthis knowledge seriously should practise this
visual instruction daily, should constantly seek ways of renewing
his perception of the interrelations in this living miracle. If he
were aware of the advantage gained, he would, as he probably
lacks the time for such work himself, employ an anatomist who,
working under his guidance quietly in the background in the
presence of all the 'interwoven intricacies of life', would be able
to give an immediate answer to the most complicated questions.
The more one acknowledges this, the more actively, ardently and
passionately will doctors study the human anatomy..."
Goethe (" Wilhelm Meister's Travels", Book III, Chapter 3)
v
Acknowledgements
The authors are very grateful to Mrs. Dettmer and Mrs. Hieke for
technical assistance. They would like to thank Mr. Mondry for
computer-related help.
VII
Contents
Introduction . . . . . . . . ......
2 Materials and Methods. 5
3 Musculus Detrusor Vesicae 7

3.1 Musculus Detrusor Vesicae 7
3.2 Musculus Pubovesicalis .. 10
3.3 Musculus Vesicoprostaticus
and Musculus Vesicovaginalis . 10
3.4 Summary . . . . . . . . . . . . . 14
4 The Musculature of the Trigonum Vesicae 17

4.1 Musculus Interuretericus ... 18
4.2 Musculus Sphincter Vesicae
(Vesical or Internal Sphincter) 18
4.3 Trigonum Vesicae. 27
4.4 Summary . . . . . . . . . . 29
5 Diaphragma Urogenitale 31
5.1 Summary . . . . . . . . . . 36
6 Musculus Sphincter Urethrae

(Urethral or External Sphincter) 41
6.1 Summary . . . . . . . . . . . . 50
7 Musculus Dilatator Urethrae 51

7.1 Summary . . . . . . . . . 58
8 Musculus Ejaculatorius 59
8.1 Summary . . . . . . . . . 69
9 Changes of the Muscles of the Lower Urinary Tract

with Age 71
9.1 Summary . . . . . . . . . . . . . . . . . . . . . . . . . 72
IX
10 Three-Dimensional Model of the Anatomy
ofthe Lower Urinary Tract . . . . . . . . . . .. 73
11 Fundamentals ofthe Neuroanatomy

of the Lower Urinary Tract 77
ILl Autonomous Innervation
of the Lower Urinary Tract 77
11.2 The Voluntary Innervation
of the Musculus Sphincter Urethrae 78
11.3 The Sensory Innervation of the Urinary Bladder
and the Urethra . . . . . . . . . . . 79
11.4 Spinal and Supraspinal Influence
on the Urinary Reflexes 81
11.5 Summary . . . . . . . . . . . . . . 82
12 Discussion (Functional Interpretation

ofthe Anatomical Findings) 83
12.1 Continence 83
12.2 Micturition 84
12.3 Ejaculation 86
13 Further Studies and New Approaches. 89

13.1 Summary ......... . . . . . . . . 90
14 Terminologia Anatomica
of the Lower Urinary Tract . . . . . . 93
15 Summary . 97
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Subject Index . . . . . . . . . . . . . . . III
x
Abbreviations (English in Brackets)
bn bladder neck (neck of bladder)

Bp bulbus penis (bulb of penis)
Bv bulbi vestibuli (bulb of vestibuli)
Cc corpus cavernosum penis
Cs colliculus seminalis (seminal colliculus)
Ct centrum tendineum
Cu crista urethralis (urethral crest)
De ductus ejaculatorius (ejaculatory duct)
Gb glandula bulbourethralis (bulbo-urethral gland
or Cowper's gland)
Mb musculus bulbospongiosus (bulbospongiosus)
Md musculus dilatator urethrae (dilator urethrae)
Mdv musculus detrusor vesicae (detrusor)
Me musculus ejaculatorius (ejaculatorius)
Mi musculus interuretericus (interuretericus)
Ml musculus levator ani (levator ani)
Mo musculus obturatorius internus
(obturatorius internus)
Mpv musculus pubovesicalis (pubovesicalis)
Mu musculus sphincter urethrae
(urethral or external sphincter)
Mug musculus sphincter urethrae glaber
(smooth muscular part of urethral sphincter)
Mut musculus sphincter urethrae transversostriatus
(striated part of urethral sphincter)
Mv musculus sphincter vesicae
(urethral sphincter or internal sphincter)
Mvp musculus vesicoprostaticus (vesicoprostaticus)
Mvv musculus vesicovaginalis (vesicovaginalis)
Q ostium ureteris (ureteric orifice)
Qui ostium urethrae internum (internal urethral orifice)
P prostate
Pi plica interureterica (interureteric crest)
R rectum
S symphysis
Tv trigonum vesicae (trigone of bladder)
U urethra
XI
ub urinary bladder
Dr ureter
Dt uterus
V vagina
Vs vesicula seminalis (seminal vesicle)
XII
1 Introduction
The alternation between urine retention and discharge several times daily from a
baby's first wet nappy to the cessation of all vital functions only becomes the subject
of greater attention if the harmony of the structure and function of the bladder is
disturbed. Functional disturbances of the lower urinary tract are not only of great
socio-economic importance, but are also a considerable personal burden for the
patient. Hence urinary incontinence is rightly classified as a severely disabling illness
(Hauri 1985).
Opinions still differ regarding the morphological basis of urinary continence. The
Terminologia Anatomica (1998) defines a musculus sphincter urethrae internus (in-
ternal urethral sphincter) and a musculus sphincter urethrae externus (external ure-
thral sphincter), which in the older nomenclature were known as musculus sphincter
vesicae and musculus sphincter urethrae, respectively. The internal urethral sphincter
is ascribed a purely involuntary and the external urethral sphincter a purely voluntary
innervation. The significance of the musculature of the pelvic floor for maintaining
urinary continence has not yet been ascertained.
During numerous urological operations (for instance transurethral resection of the
prostate and bladder neck incisions), the only involuntarily innervated sphincter at
the collum vesicae, the internal urethral sphincter, is partially or completely destroyed
(Fig. 27C,D). All the patients remain continent as long as the external urethral sphinc-
ter remains intact. How can a purely voluntarily innervated sphincter like the external
urethral sphincter ensure constant continence in such cases?
Improving the continence rate after radical surgery is a key topic of urological
research. The incontinence rate after radical prostatectomy is still between 8.1 %
(third-degree incontinence) and 41.4% (first- to second-degree incontinence; Rudy et
al. 1984; Igel et a1.1987; Schroder and Ouden 1992).
Exact knowledge of the topographical anatomy of this region, especially the course
of the sphincter systems (Dorschner 1984; Myers et a1.1987; Walsh et al. 1990; Myers
1991; Steiner et al. 1991; Kaye et al. 1997), is essential to ensure sufficient anastomosis
between the internal and external urethral sphincter after extirpation of the prostate
and the vesiculae seminales (seminal vesicles). Very carefully treating both sphincters
ensures the best results with regard to postoperative urine continence.
Thanks to constant technical progress, the entire urinary tract can nowadays be
inspected from the ostium urethrae externum (external urethral orifice) to the pelvis
renalis (renal pelvis) using endoscopy, and a large number of operations can be
performed without the need for incision. Endoscopy facilitates the morphology and
partly also the function of the anatomic structures to be assessed. For instance, it is
possible to clearly distinguish the pars membranacea (external urethral sphincter)
W. Dorschner et al., Structure and Function of the Bladder Neck

and the pars prostatica of the urethra from the internal urethral sphincter. Especially
prominent in the male urethra is the crista urethralis (urethral crest; Fig. 27H). What
is the secret of this mucosal fold stretching from the colliculus seminalis (seminal
colliculus) to the bulbus penis (bulb of penis)? Is there an anatomical connection
between the urethral crest and a second function of the male urethra, sperm emission
and ejaculation?
A so-called musculus retractor uvulae is described in numerous anatomical text-
books. This muscle is supposed to raise a mucosal fold in the area of the internal
urethral orifice - the uvula vesicae (Rauber-Kopsch 1951; Hamilton 1976). Various
authors (Bell 1812; Power 1954; Gil Vernet 1960; Hutch 1965; Tanagho and Smith 1966;
Homsy 1967; Van Ulden 1975) defined a muscle ("Bell's muscle") which is supposed to
emerge from the ureter musculature and stretch from the trigonum vesicae to the
colliculus seminalis. However, endoscopic examination of the lower urinary tract does
not reveal any structure which might correspond to one of these muscles.
Micturition is the second important process which is closely associated with the
anatomical structures of the lower urinary tract. These days it is generally understood
as a mass action by the musculus detrusor vesicae. It is assumed that the sphincter
systems of the lower urinary tract are passively "pressed open" after relaxation merely
by an increase in intravesical pressure. Although the possibility of micturition starting
with an active muscular process has been discussed on occasion, no muscular struc-
ture is yet known which by virtue of its specific course would be able to actively
trigger micturition.
These numerous questions and unsolved problems prompted us to compile a new
description of the musculature of the lower urinary tract, including the interrelations
of the urinary bladder and the collum vesicae with the adjoining structures in the
minor pelvis in both men and women. This will provide a basis which is as detailed as
possible for interpreting the basic functions of the lower urinary tract.
The results of our own studies often contradict the classical textbooks (Rauber-
Kopsch 1951; Alverdes 1959; Hamilton 1976; Pernkopf 1994) and the published litera-
ture, which is discussed in detail in the individual chapters. This concerns in particu-
lar our findings concerning an apparently compounded internal urethral sphincter
and the apparent involvement of the so-called diaphragma urogenitale (urogenital
diaphragm) in the formation of the external urethral sphincter. For didactic reasons,
however, Chapter 3 contains a description of the musculature of the vesica urinaria
(urinary bladder) as the organ for the retention of urine produced by the kidneys.
Afterwards, the muscle systems for the maintenance of urine continence are dis-
cussed. In this respect, the existence of the repeatedly quoted musculus transversus
perinei profundus (deep transverse perineal muscle) is critically examined.
The literature contains numerous terms for the two sphincters of the collum vesi-
cae, which are defined by the Terminologia Anatomica (1998) as musculus sphincter
urethrae internus (internal urethral sphincter) and musculus sphincter urethrae ex-
ternus (external urethral sphincter). Our own studies have convinced us that the
terms musculus sphincter vesicae instead of musculus sphincter urethrae internus
and musculus sphincter urethrae instead of musculus sphincter urethrae externus
(already defined thus by the Paris Nomina Anatomica 1955) characterise these mus-
cles more correctly. A detailed discussion of the morphological findings is contained
in the respective chapters. In the following, the terms musculus sphincter vesicae
2
(vesical or internal sphincter) and musculus sphincter urethrae (urethral or external
sphincter) are always used for clarity's sake.
The longitudinal muscle systems of the urethra are often negated in descriptions of
the complex structures of the lower urinary tract. Their description and resulting
functional interpretations of important functions of the lower urinary tract are con-
tained in the closing chapters of this monograph.
3
2 Materials and Methods
The autopsy specimens for the present histomorphological study were taken from 50
male and 15 female deceased of all age groups (ranging from premature infants to the
very elderly). The special feature of our study was the extensive en bloc preparation of
all the organs of the minor pelvis of the deceased. In order to preserve the topographic
state, not only the lower urinary tract with the urinary bladder and urethra, but also
the surrounding organs including the bulb of penis, seminal vesicles, prostate, vagina,
uterus, rectum, symphysis as well as the surrounding musculature of the pelvic floor
were removed as a whole (Fig. 1). The organ packages were fixed in 4% formalin and
embedded in paraffin. In the case of newborns, the organ packages containing parts of
the osseous pelvis were resected, fixed in 4% buffered paraformaldehyde for 1 week,
and embedded in paraffin after decalcification in EDTA (19.5%,3 weeks). Due to the
large size of the paraffin blocks, a microtome (Tetrander; lung) was adapted so the
entire collum vesicae could be prepared in the form of complete serial cuts in frontal,
sagittal and transversal directions. In the majority of the serial sections for investigat-
ing the structure of the vesical sphincter, the strictly transversal section level was
varied to match the physiological curvature of the bladder neck. As it was essential to
distinguish between connective tissue and musculature, every fifth section was
stained as described by Crossmon (Crossmon 1937; Romeis 1989). The other staining
methods used were silver staining according to Pap, and resorcin-fuchsin nuclear fast
red staining and hematoxylin-eosin staining as described by Ehrlich (HE; Romeis
1989). All in all, some 36,000 histological specimens were available for evaluation
using light microscopy.
A monoclonal anti-a-smooth muscle actin antibody (A-2547, 1:2000; Sigma) was
used to demonstrate the smooth musculature. After blocking endogenous peroxidase
activity for 10 min with 3% H202 in 70% methanol at room temperature, the sections
were incubated with the primary antibody in 0.1 M PBS containing 0.32% DMSO,
0.8% Triton X-I00 and 3% BSA at 4°C. Afterwards, a peroxidase detection system was
used to detect the primary antibody (LSAB-Kit; DAKO). Finally, the histological sec-
tions were stained with hematoxylin-eosin in order to highlight the nuclei. Once
again, light microscopy was used for evaluation.

\,
Fig, L Collum vesicae. Sagittal, newborn infant, male, 10 f.Im, Crossmon (Mu, musculus sphincter
urethrae; Mdv, musculus detrusor vesicae; P, prostate; Vs, vesicula seminalis; R, rectum; S, symphysis;
Gb, glandulae bulbourethrales; Bp, bulbus penis; asterisk, musculus pubovesicalis). The section
shows the urinary bladder and the entire collum vesicae from the ostium urethrae intern urn up to the
bulbus penis. The arrow marks the still little developed nodus vesicae as a special part of the coliare
vesicae. Furthermore, all the organs of the small pelvis are visible (rectum, symphysis, pelvic floor
musculature). (From Dorschner et al. 1994a) x2.l
6
3 Musculus Detrusor Vesicae
"He who is astonished to see this oft-discussed question being the subject ofyet another
anatomical investigation is requested to read the literature on the anatomy and physi-
ology of the urinary bladder; he will then be properly astounded. "
(Heiss 1928)
3.1
Musculus Detrusor Vesicae
As early as 1645, Adriaan van der Spieghel named the external muscle layer of the
urinary bladder musculus detrusor urinae. Nowadays, the term musculus detrusor
vesicae is generally used for the entire bladder musculature (Rohen 1973; Termi-
nologica Anatomica 1998). Some sources call the middle circular layer of the detrusor
musculature musculus compressor vesicae (Pernkopf 1941).
The lamellae of the detrusor musculature make up a three-layer formation: a
stratum internum et externum longitudinale (internal longitudinal and external lon-
gitudinallayer) with a stratum circulare (circular layer) between them (Finger 1896;
Waldeyer 1899; Kalischer 1900; Heiss 1915; Hutch et al.1961; Tanagho and Smith 1966,
1968; Hutch 1967). Krantz (1951) describes two layers of the detrusor musculature,
Van den Bulcke et al. (1970) found a fourth layer running diagonally. Although a few
authors (Liidinghausen 1932; Graning 1934, 1936) reject the idea of the bladder
musculature having a lamellar structure, most describe a densely interwoven muscle
system featuring the lamellae of the detrusor musculature running in three directions
as described above (Hunter 1954; Woodburne 1960,1961,1964,1967,1968; Donker et
al. 1976; Gosling 1979).
Views differ concerning the extent to which the lamellae of the detrusor muscula-
ture extend beyond the spatial dimension of the urinary bladder and make up part of
the muscle structure of the urethra. Some authors do not agree that the bladder
musculature is part of the neck of bladder, or that the detrusor musculature continues
to the urethra (Finger 1896; Waldeyer 1899; Kalischer 1900; Droes 1974; Droes et al.
1974; Donker et al. 1976; Gosling 1979). By contrast, numerous authors describe the
bladder musculature as continuing to the urethra, albeit to a varying extent. Ricci et al.
(1950), Krantz (1951), Langreder (1956), Woodburne (1960, 1961, 1964, 1967, 1968)
and Beck (1969, 1971) found the detrusor musculature to continue to the urethra
without forming a loop. Hutch (1965, 1966, 1967a, 1967b, 1971), Tanagho and Smith
(1966) and Hutch and Rambo (1967) showed that only the lamellae of the stratum
internum longitudinale continue up to the urethra as an internal longitudinal layer.

Is the looping of the detrusor musculature also involved in the formation of the
vesical sphincter? The term "lissosphincter" is often used in this respect, even though
the expression sphincter urethrae laevis or lissosphincter urethrae was originally
used by Waldeyer (1899) to refer to a sphincter system independent of the lamellae of
the detrusor. Starting from the theory of a vesical sphincter which does not exist
independently, numerous authors describe lamellae of the stratum externum longitu-
dinale which continue directly to the urethra. These continuations of the detrusor are
thought to form the anatomical basis for the entire circular urethra musculature
(Krantz 1951; Langreder 1956; Lapides et a1.1957; Beck 1969,1971; Tanagho 1973).
Our own studies show that the musculus detrusor vesicae consists of a network of
smooth muscle cell bundles which tend to have three layers (Figs. 2, 7). The internal
longitudinal layer is the thinnest of all three muscle layers. The muscle cell bundles
taper from cranial to caudal direction, and end in the form of fibrous tendons at the
dorsal circumference of the musculus interuretericus, which forms the dorsal bound-
ary of the geometrically defined trigonum vesicae (trigone of bladder; cf. Chap. 4).
There is no muscular loop of the stratum internum longitudinale around the ostium
urethrae internum (Alverdes 1959). We must also discount the continuation of this
muscle layer to the urethra as its innermost muscle lamella (Ricci et a1. 1950; Krantz
1951; Langreder 1956; Woodburne 1960, 1961, 1964, 1967, 1968; Hutch 1965, 1966,
1971; Tanagho and Smith 1966,1968; Hutch and Rambo 1967; Beck 1969, 1971).
The caudal looping of the middle stratum circulare forms the thickest portion of
muscle ventrally in both sexes (Figs. 2, 6, 7). These muscle lamellae eccentrically
encircle the ostium urethrae internum (internal urethral orifice) perpendicular to the
urethra's longitudinal axis. However, the lamellae of the middle circular layer never
directly adjoin the internal urethral orifice. The vesical sphincter, which elliptically
encloses the ostium urethrae internum, is located dorsally, laterally and ventrally,
between the ostium urethrae internum and the middle layer of the bladder muscula-
ture. Owing to its special course (cf. Chap. 4), however, the circular detrusor muscula-
ture and the urethra are very close to each other ventrally.
This high concentration of different muscle systems in a very small space necessi-
tates a very detailed histological approach (cf. "Materials and Methods"). Preparation
techniques are doomed to fail or often produce artificial results. This is probably the
case regarding the findings of Heiss (1915, 1928), Liidinghausen (1932) and Graning
(1934,1936), which describe a muscle loop emerging in the circular layer and embrac-
ing the internal urethral orifice. Our own studies, especially regarding the vesical
sphincter (cf. Chap. 5), show that no such muscle loop splits off from the detrusor, and
that the ostium urethrae internum is only adjoined by the muscle cell bundles of the
musculus sphincter vesicae.
The stratum externum longitudinale of the detrusor is certainly the most interest-
ing muscular structure of the urinary bladder from an anatomical, functional view,
and numerous functions are attributed to it in the literature. Our investigations show
that in both sexes, all the lamellae of the external longitudinal layer end in a muscle
torus reinforcing the bladder wall caudally. Due to its collar-shaped configuration, this
reinforcement of the musculature is termed the collare vesicae (Fig. 6). Ventrally, the
collare vesicae becomes thicker as it is interwoven by the ventral and dorsal lamellae
of the stratum externum longitudinale to form a node. This special part of the collare
vesicae is defined as the nodus vesicae (Figs. 6,7; Dorschner 1984; Dorschner et a1.
1994a).
8
Fig. 2A-F. Musculus detrusor vesicae. Transversal, 4 years, female, 10 flm, Crossmon, image series
from cranial to caudal direction. A,C,E Overall views, x3.7. B,D,F Details, x13 (ub, urinary bladder;
Qui, ostium urethrae internum). The overall views are flanked by enlargements of details. At the
height of the ureter entry (arrow in A), the three layers of the bladder musculature can be seen
ventrally (open circle, stratum internum longitudinale; asterisk, stratum circulare;filled circle, stra-
tum externum longitudinale). A little lower in the trigonum area (C,D), the internal longitudinal layer
on the ventral side tapers and completely vanishes at the bladder outlet (E,F)
9
According to Heiss (1915), Scher (1950) and Woodburne (1968), the dorsolateral
longitudinal bundles of the external longitudinal layer are fixed at the front or lateral
edge of the lateral lobes of the prostate. This misconception is caused by the fact that
part of the muscle cell bundles of the external longitudinal layer reach the symphysis
without crossing while bypassing the nodus vesicae. This can clearly be seen in
newborn infants. If the prostate increases due to an adenoma, the muscle cell bundles
leading to the symphysis are raised and appear to insert into the front of the gland.
Studies of our own histological specimens (Latka 1989) show that the musculus
detrusor vesicae already undergoes histological differentiation within the first
3 months. The three layers of the detrusor have fully developed by the third fetal
month. The histomorphological picture corresponds to that of the adult urinary
bladder. As in the adult, the inner longitudinal smooth muscle layer in foetuses ends
ventrally at the ostium urethrae internum and dorsally at the musculus interure-
tericus, forming the dorsal limit of the geometrically defined "trigonum vesicae". In
younger stages of embryogenesis, this layer of longitudinal muscle cell bundles ends
even further in the cranial direction. Therefore, even in the fetal stage, there is no
indication that the stratum internum or externum longitudinale of the detrusor
continues into or onto the urethra; nor does the stratum circulare turn into the
urethra. In foetuses, too, the nodus vesicae can be shown to comprise the particular
interweaving of the detrusor's external longitudinal layer ventrally in the collare
vesicae.
3.2
Musculus Pubovesicalis
The structural unit of the coliare vesicae, which reinforces the bladder like the neck of
a bottle, is fixed by two precisely defined local muscle systems. In both men and
women, the lamellae of the stratum externum longitudinale of the detrusor starting
from the nodus vesicae reach the lower edge of the symphysis. From the ventral
perspective, there are two muscle cords similar to an inverted V running from the
dorsocranial to ventrocaudal direction. This pubovesicale musculature is, as shown by
our studies, already strongly developed in the neonatal stage (Fig. 1), tapers increas-
ingly towards the symphysis, and inserts into the low edge of the symphysis (Fig. 3) as
a tendon. Contrary to some authors (Pernkopf 1941; Alverdes 1959), who merely
describe ligamenta pubovesicalia, these bundles were always of a muscular nature in
our specimens (Fig. 14). The musculus pubovesicalis can clearly be seen in Figs. 3,6
and 7.
3.3
Musculus Vesicoprostaticus and Musculus Vesicovaginalis
The dorsal fixing of the collare vesicae clearly differs between the two sexes. At the
uretero-vesical junction, a medial bundle is formed from the stratum externum longi-
tudinale of the detrusor in both men and women. This bundle of smooth musculature
covers the entire trigone of bladder from the dorsal side and thus forms its rear wall.
In the male, these muscle bundles split up again shortly above the prostate. The two
10
Fig. 3A-E. Musculus pubovesicalis. A Sagittal, 80 years, male, 10 flm, Crossmon, x2. B-E Transversal,
newborn infant, 10 flm, Crossmon (B,E), H&E (Cl, silver staining according to Pap (D), x13 (arrows,
musculus pubovesicalis; P, prostata). The edge of the symphysis removed during preparation is
marked by a broken line. The musculus pubovesicalis originates in the nodus vesicae (asterisk) and
runs along the ventral side of the prostate to the lower edge of the symphysis where it inserts in
sinewy points of attachment (E). (From Dorschner 1984)
11
Fig. 4A,B. Musculus vesicoprostaticus. A,B
Frontal, male, 10 flm. A 7 years, Crossmon,
x3. B 70 years, resorcin-fuchsin-nuclear fast
red, x2 (Mvp, musculus vesicoprostaticus;
Mdv, musculus detrusor vesicae; P, prostate;
R, rectum; Bp, bulbus penis). The dorsal-me-
dian bundle of the external longitudinal layer
has the same course in all age groups. The
musculus vesicoprostaticus inserts in the im-
mediate vicinity of the ductus ejaculatorii (ar-
rows). (From Dorschner 1984; Dorschner et al.
1994a)
Fig. SA-F. Musculus vesicoprostaticus.

A-F Transversal, 22 years, male, 10 flm, silver
staining according to Pap. A,C,E Overall
views, x2. B,D,F Details, x8, image sequence
from cranial to caudal direction (Mv,
musculus sphincter vesicae; De, ductus
ejaculatorius; P, prostate; Vs, vesicula
seminalis). The sections show the course of
the dorsal-median longitudinal bundles of the
external longitudinal layer of the detrusor
(musculus vesicoprostaticus) from cranial to
caudal direction. The muscle cell bundles of
the musculus vesicoprostaticus (arrows) run
caudally between the vesicula seminalis (A,B),
penetrate into the prostate further below
(C,D), and insert in the immediate vicinity of
the ductus ejaculatorii (E,F)
12
13
lateral muscle cords of the medial bundle move aside laterally depending on the size
of the prostate and cover the middle lobe or isthmus prostatae in the form of a finger.
Individual muscle bundles penetrate into the gland tissue. The median muscle cord of
the medial bundle does not insert into the trigone of bladder or the isthmus prostatae,
but moves directly in the caudal direction. Constantly tapering, it runs into the
prostate tissue, and only inserts into the dorsal side in the immediate vicinity of the
orifices of the ductus ejaculatorii at the level of the colliculus seminalis (Figs. 4, 5).
Due to its particular course, the term musculus vesicoprostaticus has been chosen for
this structure (Fig. 7; Dorschner 1984).
In the female, these muscle cell bundles take another course. Firstly, the median
muscle layers of the stratum externum longitudinale form the back wall of the
trigonum vesicae (see above). Below the ostium urethrae internum, the originally flat
bundle becomes increasingly thickset, tapering in the caudal direction. The muscle
cell bundles then run between the collum vesicae (neck of bladder) and the vaginal
wall in the septum urethrovaginale in the caudal direction and insert at the height of
the transition between the first and the second third of the urethra in the vaginal wall.
The term musculus vesicovaginalis has been coined for this special musculature
(Dorschner 1984).
3.4
Summary
The histologically provable division of the detrusor into lamellae must not be allowed
to obscure the fact that the musculus detrusor vesicae is a morphological unit. The
individual layers of the detrusor (stratum internum longitudinale=internallongitudi-
nallayer, stratum circulare=circular layer, stratum externum longitudinale=external
longitudinal layer) are the main directions of an otherwise densely interwoven muscle
system. Our own studies clearly show that none of the muscle systems of the detrusor
leave the local dimension of the urinary bladder. All the layers of the detrusor muscu-
lature end in the collare vesicae apart from two exceptions, namely the musculus
pubovesicalis, running from the nodus vesicae, a ventral reinforcement of the collare
vesicae, to the symphysis, and the musculus vesicoprostaticus or musculus vesicovagi-
nalis (Figs. 6,7; Dorschner et al. 1989a, 1994a). These muscle bundles serve to attach
the urinary bladder in the pelvis and have no relation to either the internal urethral
orifice or the neck of bladder. There are no circular systems of the detrusor layers
around the internal urethral orifice (Heiss 1915,1928; Wesson 1920; Young and Wes-
son 1921; Liidinghausen 1932; Graning 1934, 1936; Martius 1942; Langreder 1956;
Alverdes 1959; Tanagho and Smith 1966; Husslein and Martius 1971). The continu-
ation of the bladder musculature to the urethra as its external circular layer or inner
longitudinal layer (Ricci et al. 1950; Krantz 1951; Woodburne 1960, 1961, 1964, 1967,
1968; Beck 1969,1971; Tanagho 1973) must also be rejected on the basis of our results.
The musculature around the ostium urethrae internum forms an independent muscu-
lar unit and is described in detail in the following chapter.
14
Fig. 6 Fig. 7
Fig. 6. Diagram of the bladder muscles. (A, ventral external longitudinal layer; B, symphysis; C, dorsal
external longitudinal layer; D, dorsal medial bundle; E, nodus vesicae; F, musculus pubovesicalis; G,
collare vesicae; H, colliculus seminalis; I, prostate; j, fossa bulbi; K, bulbus penis; from Dorschner
1984; Dorschner et al. 1994a)
Fig. 7. Diagram of the bladder muscles (A internal and B external ventral longitudinal layer; C,
middle circular layer with caudal bundle (D); E, dorsal part of the collare vesicae; F, nodus vesicae
(ventral part of the collare vesicae); G, musculus vesicoprostaticus; H, middle lobe of the prostate; I,
lateral lobe of the prostate; j, ductus ejaculatorius; from Dorschner 1984; Dorschner et al. 1994a)
15
4 The Musculature of the Trigonum Vesicae
"... it should also be mentioned that the recent anatomical nomenclature does not
include a term for a smooth sphincter. Though we find descriptions of the same in the
most common anatomical and clinical manuals, opinions diverge concerning its loca-
tion and extent ... "
(Kalischer 1900)
In 1753, Lieutaud described the trigonum Lieutaud named after him (or trigonum
vesicae). In modern anatomy textbooks (Schiebler et aI.1999), the trigonum vesicae is
described as a creaseless triangular area, limited by the prominent corners of the
ureteric orifices and the ostium urethrae internum. The literature contains differing
opinions over whether the trigonum vesicae is formed by an independent muscular
structure (Kalischer 1900; Dorschner 1984) or whether (as described above) it is just
a prominent area in the bottom area of the bladder. Another topic of discussion is
whether the trigonum vesicae is formed by one or more muscle layers and the extent
to which these muscle layers expand into their surroundings, especially to the collum
vesicae. The Terminologia Anatomica (I998) defines a musculus trigoni vesicae su-
perficialis and musculus trigoni vesicae profundus, and therefore favours the view
that the trigonum vesicae consists of a number oflayers.
Most authors believe that the trigonum vesicae has two layers; a few isolated
accounts also speak of there being three layers. Bell's muscle (Bell 1812) is often
mentioned in this connection. This particular muscle unit is supposed to form an
inner longitudinal muscle layer, starting in the ureter musculature and running in
men from the trigonal area dorsally along the urethra wall to the colliculus seminal is.
In women, this muscle is said to even continue up to the ostium urethrae externum,
where it inserts. Despite some minor differences regarding its course, many re-
searchers support the thesis of the existence of this muscle unit (Waldeyer 1899; Krasa
and Paschkis 1921; Liidinghausen 1932; Graning 1934, 1936; Ricci et al. 1950; Scher
1950; Power 1954; Langreder 1956; Korner 1963; Marberger 1965; Hutch 1966; Wood-
burne 1968; Van Den Bulcke et al. 1970; Droes et al. 1974; Donker et al. 1976). Only Gil
Vernet (1960) denied the existence of Bell's muscle.
The technique of endoscopy, which has continuously improved over the past few
years, enables the lower urinary tract to be examined in detail. Neither the area of the
internal urethral orifice nor the neck of bladder contain a mucosal fold which could
correspond to Bell's muscle or the musculus retractor uvulae. Only below the collicu-
Ius seminalis, a mucosal fold, does the crista urethralis or urethral crest become
visible in the urethra lumen (Fig. 27H). In the female, the crista urethralis is com-
pletely absent. The histological approach does not support the supposition that the
17

ureter musculature or the lamellae of the detrusor musculature continue to the ure-
thra either. A muscular structure which could correspond to Bell's muscle exists in
neither the female nor the male.
What muscle systems actually define the trigonum vesicae? Our own histomor-
phological studies show two muscle systems with a clearly defined course in the
topographic region of the trigone of bladder. This is the musculature of the intramural
part of the two ureters (musculus interuretericus) forming the dorsocranial border of
the trigonum vesicae, which has been newly defined by the authors, and the trigonal
musculature itself (musculus sphincter vesicae or vesical sphincter).
4.1
Musculus Interuretericus
Both ureters penetrate the wall of the bladder at a defined place and then run within
the urinary bladder musculature (the so-called intramural part) until the opening
into the urinary bladder at the ureteric orifices. Figure 8 shows the orifice of the ureter
at the ostium ureteris (ureteric orifice) into the urinary bladder. At the orifice into the
urinary bladder, the ureter musculature separates from the bladder. The fine muscle
cell bundles of the ureter run beneath the mucous membrane of the bladder in the
medial direction without getting much thinner. There they meet the muscle cell
bundles of the ureter from the opposite side (Figs. 8,9). Via this particular course, the
mucous membrane of the bladder between the two ureteric orifices is raised to form
the plica interureterica (interureteric crest; Fig. 27G). For this ureteral musculature
running through the bladder which is described as an independent structure for the
first time, the term musculus interuretericus is suggested (Fig. 12; Dorschner 1984;
Dorschner et al. 1994b). The same findings were made in both sexes (Fig. 9). This
muscle is very likely to have the important function of preventing the pathological
urine reflux to the ureter/kidneys during the urine storage process in the urinary
bladder. The physiology of this process has yet to be investigated.
The clinical picture of the so-called bladder neck sclerosis often includes a promi-
nent plica interureterica, which can be verified by endoscopic examinatiol1. From a
clinical viewpoint, the question arises over whether the simultaneous occurrence of
the hypertrophy of the musculus interuretericus in connection with the hypertrophy
of the musculus sphincter vesicae as the morphological substrate of bladder neck
sclerosis argues in favour of an evolutionary relationship of both muscles. This prob-
lem still has to be studied in detail.
4.2
Musculus Sphincter Vesicae (Vesical or Internal Sphincter)
The first detailed description of the so-called trigonal musculature was provided by
Kalischer (1900). He documented in male and female infants a dense muscle ring at
the transition from the urethra to the bladder which instead of concentrically enclos-
ing the ostium urethrae internum runs diagonally from the top rear to the bottom
front. The rear circumference of this muscle is much larger than the ventral circumfer-
ence, resulting in an elliptical course. The urinary bladder musculature running in the
18
',t
F
Fig.8A-F. Musculus interuretericus, A-F Transversal, 22 years, male, 10 f'm. A-D Crossmon, E,F
Silver staining according to Pap, image series from cranial to caudal direction, A,C,E Overall views,
x1.8, B,D,F Details, xS (Mi, musculus intentretericus; Ur, ureter), A,B The left urereral musculature
shortly before it enters into the bladder. This smooth musculature continues medially (C,D), and then
joins up in the median line with the ureteral musculature from the opposite side (E,F). These bundles
of smooth muscle cells are called interureteral musculature or musculus interuretericus. Owing to
this special course, a mucosal fold, the plica interureterica (Fig, 27G), is raised in the bladder. (From
Dorschner 1984)
19
B
Fig. 9A- L. Musculus interuretericus. A-D Sagittal, newborn infant, male, 10 fim, Crossmon. A Overall
view - medio-sagittal plane, xl. B-D Details, x 13. E-H Sagittal, 45 years, male, 10 fim, Crossmon. E
Overall view - medio-sagittal plane, x1.8. F-H Details, x8. I-L Sagittal, 10 years, female, 10 fim,
Crossmon. I Overall view - medio-sagittal plane, x2. J-L Details, x13. The image sequence in each
series (A-D, E-H, I-L) corresponds to the section sequence from medial to lateral direction (arrows,
musculus interuretericus; asterisk, ostium uretericum; Ur, ureter; Vs, vesicula seminalis; S, sym-
20
c D
physis; R, rectum; P, prostate; U, urethra; V, vagina). The detailed views in the medio-sagittal plane
(B,F,J) show the course of the interureteral musculature. This musculature is both part and continu-
ation of the urethra musculature to the trigone of the bladder while the musculature of both ureters
merges in the median line. The course of the musculus interuretericus is the same in both sexes and
in the various age groups. C,G,K The orifice of the ureter into the urinary bladder (ostium ureteris).
D,H,L The corresponding part of the ureter
21
Fig. lOA-I. Musculus sphincter vesicae (vesical sphincter). A Diagram of the histological section
plane. H,C Strictly transversal section planes; 41 years, male, 10 J.lm, silver staining pursuant to Pap,
x2. D-I In correspondence with the physiological curve of the urethra, the transversal section plane
is tipped ventrally and caudally, image series from cranial to caudal direction; 16 years, male, 10 J.lm,
silver staining according to Pap, D,F,H x2; E,G,I x5 (Mv, musculus sphincter vesicae; Mdv, musculus
detrusor vesicae; P, prostate). In the strictly transversal section plan, the vesical sphincter appears as
a compound structure, consisting on the ventral side of lamellae of the bladder musculature (Mdv)
22
and on the dorsal side of parts of the trigonal musculature or parts of the vesical sphincter (Mv). D-I
Clearly, the actual vesical sphincter or musculus sphincter vesicae represents a morphological unit,
which is arranged in a circular formation around the internal urethral orifice and completely
surrounds it. The muscle stretches far in the caudal direction and reaches deep into the prostate
above the colliculus seminalis (H,I), while the circular arrangement of the muscle cell bundles is
always maintained. The circular unity of the muscle can be seen particularly clearly in the enlarged
details (E,G,I)
23
Fig. llA,B. Musculus sphincter vesicae (vesical sphincter). Sagittal, male, 10 J.!m, Crosssmon. A
Overall view, x1.5, B detail, x6 (Mv, musculus sphincter vesicae; Mpv, musculus pubovesicalis; P,
prostate; Vs, vesicula seminalis; ub, urinary bladder). This sagittal section on the lateral side of the
urethra shows the typically diagonal course of the musculus sphincter vesicae (vesical sphincter)
from the dorso-cranial to ventro-caudal direction (broken line)
transversal direction is not thought to be part of this anatomical structure. Kalischer

denotes this muscle unit as the musculus sphincter trigonalis. He describes the struc-
ture of these muscle cell bundles as fine, dense and separated by little connective
tissue. This homogeneous musculature must be clearly distinguished from the blad-
der musculature. The author found the same structure in adults. Other descriptions of
the vesical sphincter resemble the musculus sphincter trigonalis regarding its extent
and course (Zangenmeister 1909; Power 1954; Van Den Bulke et al. 1970; Droes 1974;
Donker et al.1976), without recognising the connection between the vesical sphincter
and trigonum vesicae.
Similarly to Kalischer, Krasa and Paschkis (I921) describe a muscle layer running
transversally mainly in the trigonum, which is supposed to correspond to the lisso-
sphincter urethrae or musculus sphincter trigonalis. However, this very detailed de-
scription of the musculature around the bladder outlet was largely quickly forgotten
and nowadays only has few followers. In Chap. 3, we have already mentioned the often
incorrectly used term of the so-called lissosphincter, dating back to Waldeyer (1899).
The literature on the musculus sphincter vesicae can be summarised as follows. At
the beginning of the twentieth century in particular, several authors described the
vesical sphincter as an integrated structure. They noted that lamellae of detrusor are
located around the bladder outlet (Heiss 1915; Wesson 1920; Uidinghausen 1932; and
24
Fig. 12. Diagram of the musculus sphincter vesicae (vesical sphincter; A, extravesical ureter; B,
ureteric orifice; C, musculus interuretericus; D, middle circular layer of detrusor with caudal bundle;
E, nodus vesicae; vesical part (F) and urethral part (G) of the vesical sphincter; H, corpus caverno-
sum; right-hand diagram: vesical part (I) and urethral part U) of the vesical sphincter; K, intrapro-
static musculature; from Dorschner et al. 1994b)
many subsequent authors). Starting from the theory of a non-independent vesical

sphincter, other authors described the entire circular urethra musculature as a con-
tinuation of the lamellae of the external longitudinal detrusor musculature. These
lamellae are supposed to continue directly into the urethral musculature and encircle
the bladder outlet, forming a continence-ensuring structure (Krantz 1951; Langreder
1956; Lapides et al. 1957; Lapides 1958, 1965; Beck 1969, 1971; Tanagho 1973).
From a functional view, the vesical sphincter is frequently described as the only
circular-smooth muscle structure of the neck of bladder, guaranteeing constant conti-
nence on its own. How does this anatomical opinion square with the clinically impor-
tant "phenomenon" that all patients remain continent after the deliberate operative
destruction of the vesical sphincter, for instance during a transurethral resection of
the prostate or a bladder neck incision (Fig. 27 C,D)?
Today, most authors define the musculus sphincter vesicae as a compound muscle
which is supposed to consist of detrusor musculature ventrally and of parts of the
so-called trigonal musculature dorsally. They often use the term "base-plate" (Hutch
1965,1966, 1967a,b, 1971; Hutch and Shopfner 1968a,b; Hanke et al. 1986). Tanagho
and Smith (1966) closely follow Hutch and his colleagues in the description of the
vesical sphincter, without directly using the term base-plate.
Our own studies suggest that this base-plate theory is a classical case of a morpho-
logical interpretation mistake resulting from the incorrect choice of examination
technique. This is shown in the following.
25
Figure lOB,C shows two transversal sections through the neck of bladder of a
41-year-old man. It should be emphasised that it is a paraffin section in a strictly
transversal cutting direction. By definition, this level is exactly horizontal in the
upright standing human. At this level, the vesical sphincter actually appears to be a
compound structure. Ventrally, the lamellae of the detrusor musculature appear to
form a semicircular layer around the internal urethral orifice. Dorsally, semicircular
parts of the trigonal musculature can be seen around the ostium urethrae internum.
Viewed in 3D, this arrangement would correspond to the above-mentioned com-
pound base-plate.
If, however, the location of the neck of bladder is studied in situ, it must be taken
into consideration that the neck of bladder is not located vertically in the pelvis, but is
fixed in a slightly ventrally tilted position vis-a-vis the frontal plane. When choosing a
plane for examining the structure of the vesical sphincter, this physiological bend in
the neck of bladder must also be taken into account ex vivo. Therefore, whole organ
packages were embedded in paraffin and sectioning planes were adjusted strictly
transversal to the real course of the urethra. With regard to the classical transversal
plane, the resulting transversal sections are now tipped in the ventral or caudal
direction. From the level of the ureteric orifices up to the internal urethral orifice and
still into the neck of bladder, it becomes clear that the sphincter has a circular form
(Fig. 10D-I). It can also be seen that the internal urethral orifice lies in an eccentric
position at the front of this muscle. The muscle cell bundles of this smooth vesical
sphincter enclose the ostium urethrae internum in the form of an ellipse. The dorsal
circumference almost reaches the ureteric orifices. The ventral circumference of this
ellipsis lies dorsally of the nodus vesicae and clearly caudally of the lowest middle
circular bladder muscle layer (Figs. 11,12).
In the entire material examined, the muscle cell bundles caudally of the vesical
sphincter enclose the urethra in a circular manner (Fig. 10H,I). In young men, this
circular structure ends dorsally above or at the level of the collicuius seminalis within
the prostate. Large parts of the vesical sphincter are interspersed with prostate tissue.
This argues for the assumption that the vesical sphincter and parts of the intrapro-
static musculature are of the same origin. Deeper circular smooth muscle structures
(d. Chap. 6) have a considerably different basic structure. There is no continuous
"intrinsic sphincter" running from the internal urethral orifice to the bulb of penis
(McGuire 1986).
The vesical sphincter is the only muscular structure directly encircling the ostium
urethrae internum. Muscle lamellae of the detrusor are not involved in the formation
of the vesical sphincter or musculus sphincter vesicae (Dorschner et al. 1989b,
1994a,b). The above-described system of muscle loops of the vesical or internal
sphincter is an artificial result of an inadequate investigation technique. The bladder
outlet with the internal urethral orifice is only defined by the musculus sphincter
vesIcae.
The individual sections of the lower urinary tract show a specific formation of the
smooth muscle cell layers, the epithelium and the glands, which cannot be explained
by the different origin of individual tissue parts, but which is based on morpho- and
histogenetic processes determined by a chronologically determined sequence of in-
duction, hormonal control and function. Examinations of our own histological mate-
rial (Latka 1989) show that the musculus sphincter vesicae can be demonstrated as
early as the fourth fetal month. On the other hand, the musculus detrusor vesicae is
26
already visible within the first 3 months with its typical three layers, the stratum
internum longitudinale, stratum circulare and stratum externum longitudinale. The
appearance of the two muscles at different times of development supports the view of
an independently existing musculus sphincter vesicae.
The course of the muscle cell bundles of the vesical sphincter in older men differs
from that in younger men due to the growth of the prostate. The vesical sphincter
forming a circle around the ostium urethrae internum and reaching far into the neck
of bladder is increasingly interspersed with adenomatous tissue starting from the
caudal side. The adenomatous tissue displaces the intravesical part of the vesical
sphincter into the bladder lumen. Simultaneously, the musculus interuretericus is
pushed upwards, thus causing the typical fish-hook form of the ureters in the excre-
tory urography of BPH (benign prostate hyperplasia) patients.
In the female, the neck of bladder seems generally more thickset due to the clearly
shorter urethra compared to the male. This is also reflected in the course of the
musculus sphincter vesicae. The muscle cell bundles embrace the bladder outlet in
more circular, less elliptical fashion. They are located around the proximal third of the
urethra and are directly adjacent to the musculus sphincter urethrae (urethral sphinc-
ter). As a whole, the vesical sphincter is clearly less distinctive in women than in men.
The topographic-anatomical characteristics of the musculus sphincter vesicae
(strictly circular course, marking the boundary of the ostium urethrae internum etc.)
in the female do, however, correspond in all age groups to those in the male.
The different course of the vesical sphincter results from the different functions of
the neck of bladder in the sexes. The vesical sphincter in women probably just has a
continence function while the vesical sphincter or musculus sphincter vesicae in men
also has an important function regarding ejaculation (cf. Chap. 12). The contraction
of this muscle prevents retrograde ejaculation. The vesical sphincter, which is rela-
tively weakly developed in the female, might be the reason for the absence of an illness
which is one of the most important differential diagnoses of a bladder outlet obstruc-
tion in the male, bladder neck sclerosis. In clinical practice, this clinical picture
(whose pathomorphology is characterised by a hypertrophy of the internal sphincter)
has not yet been observed in women.
4.3
Trigonum Vesicae
The trigonum vesicae or trigone of bladder is defined as a geometrical triangle

marked by the three corner points of the two ureteric orifices and the internal urethral
orifice. This geometrical triangle has on occasion even been declared to be an inde-
pendent structural unit due to differences in the macroscopic composition and fine
structure (Waldeyer 1897).
The muscle cells of the trigonum vesicae clearly differ from the bladder muscula-
ture (Fig. 33). They are thinner and shorter and are not combined in muscle lamellae.
In newborn infants, the cells are still somewhat disordered; with advancing age they
run strictly parallel. These muscle cells as a whole belong to the vesical sphincter or
musculus sphincter vesicae. The vesical sphincter, however, embraces the bladder
outlet elliptically as described above. Only its dorsal circumference is located in the
trigone of the bladder, not the whole muscle. The trigonum vesicae must therefore be
27
regarded as a purely arbitrarily defined structure which only serves orientation in the
bladder bottom area. The dorsocranial border is formed by the musculus interure-
tericus. Dorsally, the trigonum vesicae is covered by the medial bundle of the outer
longitudinal layer of the detrusor. All the other parts of the detrusor musculature are
positioned further cranially and end in the coliare vesicae.
All in all, the term musculus sphincter urethrae internus, chosen by the Termi-
nologica Anatomica (1998) for the vesical or internal sphincter, appears unsuitable for
the more detailed identification of its topography. This term implies a primary closure
of the urethra in order to maintain urine continence. The urinary bladder and not the
urethra is the organ for the storage of urine produced by the kidneys. A sphincter
directly around the ostium urethrae internum, even if it exists independently of the
bladder musculature, closes up the urinary bladder and not the urethra and thus
prevents urine "flowing out" of this reservoir. Furthermore, the dorsal circumference
of the vesical sphincter reaches far into the area of the bladder bottom and forms the
main part of the trigonum vesicae. In addition, the vesical sphincter separates the
urinary tract from the genital organs. During ejaculation, it locks the urinary bladder
(not the urethra) and thus prevents retrograde ejaculation (d. Chap. 12). Therefore it
is suggested to use the term musculus sphincter vesicae or vesical sphincter already
used in the Paris Nomina Anatomica (1955) for this muscle.
Another argument for adopting the term musculus sphincter vesicae is the result-
ing clear distinction from the second circular sphincter of the collum vesicae, the
actual urethral sphincter. The urethral sphincter is defined by the Paris Nomina
Anatomica (1955) as musculus sphincter urethrae. This musculus sphincter urethrae
really locks the urethra. The musculus sphincter vesicae, however, surrounds the
ostium urethrae internum and not the urethra.
Furthermore, the Terminologica Anatomica (1998) defines in the same context a
musculus sphincter supracollicularis (supracollicular sphincter) and the musculi
trigoni vesicae (musculus trigoni vesicae superficialis et profundus).
The only morphological substrate which might correspond to the musculus
sphincter supracollicularis are the parts of the musculus sphincter vesicae within the
prostate reaching to the colliculus seminalis. A separate sphincter does not exist in
this area and therefore cannot be defined.
As the histological findings show, the geometrical trigonum vesicae is only formed
by one muscle layer. This muscle layer is part of the muscle cell bundles of the dorsal
circumference of the musculus sphincter vesicae. In the urinary bladder lumen, this
muscle is covered by urothelium. Solely dorsally, medial bundles of the outer longitu-
dinallayer of the detrusor pass over the vesical sphincter, where they split in two to
form the musculus vesicoprostaticus or end in the coliare vesicae (d. Chap. 3.3).
It should be emphasised again that the musculature of the trigonum vesicae does
not consist of a deep trigone and a superficial trigone or of a musculus trigoni vesicae
superficialis and musculus trigoni vesicae profundus, as suggested in the Termi-
nologica Anatomica (1998), but that the superficial layer of dorsal parts of the muscu-
lus sphincter vesicae and the so-called deep trigone are formed by parts of the bladder
musculature (Figs. 6,7,12).
28
4.4
Summary
The musculus sphincter vesicae is an independent morphological unit and is the only
muscle marking the boundary to the ostium urethrae internum. The muscle cell
bundles of the vesical or internal sphincter form an ellipsis around the internal
urethral orifice and reach up to the level of the seminal colliculus on the caudal side,
and thus form parts of the neck of bladder in the male. In the female, they are
arranged in a more circular fashion around the internal urethral orifice. In both sexes,
the lamellae of the detrusor musculature do not continue to the neck of bladder or the
urethra and therefore are not involved in the formation of the internal urethral orifice.
A musculus retractor uvulae cannot be demonstrated, nor do a musculus trigoni
vesicae superficialis or a musculus trigoni vesicae profundus exist. The trigone of the
bladder is 'merely' the description of a topographic region limited by both ureteric
orifices and the internal urethral orifice, whose purpose is mainly orientation in the
urinary bladder.
29
5 Diaphragma Urogenitale
"All these distinctions go either too far or not far enough. If the muscle mass filling a
certain space were to be separated further, the number of muscle cords deserving a
special term could be easily increased. The first thing to do is to find a name for the
whole, more or less complicated muscular plate from the front point of the pelvic
aperture, and I choose the oldest name, which has the advantage of suiting both sexes
and which does not prejudge anything by virtue of its physiological name."
Henle (1866)
For many years, the radical prostatectomy has been an established method for treating
prostatic cancer in the clinical stage T1-T2. In terms of operative technique, although
both suprapubic and perineal access are possible, the latter having a number of
advantages. Both sphincters of the neck of bladder, the vesical sphincter and the
urethral sphincter, can easily be prepared and anastomosed. During preparation, it
becomes apparent that in the area of the urethral sphincter there is no continuous
transversal muscle plate which could correspond to the diaphragma urogenitale (uro-
genital diaphragm). This is even more surprising as this structure has been described
in well-known anatomical textbooks (Pernkopf 1994) and urological surgery manuals
(Marshall 1991; Glenn 1992) as a prominent structure in the small pelvis. Apparently,
fascie and transversal muscle fibres are supposed to strengthen the pelvic floor be-
tween the lower branches of the pubic bone, keep the urethra (and in the female the
vagina, too) in the median line in both sexes. This muscle plate enclosed by fascie is
called the diaphragma urogenitale, the main element of which has been defined as the
musculus transversus perinei profundus (deep transverse perinei muscle; Alverdes
1959; Brooks et aI.1998).
Although the term diaphragma urogenitale itself is not mentioned in the latest
Terminologia Anatomica (1998), clinicians use it very frequently to describe the pelvic
floor. Furthermore, this diaphragma urogenitale is emphasised in numerous conti-
nence theories, because fibres of the deep transverse perineal muscle partly or com-
pletely enclose the urethra and are thus supposed to form the striated musculus
sphincter urethrae (Finger 1896; Rehfisch 1897; Waldeyer 1899; Zangenmeister 1909;
Pernkopf 1941, 1994; Langredern 1956; Alverdes 1959; Tanagho and Smith 1966;
Hutch 1967; Hutch and Rambo 1967; Rohen 1973; Tanagho 1973). Some authors name
a separate extrinsic striated urethral sphincter as being part of the musculature of the
pelvic floor (Warwick 1979; Hinman 1993).
As described above, in an operative view, considerable doubt surrounds the exist-
ence of a classical diaphragma urogenitale. In the more recent literature, too, the
existence of a classical diaphragma urogenitale has not been described (Lawson 1995)
31

or has been critically questioned (Kaye et al. 1997), and several authors reject the
existence of a muscular connection between the musculature of the pelvic floor and
the pars membranacea urethrae (Oelrich 1980, 1983; Dorschner 1984; Meyers 1987;
Dorschner and Stolzenburg 1994a).
In 1873, Henle described for the first time an upper and a lower aponeurosis, which
is supposed to envelope the musculus transversus perinei profundus. This deep trans-
verse perineal muscle in the male is supposed to run below the prostate and above the
urethra cavernous body between the two rami inferiores ossis pubis and the rami
ossis ischii, and to dorsally enclose Cowper's glands (Pernkopf 1994). Holl (1897)
divides the musculus transversus perinei profundus into a musculus sphincter ure-
thrae membranacea, a musculus compressor glandulae Cowperi and a musculus
transversus perinei profundus, and was thus one of the founders of the concept of a
diaphragma urogenitale, which is still accepted.
It should be underlined again that the term diaphragma urogenitale is very impor-
tant in practical clinical language. With light forms of stress-related urinary inconti-
nence, the first therapeutic measure almost always comprises special exercises for the
pelvic floor. Numerous studies prove that symptoms improve in post-operative thera-
pies and in the treatment of old-age stress incontinence (Chang et a1.1998; Chen et al.
1999; Weinberger et al. 1999). The physiology or the way it works is explained such
that pelvic floor exercises train the urethral sphincter as it is supposed to originate
directly in the "main element" of the diaphragma urogenitale, the deep transverse
perineal muscle.
Our own conflicting operative experience prompted us to conduct a series of
histological studies to ascertain whether a musculus transversus perinei profundus
can be shown to be the main element of the diaphragma urogenitale. Due to the
course of this muscle, the transversal and frontal section are particularly suited for
this purpose. In the male, this muscle ought to be particularly well visible in a
transversal serial section with a high quantity of sectional images starting directly
below the prostate until the bulb of penis. Figure 13 shows parts of such a serial
section from a newborn infant. Figure 13A also shows parts of the lower edge of the
prostate at the height of the colliculus seminalis dorsally of the symphysis. Individual
fibres of the musculus sphincter urethrae overlap the ventral part of the prostate.
Figure DB shows the typical course of the urethral sphincter in the transversal level.
The muscle embraces the urethra in the shape of a horseshoe. The lateral muscular
Fig.13A-D. Pelvic floor musculature and urethral sphincter. Transversal, newborn infant, male,
10 flm, Crossmon, x4. Section series from cranial to caudal direction (asterisk, musculus sphincter
urethrae; MI, musculus levator ani; Mo, musculus obturatorius intern us; Cs, colliculus seminalis; Bp,
bulbus penis; Gb, glandula bulbourethralis (Cowper's gland); Ct, centrum tendineum; R, rectum). The
photo shows a selection of serial sections starting at the height of the colliculus seminalis up to the
bulbus penis. The musculus transversus perinei profundus (deep transverse perineal muscle)
frequently described as the main element of the diaphragma urogenitale cannot be seen. The musculus
sphincter urethrae exists independently of the surrounding pelvic floor musculature (musculus
levator ani and musculus obturatorius internus). It surrounds the urethra (cf. B) in the shape of a
horseshoe. The arrows mark separating fatty and connective tissue containing blood vessels and
individual nerves. In particular at the height of the glandula bulbourethralis. which is supposed to be
surrounded by the so-called musculus transversus perinei profundus, no such muscle exists. (From
Dorschner et al. 1999)
32
".
",.'
",
."1,'
.'.r
:.
~
,"
- .....,
33
border is formed by the musculus levator ani (levator ani) and the musculus obturato-
rius internus (obturator internus). The musculus sphincter urethrae itself is encircled
by green-coloured connective tissue in this Crossmon staining. The findings in the
next picture (Fig. 13C) are almost identical. The urethral sphincter is again completely
separated from the surrounding musculature of the pelvic floor by a layer of connec-
tive tissue containing individual blood vessels and nerves. Here, too, there is no
continuous transversal muscle plate in the sense of the musculus transversus perinei
profundus. Figure 13C also shows Cowper's glands (glandulae bulbourethralis) in the
dorsal circumference of the musculus sphincter urethrae separated by connective
tissue from the musculus levator ani and the musculus obturatorius intern us. In this
case in particular, the musculus transversus perinei profundus ought to be clearly
visible.
The final picture (Fig. 13D) in this serial section shows the bulbar part of the
urethra. The pars membranacea urethrae is separated throughout its entire course
from the adjoining pelvic floor musculature by connective tissue. The urethral sphinc-
ter exists as an independent structure and is solely anchored in the pelvic floor by
connective tissue. The musculus levator ani and the musculus obturatorius internus
are located laterally. A musculus transversus perinei profundus or deep transverse
perinei muscle constituting the main element of the diaphragma urogenitale is not to
be seen.
The studies of the transversal and frontal serial sections of all age groups demon-
strate that there is no transversal muscle plate in the sense of the musculus transver-
sus perinei profundus in the whole urethra area (Figs. 13-16). This is particularly
apparent in Fig. 16A-C. Figure 16A shows a frontal section through the entire neck of
bladder starting from the trigone of bladder until the bulb of penis. The whole of the
urethral sphincter is separated from the pelvic floor musculature by green-coloured
fatty connective tissue containing blood vessels and nerves. The transversal sections
(Fig. 16B,C) show the same results in both sexes.
Matsuno et al. (1984) emphasize that in the embryonic stage the urethral muscula-
ture and the surrounding pelvic floor musculature are clearly separated by a connec-
tive tissue cover. Furthermore, the striated muscle fibres of the musculus sphincter
urethrae are significantly smaller than those of the pelvic floor, something which is
also found in adults (Neuhaus and Stolzenburg, unpublished data). For example,
according to our own investigations, the average diameter of the muscle fibres of the
striated parts of the musculus sphincter urethrae is 13.4 I.lm (n=200, standard devia-
Fig. 14A-D. Pelvic floor musculature and urethral sphincter. A Diagram of the histological section
plane. B-D Transversal, newborn infant, male, 10 flm, Crossmon, xs. Section series from cranial to
caudal direction (Mu, musculus sphincter urethrae; MI, musculus levator ani; Mpv, musculus
pubovesicalis; Mb, musculusbulbospongiosus; Gb, glandula bulbourethralis (Cowper's gland); Cs,
colliculus seminalis; R, rectum; S, symphysis; Ct, centrum tendineum). In a transversal section series
between colliculus seminalis (B) up to the height of the glandula bulbourethralis (D), no transversal
musculature in the sense of the musculus transversus perinei profundus can be found. There are only
the musculus sphincter urethrae and, ventrally, the musculus pubovesicalis. At the edge of each
photo, at the lateral side, the musculus levator ani can be clearly distinguished on both sides. Between
urethral sphincter and musculus levator ani there is always separating fatty and connective tissue
(arrows). At the height of the glandula bulbourethralis, the musculus bulbospongiosus can be seen
on the lateral side
34
A
35
tion=5.8), while the average diameter of the muscle fibres of the adjoining musculus
levator ani is 32.6 11m (n=200, standard deviation=7.2).
In order to verify these histomorphological findings with the latest methods of
imaging diagnosis, a series of histological specimens was compared with various MRI
series of the small pelvis, focusing on the muscular structure of the pelvic floor
(Thiele et al. 1997; Dorschner et al. 1999). Due to its outstanding soft tissue contrast,
magnetic resonance imaging is superior to all other sectional imaging techniques for
making out the anatomical structures of the neck of bladder (Klutke et al. 1990;
Strohbehn et a1.1996; Mikuma et aI.1998).
The MRI scanner image shows a prominent musculus sphincter urethrae as a
compact structure around the urethra, surrounded on all sides by a zone of loose fat
and connective tissue. These results coincide with the histological findings
(Fig. 16A,B) in the frontal level (Fig. 16D) as well as in the transversal level (Fig. 16E).
The horseshoe shape of the musculus sphincter urethrae can also be seen in MRI
images. Tallying with the histological findings, only the levator ani and the obturator
internus can be seen on the lateral side of the urethral sphincter. There is no deep
transverse perineal muscle.
5.1
Summary
Our own histomorphological examinations, including the MRI examinations of the

small pelvis of female and male patients, reveal a structure of the pelvic floor which
deviates from the description contained in the classical textbooks (Hamilton 1976;
Marshall 1991; Hinmann 1993; Pernkopf 1994; Feige et aI.1997). A so-called musculus
transversus perinei profundus or deep transverse perineal muscle does not exist.
Consequently, a classical diaphragma urogenitale, the main element of which is sup-
posed to be this very muscle, does not exist either (Dorschner 1992; Dorschner and
Stolzenburg 1994a; Dorschner et al. 1999). The urethral sphincter as an independent
morphological unit enclosing the urethra in the shape of a horseshoe has "merely"
fibrous connections to the surrounding pelvic floor musculature (musculus levator
ani and musculus obturatorius internus).
The "absence" of the oft-described musculus transversus perinei profundus begs a
critical examination of numerous theories of urine continence describing the
Fig. 15A-C. Pelvic floor musculature and urethral sphincter. A-C Frontal, newborn infant, male,
10 flm, Crossmon, x3. Section series from ventral to dorsal direction (Mu, musculus sphincter
urethrae; Ml, musculus levator ani; Mo, musculus obturatorius internus; Mb, musculus
bulbospongiosus; S, symphysis; P, prostate; Cs, colliculus seminalis; Bp, bulbus penis; U, urethra).
The retropubic space (A,B) as well as the space at the lateral side of the collum vesicae (C) is filled
with green-coloured connective tissue (arrows). In the frontal section, no transversal muscle filaments
in the sense of the musculus transversus perinei profundus, the so-called main element of the
diaphragma urogenitale, are to be seen. This muscle is repeatedly described as a transversal structure
between the prostate and the bulbus penis and thus would have be visible in at least Band C. The only
muscles evident in the pelvis bottom are the musculus levator ani and the musculus obturatorius
internus
36
37
Fig. 16A-E. Musculus sphincter urethrae transversostriatus et glaber (striated and smooth muscular
part of the urethral sphincter). A Frontal, 7 years, male, 10 f.lm, Crossmon, x4.8. B Transversal,
56 years, male, 10 f.lm, Crossmon, x4. C Transversal, 4 years, female, 10 f.lm, silver staining according to
Pap, x6 (asterisk, musculus sphincter urethrae transversostriatus; filled circle, musculus sphincter
urethrae glaber; Mdv, musculus detrusor vesicae; MI, musculus levator ani; Tv, trigonum vesicae; P,
prostate; V, vagina; R, rectum; U, urethra). 1n both sexes, the striated and smooth muscular part of the
urethral sphincter can clearly be distinguished. As the urethra runs in a curve behind the symphysis,
the frontal section (A) shows the cut end of the urethra on the cranial and caudal side. The main part
of the musculus sphincter urethrae lies on the ventral side of the urethra lumen (A,B,C). The whole of
the urethral sphincter is separated by connective tissue (arrows) from the surrounding pelvic floor
musculature. A musculus transversus perinei profundus (deep transverse perineal muscle) does not
exist (from Dorschner and Stolzenburg 1994a). 0 Magnetic resonance image, TI-weighted spin-echo,
coronar (frontal) image, 0.2 mmol Gd-DTPA/kg body weight intravenous, male, 52 years. E Magnetic
resonance image, T,-weighted spin-echo, 0.2 mmol Gd-DTPA/kg body weight intravenous, transver-
sal image, male, 63 years (M, musculus sphincter urethrae; L, musculus levator ani; 0, musculus
obturatorius intern us; P, prostate; R, rectum; F and arrow, fatty and connective tissue). Histological
serial sections and magnetic-resonance images show exactly the same topography. Neither in coronal
nor in transversal spin-echo images could a transversal muscular structure be found which might
represent the "deep transverse perineal muscle". The horseshoe-shaped muscular bilayer of the
urethra (E) can be distinguished from hyperintense surrounding fatty tissue. The external part of the
bilayer structure of the urethral sphincter is of lower T, signal intensity and can be distinguished
from an internal part with higher signal intensity (from Dorschner et al. 1999)
38
diaphragma urogenitale and the urethral sphincter (which is supposed to originate in
fibres of the deep transverse perinei profundus muscle) as the main morphological
basis of urine continence.
39
6 Musculus Sphincter Urethrae
(Urethral or External Sphincter)
"The urethral sphincter in the male is one of the least understood muscles in the human
body."
(Oelrich 1980)
The musculus sphincter urethrae (urethral or external sphincter) has been the subject
of numerous studies into the anatomical bases of urine continence. However, we are
still a long way off from an integrated description of its anatomy tallying with the
physiology of urine continence. A survey of the relevant literature reveals two differ-
ent concepts regarding the description of its course.
The vast majority of authors describe the urethral sphincter as part of the pelvic
floor musculature. As already shown in the chapter on the so-called diaphragma
urogenitale, the urethral sphincter is supposed to be either wholly or partly formed of
fibres of the musculus transversus perinei profundus (Finger 1896; Rehfisch 1897;
Waldeyer 1899; Zangenmeister 1909; Pernkopf 1941, 1994; Langredern 1956; Alveraes
1959; Hutch 1965, 1967a; Tanagho and Smith 1966; Hutch and Rambo 1967; Rohen
1973; Tanagho 1973). The second concept presupposes a striated muscle, extending
from the basis of the urinary bladder to the so-called diaphragma urogenitale and
overlapping parts of the prostate (Oelrich 1980; Myers et al. 1987; Walsh 1990). No
direct connection to the diaphragma urogenitale was found. According to Oelrich
(1980), the musculus sphincter urethrae does not form a horizontal plate but runs
vertically.
Kalischer (1900), Kennedy (1946) and Donker et al. (1976) have already described
the urethral sphincter separately from the deep transverse perinei muscle. Engels
(1939), Hayek (1960, 1962) and Gosling (1979) found histological differences between
them.
Hayek (1962) even describes the musculus sphincter urethrae as a structure con-
sisting of four parts. The rhabdosphincter prostaticus is supposed to consist of muscle
cords ventrally overlapping the prostate. He describes a second part, the rhab-
dosphincter infraprostaticus, as an independent muscle, which is separated cranially
and laterally by plenty of smooth musculature from the neighbouring organs. The
third part is supposed to be formed by the musculus transversus perinei profundus;
the fourth by parts of the musculus bulbospongiosus.
The musculus sphincter urethrae is considered to be a rhabdosphincter. In many
cases, the terms rhabdosphincter and urethral sphincter are used synonymously
(Strasser et al. 1996; Elbadawi et al. 1997). By definition, the term rhabdosphincter
describes an exclusively voluntarily innervated sphincter. The muscle filaments of the
41

A
Fig. 17A-K. Musculus sphincter urethrae transversostriatus et glaber (striated and smooth muscular
part of the urethral sphincter). Frontal, 7 years, male, 10 ).1m, Crossmon, serial sections from ventral
to dorsal direction. A Diagram of the musculus sphincter urethrae with its two parts. B-F Overall
views, xl. G-K Details, x6 (asterisk, musculus sphincter urethrae transversostriatus; filled circle,
musculus sphincter urethrae glaber; MI, musculus levator ani; Tv, trigonum vesicae; P, prostate; Cs,
colliculus seminalis; S, symphysis removed during preparation). B-F The two parts of the urethral
sphincter in the enlargement of the overall view. The enlargement of details of the above overall
42
sphincter in the enlargement of the overall view. The enlargement of details of the above overall
views in G-K shows the differentiated structure of the musculus sphincter urethrae. The series clearly
shows that the muscle forms a morphological unit, consisting of a striated part (dark colour) and a
smooth muscular part (light colour). The muscle cell bundles of the smooth part are relatively thick
and divide. There is a loose separation of connective tissue (arrows) between the musculus sphincter
urethrae and the pelvic floor musculature (musculus levator ani). A musculus transversus perinei
profundus, the so-called main element of the diaphragma urogenitale, does not exist. (From
Dorschner 1984)
43
Fig. 18A-D. Musculus sphincter urethrae (urethral sphincter). Frontal, 16 years, male, 10 flm, Cross-
mon, section series from ventral to dorsal direction. A,C Overall views, xl. B,D Details, x8 (Mug,
musculus sphincter urethrae glaber; Mut, musculus sphincter urethrae transversostriatus; P, prostate;
U, urethra; Cc, corpus cavernosum; Bp, bulbus penis; arrows, musculus dilatator urethrae). The striated
part of urethral sphincter (musculus sphincter urethrae transversostriatus) surrounds the smooth
muscular part (musculus sphincter urethrae glaber). This part is lightly coloured in the photos and has
no connective tissue septa dividing it from the musculus sphincter urethrae transversostriatus
44
Fig. 19A-D. Musculus sphincter urethrae (urethral sphincter). Frontal, 69 years, male, 10 flm, section
series from ventral to dorsal direction. A,C Overall views, Crossmon, xl,S. B,D Details; Crossmon
(A,B), silver staining according to Pap (C,D), x8 (Mug, musculus sphincter urethrae glaber; Mut,
musculus sphincter urethrae transversostriatus; Md, musculus dilatator urethrae; P, prostate). In males
of advanced age, the situation is the same as in young males. Due to the growth of the prostate
adenoma, the musculus sphincter urethrae are merely compressed on the caudal side
45
urethral sphincter have somatomotoric end plates and show a positive immunostain-
ing for acetylcholinesterase (AChE; Lincoln et al. 1986; Crowe and Burnstock 1989).
Our own studies of the musculus sphincter urethrae have resulted in partly corre-
sponding, yet also partly very discrepant findings compared with the literature con-
cerning its detailed course and its connection to the surrounding pelvic floor muscu-
lature. As described in the chapter on the so-called diaphragma urogenitale, the
urethral sphincter exists as an independent structure and has no muscular connec-
tion to the surrounding pelvic floor musculature. These findings were made in all age
groups (Figs. 13-16).
Tichy (1989) differentiates between three stages of the ontogenesis: (1) the sexually
indifferent stage up to a crown rump length (CRL) of 50 mm (about 10 weeks old); (2)
the stage of sexual differentiation until birth; (3) the morphogenetic postnatal stage.
During stage 1, the musculus sphincter urethrae is supposed to be merely a primor-
dium situated on the ventrolateral wall of the urethra. In the course of sexual differen-
tiation in stage 2, the vagina or prostate are formed. The musculus sphincter urethrae
extends to the dorsal wall of the urethra. In the post-natal stage, the typical horseshoe
form of the external sphincter can already be observed (Fig. 13).
In adolescents, the topography of the musculus sphincter urethrae can be particu-
larly clearly seen in a frontal section through the entire neck of bladder (Figs. 16A, 17)
and in transversal sections (Fig. 16B,C). The muscle filaments of the striated musculus
sphincter urethrae run strictly parallel to each other in a semicircle around the
urethra. Ventrally, the muscle is developed strongest (Figs. 14, 16B,C). Dorsally, the
muscle filaments arranged around the urethra are never completely closed. This
explains the picture of a muscle in a horseshoe shape in the transversal plane. Other
authors speak of an omega shape (Strasser et al. 1996), which has been found in both
adult males and females (Fig. 16B,C).
All the strongly developed muscle filaments on the ventral side meet dorsally
between the lower edge of the prostate and the bulb of penis. The upper and centre
muscle filaments run steeply from ventral-cranial to caudal-dorsal. The lower part of
the striated musculus sphincter urethrae is most strongly developed and tends to run
horizontally. In the lateral view, the muscle therefore has the shape of a truncated cone
(Figs.17A,21).
With advancing age, the form of the cone changes due to the growth of the prostate
such that the surface of the cone where it is truncated becomes steeper as the ventro-
lateral parts of the external urethral sphincter are increasingly compressed by the
adenoma (Figs. 18,19).
Ventrally, the muscle filaments of the musculus sphincter urethrae extend cranially
from the bulb of penis over the colliculus seminals. The front circumference covers
parts of the prostatic capsule. Since in the male the vesical sphincter settles circularly
around the urethra reaching far into the neck of bladder, the lower third of the
intraprostatic part is covered by filaments of the striated urethral sphincter. The
intraprostatic part of the vesical sphincter and the filaments of the urethral sphincter,
are, however, separated by gland tissue of the prostate.
Various authors (Gil Vernet 1960; Hayek 1962; Manley 1966) describe a separate
prostatacapsular rhabdosphincter, which is supposed to overlap the ventral part of the
prostatic capsule in the form of a butterfly and to form part of the capsule. Although
in histological specimens this area also contains filaments of striated musculature, the
above-mentioned authors only describe a sector with respect to the prostate. These
46
Fig. 20A-D. Musculus sphincter urethrae (urethral sphincter). Sagittal, newborn infant, female, 10
flm, Crossmon (A,B), H&E (C,D). A,C Overall views, xl.5 image sequence from lateral left to medial.
B,D Details, x7. The enlargements of details show the musculus sphincter urethrae glaber and the
typical division (arrows) of its muscle cell bundles
47
filaments of striated musculature belong directly to the musculus sphincter urethrae,
the striated muscle filaments of which, as described, extend ventrally relatively far in
the cranial direction and cover parts of the prostatic capsule.
In contrast to the male, the urethral sphincter of the female runs more horizontally
and can best be described as having the shape of a number of horseshoes one on top
of the other rather than a truncated cone. Hence the picture of an almost complete
circular muscle (Fig. 20) arises. However, as in the male, the curve is not completely
closed (Fig. 16C). Dorsally, there are always fibrous structures. As a whole, the middle
third of the female urethra is surrounded by the musculus sphincter urethrae.
Contrary to the information in the literature, the musculus sphincter urethrae in
both sexes does not only consist of striated muscle filaments. Towards the urethra,
below the muscle filaments of the striated urethral sphincter, a layer of smooth muscle
cells is always visible (Figs. 16-20). The individual muscle cell bundles of this smooth
muscle are relatively thick and in contrast to the striated filaments of the urethral
sphincter branch out regularly (Figs. 20, 33C,D). The local extension of this smooth
muscle corresponds as a whole to the course of the striated muscle filaments of the
musculus sphincter urethrae (Fig. 36B,C; d. also the enclosed CD-ROM).
During adulthood, this layer of smooth muscle cells takes up a third of the outer
striated muscle filaments. In the female, the same layer of smooth muscle cells can be
shown (Figs. 16C, 24B,C). Here, too, these cords of smooth muscle cells possess the
same spatial extent as the striated muscle filaments of the urethral sphincter. As a
whole, this layer of smooth muscle cells, however, is even more strongly developed
than in the male and has the same wall thickness as the striated part of the urethral
sphincter (Fig. 16C). Cranially, the bundles of smooth muscle cells pass almost imper-
ceptibly into the vesical sphincter. An "intrinsic sphincter- (McGuire 1986) reaching
all the way from the bladder outlet up to the bulb of penis does not exist in humans.
Both parts of the musculus sphincter urethrae develop from a single mesenchyme
consolidation forming a circle around the urethra, which can already be shown in
human embryos measuring 12-15 mm CRL (Bourdelat et al.1992). This consolidation
increases and after 15 weeks, two layers - an inner layer of smooth muscle cells and an
outer layer of striated muscle filaments - become visible (Bourdelat et al. 1992). As
Kokoua et al. (1993) were able to show, the typical horseshoe form of the striated part
of the musculus sphincter urethrae (musculus sphincter urethrae transversostriatus)
in males only develops during the first 5 postnatal months. Due to the development of
the prostate and the glandulae bulbourethralis, this form of the muscle develops at
different section cutting heights (crista urethralis, apex prostatae, glandulae bul-
bourethralis) at different times. From the seventh postnatal month onwards, the stri-
ated part of the musculus sphincter urethrae in the male occurs in the shape of an
omega throughout its whole length (Kokoua et al. 1993). In the female, the horseshoe
or omega shape may already be found as of the first postnatal month. Whereas Oelrich
(1980) interprets the chronological changes of the muscle form in the male as being
caused by the growth of the prostate, Kokoua et al. (1993) point out that the muscle
changes in the female, too.
Borirakchanyavat et al. (1997) examined the development of the musculus sphinc-
ter urethrae in rats, embryos, neonatal and adult animals. They tracked differentiation
into smooth and striated muscle cells with the help of immunohistological detection
of smooth muscular actin (SMC actin), a-sarkomer actin (a-S-actin) and the myosin
heavy chain (MHC). They found SMC-actin-positive smooth muscle cells in a circular
48
Fig. 21. Diagram of the two parts of the musculus sphincter urethrae in the male (urethral sphincter).
Ventral cranial (A), ventral caudal (B) and lateral (e) circumference of the urethral sphincter (D)
vesical sphincter (musculus sphincter vesicae); asterisk, musculus sphincter urethrae transversos-
triatus (striated part of the urethral sphincter); filled circle, musculus sphincter urethrae glaber
(smooth muscular part of the urethral sphincter). (From Dorschner and Slolzenburg 1994a)
formation around the urethra right during the early embryonic stage. They did not
observe an immunoreactivity for the markers of striated musculature in the embry-
onic stages. a-S-Actin-positive cells occurred for the first time in the perinatal period
and MHC-positive cells were only found in adult animals. Striated muscle filaments in
the urethral sphincter occurred for the first time in the neonatal period, while the
musculus levator ani was shown to already have transverse filaments in young em-
bryos (Borirakchanyavat et al. 1997). The authors describe SMC-actin-positive reac-
tions in both smooth muscle cells and striated myotubules until the neonatal stage.
Afterwards, the immunoreactivity for SMC-actin in the striated muscle filaments
decreases and can only be found in smooth muscle cells with the adult animal. From
49
these findings, the authors concluded that there must be a common parent cell for the
smooth and the striated part of the musculus sphincter urethrae. They refer in par-
ticular to the fact that the development of the pelvic floor musculature in the form of
the musculus levator ani is completely independent of the musculus sphincter ure-
thrae, and conclude that this muscle should be regarded as an independent unit.
6.1
Summary
Our investigations show that a musculus sphincter urethrae exists independently of

the pelvic floor musculature, forming a horseshoe around the urethra, and entirely
consisting in both sexes of a striated and a smooth muscle part. Both the smooth
muscle cell bundles and the striated muscle filaments have the same three-dimen-
sional extension and belong to the urethral sphincter. In order to differentiate between
both parts of the musculus sphincter urethrae, we propose the terms musculus sphinc-
ter urethrae glaber for the smooth muscle part of the urethral sphincter and musculus
sphincter urethrae transversostriatus for the striated part of the urethral sphincter
(Figs. 17-21,33; Dorschner 1984; Dorschner et al.1989b; Dorschner and Stolzenburg
1994a).
This particular structure of the musculus sphincter urethrae calls for a differenti-
ated interpretation of its function regarding rest and stress under particular consid-
eration of its two parts and its sex differences. All the conclusions concerning the
function of the described muscles and muscle systems are summarised in Chap. 12.
so
7 Musculus Dilatator Urethrae
"The urethra, which connects the bladder to the exterior, is a highly complex organ. This
is true whether one considers its function, its structure or the mechanisms involved in
its control, and it applies both to the male and the female. Nevertheless the majority of
normal humans are probably totally unaware of the complexities of the system. How-
ever, when something goes wrong, the importance of a perfectly functioning outflow
tract is immediately apparent, and the considerable difficulties both for the patient and
the clinician in improving the function lead to an appreciation ofjust how complex the
system is, and how little we really understand it. "
(Brading 1999)
The ventral longitudinal urethra musculature is widely ignored in the anatomical

literature. In his Handbuch der systematischen Anatomie des Menschen, Henle (1866)
writes that the trigonal musculature continues into the urethra. The longitudinal fibre
layer of the urethra is stated to be 0.3 mm thick. Waldeyer (1899) also describes the
continuation of the trigonal musculature into the urethra.
Subsequent publications contain almost identical descriptions, and it is repeatedly
emphasised that the inner longitudinal musculature of the urethra is a direct continu-
ation of the internal longitudinal layer of the detrusor to the urethra (Ricci et al. 1950;
Scher 1950; Clegg 1957; Woodburne 1961; Hutch and Rambo 1967; Woodburne 1968).
Like the above-mentioned authors, Tanagho and Smith (1966, 1968) and Tanagho et
al. (1969) show an inner longitudinal layer of the urethra, the thickness of which
remains constant along the urethra - in contrast to the circular muscular layer above.
Again, the internal longitudinal layer of the detrusor and the smooth longitudinal
musculature of the urethra are considered to form a single unit. In the male, the lower
end of the smooth longitudinal musculature of the urethra is supposed to be less
pronounced than in the female. In the caudal direction, it is said to mix with the
prostate musculature and to end within this musculature.
In the literature, the smooth ventral longitudinal musculature of the urethra is
regarded not as independent musculature, but rather as a continuation of the lamellae
of the stratum internum longitudinale to the urethra. However, Kalischer (1900)
argued that the muscle system of the urinary bladder exists separately from that of the
urethra. According to Kalischer (1900), the importance of the longitudinal muscle
layer of the urethra "must be seen in the expansion of the urethra during urinary
evacuation due to a contraction of this layer".
The results presented in Chap. 3 dearly show that all the lamellae of the detrusor
musculature terminate at the collare vesicae or nodus vesicae. The only muscle parts of
the musculus detrusor vesicae going beyond this limit are the musculus pubovesicalis
51

I
I
I
Fig. 22A-D. Musculus dilatator urethrae (ventral longitudinal urethral muscle system). Sagittal
(mediosagittal plane), 15 years, male, 10 f1m, Crossmon. A,C Overall views, x2. B,D Details, xl3
[asterisks, musculus sphincter vesicae (vesical sphincter); P, prostate; Cs, colliculus seminal is; Vs,
vesicula seminalis; U, urethra; ub, urinary bladder]. The enlargement of details clearly show that the
striated muscle cell bundles of the musculus sphincter vesicae (asterisks) are interwoven with parts
of the ventral longitudinal bundles of the musculus dilatator urethrae (arrows; C,D from Dorschner
et al. 1994c)
52
Fig. 23A-D. Musculus dilatator urethrae (ventral longitudinal urethral muscle system). Sagittal
(mediosagittal plane), newborn infant (A,B), 90 years (C,D), male, 10 flm, Crossmon, A x2, B x8, C
xl.5,D xl3 [asterisks, musculus sphincter vesicae (vesical sphincter); arrows, musculus dilatator
urethrae; R, rectum; S, symphysis; ub, urinary bladder]. The typical course of the musculus dilatator
urethrae (dilator urethrae) can be shown in all age groups. The asterisk in C marks the source of the
musculus dilatator urethrae at the symphysis. Even in the presence of a large prostate adenoma (C,D),
the typical course of the musculus dilatator urethrae does not change
53
Fig. 24A-I. Musculus dilatator urethrae and musculus sphincter urethrae. Transversal, 4 years, female,
10 flm, immunohistochemical image of smooth muscular a-actin using the peroxidase technique
(A,B), silver staining according to Pap (C-F,I), Crossmon (G,H). A,D,G Overall views, x3. B,E,H
Details ofA, D and G, x8. C,F,I Details from the neighbourhood ofB, E and H, x20. Section series from
cranial to caudal direction (Mut, musculus sphincter urethrae transversostriatus; Mug, musculus
sphincter urethrae glaber; Md, musculus dilatator urethrae; R, rectum; If, vagina). A,B,C The muscu-
lus sphincter urethrae glaber can clearly be distinguished. The musculus sphincter urethrae transver-
54
sostriatus and the musculus dilatator urethrae can also be clearly seen. Only the smooth muscle parts
of the musculus sphincter urethrae glaber and the musculus dilatator urethrae (A,B) show a-act in-
immunoreactivity. The musculus sphincter urethrae transversostriatus as striated muscle is not
coloured (A,B). In deeper parts (D-F) the musculus dilatator urethrae is developed strongest.
Caudally, near the ostium urethrae externum, the musculus sphincter urethrae glaber can no longer
be seen (G-I). The muscle cell bundles of the musculus dilatator urethrae taper here towards sinewy
points of attachment
55
Fig. 25. Diagram of the musculus dilatator urethrae (A ventral extraurethral part of the musculus
dilatator urethrae, B insertion of the urethral part of the musculus dilatator urethrae, C preurethral
part of the musculus dilatator urethrae, D interweaving of the vesical sphincter by the muscle cell
bundles of the musculus dilatator urethrae). The muscle cell bundles of the musculus dilatator
urethrae interlace with the ventral circumference of the musculus sphincter vesicae (vesical sphinc-
ter; from Dorschner et al. 1994c)
ventrally and the musculus vesicoprostaticus (Figs. 6, 7) or musculus vesicovaginalis

dorsally. There is no continuation of the musculature of the detrusor to the urethra.
The smooth muscular vesical sphincter or musculus sphincter vesicae described in
Chap. 4.2 is an independent muscle, fully embracing the ostium urethrae internum
and reaching far into the urethra. However, it takes a strictly circular and not a
longitudinal form (Figs. 10,12,21). Ventrally, this muscle is crossed by longitudinally
running muscle cell bundles, which come together to form an independent urethral
longitudinal muscle layer in the area of the collum vesicae in both sexes. This muscu-
lature is characterised by a special course in both males and females.
In the male, smooth muscle cell bundles originate on the caudal lower edge of the
symphysis (Figs. 23,25) between the musculus pubovesicalis and head towards the
ostium urethrae internum. In their course, they interlace at various levels with the
circular musculus sphincter vesicae (Figs. 22,23,25). This interlacing with the vesical
56
Fig. 26A-C. Voiding cystourethrography. Lateral X-ray direction, 45 years, male. A The urinary blad-
der filled with 400 mt contrast medium (cystography). At the onset of micturition (B), the bladder
neck opens in the shape of a funnel (arrow) and is kept open during micturition while the sphincters
are relaxed (C)
57
sphincter can clearly be seen in histological sections (Figs. 22,23, 27F) and during the
operative transurethral resection of the prostate (Fig. 27E). Even before reaching the
ostium urethrae internum, all the muscle cell bundles bend caudally, thereupon run-
ning caudally in the immediate vicinity of the urethra lumen directly beneath the
mucous membrane of the urethra (Fig. 24). The bundles of smooth musculature
insert deep into the bulb of penis. These bundles of smooth muscle cells run through
the entire neck of bladder from the ostium urethrae internum to the bulb of penis.
In the female, the ventral longitudinal musculature basically takes the same course.
Again, the lower edge of the symphysis is defined as their point of origin. The muscle
runs cranially from the lower edge of the symphysis, interlaces with the vesical
sphincter, and then runs caudally in the immediate vicinity of the urethra lumen,
between the two parts of the external urethral sphincters and the urothelium (Fig. 24).
The smooth muscle cell bundles of the ventral longitudinal musculature insert into
the bulbi vestibuli similar to in the male.
In both sexes, this muscle has a very fine structure. The muscle cell bundles are
altogether shorter and considerably stronger than those of the vesical sphincter. These
differences become very clear at higher magnifications (Fig. 33).
Our his tomorphological results clearly argue against the view held by many
authors that the ventral urethral longitudinal musculature is a continuation of the
longitudinal musculature of the detrusor into the urethra. Instead, this musculature is
an independent morphological unit (Dorschner 1984, 1989; Dorschner et al.1989c)-
a view which is also supported by the embryologically different origin of trigonum
vesicae and urethra (Dros et al. 1974; Donker et al. 1976).
From a functional view, a contraction of this ventral longitudinal urethral muscu-
lature would include the entire neck of bladder. The contraction of the cranial part
interlacing with the vesical sphincter, the neck of bladder is to a certain extent actively
pulled open, which correlates to the funnel-shaped opening of the internal urethral
orifice at the start of micturition as shown in the X-ray in Fig. 26. The caudal part of
this smooth musculature is able to keep the urethra open during micturition due to its
'anchoring' in the bulb of penis or the bulbi vestibuli. Therefore we propose the term
musculus dilatator urethrae for the ventral longitudinal urethra musculature (Fig. 25;
Dorschner 1984; Dorschner et al.1994c). Chapter 12 contains a detailed interpretation
of the function of the ventral longitudinal urethra musculature, which follows from
the particular course of these bundles of smooth muscle cells.
7.1
Summary
The ventral longitudinal musculature of the urethra is an independent structure. This

musculature originates on the lower edge of the symphysis and heads towards the
internal urethral orifice, interlacing with the vesical sphincter. Before it reaches the
internal urethral orifice, the bundles of smooth muscle cells bend caudally and run in
the immediate vicinity of the urethra lumen, between urothelium and the two parts of
the urethral sphincter in the caudal direction. There is no direct continuation of the
internal longitudinal layer of the detrusor to the urethra as its longitudinal muscula-
ture. From a functional viewpoint (cf. Chap. 12), we suggest the term musculus dilata-
tor urethrae for this ventral longitudinal urethral musculature.
58
8 Musculus Ejaculatorius
"It must be kept in mind that scientific problems never come to an end. The work that
all of us, everyone of us carries out, is nothing else but the continuation of the work done
by those who came before us; and others in turn will come who will continue it,
rectifying and improving it, and so on indefinitely, because science has no end. "
(Gil Vernet 1968)
If descriptions of the ventral longitudinal musculature of the urethra in the literature

are rare, the existence of a dorsal urethral longitudinal musculature is almost com-
pletely negated. Only a few authors (Kalischer 1900; Clegg 1957; Gil Vernet 1960;
Hayek 1962) describe an accumulation of longitudinal muscle cell bundles in the
region of the colliculus seminalis.
Clegg's description of the dorsal urethral longitudinal musculature (1957) contains
a number of special details. The author describes longitudinally running fibres in the
upper part of the male urethra starting from the trigonum vesicae. Their diameter is
smaller than of those in the concentric layer and they converge distally beneath the
mucous membrane of the rear urethral wall. In the "intermediate part" of the urethra,
he describes a musculature in the dorsal crest with a Y-shaped cross-section. This
muscle formation is supposed to continue to under the submucosa. In the fork of the
Y, the ductus ejaculatorii and the utriculus prostaticus arrive at the front. Dorsally, the
colliculus is divided into two halves. Here, the passages of the prostate reach the
urethra lumen on both sides. In the lower part of the crista urethralis, the legs of the Y
merge together. This formation can be followed up to the lowest part of the prostatic
urethra.
Scher (1950) augments the trigonal system running dorsally into the urethra with
two more muscle cords at the sides originating from the bladder musculature and also
inserting into the colliculus seminalis. Van Den Bu1cke et al. (1970) describe detrusor
muscle parts extending beyond the bladder outlet and forming loops around the
prostatic passages.
According to Hayek (1962), the striated musculature caudally enclosing the urethra
is interspersed dorsally by smooth muscular lamellae of the stratum internum longi-
tudinale of the detrusor coming from inside, which then lead into the "centrum
perinei" outside the voluntary sphincter. A similar description was given by Gil Vernet
(1960). A first group of "prostato-urethral" fibres is supposed to originate below the
seminal colliculus, taper towards the bulb of penis and insert into the membranous
urethra. A second "anterolateral" group of muscle cells is supposed to start from the
stroma of the caudal prostate glands and insert into the voluntary sphincter.
59

Hutch and Rambo (1967) describe a crista urethralis (superior) at the back wall of
the male urethra, which is supposed to extend from the internal urethral orifice to the
seminal colliculus. They regard this mucosal fold as a direct continuation of Bell's
muscle, which is supposed to be an "extension" of the ureter musculature reaching up
into the urethra. This "rear urethral crest" in the area of the entire urethra is described
in the female, too.
The endoscopic picture of the urethra (Figs. 27H, 28A) shows a mucosal fold
known as the crista urethralis running from the seminal colliculus in the caudal
direction. However, there is no mucosal fold above the seminal colliculus which could
correspond to the so-called musculus retractor uvulae or Bell's muscle. In Chapter 4,
it was proved using the histological findings on the trigonum vesicae that there is no
morphological correlate for these muscles.
Our own histomorphological investigations indicate in the sexually mature male in
the region on the caudal side of the seminal colliculus a strongly developed smooth
musculature. From the histological point of view, too, the course of the dorsallongitu-
dinal urethral musculature is strictly limited to the dorsal urethra region on the
caudal side of the colliculus seminalis (Figs. 28-30).
In the female, no dorsal longitudinal musculature was found within the two
sphincters (musculus sphincter urethrae and musculus sphincter vesicae). Longitudi-
nal muscle cell bundles can only be found in the immediate vicinity of the vagina.
They originate in the vicinity of the dorsal medial muscle cell bundles of the stratum
externum longitudinale of the detrusor and insert into the inner sides of the bulbi
vestibuli.
The dorsal longitudinal musculature in the male originates in a muscle ring em-
bracing the ductus ejaculatorii and the utriculus prostaticus (Figs. 28B, 29A). Fig-
ure 30A shows the two spermatic ducts still with strongly developed musculature,
which is then ventrally reduced (Fig. 30B). In this layer, a muscle ring is formed which
embraces both spermatic ducts and which becomes stronger as shown in Fig. 30C.
Figures 28B,C, 29 and 30D-H show how this musculature takes a direct course in the
caudal direction. Due to this particular course, a mucosal fold - the crista urethralis -
Fig. 27A-H. Endoscopy (comparison). A Endoscopic picture of the musculus sphincter vesicae (MY,
vesical sphincter). The ostium urethrae internum can be seen at the centre of the picture. B
Intraoperative picture of the musculus sphincter vesicae (My, vesical sphincter) with lying urethra
catheter in the ostium urethrae internum during a perineal radical poastatectomy after excision of the
prostate and the seminal vesicles. C,D (62 years) after transurethral resection of the prostata (TUR-P).
C Endoscopic picture: while the urethral sphincter is open, a wide bladder outlet and an "empty"
prostate lodge (filled circle) can clearly be seen from the colliculus seminalis (Cs). The vesical sphincter
is almost completely resected (arrows; cf. normal state in A). D Cystography of the same patients: the
contrast medium fills the urinary bladder and the entire prostate lodge. A vesical sphincter does not
exist anymore (arrows; cf. normal state in Fig. 26A). The contrast medium level reaches up to the height
of the urethral sphincter. This sphincter now ensures continence under rest conditions. E Neck of
bladder at the 12 o'clock position during a TUR-P with visible resection loop (diameter of resection
100p=6 mm): the muscle cell bundles of the musculus sphincter vesicae (My) travel in the direction of
the resection loop and are interlaced with the muscle cell bundles of the musculus dilatator urethrae
(asterisks). F The same findings as in E in the histological picture, transversal, 16 years, male, 10 flm,
Crossmon, x 10. G Endoscopic picture of the left ureter ostium (filled triangle) and of part of the plica
interureterica (Pi). H Endoscopic picture of the crista urethral is (Cu) below the colliculus seminalis
60
Fig. 27A-H.
61
Fig. 28A-C. Musculus ejaculatorius (dorsal longitudinal urethral muscle system). A Endophoto, 42
years, male, view of the crista urethralis. B Frontal, 52 years, male, 10 f1m, Crossmon, x5.
C Mediosagittal, 22 years, male, 10 f1m, Crossmon, x4.6 (Mu, musculus sphincter urethrae; Cs,
colliculus seminalis; P, prostata; Vs, vesicula seminal is; U urethra). The musculus ejaculatorius
(arrows) surrounds the colliculus seminalis and runs dorsally as strongly developed musculature
under the mucosa of the urethra in the caudal direction. In the urethra, a mucosal fold (the crista
urethralis) is raised. (From Dorschner and Stolzenburg I994b)
62
Fig. 29A-E. Musculus ejaculatorius (dorsal longitudinal urethral muscle system). A Diagram, posi-
tion of the muscle to the urethra. B-E Transversal, 14 years, male, 10 flm, Crossmon (B,C), resorcin-
fuchsin-nuclear fast red (D). silver staining according to Pap (E), B-E x8. Serial sections from the
colliculus seminalis (B) to the bulbus penis (E). The whole extent of the musculus ejaculatorius
(asterisks) from the colliculus seminalis to the bulbus penis is shown. In young males, the muscle is
characterised by a high number of elastic fibres (D). On the caudal side of the seminal colliculus, the
characteristic urethral cross-section in the shape of a sickle is clearly forced by the dorsallongitudi-
nal musculature (musculus ejaculatorius; from Dorschner and Stolzenburg 1994b)
63
Fig. 30A-H. Ejaculatory ducts and musculus ejaculatorius. Transversal, male, 16 years, 10 j.lm, Cross-
mono A-D Details, xiI. E-G Overall views, x4. H Overall view, x2.S (Me, musculus ejaculatorius; De,
ductus ejaculatorius). A,B The musculature of the ductus ejaculatorii. In its further course in the
caudal direction, this musculature surrounds the colliculus seminalis (arrow in C), then forms the
crista urethralis (arrow in D), continues as the musculus ejaculatorius (E-G) to the dorsal urethra,
and finally inserts into the bulbus penis (H)
64
Fig. 3IA-C. Musculus ejaculatorius. Transversal, 93 years, male, 10 flm, Crossmon. A,B x2, C (detail of
B) x20 (Me, musculus ejaculatorius; P, prostate). Even in the case of an overgrown pathologically
changed prostate (A) in very old males, the musculus ejaculatorius can clearly be made out. (From
Dorschner 1984)
65
Fig. 32A-C. Maturation of the musculus ejaculatorius. A Newborn infant, B 4 years, C 25 years, male,
10 flm, Crossmon (Me, musculus ejaculatorius). The dorsal longitudinal muscle system of the urethra
is differently developed in humans of different age. In newborn infants. this structure is merely a
mesenchymal swelling in the shape of a blastema (asterisk). As the sexual organs mature. smooth
muscle cell bundles (B) start to form, which are only fully developed upon sexual maturity (C)
66
Fig. 33A-H. Comparison of various muscles of the collum vesicae. A Musculus detrusor vesicae,
newborn infant. B Musculus sphincter vesicae (vesical sphincter), 45 years. C Musculus sphincter
urethrae glaber (smooth muscular part of the urethral sphincter), newborn infant. D Musculus
sphincter urethrae glaber (smooth muscular part of the urethral sphincter), 7 years. E Musculus
dilatator urethrae, newborn infant. F Musculus ejaculatorius,22 years. G Musculus sphincter urethrae
transversostriatus (striated part of the urethral sphincter), 7 years. H Musculus levator ani, 7 years.
A-H Male, 10 fim, Crossmon, x225
67
Fig. 34. Theory of the process of micturition (diagram). During contraction, the musculus dilatator
urethrea stretches the relaxed musculus sphincter vesicae (vesical sphincter). Due to the movement
forwards and downwards, the bladder neck opens like a funnel (A). At the same time the musculus
sphincter urethrae (urethral sphincter) relaxes (C). The lower part of the ventral longitudinal muscle
system is able to contract the urethra caudally (B) and to keep the lumen of the urethra open. Now the
urine put under pressure by the musculus detrusor vesicae (D) is able to pass through the urethra.
(From Dorschner et al. 1994c)
Fig. 35. Theory of seminal emission and ejaculation (diagram). Seminal emission and ejaculation are
mass action. It consists of a contraction of the musculus sphincter vesicae (A, vesical sphincter) to
prevent retrograde ejaculation, and at the same time there is a contraction of the circular muscle of
the prostate (B) as part of the musculus sphincter vesicae. This leads to the secretion of prostate
secrete. The musculus ejaculatorius (C) initiates the actual ejaculation (expulsion; from Dorschner
and Stolzenburg 1994b)
is raised in the urethra. Owing to the flattening of the crista urethralis before the bulb
of penis, which can be observed during endoscopic examinations, the musculature in
the medial line moves out of the actual urethra area in the dorsal direction and inserts
deeply between the corpora cavernosa of the bulb of penis (Fig. 30H).
The dorsal longitudinal muscle system of the urethra exhibits clear differences
depending on age (Fig. 32). In newborn infants, this structure can merely be observed
as a mesenchymal swelling in the form of a blastema (Fig. 32). As the sexual organs
mature, smooth muscle cell bundles start to form (Fig. 32B), which are only fully
developed in the sexually mature individual (Fig. 32C). The muscle is characterised by
a high content of elastic fibres (Fig. 29D). Even at an advanced age, strongly developed
muscle cell bundles remain (Fig. 31).
The function of the dorsal urethral longitudinal muscle system has not yet been
fully clarified. However, due to the particular course of the smooth muscle cell bun-
68
dies, which are only fully developed upon sexually maturity, it is very likely that this
muscle has an important function in the process of ejaculation (d. Chap. 10). There-
fore the term musculus ejaculatorius has been introduced for the dorsal longitudinal
musculature of the urethra (Fig. 35; Dorschner 1984, 1989; Dorschner and Stolzen-
burg 1994b; see also Figs. 33,34).
8.1
Summary
Smooth longitudinal muscle cell bundles of the dorsal urethra in the male are strictly
limited to the region below the colliculus seminalis. There is no dorsal longitudinal
musculature above the seminal colliculus starting from the trigone of bladder in the
sense of the musculus retractor uvulae or Bell's muscle. In the female, no dorsal
longitudinal musculature can be detected within the circular sphincter systems of the
urethra.
Cranially, the dorsal longitudinal musculature starts at the height of the opening of
the ductus ejaculatorii in the colliculus seminalis and runs directly below the urethral
mucosa. These muscle cell bundles, which are strongly developed in the sexually
mature male, run from the colliculus seminalis in the caudal direction and insert
deeply in the bulb of penis. Due to this particular course, the crista urethralis is raised
in the urethra. As the muscle is thought to be involved in the process of ejaculation (d.
Chap. 12), we suggest the term musculus ejaculatorius for the dorsal longitudinal
musculature of the male urethra.
69
9 Changes of the Muscles of the Lower Urinary Tract
with Age
The organs of the lower urinary tract are subject to structural changes due to age
which may considerably impair its function. Thus, for example, the prevalence of
urinary incontinence among the non-institutionalised population aged over 65 years
is estimated to be 18.8% (Wagner and Hu 1998). Among nursing home residents, this
rate is even 56% (Diokno et al. 1986). While urinary incontinence can be mainly
observed in women, changes of the prostate due to age, for instance benign prostate
hyperplasia (BPH), often cause considerable micturition problems for older men.
The extent to which the individual muscles of the lower urinary tract themselves
are subject to structural changes due to age is largely unknown. Based on our own
histological material we carried out a morphometric study to analyse the muscle-con-
nective tissue relation of various muscles (Rother et al. 1996; Bengs 1998) by examin-
ing specimens from deceased male individuals of all age groups (newborn infant to
93-year-old man). The individual muscles show clear changes in the muscle structure
depending on age. In the musculus detrusor vesicae for instance we measured 32%
muscle cells in a newborn infant compared to 63% muscle cells in a 7-year-old boy.
These differences may be attributed to different functional load. After an initial
increase of the muscle part of the musculus detrusor vesicae, the percentage of muscle
cells starts to decrease again from about the 15th year by approximately 0.2% per year.
Despite the fact that the three layers of the musculus detrusor vesicae are already
formed in the fetal stage (third month; Latka 1989), the main differentiation of the
smooth muscle cells only seems to occur after birth.
The muscle cells of the musculus sphincter vesicae, too, further differentiate after
birth. The muscle cells of this muscle increase up to the 8th year before continuously
decreasing by 0.3% per year. By contrast, we found no significant age-related changes
in the musculus interuretericus and the musculi pubovesicales.
With regard to the musculature of the urethra, it has been shown that the muscle
part of both the smooth and the striated part of the urethral sphincter and of the two
longitudinal muscle systems decreases with age. The highest decrease (0.3% per year)
occurs in the musculus dilatator urethrae. The musculus sphincter urethrae loses
about 0.2% per year of its smooth and striated muscle part, while the decrease in the
muscle cells is lowest in the musculus ejaculatorius (0.1% per year) once sexual
maturity has been reached. The morphometric data support the already observed
postnatal development of the musculus ejaculatorius, which can merely be recognised
as a mesenchyme crest in foetuses and newborn infants (Fig. 32) and only develops
differentiated muscle cells with the onset of puberty. In a 5-year-old boy, the smooth
muscle cells only accounted for 18% of the overall space of the muscle, this figure
rising to approximately 45% in sexually mature individuals.
71

This change in the relation between muscle and connective tissue with age is
probably the reason for some of the urological functional disturbances occurring
more frequently with age. The decrease in smooth muscle cells causes a drop in the
contractility of various smooth muscles. Semmelink et al. (1990) showed in a histo-
morphometric study of pre- and post-menopausal women that the atrophy of the
smooth musculature associated with hormones differs from senile atrophy occurring
in other parts of the urogenital system.
It should also be mentioned that it is not just the histological structure of the
musculature which changes with age. Important factors which should be discussed as
possible causes of functional disturbances include diminished blood flow, an insuffi-
cient stimulation of the a-adrenergic receptors and a weakening of the connective
tissue (Beisland et al.I984). It is known from experiments that the innervation density
for various transmitter systems changes in the course of genesis and during the ageing
process (Feruson and Christopher 1996; Chow et al.1997).
9.1
Summary
The present results indicate a link between the functional requirements vis-a.-vis the
overall system and the maturing of the individual system components (e.g. musculus
ejaculatorius). It cannot yet be decided whether morphogenetic impulses are given by
functional necessities or whether merely temporally co-ordinated parallel develop-
ment takes place. Histomorphological changes occur in the course of the ageing
process, the main result of which is the reduction of the smooth muscle part of
various muscles in the lower urinary tract. These changes are probably of functional
importance - which, however, has to be clarified by further clinical and experimental
studies. The investigation of ontogenetic mechanisms is very important due to its
significance for the pathogenesis of urological functional disturbances and would
make an important contribution to the development of innovative therapy ap-
proaches.
72
10 Three-Dimensional Model of the Anatomy
of the Lower Urinary Tract
To improve understanding of the pelvic anatomy, different models of the anatomy of

the lower urinary tract were generated. Using exabyte tapes of pelvic images of the
male Visible Human data set and high-speed computing and rendering software,
three-dimensional models of anatomical structures of the lower urinary tract includ-
ing the prostate, bladder, urethra, rectum and musculature of the pelvic floor were
generated (Brooks et al. 1998). Furthermore, several attempts were made to create
computer-generated three-dimensional reconstructions of anatomical structures of
the human pelvis in cadavers (Colleselli et al. 1998) and in vivo (Stenzl et al. 1999). The
advances in computerised and imaging technology permit for the first time a dy-
namic three-dimensional view of structures of the bladder neck and their spatial
relationship. In future, virtual reality endoscopy may become a valuable tool for
teaching residents, students and nurses and for scientific purposes (Stenzl et al. 1998).
The exactness of the reconstruction of the structures of the small pelvis with the
help of imaging technology such as CT and MRI is still limited by various technical
factors. The decisive disadvantage of reconstructions carried out so far has been the
limited resolution ability of the technology used. Thus, important smooth muscular
longitudinal muscle systems of the collum vesicae such as the musculus dilatator
urethrae and the musculus ejaculatorius were absent from the generated computer
models (Brooks et al. 1998; Colleseli et al. 1998). One particular difficulty of imaging
techniques is differentiation between smooth and striated musculature. Differentia-
tion between the musculus sphincter urethrae transversostriatus (striated part of ex-
ternal urethral sphincter) and musculus sphincter urethrae glaber (smooth muscular
part of urethral sphincter) is assumed in the MRI (Dorschner et al. 1999), but has not
been clearly proven yet. In well-known models of the anatomy of the lower urinary
tract, this differentiation is completely missing (Stenzl et aI.1999).
All histological findings described in the foregoing chapters were used for the
construction of a new digital three-dimensional model of the complex anatomy of the
lower urinary tract. In numerous design steps, starting from the geometrical basic
elements and operations, virtual "wire" models of the individual organic components
were developed on PC and integrated to form one complex model. Figure 36 shows the
three-dimensional model of the lower urinary tract as well as various stages of its
implementation. All muscular structures have different colours and are shown in their
schematic course and their typical location in space.
In a number of steps (Stolzenburg et al. 1999), computer animations of the model
were generated, showing the organs in virtual space in three dimensions. The digitised
original histologies were then integrated into the animation using an animation
73

software package (Autodesk Animator Pro) in order to show the connection of ab-
stract modelling and histological appearance in three dimensions.
The complete animation sequence was furnished with German and English text
and also stored as a computer video on the CD-ROM accompanying this monograph
(d. CD-ROM: "The Anatomy of the Distal Urinary Tract"; Dorschner et al. 1996 for
details).
Fig. 36A-C. Three-dimensional model of the anatomy of the lower urinary tract. A From the hand
drawing to the computer model. B Collum vesicae: dorsal-lateral view. To visualise the musculus
dilatator urethrae, the structures of the ventral bladder neck are shown as a grid structure. C Collum
vesicae: ventral-lateral view. By definition, the term collum vesicae comprises the whole of all the
structures surrounding the urethra from the ostium urethrae internum to the bulbus penis/bulbi
vestibuli (orange, musculus detrusor vesicae; yel/ow, urethra and spermatic duct; grey marble,
prostate;green, musculus sphincter vesicae - vesical sphincter; dark red, musculus sphincter urethrae
transversostriatus - striated part of the urethral sphincter; blue, musculus sphincter urethrae glaber
- smooth muscular part of the urethral sphincter; purple, musculus dilatator urethrae; red, musculus
ejaculatorius) With the exception of the musculus ejaculatorius, all these structures are also found in
women. (From Stolzenburg et al. 1999)
74
75
11 Fundamentals of the Neuroanatomy
11.1
Autonomous Innervation of the Lower Urinary Tract
The lower urinary tract receives exitatory and inhibitory input from sympathetic,
parasympathetic and somatic efferent nerve fibres. Furthermore, afferent C- and
A-delta fibres ensure the flow of sensory information from the periphery to the
central nervous system. The control of urine storage and voiding is hierarchically
organised and is implemented at various levels. Cortical and diencephal influences on
the pontine micturition centre control continence and micturition via sympathetic
and parasympathetic or somatic spinal reflex arcs. Feedback is ensured by sensory
nerve fibres reacting to stretch condition (A fibres) and noxious substances (C fibres)
in the area of the detrusor and the urethra. Fine regulation of the central nervous
activity is effected in the visceral autonomous ganglia, the ganglion mesentericum
inferius and the plexus pelvicus, as well as in the intramural ganglia in the urinary
bladder wall.
Individual muscles show a characteristic distribution of muscarinic (M3), adrener-
gic (aI, (3) receptors and NANC-receptors, which allows individual activation or inhi-
bition.
Parasympathetic preganglionic nerve fibres originate in the nucleus intermediolat-
eralis of segments 52-54 of the sacral spinal cord and run via the nervi splanchnici
pelvici to the plexus pelvicus and the intramural ganglia of the urinary bladder, where
they are switched to postganglionic neurons.
The effector neurons of the sympathetic reflex arc are located in various nuclei of
segments ThlO-L2 of the thoracolumbal spinal chord (nucleus intermediolateralis,
nucleus intercalatus, nucleus centralis, cornu laterale; de Groat et al. 1993; Kihara and
de Groat 1997). Their preganglionic axons leave the spinal cord via the anterior roots
and then run either to the ganglion mesentericum inferius or caudally to the lumbar
lateral chain ganglia.
Part of the axons of the nerve fibres running via the nervi splanchnici lumbales to
the ganglion mesentericum inferius is switched to postganglionic neurons there,
whereas other preganglionic axons run directly through the ganglion mesentericum
inferius and terminate in the plexus pelvicus (=plexus hypogastricus inferior) or the
intramural ganglia. The nervus hypogastricus running towards the plexus hypogas-
tricus inferior contains both pre- and postganglionic sympathetic axons.
Only some of the axons running via the rami communicantes albi to the sympa-
thetic lateral chain ganglia form synapses with postganglionic sympathetical neurons
there. Hence, both preganglionic and postganglionic sympathetic axons leave the
77

lumbosacral lateral chain ganglia in order to travel to the plexus hypogastricus infe-
rior (=plexus pelvicus) together with the preganglionic parasympathetic axons from
the thoracolumbal spinal cord in the nervi splanchnici pelvici. As in the lateral chain
ganglia or the ganglion mesentericum inferius, some of the axons pass directly
through these ganglia and reach the intramural ganglia as preganglionic sympathetic
axons (Lincoln and Burnstock 1993; Andersson 1999). It should be pointed out that
sympathetic and parasympathetic neurons may interact on different subspinal levels
and are ultimately also interconnected to integrative neurons in the plexus pelvicus
(Dail and Dziurzynski 1985; Janig 1986; Janig and McLachlan 1987; Kihara and de
Groat 1997; Gosling et al. 1999). The ganglion cells of the plexus pelvicus equipped
with a large variety of transmitters, neuropeptides and neuromodulators partly func-
tion as relay stations, partly as an integrative functional unit. In both sexes, these
extensive neuroplexuses are located on both sides of the urinary bladder and are
called plexus vesicalis. In the male, they are followed by the plexus prostaticus adjoin-
ing the prostate plexus prostaticus caudally, and in the female, by the plexus vaginalis
located between the vagina and urethra. In the area of the internal urethral orifice and
the ureteric orifices of both sexes, there are extensive (intramural) ganglia in the
urinary bladder wall which are ascribed a function in the local co-ordination of the
muscular activity. Thus, parasympathetic activity leads to the release of NO due to
muscarinic activation of NOS-positive ganglion cells (Andersson 1993). Owing to the
frequent occurrence of NOS-positive nerve terminals in the area of the musculus
sphincter vesicae and the urethra, the sphincter musculature is additionally relaxed
during micturition by increased parasympathetic activity (Andersson and Persson
1992,1993; Yoshimura 1998).
11.2
The Voluntary Innervation of the Musculus Sphincter Urethrae
The striated part of the musculus sphincter urethrae receives its somatic innervation
via a branch of the nervus pudendus, splitting off directly after it leaves the canalis
pudendalis (Tanagho et al. 1982; Strasser et al. 1996). The reflex activation corre-
sponds to that of the sympathetic reflex arc. The sphincter motor neurons are located
in the nucleus ventromedialis of the sacral spinal cord (Beattie et al. 1990), and are
activated when the bladder is filled by afferent influx from the urinary bladder. In
stress situations (coughing, sneezing, laughing), a reflex activates the striated part of
the musculus sphincter urethrae (musculus sphincter urethrae transversostriatus).
During micturition, however, these motor neurons are reciprocally inhibited. This
inhibition may be attributed to supraspinal influences, as it is only very weak or
completely absent in spinalised animals and paraplegics (Chancellor et al. 1990;
Schultz-Lampel et al. 1998). As has been shown in electrophysiological experiments,
inhibition is effected by disynaptic and polysynaptic reflex arcs (Mackel 1979). Apart
from excitatory influences, inhibitory spinal activity has also been proven by the
excitation of afferences in the nervus pudendus (Fedirchuk et al. 1992, 1994) and in
chronically spinalised cats when the bladder is filled (Garry et al. 1959; Rampal and
Mignard 1975; Fedirchuk et al. 1993).
In addition to these spinal reflexes controlling the filling phase and micturition, the
existence of a sphinctero-ureterovesical reflex was demonstrated. Activating the ure-
78
thral sphincter by needle electrodes led to a significant pressure decrease in the
urinary bladder and the uretero-vesical junction (UVJ; Shafik 1997). Upon voluntary
interruption of micturition, the striated part of the musculus sphincter urethrae
contracts, thus triggering a reflex mechanism, causing the musculus detrusor vesicae
to relax and simultaneously activating the musculus sphincter vesicae, which exhibits
no electromyographic activity under normal micturition conditions. These effects
were observed when the urinary stream was voluntarily interrupted and also after the
interruption of micturition triggered by electrostimulation of the externus (Shafik
1999).
11.3
The Sensory Innervation of the Urinary Bladder and the Urethra
The afferent nerve pathways can be depicted by means of anterograde tracers such as
horseradish peroxidase or by treatment with capsaicin, a pungent component of
chillies. A specific capsaicin receptor is produced by a subpopulation of sensory
neurons (Szallasi and Blumberg 1990). Capsaicin has a two-phase effect on the cap-
saicin-sensitive sensory nerves. Initial excitation is followed by a long blockage with
the effect that the primary afferences can no longer be excited by natural stimuli
(Maggi et a1.1991). This effect is used in the pharmacological classification of sensory
neurons where the term capsaicin-sensitive neurons is used.
With the help of these methods, it was shown that the lower urinary tract receives
sensory innervation by neurons, whose cell bodies are located in the dorsal root
ganglia of the lumbosacral region (Nance et al. 1988). Medullary A-delta and non-
medullated C nerve fibres run in the nervus pelvicus to the spinal cord (Torrens and
Morrison 1987). The A-delta fibres convey information on the filling level of the
urinary bladder in its normal physiological range (Habler et a1.1993), while the slow C
fibres react to an unphysiologically high intravesical pressure and other dolorogenic
conditions. There is, in particular, a subpopulation which specifically reacts to an
increase in acidity or to hypertonicity of the urine, as for instance caused by inflam-
mations (Habler et al. 1990; Maggi 1993). The stimulation of these fibres also causes
the release of neurokinins at the nerve terminals, which, in turn, can modulate the
release of neurotransmitters from other neurons (Maggi et al. 1987; Ferguson and
Christopher 1996). Thus, for example, a shift of the threshold value of the afferent
activity could be caused by NO-releasing neurons, as the inhibition of NO-synthesis
leads to the hyperactivity of the bladder and a decrease in bladder capacity (Anders-
son and Persson 1995). The chemical stimuli to which capsaicin-sensitive nerve fibres
react also include inflammation stimulators such as prostaglandins, bradykinin and
the bacterial chemotactical peptide FMLP (Maggi 1993; Khan et al. 1998). These
mediators are important stimuli in the course of an acute or chronic bladder infection
or in immunological processes such as interstitial cystitis, and can trigger cystitis,
pollakisuria and irritable bladder (Butt et al. 1995; Lundberg 1996; Lecci et a1.1999).
The peripheral branches of the capsaicin-sensitive dorsal root neurons branch out
in the urinary bladder wall and in the urethra. The location of the nerve terminals was
determined by immunohistochemical detection of the sensory neurotransmitter sub-
stance P (SP) and other tachykinins, calcitonin gene-related peptides (CGRP), secre-
toneurin in combination with capsaicin pre-treatment (Franco-Cereceda et al. 1987;
79
Maggi 1993; Kirchmair et al. 1994). In rats and guinea-pigs, SP- and CGRP-positive
nerve fibres form a dense network in the submucosa of the urinary bladder and
urethra. The bladder outlet is more densely innervated than the bladder roof and the
density is highest in the trigonum vesicae (Yokokawa et al. 1985, 1986; Su et al.1986).
In the spine, the sensory fibres terminate at two levels. (1) They travel via the nervi
splanchnici sacrales to the sacral spinal cord, where they are interconnected to the
parasympathetic neurons in the nucleus intermediolateralis and to somatomotoric
neurons, supplying the striated part of the musculus sphincter urethrae. (2) Collater-
als project via the tractus posterolateralis to the lumbar medulla and form synapses
on sympathetic neurons in the already mentioned nuclei (nucleus intermediolateralis,
nucleus intercalatus, nucleus centralis, cornu laterale; de Groat et al. 1993).
Capsaicin-sensitive primary afferent nerve fibres run through the plexus pelvicus,
where they arborise and innervate postganglionic neurons (Dail and Dziurzynski
1985; Papka 1990). In rats, these postganglionic neurons innervating the detrusor are
organised in the ganglion pelvicus major (major pelvic ganglion), while in humans,
guinea-pigs and cats, they are located in small groups on the surface of the urinary
bladder. The majority of the information about the function of the capsaicin-sensitive
afferences was gained from denervation experiments on rats (Maggi et al. 1986;
Santicioli et al. 1986). Capsaicin application leads to the release of neuropeptides from
the varicosities of the capsaicin-sensitive neurons (Amann et al. 1990; Maggi 1991). In
this connection, Maggi (1993) speaks of the efferent function of the sensory nerves.
Basket-shaped structures of CGRP-positive varicosities around neurons of the gan-
glion pelvicus major (major pelvic ganglion) have been described as the morphologi-
cal correlate in rats (Senba and Tohyama 1988).
The relevance of the afferent innervation for the aetiology of the BPH symptoms as
a consequence of the obstruction caused by the overgrown prostate is proven by
various experimental and clinical studies. In a study carried out by Chai et al. (1998),
patients with and without bladder outlet obstructions were compared in the ice water
test. This test is used for the diagnosis of neurogenous voiding disorders of the
bladder and is defined as uninhibited bladder contraction at the instillation of O°C
saline. In 71 % of patients with obstruction compared to just 7% of non-obstructed
patients, the ice water test leads to positive results. The ice water test triggers a
micturition reflex via capsaicin-sensitive C fibres. The significantly higher number of
positive results in the ice water tests with obstructed patients argues in favour of an
increased spinal micturition reflex, which might be attributed to a plasticity of the
bladder afferences after bladder outlet obstructions. Experimental studies by Steers et
al. (1991) also indicate such a plasticity. In experimentally obstructed rats, apart from
a pronounced hypertrophy of the urinary bladder (600%), they also found a signifi-
cantly increased afferent projection in the intermediolateral region of the spinal cord
at the height of L6-S1, while the number of dorsal root ganglion cells marked in the
bladder wall after injection of wheat germ agglutinin-horseradish peroxidase (WGA-
HRP) remained stable. These results do not therefore contradict the findings of
Harrison et al. (1990) in guinea-pigs, who found indications of a change in the
cholinergic and adrenergic innervation of the detrusor, but no significant changes in
the substance-P innervation of the detrusor. In an immunohistological study on
humans, on the other hand, the density of the substance- P innervation in the detrusor
of obstructed patients was described to be lower (Chapple et al. 1992). All these studies
indicate a plasticity of the afferent innervation after bladder outlet obstruction. How-
80
ever, the observed changes in the afferent side of the mictUrItIon reflex arc are
certainly not the only reason for symptoms such as urinary urgency and nycturia.
11.4
Spinal and Supraspinal Influence on the Urinary Reflexes
The functions of the lower urinary tract are under the control of central reflexes,
which are reciprocally organised and thereby guarantee the activation of the vesical
and urethral sphincteric musculature and simultaneously the inhibition of the de-
trusor and vice versa.
Sensory afferent nerve fibres in the nervus pelvicus exhibit little activity when the
bladder wall is only slightly stretched. Via somatic efferences, the striated part of the
external urethral sphincter is activated and thus probably also participates in main-
taining rest continence apart from its function of guaranteeing stress continence
(Fowler and Fowler 1987; Greenland et al. 1996; Brading 1999). The activation of the
sympathic efferences causes a tonus increase in the vesical or internal (ex-adrenergic)
sphincter and the smooth muscular part of the urethral or external sphincter (Thind
1995; Brading 1999; de Groat et al. 1999), as well as an inhibition of the detrusor
(~-adrenergic).The intramural ganglia and the parasympathetic neurons in the sacral
spinal cord are sympathetically inhibited. This reflex interconnection at the spinal
level (storage reflex) keeps the wall tension of the urinary bladder low despite an
increasing urine level, while the musculus sphincter vesicae and the urethra are toned.
Stress situations during the filling phase (coughing, laughing) are cushioned by the
sphinctero-ureterovesical reflex, which actively inhibits the detrusor by reflex and
activates the vesical sphincter upon the somatic activation of the urethral sphincter.
As the level of urine in the bladder rises, the afferent input increases until there is a
desire to urinate. This process involves higher spinal and central nervous centres.
Micturition is triggered by the discontinuation of the central inhibition (from the
cortex and the diencephalon) of the neurons of the pontine micturition centre in the
brain stem (voiding reflex) with the particular involvement of neurons in the colliculi
inferiores, receiving inhibitory input from higher level brain regions. Decerebration
above the colliculi inferiores leads to facilitation of the micturition reflex (Tang 1955;
Tang and Ruch 1956) while lesions below prevent micturition (Barrington 1925;
George et al. 1962; Satoh et al. 1978; Griffith et al. 1990). The electric stimulation of
pontine regions, however, triggered micturition in experiments with rats, cats and
dogs (Kuru 1965; de Groat 1975; McMahon and Spillane 1982; Holstege et al. 1986;
Noto et al. 1989, 1991; Kruse et al. 1990; Mallory et al. 1991; Nickel and Venker-van
Haagen 1999). More recent studies with transneuronal tracers such as the
pseudorabies virus were able to support these early lesion experiments and indicate
other brain regions participating in the control of the functions of the lower urinary
tract (Zermann et al. 1998). CT and MRI examinations of stroke patients showed that
cortex lesions in the frontal lobe (68%), the parietal lobe (20%) and the temporal lobe
(14%) lead to disturbances in the lower urinary tract, while lesions in the occipital
cortex did not result in any urological symptoms. The symptoms of the frontal lobe
lesions affected both the storage function as well as the micturition and caused
hyperreflexia of the detrusor, areflexia of the detrusor and disturbed sphincter relaxa-
tion (Sakakibara et al. 1999). Further insight into the central control of urologic
81
functions are to be expected from dynamic imaging studies (PET) on humans (Blok
and Holstege 1998; Blok et al. 1998).
11.5
Summary
The complex anatomy of the lower urinary tract i~ expressed in a complex nervous
supply and control. Apart from sympathetic and parasympathetic nerve fibres, there
are numerous NANC nerve fibres in varying distribution, whose significance with
respect to continence and micturition is not yet sufficiently known.
The opposing actions of the sympathetic and parasympathetic system may be
understood as superordinated principle of the neuronal control. These systems are
reciprocally interconnected by means of reflexes at the spinal and supraspinal level.
The control circuit for the maintenance of continence can be found in the sacral spinal
cord, while the pontine micturition centre co-ordinates the activities of the muscles
during micturition. Superordinated cerebral centres act as modulators for the control
circuits structured as simple switches. Thus, voluntary initiation of micturition and
its interruption is possible.
The sensors for these control circuits are free nerve terminals in the urinary
bladder wall and in the urethra. During the filling phase of the urinary bladder, these
sensory nerve fibres report stretch conditions to the central nervous system, and they
can also signalise pain in the case of overstretching or toxic chemical stimuli, thus
causing the known incontinence symptoms during infections of the urinary tract. Not
only may the efferent systems be changed by various pathological processes, but the
afferent innervation of the urinary bladder shows a plasticity already found for the
urgency symptoms during BPH.
Local ganglia in the plexus pelvicus and in the urinary bladder wall are thought to
act as modulators, too. However, no concrete information can yet be provided con-
cerning their function.
82
12 Discussion (Functional Interpretation
of the Anatomical Findings)
"Only the plan of the whole gives the individual elements sense and meaning. "
Goerttler (1934)
Many urological illnesses start in the area of the urinary bladder and the collum
vesicae before extending to all other parts of the urinary tract. The collum vesicae
(neck of bladder), as we understand it, is defined as the part of the lower urinary tract
which is limited cranially by the ostium urethrae internum, and caudally by the
bulbus penis or the bulbi vestibuli. Diagnostic methods for these illnesses have con-
stantly improved during the last few years. Extensive urodynamic examinations are
often the only way of diagnosing functional voiding disorders of the bladder with
sufficient certainty. The interpretation of such findings, however, is often problematic.
One main reason for this is the different descriptions of the morphology of the lower
urinary tract and the resulting differing theories on the basic functions micturition
and continence.
All the anatomical findings can only partly explain functional sequences like mic-
turition, continence and ejaculation. As experiments with humans are unethical, there
is a constant search for suitable experimental animals so that the physiology and
pathophysiology of the above-mentioned processes can be described in detail. How-
ever, comparing the findings achieved is difficult as there are no exact histomor-
phological data on the muscle systems of the lower urinary tract of many experimen-
tal animals. It is still questionable whether the anatomy of the lower urinary tract of
the human corresponds to the anatomy of frequently used laboratory animals such as
dogs, cats and guinea-pigs. This question is the subject of another study we are
currently conducting (Neuhaus et al. 1999a).
Based on the presented anatomical findings and numerous phenomena of clinical
practice, we shall draw some conclusions about the function of the muscles described
in the foregoing chapters. Further physiological studies are urgently necessary to
verify these hypotheses.
12.1
Continence
The precondition for urine continence is the adaptation of the musculus detrusor
vesicae to the urine storage phases. Bladder capacity is determined by its plasticity
potential. Three structures may be discussed as active closure mechanisms: the vesical
sphincter (musculus sphincter vesicae), the smooth muscular part of the urethral
83

sphincter (musculus sphincter urethrae glaber), and the striated part of the urethral
sphincter (musculus sphincter urethrae transversostriatus). In the male, the musculus
sphincter vesicae, by virtue of its location directly around the ostium urethrae inter-
num, separates in rest conditions the urinary from the sexual tract, thus preventing
urine reflux into the spermatic ducts. It is not yet clear what additional role the
musculus vesicoprostaticus might play. This muscle may prevent the reflux of urine
into the spermatic ducts during micturition. Due to its special course characterised by
splitting off from the muscle cell bundles of the outer, dorsal, longitudinal detrusor
lamella and embracing both spermatic ducts in front of the orifice into the urethra,
the musculus vesicoprostaticus would be eminently able to completely obstruct the
spermatic ducts during the contraction of the entire detrusor musculature in the
process of micturition. The musculus sphincter urethrae glaber, the second circular
smooth muscular component in the collum vesicae, supports the musculus sphincter
vesicae in its function of ensuring rest continence.
A special situation occurs if the vesical or internal sphincter is partly or completely
destroyed as a result of an operation on the neck of bladder (for instance during a
transurethral prostata resection, a bladder neck incision or a radical prostatectomy).
In such cases, the smooth muscular part of the external urethral sphincter alone, the
musculus sphincter urethrae glaber, guarantees continuous continence. This "self-or-
ganised variability" of the collum vesicae is used in clinical practice in cases of radical
cystectomy. In the male, apart from the urinary bladder, the entire vesical sphincter
including the prostate is excised. An ileum neobladder can be directly anastomosed to
the musculus sphincter urethrae. Most of these patients are completely continent.
The striated part of the musculus sphincter urethrae consists of two different fibre
types (Schroeder and Reske-Nielsen 1983). The percentage of so-called "slow twitch
fibres" is 35% in males, while that of "fast twitch fibres" is 65% (Ho et al. 1997a). By
contrast, the female has just 13% fast twitch fibres (Ho et al. 1997b). The slow twitch
fibres are probably the important ones contributing to sustained urethral pressure
during filling (Brading 1999). The fast-twitch fibres are thought to compensate for
sudden abdominal pressure increases. To explain postoperative urine continence, e.g.
following a radical prostatectomy, it has been hypothesised that under certain condi-
tions such as the "absence" of the smooth muscular vesical sphincter, the individual
fibre types become interchangeable. This is conjectured to be the morphological
condition for the phenomenon of continuous continence after such operations. In this
connection, a described threefold innervation of the urethral sphincter (El Badawi
and Schenk 1974) must also be critically discussed. These attempts to explain the
clinical phenomenon of continuous continence, i.e. stress and rest continence after
complete destruction of the allegedly only smooth sphincter of the neck of bladder,
ignore the existence of the musculus sphincter urethrae glaber, which is strongly
developed in both sexes.
12.2
Micturition
Micturition is the process of voiding the urinary bladder of the stored urine. The
literature contains very different descriptions of this basic physiological process. The
various theories are based on partly very different views of the authors concerning the
84
anatomy of the collum vesicae and the urethra. One particularly contentious issue is
the question of whether this process should be regarded as active or passive.
Most authors describe micturition as a mass action or the contraction of the
musculus detrusor vesicae until the urinary bladder is completely emptied by the
passive stretching apart of the urethral closure mechanisms (Lapides et al.I960). The
vesical sphincter and the urethral sphincter are pressed apart by the urine flux and are
thus passively opened. According to Zuckerkandl (1887), the urethral sphincter is
virtually "burst open" by the power of the detrusor contraction. Finger (1896) as-
sumes that with increasing urine level in the urinary bladder, the proximal urethra is
included in the reservoir function of the urinary bladder. Reflex micturition is then
supposed to be triggered by the formation of a funnel in the area of the internal
urethral orifice. Various authors support this theory (Rehfisch 1897; Zeissl 1901;
Walker 1906), while others completely reject it (Schwarz 1920; Denning 1926; Denny-
Brown and Robertson 1933; Hennig 1954). According to Hutch (1966) and Tanagho
and Smith (1966) it is the integrated action of the bladder muscle system which
triggers micturition and forms a funnel.
Neuronal mechanisms (the discontinuation of the central, inhibitory impulses in
the sacral micturition centre, the activation of stimulating efferences on the sacral
micturition centre) support this process by the simultaneous impedance of the mus-
cle tone in the bladder outlet. Bradley et al. (1976) describe four nervous control
circuits including the cortex, the brain stem, the sacral micturition centre and the
target organ co-ordinating the activation and deactivation of the micturition reflex.
Various authors (Krantz 1951; Lapides et al. 1957; Lapides 1958; Beck 1969,1971;
Tanagho et al. 1969) describe the urethral longitudinal musculature as a direct con-
tinuation of the stratum internum longitudinale of the detrusor. They argue that this
provides for the continuity of the urinary bladder and urethra is given. The urethra is
shortened and widened by the contraction of the musculus detrusor vesicae, thus
initiating micturition.
Jonas and Tanagho (1975) showed that the relaxation of the sphincter of the neck of
bladder is actively triggered immediately before detrusor contraction. These authors,
along with a few other work groups (Dorschner et al. 1994c), are advocates of a theory
of the active initiation of micturition. At the start of micturition, the bladder bottom
is lowered and the bladder outlet opened in the form of a funnel (Hinman et al. 1954).
Brading (1999) supposes that the longitudinal smooth musculature contracts, short-
ening and opening the urethra during micturition. The interplay of the individual
muscle systems has not yet been sufficiently clarified, especially since no independent
urethral musculature has been described which would be able to trigger micturition.
The ventral urethral longitudinal musculature of the collum vesicae described in
Chap. 7 is an interesting factor in this respect. Due to its special course (it originates at
the lower edge of the symphysis, interlaces with the vesical sphincter, and inserts in
the bulbus penis or the bulbi vestibuli), this musculature would be ideally suited to
open the neck of the bladder and thus the internal urethral orifice by a contraction-in-
duced movement in the ventral and caudal direction. This process is diagrammati-
cally shown in Fig. 34. In the micturition cysto-urethrogram, this process correlates
with a funnel-shaped opening of the neck of bladder (which can be shown in radio-
logical images) at the onset of micturition (Fig. 26A-C). The contraction of the ventral
urethral longitudinal musculature would thus actively induce micturition. The condi-
tion for this is an involuntary relaxation of the sphincter systems. The caudal part of
85
the ventral longitudinal musculature runs within the circular sphincter, Le. immedi-
ately beneath the urethral mucosa. The contraction of this part of the urethrallongi-
tudinal musculature could keep the urethra actively open during micturition. The
urine placed under pressure by the detrusor musculature could then pass through the
urethra unimpeded. For the ventral longitudinal urethral muscle system, the term
musculus dilatator urethrae was chosen due to its antagonistic function to the closure
system of the collum vesicae (Dorschner 1984; Dorschner et al. 1994c). The musculus
dilatator urethrae is the morphological correlate to the electrophysiologicallyverified,
active relaxation of the closure mechanism of the collum vesicae or a pressure de-
crease in the proximal urethra immediately before the contraction of the musculus
detrusor vesicae at the onset of micturition (Jonas and Tanagho 1975; Brading 1999).
12.3
Ejaculation
In the male, the collum vesicae does not just have an important task with regard to
micturition and continence. The various morphological structures also serve the
sexual function. Therefore the urethra caudally of the colliculus seminalis up to the
ostium urethrae externum is also known as the canalis urogenitalis.
Classically, ejaculation has been thought to comprise three successive phases. Emis-
sion (I) is the term for the secretion and collection of the various components of the
sperm in the far end of the urethra (Newmann et al. 1982). After the emission of
semen, a pressure chamber is formed (2) followed by the expulsion of semen (3) - the
actual ejaculation (Gallizia 1972; Marberger 1974). Which of the muscles actively
induce and effect ejaculation has not yet been fully clarified. Some authors suspect the
involvement of the musculus ischiocavernosus and the musculus bulbocavernosus
(Gerstenberg et al. 1990; Recker et al. 1993).
According to Kalischer (1900), the main function of the musculus sphincter
trigonalis (vesical sphincter) is to prevent the reflux of semen into the urinary bladder
during ejaculation (retrograde ejaculation). Heiss (1928) and Graning (1936) also
support this view. The emission of the semen is attributed to the contraction of the
voluntary musculus sphincter urethrae (Kalischer 1900). According to Gil Vernet
(1960), the dorsal urethral longitudinal muscle system plays a role in both micturition
and ejaculation. Other authors speak of an closure function during micturition (Clegg
1957). Homsy (1967) rejects the thesis of the involvement of the dorsal longitudinal
musculature in either process.
As has been proved by some interesting functional studies during operations, the
stimulation of the nerves participating in the sexual function during semen emission
causes various muscles of the collum vesicae to contract (Stockamp and Schreiter
1974; Stockamp et al. 1974; Recker and Tscholl 1992), although the muscles involved
have not been defined in more detail. The dorsal urethral longitudinal musculature
itself has not been defined either.
Our own investigations show that the dorsal longitudinal urethral musculature
originates directly at the height of the orifice region of the ductus ejaculatorii in the
colliculus seminalis, runs caudally directly below the urethra mucosa, and inserts
deep in the bulbus penis. This smooth musculature is only fully developed upon
reaching sexual maturity. It is very likely that the contraction of this muscle initiates
86
the expulsion of the semen (Fig. 35). Therefore, the term musculus ejaculatorius has
been chosen for the dorsal longitudinal urethra musculature (Dorschner 1984;
Dorschner and Stolzenburg 1994b). The musculus sphincter vesicae occludes the
ostium urethrae internum during ejaculation. This process has to take place before
ejaculation itself in order to prevent retrograde ejaculation into the bladder. Using a
real-time ultrasound study of the prostate posterior urethra and the neck of bladder
before, during and after ejaculation, it was actually possible to analyse a pre-ejacula-
tory phase (Gil-Vernet et al. 1994), which is assumed to correlate with the pre-ejacula-
tory contraction of the vesical sphincter.
Because of the extension of the musculus sphincter vesicae up to the height of the
colliculus seminalis, and due to the fact that it is increasingly interspersed with glands
in the sexually maturing male, during the contraction of the vesical sphincter the
gland tissue is "squeezed out" at the same time and the semen is therefore mixed with
the secrete of the prostate (semen emission phase). The contraction of the musculus
ejaculatorius then leads to the expulsion of parts of the semen. The complete damage
of the vesical sphincter, e.g. during a transurethral resection of the prostate or a
bladder neck incision, which is sometimes performed to ensure good postoperative
micturition, is bound to result in retrograde ejaculation.
87
13 Further Studies and New Approaches
Anatomical research has always tried not only to classify anatomical structures, but
also to describe their function. Structure and function are closely connected, and
mutual interrelations exist which call for an integrated view. Both macroscopically
and microscopically, the function of an organ depends on its structure, while at the
same time the structure is modified by the function. Just as the points of attachment
of muscles to bones are decisive for the mechanics of a joint, the arborisation of
neurons in the brain for example is decisive for possible interconnections and the
implementation of reflex pathways.
Function means dynamics. Consequently, over the years the classical anatomical
examination methods of fixed cells and tissue have been augmented by optical and
fluorescence methods, making it possible to observe living cells. The "patch-clamp
technique" developed by Neher and Sakmann (1976) enables individual ion channels
in the cell membrane or even in intracellular membranes, e.g. the sarcoplasmatic
reticulum, to be analysed. And by combining the patch-clamp technique with PCR
(polymerase chain reaction; Mullis and Faloona 1987), the expression of transmitter
receptors in previously electrophysiologically characterised individual cells can be
studied (Kirchhoff et al. 1996).
In vitro studies on cultured cells for investigation of physiological qualities of
individual cells have also proved to be a suitable approach. By using special co-cultur-
ing procedures, interactions between various cell types can be examined, too, e.g. by
electron microscopy (Neuhaus et al. 1991).
In one of our own test series, we compared cell cultures of smooth muscle cells
from various regions of the lower urinary tract taken from humans or guinea-pigs.
Tissue fragments with an edge length of approximately 0.3-0.5 mm were placed on
specially coated tissue culture dishes and incubated in a C02 incubator without being
agitated. After the adhesion of the fragments, cell colonies started forming around
them. In the initial phase, cells crept out of the fragments and began dividing mitoti-
cally. The confluent cell colony thus grown consists of urothel cells, fibroblasts and
smooth muscle cells. Smooth muscle cells can be selected by passaging so that after
1-2 passages a very pure culture of smooth muscle cells remains.
Cells from primary cultures and passaged cultures were stimulated with various
neurotransmitters to highlight possible differences in the expression of neurotrans-
mitter receptors. The increase in the intracellular concentration of calcium ions trig-
gers the contraction of the smooth muscle cells once the threshold concentration is
reached. The calcium concentration in the living cell can be determined by using
fura-2, a calcium-sensitive fluorescent dye. For this purpose, the cells are incubated
with the membrane-penetrating fura-2-acetoxymethylester. In the cell, fura-2 is split
89

off by endogenous unspecific esterases and cannot leave the cell anymore. The chela-
tion of calcium ions shifts the excitation spectrum of the dye from 380 nm to 340 nm.
This effect is used to calculate the absolute calcium concentration from the fluores-
cence intensities measured at 380 nm and 340 nm at different times during the experi-
ment. The fluorescence images recorded by a CCD camera are used to analyse the
spatial and temporal distribution of the calcium signal.
The change in calcium concentration in cultured smooth muscle cells after the
stimulation of various neurotransmitters was thus used to characterise the different
smooth muscle cells of the lower urinary tract concerning the functional expression
of neurotransmitter receptors. Our own investigations showed that the receptor spec-
trum of smooth muscle cells from the musculus detrusor vesicae differs from that of
the musculus sphincter vesicae and the prostate (Neuhaus et al. 2000). These results
are interesting with respect to the still unsolved question of the ontogenetic origin of
the musculus sphincter vesicae, as they show clear differences from the detrusor
musculature and indicate a functional relationship between the musculus sphincter
vesicae and the musculature of the prostate stromata.
This cell culture system can also be used to investigate cell-cell interactions. As we
showed in calcium-imaging experiments, smooth muscle cells in both primary cul-
tures and passaged cultures are electrically and metabolically interconnected. Using
electron microscopy, gap junctions were detected as the morphological correlate of
this coupling (Neuhaus et aI.1999b). These results indicate that the cells retain impor-
tant characteristics of their origin, despite their strong mitotic activity and dediffer-
entiation under culture conditions. Initial results of the quantitative analyses of the
frequency of gap junctions indicate that even tissue-specific qualities, such as the
coupling degree, seem to be retained or formed anew (Neuhaus et aI., unpublished
data).
As cell and tissue cultures are easy to handle, this method will probably be increas-
ingly used in future anatomical research. Analysis of individual cells, investigations of
interactions between cells and finally the regeneration of tissues and whole organs are
not only important for basic research, but can also be used for innovative therapy
approaches, as demonstrated by the success of various work groups in tissue engi-
neering (Mansbridge et al. 1998; Kaufmann et al. 1999).
13.1
Summary
Classical anatomy chiefly examines macroscopic and microscopic structures. This

approach has recently been supplemented by study techniques which provide an
insight into the functional processes in living cells. Methods such as light microscopy,
the fluorescence technique, and electrophysiological and molecular biological meth-
ods all complement each other. The development of special cell culture methods
marks a significant extension of the investigation possibilities facilitating the analysis
of receptor expression of individual cells, interactions between cells and tissue quali-
ties under controlled conditions. The calcium-sensitive fluorescence dye fura-2 can be
used to highlight changes in intracellular calcium concentration in cultured smooth
muscle cells. Analysing the neurotransmitter spectrum of individual cells resulted in
interesting indications concerning possible functional and ontogenetic common fea-
90
tures of various smooth muscles of the lower urinary tract. Intercellular connections
such as gap junctions remain present in the culture and can therefore be investigated
in cultured smooth muscle cells, too. As the most recent results in the field of "tissue
engineering" show, the results obtained with cell cultures may also be significant for
the development of new therapy options.
91
14 Terminologia Anatomica
Despite the efforts of many scientists to achieve uniformity in anatomical terms

(Federative Committee on Anatomical Terminology), clinical practice in particular
uses a variety of different terms for the anatomical structures of the lower urinary
tract, often causing more confusion rather than contributing to the exact definition of
each structure. Therefore, all the muscles of the lower urinary tract described in the
foregoing chapters are listed again in accordance with the Terminologia Anatomica
(1998). The muscles newly defined by the authors have been added. Muscles for which
no morphological substrate has been found bear the symbol 0 (Table 1). Finally, some
terms frequently used in clinical practice are explained which according to the
authors should no longer be used.
• Musculus retractor uvulae: This muscle is described as the continuation of the
stratum internum longitudinale of the detrusor via the internal urethral orifice
into the urethra. The ostium urethrae internum is exclusively defined by the vesical
sphincter. There is no continuation of the lamellae of the detrusor musculature to
the urethra. A continuation of the ureter musculature via the trigonum vesicae to
the urethra in the sense of Bell's muscle was not found either.
• Diaphragma urogenitale:This term is frequently used in clinical practice. The mus-
culus transversus perinei profundus is considered to be the main element of the
so-called diaphragma urogenitale. As this muscle does not exist, the existence of
the classical diaphragma urogenitale is doubted by the authors.
• Rhabdosphincter:This term only describes the striated part of the urethral sphinc-
ter and therefore provides an insufficient characterisation of the urethral sphincter,
as this muscle consists of a striated part (musculus sphincter urethrae transversos-
triatus) and a smooth muscular part (musculus sphincter urethrae glaber). The
term should therefore no longer be used.
• Base-plate:The musculus sphincter vesicae is defined as a compound "base-plate"
supposed to consist ventrally of lamellae of the detrusor musculature and dorsally
of trigonal muscles. However, lamellae of the detrusor musculature are not in-
volved in the formation of the musculus sphincter vesicae. This muscle exists as an
independent structure, the muscle cell bundles of which are located in a circle
around the ostium urethrae.
• Lissosphincter:This term is mistakenly used for an alleged system of loops of
detrusor lamellae around the ostium urethrae internum. We found an anatomical
correlate for neither this muscle nor the so-called base-plate.
93

Table I. Terminologia Anatomica of the lower urinary tract
Nomina generalis General term Terms alternatively Newly defined muscles,

used ("clinical suggestions for the
language practice") nomenclature, notes
Musculus Detrusor
detrusor vesicae
Stratum internum Internal and external Collare vesicae and
et externum longitudinal layer, nodus vesicae as
longitudinale, circular layer particular structures
stratum circulare of detrusor of the stratum externum
longitudinale
Musculus vesicoprostaticus
Musculus vesicovaginalis
Musculus Pubovesicalis
pubovesicalis
Musculus Rectovesicalis o
rectovesical is
Musculi Trigonal muscles o
trigoni vesicae
Musculus trigoni Superficial trigone o
vesicae superficialis
Musculus trigoni Deep trigone o
vesicae profundus
Musculus interuretericus
(interureteric muscle)
Musculus sphincter Supracollicular o
supracollicularis sphincter
Musculus sphincter Internal urethral Lissosphincter Musculus sphincter

urethrae internus sphincter vesicae (vesical sphincter
or internal sphincter)
Musculus sphincter External urethral Rhabdosphincter Musculus sphincter
urethrae externus sphincter urethrae (urethral or
external sphincter)
Musculus sphincter
urethrae glaber (smooth
muscular part of urethral
sphincter)
Musculus sphincter
urethrae transversos-
triatus (striated part of
urethral sphincter)
Musculus Deep transverse - o
transversus perinei perineal muscle
profundus
94
Table 1 (continued). Terminologia Anatomica of the lower urinary tract
Nomina generalis General term Terms alternatively Newly defined muscles,

used ("clinical suggestions for the
language practice") nomenclature, notes
Musculus o
rectourethralis
Colliculus seminalis Seminal colliculus Verumontanum
Crista urethralis Urethral crest A crista urethral is above
the colliculus seminalis
does not exist
Musculus ejaculatorius
Musculus Puboprostaticus o
puboprostaticus
Musculus dilatator urethrae
(dilator urethrae)
Collum vesicae Structures of the lower
urinary tract, bounded
cranially by the ostium
urethrae internum and
caudally by the bulbus
penis or the bulbi vestibuli
o muscles for which no morphological substrate has been found.
95
15 Summary
Many urological illnesses start in the area of the collum vesicae. The dynamic proc-
esses of the basic functions of the lower urinary tract, urine storage, urine continence,
micturition and ejaculation in the male, may be disturbed. Despite ever more special-
ised diagnostic and therapy methods, the reasons for such disturbances often remain
unclear and treatment does not always have the desired success. One reason is that we
still do not have an exact knowledge of the anatomical basis of various diseases of the
collum vesicae. Therefore questions arise in urological practice which are difficult or
even impossible to answer with the generally acknowledged teaching on the structure
of the lower urinary tract. This is especially true for the structure and course of the
two sphincters of the neck of bladder, the musculus sphincter urethrae and the
musculus sphincter vesicae, as well as the so-called musculus transversus perinei
profundus, the supposed main element of a frequently mentioned diaphragma uro-
genitale. Furthermore, there is no uniform opinion regarding the question whether
and in how far the lamellae of the detrusor musculature leave the local borders of the
organs and continue to the urethra or the surroundings.
As a basis for the present study, 75 human autopsy preparations of the entire lower
urinary tract (urinary bladder, collum vesicae, urethra) of male and female deceased
of all age groups were histologically examined. Not only the organs of the lower
urinary tract, but also all surrounding structures were removed as a whole in order to
preserve the topographic unity and complexity of the collum vesicae. With the help of
a special microtome, serial cuts of the organ blocks were made and stained in different
ways. Altogether approximately 36,000 histological sections were available for studies
using light microscopy.
It is generally acknowledged that the musculus detrusor vesicae consists of three
layers. The individual layers of the detrusor, formed by muscle lamellae (stratum
internum longitudinale, stratum circulare, stratum externum longitudinale) represent
the main direction of an otherwise closely interwoven muscle system. Our own inves-
tigations show that the detrusor musculature in both sexes ends in a collar-shaped
muscle bulge, the collare vesicae, which caudally reinforces the bladder wall. Apart
from two exceptions, all the lamellae of the detrusor end in the collare vesicae. These
exceptions are the musculus pubovesicalis on the ventral side, running from the nodus
vesicae (a ventral reinforcement of the collare vesicae) to the symphysis, and the
musculus vesicoprostaticus or the musculus vesicovaginalis on the dorsal side. These
muscle bundles fix the urinary bladder in the pelvis and have no connection to the
internal urethral orifice or the urethra. Frequently described ring systems of the
detrusor lamellae around the internal urethral orifice do not exist. A continuation of
97

the bladder musculature to the urethra as its external circular layer or internallongi-
tudinallayer must also be negated as a consequence of our own research.
The Terminologica Anatomica (1998) defines a musculus sphincter urethrae inter-
nus as well as a musculus sphincter urethrae externus. For these two circular sphinc-
ters of the collum vesicae, we suggest the terms already used in the Paris Nomina
Anatomica (1955): musculus sphincter vesicae (vesical or internal sphincter) and
musculus sphincter urethrae (urethral sphincter or external sphincter). Based on the
present histomorphological examinations it was shown that both muscles are more
exactly defined by the original terms and that the changes of the nomenclature were
inopportune.
The musculus sphincter vesicae is an independent morphological unit and the only
muscle marking the boundary of the ostium urethrae internum. In the male, the
muscle cell bundles of the vesical sphincter which are elliptically arranged around the
internal urethral orifice continue in the caudal direction until the level of the seminal
colliculus and thus form parts of the neck of bladder. In the female, the muscle cell
bundles of the vesical sphincter, which are clearly less developed than in the male,
surround the internal urethral orifice in a more circular form. In both sexes, lamellae
of the detrusor musculature do not continue to the neck of bladder or the urethra and
therefore are not involved in the formation of the internal urethral orifice.
The dorsal circumference of the musculus sphincter vesicae and not the whole
muscle is located in the trigone of bladder. An isolated trigonum musculature or a
musculus trigoni vesicae superficialis and a musculus trigoni vesicae profundus do
not exist. The trigonum vesicae must therefore be regarded as a purely arbitrarily
defined structure, merely serving orientation in the bladder bottom area. The dor-
socranial border is formed by the musculus interuretericus.
Our own histomorphological studies indicated the pelvic floor to have a structure
differing from that described in classical textbooks. A so-called musculus transversus
perinei profundus or deep transverse perinei muscle does not exist. The histological
findings correlate with our own MRI examinations of the small pelvis, which reveal
that the classical diaphragma urogenitale, the main element of which is supposed to
be this very muscle, does not exist either. This is all the more surprising as the
diaphragma urogenitale is described in numerous textbooks of urology and gynae-
cology as being an important structure regarding urine continence. The external or
urethral sphincter surrounds the urethra as a morphological horseshoe-shaped unit
and has "merely" fibrous connections to the surrounding pelvic floor musculature
(musculus levator ani and musculus obturatorius internus).
The musculus sphincter urethrae is characterised by a morphological particularity.
In its entirety and in both sexes it consists of a striated and a smooth muscular part.
The smooth muscle cell bundles as well as the striated muscle filaments have the same
dimensions and are two parts of the same muscle. To distinguish between these two
parts of the musculus sphincter urethrae, the terms musculus sphincter urethrae
glaber for the smooth muscular part and musculus sphincter urethrae transversos-
triatus for the striated part are suggested. The musculus sphincter urethrae glaber is
ascribed an important function for the maintenance of rest continence and the mus-
culus sphincter urethrae transversostriatus a function for the maintenance of stress
continence.
The longitudinal musculature of the neck of bladder is often neglected in the
literature. In the autopsy material examined, a ventral longitudinal muscle system
98
which was less developed in the male and stronger in the female was found, as well as
a strongly developed dorsal longitudinal muscle system in the male.
The ventral longitudinal urethral musculature forms an independent muscle which
originates at the lower edge of the symphysis and travels in the direction of the
internal urethral orifice, thereby interlacing with the vesical sphincter. Before they
reach the internal urethral orifice, the smooth muscle cell bundles bend caudally and
continue in the immediate vicinity of the urethra lumen, between the urethra mucosa
and the two parts of the urethral sphincter in the caudal direction. There is no direct
continuation of the internal longitudinal layer of the detrusor to the urethra as its
longitudinal musculature. From a functional angle, the term musculus dilatator ure-
thrae is suggested for this ventral longitudinal urethra musculature. Owing to its
special course, this muscle would be ideally suited to actively trigger micturition.
The course of the smooth dorsal longitudinal muscle cell bundles in the male sex is
strictly limited to the region below the colliculus seminalis. A dorsal longitudinal
musculature above the seminal colliculus starting from the trigone of bladder in the
sense of the musculus retractor uvulae or Bell's muscle does not exist. In the female,
no dorsal longitudinal musculature can be detected within the circular sphincter
systems of the urethra; instead, it lies outside the vesical and urethral sphincter.
In the sexually mature male, the dorsal longitudinal musculature is strongly devel-
oped and originates at the level of the orifice of the ductus ejaculatorii. It continues
caudally from the colliculus seminalis and inserts deep into the bulbus penis. In the
urethra, a mucosal fold, the crista urethralis is raised by the special course of this
musculature. Due to its special course, this muscle probably has a function in the
process of ejaculation. Therefore, the term musculus ejaculatoriu5 is suggested.
All the histomorphological findings contributed to the construction of a digital
three-dimensional model of the complex anatomy of the lower urinary tract. In
numerous design stages, starting from the geometrical basic elements and operations,
"wire" models of the individual organic components were developed and incorpo-
rated into a comprehensive model. This model shows the schematic course and spatial
arrangement of all the muscular structures of the collum vesicae in different colours.
Examinations of our own histological material of various age groups indicate that
the above-described muscles undergo histomorphological changes in the course of
the ageing process, mainly a reduction of the smooth muscular part. These changes
are assumed to play a significant role in the pathogenesis of urological functional
disturbances such as urinary incontinence. Further studies of ontogenetic mecha-
nisms may make a significant contribution to the development of innovative therapy
approaches.
Modern techniques based on immunocytochemistry, molecular biology and elec-
trophysiology have led to many new discoveries concerning the innervation and
neuronal control of the functions of the lower urinary tract. Although the basic reflex
arcs for continence and micturition at a spinal and supraspinal level have been
defined, our knowledge of the function of local and organ-proximate ganglia for the
modulation and co-ordination of muscle activity as well as of the central neuronal
representation of individual structures of the lower urinary tract is still insufficient.
Based on the presented anatomical findings, various, frequently used experimental
animals are currently being examined with respect to their suitability for comparison.
Regarding the analysis of the smooth muscular neurotransmitter receptors and ion
channels at the level of the individual cell, these studies are being augmented by
99
investigations of cultured smooth muscle cells of these animals and of human cells.
This analysis of individual cells and individual ion channels will provide necessary
information for better understanding of the function of the whole ensemble on the
basis of exact anatomical and histological knowledge.
Our own histological findings, which often do not correspond to the descriptions
in the literature, have led us to fresh interpretations of basic functions of the lower
urinary tract. In a separate chapter, new theories are presented on the physiology of
urine continence, micturition and ejaculation based on the anatomical findings. Nev-
ertheless, we regard our studies as a contribution to the continuous critical discussion
of the complex anatomy and physiology of the lower urinary tract.
100
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109
Subject Index
Boldface number indicates occurence of term in figure
A D
A-delta fibres 77,79 deep transverse perineal muscle 2,31,32,36,
adenoma 10,27.45,46,53 38,94
anterograde tracers 79 detrusor musculature 7,8,14,18,25,26,28,29,
base-plate 25,26.93 51,59,84,86,89,93,94,97,98
- circularlayer 7,8,14,15.25,94.98
B - internal longitudinal layer 7,8,9,14,51,58,
Bells muscle 2, 17,18,60,69,93,99 98,99
benigne prostate hyperplasia (BPH) 27,71,80, - external longitudinal layer 7,8,10,12,14,
82 15,94
bladder neck incision 1,25,84,87 development 27,48,50,71.72,90.91,99
bladder neck sclerosis 18,27 Diaphragma urogenitale 2,31.32.34,36,39,41,
bladder outlet 9,24,25,26.27,48,59,60,80,85 43, 46. 93, 97,98
bladder outlet obstruction 27,80 dorsal urethral longitudinal musculature 59.86
bradykinin 79 Ductus ejaculatorius 12.14,15.59,60,64,69,
Bulb of penis 2,5.26,32.34,46.48,58.59,68,69 86,99
Bulbi vestibuli 58,60,74,83,85,95
Bulbus penis 6,12.15,26.32,36,44,63,64,74, E
83,85,86,95.99 ejaculation 2,27,28.68,69,83,86,87,97.99,100
electron microscopy 89,90
C em bryogenesis 10
C fibres 77,79,80 Endoscopic 2, 18,60,68
capsaicin 79,80 endoscopy I, 17.60,73
Centrum perinei 59 external urethral orifice 1,2
Centrum tendineum 32,34 extrinsic striated urethral sphincter 31
CGRP 79,80
Collare vesicae 6,8,10,14,15,28,51.94,97 F
Colliculi inferiores 81 Female in fig.: 9,20,38,47,54
Colliculus seminalis 2, 14, 17,26,28,59,69,86, Fossa bulbi 15
87,95,98,99 Frontal in fig.: 12,36,38.42,44,45,62
in fig.: 15,23,32,34,36,42,52,60,62,63,64 frontal lobe lesions 81
Collum vesicae 1,2,5,6, 14, 17.28,36,46,56, functional expression
67,73,74,83,84.85,86,95,97,98,99 of neurotransmitter receptors 90
continence 1,2,25,27.28,31,36,39.41,60,77, fura-2 89.90
81,82,83,84,86.97,98.99, 100
Cornu laterale 77,80 G
Corpus cavernosus 44 Ganglion mesentericum inferius 77.78
Cowpers glands 32, 34 ganglion pelvicus major 80
Crista urethralis 2,17,48,59,60,62,64,68,69, gap junction 90,91
95.99 Glandula bulbourethralis 6,32,34,48
CT 73,81 glandulae Cowperi 32
cultured cells 89 incontinence 1,32,71,82,99
Cystography 57,60 incontinence rate 1
III
inflammation 79 - externus 1,2,94,98
internal urethral orifice 2,8,14,17,23,26,27, - glaber 38,42,44,45,47,49,50,54,55,67,73,
29,58,60,78,85,93,97,98,99 74,84,93,94,98
interstitial cystitis 79 - internus 1,2,28,94,98
intramural ganglia 77,78,81 - transversostriatus 8,42,44,45,48,49,50,54,
levator ani 32,34,36,38,42,43,49,50,67,98 55,67,73,74,78,84,93,94,97,98
Lissosphincter 8,24,93,94 Musculus sphincter vesicae 1,2,8,12,18,22,
Lower urinary tract 2,17,71,73,74,77,78,79, 23,24,25,26,27,28,29,52,53,56,60,67,68,
80,82,83,84,93,97,100 71,74,78,79,81,83,84,87,90,93,94,97,98
- innervation 1,72,77,78,79,80,82,84,99 Musculus transversus perinei profundus 2,31,
- autonomous 77 32,34,36,38,41,43,93,94,97,98
- parasympathetic 77,78,80,81,82 Musculus trigoni vesicae profundus 17,28,29,
- sensory 77,79,80,81,82 94,98
- somatic 77,78,81,84 Musculus trigoni vesicae superficialis 17,28,
- sympathetic 77,78,80,81,82 29,94,98
- voluntary 1,78 Musculus vesicoprostaticus 10,12,14,15,28,
magnetic resonance imaging (MRI) 36,38,73, 56,84,94, 97
81,98 Musculus vesicovaginalis 10,14,56,94,97
major pelvic ganglion 80
male in fig.: 6, II, 12, 19, 20, 22, 24, 32, 34, 36, N
38,42,44,45,49,52,53,57,60,62,63,64,65, neckofbladder 7,14,17,25,26,27,29,31,34,
66,67 36,46,58,60,83,84,85,87,97,98
micturition 2,57,58,68,71,77-87,97,99,100 Nervi splanchnici lumbales 77
micturition reflex 80,81,85 Nervi splanchnici pelvici 77,78
morphometry 71,72 Nervus hypogastricus 77
Musculus bulbospongiosus 34,36,41 Nervus pudendus 78
Musculus compressor vesicae 7 neuroanatomy 77
Musculus detrusor vesicae 2,6,7,8,9,10,12, neurokinins 79
14,22,26,38,51,67,68,71,74,79,83,85,86, NO 78,79
90,94,97 Nodus vesicae 6,8,10, II, 14, 15,25,26,51,94,
- Stratum longitudinale internum 7,9,10,14, 97
26,51,59,85,93,94,97 Nucleus centralis 77,80
- Stratum longitudinale externum 7,8,9,10, Nucleus intercalatus 77,80
14, 26, 60, 94, 97 Nucleus intermediolateralis 77,80
- Stratum circulare 7,8,9,10,14,26,94,97 Nucleus ventromedialis 78
Musculus dilatator urethrae 44,45,51,52,53,
54,55,56,58,60,67,68,71,73,74,77,86,89, o
96,99 obstruction 27,80
Musculus ejaculatorius 59,62,63,64,65,66,67, obturator internus 34,36
68,69,71,72,73,74,87,95,99 ontogenesis 46
Musculus interuretericus 8,10,18,19,20,21, Ostium ureteris 18,21
25,27,28,71,94,98 Ostium urethrae externum 1,17,55,86
Musculus levator ani 32,34,36,38,42,43,49, Ostium urethrae internum 6,8,9,10,14,17,18,
50,67,98 26,27,28,29,56,58,60,74,83,84,87,93,98
Musculus obturatorius internus 32,34,36,38,
98 p
Musculus pubovesicalis 6,10,11,14,15,24,34, parasympathetic 77,78,80,81,82
51,56,71,94,95,97 Pars membranacea urethrae 32,34
Musculus retractor uvulae 2,17,29,60,69,93, Pars prostatica 2
99 pelvic floor 1,5,6,31,32,34,36,38,41,43,46,
Musculus sphincter supracollicularis 28,94 50,73,98
Musculus sphincter urethrae 28,32,34,41,42, Plexus hypogastricus inferior 77,78
43,44,45,46,47,48,49,50,62,71,78,79,80, Plexus pelvicus 77,78,80,82
84,86,97,98 Plexus prostaticus 78
112
Plexus vaginalis 78 transurethral resection of the prostate t,25,
Plexus vesicalis 78 58,87
Plica interureterica 18,19,60 transversal 5,24,26,31,32,34,36,38,46,60
prostaglandins 79 in fig.: 9, II, 12, 19, 22, 31, 32, 34, 36, 38, 54, 60,
Prostate 1,10,14,26,27,28,31,32,41,46,48, 64,65
51,58,59,71,73,78,80,84,87,90 Trigonum Lieutaud 17
in fig.: 6, II, 12, 15,21,22,23,24,25,36,38,42, Trigonum vesicae 2,8,10,14,17,18,24,27,28,
44,45,52,53,60,65,68,74 42,58,59,60,80,93,98
TUR-P 60
R
Rami communicantes albi 77 U
Rectum 34,38,53,73 ureteric orifice 8,17,18,25,26,27,29,78
retrograde ejaculation 27,28,68,86,87 uretero vesical junction (UVj) 79
Rhabdosphincter 41,46,93,94 urethra
- circular musculature 8,14,25,69,84,86,98,
S 99
Sagittal in fig.: 6, II, 20, 21, 24, 47, 52, 53, 62 - ventral longitudinal musculature 51,52,53,
seminal colliculus 2,29,59,60,63,69,95,98,99 58,59,68,86,98,99
seminal vesicles 1,5,60 - dorsal longitudinal musculature 60,62,63,
sensory 77,79,80,81,82 68,69,86,87,99
sensory innervation 79 urethral crest 2,17,60,95
Septum urethrovaginale 14 urethral sphincter 31,45,50,60
small pelvis 6,31,36,73,98 - internal urethral sphincter 1,2,94
smooth muscle cell 8,19,26,48,49,50,56,58, - external urethral sphincter 1,2,46,58,73,
66,68,71,72,89,90,91,98,99,100 81,84,94
somatic 77,78,81 urinary reflexes 81
somatic innervation 78 urogenital diaphragm 2,31
Sphincter urethrae laevis 8 Utriculus prostaticus 59,60
sphinctero-ureterovesical reflex 78,81 Uvula vesicae 2
storage reflex 81
stress 32,50,78,81,84,98 V
substance P (SP) 79,80 Vagina 5,14,21,31,38,46,54,60,78
supracollicular sphincter 28
sympathetic 77,78,80,81,82 vesical sphincter 5,8,18,24,25,26,27,28,31,
sympathetic lateral chain ganglia 77 46,48,49,58,81,83,84,85,86,87,93,94,98,99
sympathetic reflex arc 77,78 in fig.: 22,23,24,25,49,52,53,56,60,67,68,
Symphysis 5,10,,14,32,38,56,58,85,97,99 74
in fig.: 6, II, 15,34,36,42,53 vesicula seminalis 12,20,24
Voiding cystourethrography 57
T voiding reflex 84
three-dimensional model 73,74,99 voluntary innervation 1,81
113

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Advances in Anatomy

Embryology and Cell Biology

With 36 Figures and 1 Table

Library of Congress-Cataloging-in- Publication- Data

1. B1adder-Histology. 1. Stolzenburg, J.-U. (Jens-Uwe), 1964- II. Neuhaus,

© Springer-Verlag Berlin Heidelberg 2001

The use of general descriptive names, registered names, trademarks, etc. in

Goethe (" Wilhelm Meister's Travels", Book III, Chapter 3)

3 Musculus Detrusor Vesicae 7

4 The Musculature of the Trigonum Vesicae 17

6 Musculus Sphincter Urethrae

7 Musculus Dilatator Urethrae 51

9 Changes of the Muscles of the Lower Urinary Tract

11 Fundamentals ofthe Neuroanatomy

12 Discussion (Functional Interpretation

13 Further Studies and New Approaches. 89

Subject Index . . . . . . . . . . . . . . . III

bn bladder neck (neck of bladder)

W. Dorschner et al., Structure and Function of the Bladder Neck

W. Dorschner et al., Structure and Function of the Bladder Neck

W. Dorschner et al., Structure and Function of the Bladder Neck

Fig. SA-F. Musculus vesicoprostaticus.

W. Dorschner et al., Structure and Function of the Bladder Neck

transversal direction is not thought to be part of this anatomical structure. Kalischer

many subsequent authors). Starting from the theory of a non-independent vesical

The trigonum vesicae or trigone of bladder is defined as a geometrical triangle

W. Dorschner et al., Structure and Function of the Bladder Neck

Our own histomorphological examinations, including the MRI examinations of the

W. Dorschner et al., Structure and Function of the Bladder Neck

Our investigations show that a musculus sphincter urethrae exists independently of

The ventral longitudinal urethra musculature is widely ignored in the anatomical

W. Dorschner et al., Structure and Function of the Bladder Neck

ventrally and the musculus vesicoprostaticus (Figs. 6, 7) or musculus vesicovaginalis

The ventral longitudinal musculature of the urethra is an independent structure. This

If descriptions of the ventral longitudinal musculature of the urethra in the literature

W. Dorschner et al., Structure and Function of the Bladder Neck

W. Dorschner et al., Structure and Function of the Bladder Neck

To improve understanding of the pelvic anatomy, different models of the anatomy of

W. Dorschner et al., Structure and Function of the Bladder Neck

W. Dorschner et al., Structure and Function of the Bladder Neck

W. Dorschner et al., Structure and Function of the Bladder Neck

W. Dorschner et al., Structure and Function of the Bladder Neck

Classical anatomy chiefly examines macroscopic and microscopic structures. This

Despite the efforts of many scientists to achieve uniformity in anatomical terms

W. Dorschner et al., Structure and Function of the Bladder Neck

Nomina generalis General term Terms alternatively Newly defined muscles,

Musculus sphincter Internal urethral Lissosphincter Musculus sphincter

Nomina generalis General term Terms alternatively Newly defined muscles,

o muscles for which no morphological substrate has been found.

W. Dorschner et al., Structure and Function of the Bladder Neck

Alverdes K (1959) Grundlagen der Anatomie, 2nd edn. Thieme, Leipzig

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