CHAPTER 13■ ANATO MY O F THE

BLADDER
CLINTON W. COLLINS AND ADAM P. KLAUSNER

GENERAL DESCRIPTION
The bladder is a hollow, muscular retroperitoneal organ with a capacity of 400 to 500 mL in
the normal adult. When empty, it is a pelvic organ, lying behind the pubic symphysis.
However, when distended, it can be palpated above the pubic symphysis and can protude
well into the abdomen during an episode of severe urinary retention.

PERITONEAL RELATIONSHIPS
The peritoneum covers the superior bladder and a portion of the posterior bladder. In
women, the peritoneum continues posteriorly onto the surface of the uterus and rectum,
establishing the vesicouterine and rectouterine pouches, respectively (Fig. 13.1) (1). In men,
the peritoneum continues along the surface of the rectum, establishing the rectovesicalpouch
of Douglas. The two leaves of the peritoneum embryologically coalesce to form the anterior
and posterior layers of the Denonvilliers fascia (rectovesical fascia), a critical landmark in the
performance of a radical retropubic prostatectomy (Fig. 13.2) (13).
Peritoneal Folds
As seen from a typical laparascopic approach to the abdominal cavity, the anterior surface
of the peritoneum has three characteristic deflections, also called folds. The midline fold is
called the “ median umbilical ligament,” and the paired paramedian folds are called the
“medial umbilical ligamants.”
Fortunately, the anatomy itself is less confusing than the terminology. In relation to the
bladder, the median umbilical fold is the most important of these structures as it
contains the urachal ligament. Attaching to the bladder anteriorly at its dome, this
ligamentous structure, containing fatty and vascular tissue, tethers the bladder to the
umbilicus. This stucture, which represents the obliterated urachus, contains paraumbilical
veins and must be ligated when divided during surgical exposure of the bladder. The
bladder muscle, also called the “ detrusor” is attenuated where the urachal ligament
attaches, predisposing this area to the formation of diverticuli.
Retropubic and perivesical fat is present anteroinferior and lateral to the bladder.
LIGAMENTOUS ATTACHMENTS
In the pelvis, the bladder is supported anatomically by two types of ligaments:
fibroareolar (true) ligaments and peritoneal folds. True ligaments provide support for
the bladder laterally via the lateral ligament of the bladder and posteriorly via the
vesicovenous plexus. The lateral ligament derives from the transversalis (endopelvic) fascia
as it courses over the levators and attaches the bladder to the tendinous arch of the
endopelvic fascia. This ligament contains the inferior vesical and vesicodeferential arteries
in the lateral extensions, as well as the pudendal plexuses of nerves and vessels.
In addition, in men, this ligament contains the vasa deferentia. The posterior ligaments
provide posterolateral support to the bladder. These ligaments are connective tissue
condensations in which the vesicovenous plexus drains into the internal iliac veins.
Peritoneal folds also connect the bladder to the pelvic sidewalls and consist of the
median, medial, and lateral umbilical folds as well as the sacrogenital folds. The median
umbilical fold and medial umbilical folds originate at the bladder and terminate at the
umbilicus. They contain the urachus and the obliterated umbilical arteries, respectively.
The lateral umbilical folds attach the bladder to the pelvic sidewalls and contain the inferior
epigastric arteries. The sacrogenital folds connect the bladder to the sacrum (Fig. 13.3) (7).
The bladder is also fixed to the symphysis pubica by the pubovesical ligaments in
women and the puboprostatic ligaments in men. The dorsal vein of the clitoris or penis
passes between these paired ligaments. These ligaments represent an important surgical
landmark as they form the anteromedial portion of the retropubic space, also called
the space of Retzius.
The space of Retzius is bound anteriorly by the transversalis fascia, inferiorly by the
puboprostatic (pubovesical) ligaments, and infralaterally by the lateral ligaments of the
bladder (Fig. 13.4).
HISTOLOGIC STRUCTURE
The lumen of the bladder is lined by transitional epithelium, also called “urothelium.”
This unique epithelium is characterized by its outer layer of “ umbrella cells,” which are
sealed closely together and communicate via tight junctions. The term
transitionaldenotes the ability of these outer cells to undergo significant transitions in
shape depending on the state of bladder filling. Thus, the cells are puffy and cuboidal
when the bladder is empty and become flat and elongated when the bladder is distended
(6).Beneath these umbrella cells, the transitional epithelium contains additional layers of
cells (usually about seven) and a distinct layer of basal cells. Deep to the transitional
epithelium lies the lamina propria, composed of fibroelastic connective tissue through
which vessels course.
Wisps of smooth muscle also course within the lamina propria, and this portion of the
lamina propria is sometimes referred to as the muscularis mucosa (Fig. 13.5)

The distinction between the muscularis mucosa and the muscularis propria, or true
muscular layer of the bladder that lies deep to the lamina propria, is critical in the staging
and prognosis of urothelial cancer. Cancer that is confined to the urothelium or lamina
propria, even when surrounded by wisps of muscularis mucosa, is considered superficial
disease and is mainly treated via local resection or with intravesical immuno- or
chemotherapeutic agents. However, cancer that penetrates into the muscularis propria,
characterized histologically by large, distinct detrusor smooth muscle bundles (Fig. 13.6),
is considered invasive cancer and is treated more aggressively; it usually requires surgical
removal of the entire bladder.
Within the muscularis propria, detrusor smooth muscle bundles course in inner longitudinal,
middle circular, and outer longitudinal orientations. In addition, interstitial cells
surround and percolate within the muscle bundles and may be important in the maintenance
or modulation of bladder muscle tone (8). These muscle layers are less distinct in the upper
aspect of the bladder.
However, they become quite prominent at the bladder neck, although composed of finer
fibers. In men, the middle layer of circular detrusor smooth muscle forms a preprostatic
layer that has robust expression of alpha receptors (mainly alpha 1a) and contributes to
continence at the bladder neck. Furthermore, the success in treatment of benign prostatic
hypertrophy (BPH) with alpha blockers stems, in part, from a pharmacologic reduction in
tone in the smooth muscle surrounding the prostate and bladder neck (2). In women,
the bladder neck differs dramatically, having a less distinct middle layer of smooth
muscle (1,5).

URETEROVESICAL JUNCTION AND TRIGONE

The spiral fibers of the ureter become more longitudinally oriented near the bladder and
are encased in the fibromuscular Waldeyer sheath from a distance just proximal to its
entrance into the bladder wall through its course to the trigone (1,11).
Obliquely, the ureters enter the bladder posteroinferiorly and course approximately 2 cm
toward the ureteral orifice, narrowing as the intramural ureter is compressed by the
detrusor of the bladder surrounding it. The ureter lies just beneath the bladder mucosa with
a muscular layer backing (1).
A distinct landmark is formed at a triangle located between the ureteral orifices and the
bladder neck, referred to as the bladder trigone. Layers of ureteral and bladder smooth
muscle coalesce here as a raised ridge of tissue between the two orifices referred to as the
interureteric ridge. This ridge is helpful in identifying orifices endoscopically (Fig. 13.7).
The trigone is composed of three distinct layers: (a) a superficial layer derived from
the longitudinal layer of ureteral smooth muscle; (b) a deep layer that is continuous from
the Waldeyer sheath, inserting at the bladder neck (Fig. 13.8); and (c) the detrusor layer,
derived from the outer longitudinal and middle circular layers of smooth muscle (1). The
unique anatomic structure of the intramural ureter and trigone contributes to the intrinsic
continence mechanism that prevents vesicoureteral reflux during bladder filling and voiding.
BLOOD SUPPLY
Multiple blood vessels supply the urinary bladder; however, the exact vascular
anatomy can vary somewhat between individuals. Less variable is the presence of two
more distinct collections of vessels, referred to as the lateral and posterior pedicles (Fig.
13.9). In men, the lateral and posterior pedicles are also called the lateral and posterior
ligaments. In women, these vascular pedicles are part of the cardinal and uterosacral
ligaments. The blood vessels within these pedicles branch from the superior and
inferior vesical arteries. The superior vesical artery arises from the internal iliac close
to its origin from the common iliac. It can also arise as a branch from the umbilical artery,
which branches off of the proximal internal iliac. The inferior vesical artery branches off of
the internal iliac artery at a more distal location. However, it is important to recognize
that the arterial supply to the bladder may arise from anyportion of the internal iliac. In
terms of venous drainage, veins from the bladder drain predominantly into lateral
plexuses and then empty into veins within the lateral prostatic ligaments and ultimately into
the internal iliac veins (1).

INNERVATION
Sensory Innervation
In the bladder, there are two types of sensory (afferent) nerve fibers: alpha-delta and C
fibers. Alpha-delta fibers are partially myelinated and carry information to the central
nervous system regarding bladder fullness and wall tension. These sensory fibers are
responsible for initiating the normal voiding reflex.
On the other hand, C fibers are unmyelinated nociceptive fibers that mainly carry
information to the central nervous system regarding noxious or painful stimuli. Although
these C fibers comprise about 70% of the total afferent nerves supplying the bladder, they are
generally silent and only become sensitive during inflammation, irritation, or suprasacral
spinal cord injury.
Prolonged activation of C fiber afferents may be responsible for the development of
pathologic voiding reflexes associated with some forms of overactive bladder.
Motor Innervation
Motor innervation to the bladder arises from three sets of nerves: (a) the
parasympatheticsacral (pelvic) nerve, arising from the sacral spinal cord between S2 and
S4; (b) the sympathetic thoracolumbar (hypogastric) nerve, arising from the spinal cord
between T10 and L2; and (c) the somaticpudendal nerve, which also arises between S2 and
S4.
Preganglionic parasympathetic motor efferent fibers exit between S2 and S4 via pelvic
nerves, with nerve bodies located in the sacral parasympathetic nucleus (SPN). The SPN
is located in the intermediolateral region of the sacral spinal cord. Importantly, an increase in
parasympathetic tone, supplied by these nerves, is the main trigger for a coordinated
contraction of the detrusor muscle that leads to voiding. In the bladder body,
sympathetic fibers supply beta receptors contributing to smooth muscle relaxation during
filling and also synapse prejunctionally along axons of parasympathetic nerves.
This anatomic relationship may allow for additional reduction of detrusor smooth
muscle tone during the filling phase, a process that is likely necessary to prevent
involuntary contractions and urge incontinence. The only somatic (voluntary) motor fibers
in the lower urinary tract supply the external urethral sphincter, sometimes called the
rhabdosphincter (9).
Preganglionic somatic motor efferent fibers exit between S2 and S4 with nerve bodies
located in the Onuf nucleus in the anterolateral horn of the sacral spinal cord. These somatic
fibers run in the pudendal nerve, modulating striated (voluntary) urethral sphincter
contraction.
The Micturition Reflex
Sensory or “ afferent ” fiber sfrom the bladder are contained in the pelvic, hypogastric, and
pudendal nerves. The pelvic and pudendal nerves enter the sacral spinal cord via dorsal
root ganglia, with the most prominent projection passing anterolateral toward the SPN.
Afferent fibers in the hypogastric nerves also enter the spinal cord via dorsal root ganglia
in the lumbar spinal cord. Afferent fibers from the external urethral sphincter pass through
the Onuf nucleus in the sacral spinal cord. All of these inputs relay sensory information to
the lateral pons, referred to as the pontine storage center. After processing in higher brain
centers, motor signals are then relayed back through the pontine micturition center (PMC)
located in the Barrington nucleus in the dorsal medial pons. These pontine centers receive
input indirectly through relay neurons in the periaqueductal gray (PAG) or directly from
lateral spinal tract neurons. There is also input from the cerebellum, basal ganglia, thalamus,
hypothalamus, and cerebral cortex (4,12). Therefore, these PMCs are responsible for the
coordination of urine storage and voiding. Thus, damage to the spinal cord between the
sacral motor outflow and the PMCs leads to a characteristic pattern of neurogenic detrusor
overactivity (involuntary contractions) and detrusor sphincter dyssynergia (lack of
coordination between the bladder and urethral sphincter).
In this situation, the coordinated spinal bulbo spinal reflex is converted to an uncoordinated
spinal spinal reflex.
Storage Reflex
Storage is facilitated by bladder afferent stimulation of the Onuf nucleus, which
increases the tone of the external urethral sphincter via the somatic pudendal nerve.
The pontine storage center, in the lateral pons, also stimulates the Onuf nucleus and the
pudendal nerve output to the external urethral sphincter. Simultaneously, the hypogastric
(sympathetic) nerve, receiving input from pelvic afferents, inhibits the detrusor muscle
and bladder ganglia while stimulating the internal urethral sphincter (bladder neck), which
has robust expression of alpha-1 receptors. As mentioned earlier, pharmacologic reduction in
this bladder neck tone with alpha blockers is a mainstay for the treatment of BPH as well
as detrusor-sphincter dyssynergia and other forms of voiding dysfunction (Fig. 13.10).
Emptying Reflex
Emptying is mediated through the PMC, which stimulates parasympathetic motor or
“efferent” fibers whose cell bodies are in the SPN. Parasympathetic outflow via the pelvic
nerve causes detrusor contraction and inhibition of the internal sphincter (bladder
neck), processes that facilitate emptying. In addition, signals from the PMC also inhibit
sympathetic outflow from the hypogastric nerve, leading to relaxation of the bladder neck,
a process that also facilitates emptying. Furthermore, signals from the PMC also inhibit
the motor outflow to the pudendal nerve, leading to relaxation of the striated urethral
sphincter, again facilitating emptying (Fig.13.11) (10).

LYMPHATICS
The lymphatic drainage of the bladder is to the external iliac vein, the hypogastric nodes, or
the presacral promonotory.

CONTIGUOUS STRUCTURES
In men, the bladder joins the prostate and is anterior to the seminal vesicles and
ampulla of the vas deferens. In women, the bladder is in more direct contact with the
pubococcygeus portion of the levator ani. Superiorly, the bladder is covered by
peritoneum in both men and women. Posteriorly in women, the bladder is adjacent to
the uterus and vagina. In men, the posterior bladder is adjacent to the seminal vesicles and
rectum.