Relations in Females

The female ureter is a muscular retroperitoneal tube that carries urine from the renal pelvis to the urinary bladder. Although much of its abdominal course is similar to that in the male, its pelvic relationships are strongly influenced by the female reproductive organs. In particular, the ureter has important relationships with the ovary, ovarian vessels, uterine artery, cervix, and vagina.

These relationships are especially important in pelvic surgery. The close relationship between the ureter and uterine artery near the cervix is a major surgical landmark because the ureter may be injured during hysterectomy and other gynecological procedures.

General Course

Each ureter begins at the renal pelvis and descends retroperitoneally along the posterior abdominal wall. It crosses the pelvic brim and continues along the lateral pelvic wall before turning anteromedially toward the urinary bladder.

The female ureter can therefore be considered in two broad anatomical portions:

• Abdominal ureter
• Pelvic ureter

Retroperitoneal Position

The ureter is primarily a retroperitoneal structure. Throughout its abdominal course it lies posterior to the parietal peritoneum.

Within the pelvis, the ureter remains largely extraperitoneal as it descends along the pelvic wall and approaches the urinary bladder.

Abdominal Relations

The abdominal relations of the female ureter are broadly similar to those of the male ureter. The ureter descends on the anterior surface of the psoas major muscle and is crossed by several vessels and other structures during its course.

Posterior Relation to Psoas Major

The psoas major forms an important posterior muscular relation of the abdominal ureter.

The ureter descends on the anterior surface of this muscle toward the pelvic brim.

Genitofemoral Nerve

The genitofemoral nerve descends on the anterior surface of psoas major posterior to the ureter.

This relationship can be appreciated during retroperitoneal surgical exposure of the ureter and posterior abdominal wall.

Gonadal Vessels

The ovarian vessels descend in the retroperitoneum and cross anterior to the ureter during their course toward the pelvis.

This relationship between the gonadal vessels and ureter is an important landmark in abdominal and pelvic anatomy.

Relationship to the Ovary

Within the pelvis, the ureter has an important relationship with the ovary and the structures associated with the ovarian fossa.

The ureter lies posterior and medial to the ovary as it descends along the lateral pelvic wall.

Ovarian Fossa

The ovarian fossa is a depression on the lateral pelvic wall in which the ovary commonly lies.

The ureter is related to the posterior boundary or floor region of the ovarian fossa, making its location clinically important during procedures involving the ovary.

Relationship to the Ovarian Vessels

The ovarian vessels approach the ovary through the suspensory ligament of the ovary.

The ureter passes posterior to these vessels, creating an important relationship near the pelvic brim and lateral pelvic wall.

Crossing the Pelvic Brim

The ureter enters the pelvis by crossing the pelvic brim, usually near the bifurcation of the common iliac artery or over the external iliac artery.

This crossing represents one of the locations where the ureter may be relatively narrowed and where ureteric calculi may become lodged.

Pelvic Course

After entering the pelvis, the ureter descends along the lateral pelvic wall.

It then turns anteromedially toward the urinary bladder, passing through the connective tissue of the pelvic viscera and developing particularly important relationships with the female reproductive tract.

Lateral Pelvic Wall

During the first part of its pelvic course, the ureter lies against the lateral pelvic wall and is covered medially by pelvic peritoneum.

Its course places it near branches of the internal iliac vessels and pelvic autonomic nerves.

Relationship to the Internal Iliac Artery

The pelvic ureter descends anterior to or in close relationship with branches of the internal iliac artery.

The precise vascular relationships vary as the artery divides into its pelvic branches.

Relationship to the Uterus

As the ureter approaches the lower reproductive tract, it turns anteromedially toward the bladder and passes lateral to the cervix of the uterus.

This region contains one of the most clinically significant anatomical relationships of the female ureter.

Relationship to the Uterine Artery

The uterine artery crosses superior to the ureter near the lateral aspect of the cervix.

Thus, the ureter passes inferior to the uterine artery as both structures approach the uterus and lower reproductive tract.

Water Under the Bridge

The relationship between the ureter and uterine artery is commonly remembered by the phrase "water under the bridge".

The "water" represents urine traveling through the ureter, while the "bridge" represents the uterine artery passing above it.

Relationship to the Cervix

The ureter passes lateral to the cervix before continuing toward the urinary bladder.

Near the cervix, it lies within the connective tissue at the base of the broad ligament and is closely related to the uterine vessels.

Distance from the Cervix

The ureter commonly passes approximately 1 to 2 cm lateral to the cervix, although the exact distance varies between individuals and may be altered by pelvic pathology.

This close relationship explains the vulnerability of the ureter during surgery involving the cervix and uterine vessels.

Relationship to the Broad Ligament

The ureter passes through the connective tissue associated with the base of the broad ligament.

It does not lie freely between the two peritoneal layers throughout the broad ligament. Instead, its clinically important course is within the underlying extraperitoneal connective tissue.

Cardinal Ligament Region

Near the cervix, the ureter traverses the parametrial connective tissue associated with the cardinal ligament, also called the transverse cervical ligament.

The uterine vessels also traverse this region, accounting for their close relationship with the ureter.

Parametrium

The parametrium is the connective tissue surrounding the uterus and cervix between the layers of pelvic fascia and peritoneal reflections.

The ureter passes through this tissue as it courses toward the urinary bladder.

Relationship to the Vagina

After passing lateral to the cervix, the ureter continues forward in close relationship to the upper vagina.

It passes near the lateral vaginal fornix before entering the wall of the urinary bladder.

Lateral Vaginal Fornix

The lateral vaginal fornix lies close to the terminal pelvic ureter.

This relationship is clinically relevant because pelvic procedures involving the upper vagina or cervix can potentially affect the ureter.

Relationship to the Urinary Bladder

After passing the cervix and upper vagina, the ureter approaches the posterolateral aspect of the urinary bladder.

It enters the bladder wall obliquely and travels through an intramural segment before opening into the bladder lumen.

Intramural Course

The ureter traverses the bladder wall in an oblique direction rather than entering it perpendicularly.

This oblique intramural course contributes to a functional valve mechanism that limits retrograde flow of urine from the bladder into the ureter during bladder filling and contraction.

Ureteric Orifice

Each ureter opens into the urinary bladder at a ureteric orifice.

The two ureteric orifices form the superolateral corners of the bladder trigone, while the internal urethral orifice forms its inferior corner.

Important Female Pelvic Relations

Structure	Relationship to the Ureter
Ovary	Ureter lies posterior and medial to the ovary
Ovarian vessels	Pass anterior to the ureter
Uterine artery	Crosses superior to the ureter
Cervix	Ureter passes lateral to the cervix
Upper vagina	Terminal ureter passes close to its lateral aspect
Urinary bladder	Ureter enters the posterolateral bladder wall obliquely

Anterior and Posterior Relationships

The relationships of the ureter change considerably as it travels from the abdomen into the pelvis.

In the abdomen, it lies anterior to psoas major and posterior to structures crossing the posterior abdominal wall. In the female pelvis, its most important anterior and superior crossings involve reproductive vessels and organs.

Peritoneal Relationship

The pelvic ureter lies beneath the pelvic peritoneum and can sometimes be identified by observing its course through the translucent peritoneal covering during surgery.

Its extraperitoneal position allows surgical identification and mobilization without entering the ureteral lumen.

Sites of Physiological Narrowing

Three regions are traditionally emphasized as sites where the ureter is relatively narrow:

1. The ureteropelvic junction, where the renal pelvis becomes the ureter
2. The region where the ureter crosses the pelvic brim and iliac vessels
3. The ureterovesical junction, where the ureter traverses the bladder wall

These regions are clinically important because ureteric calculi may become impacted at or near them.

Relationship to the Uterine Artery During Surgery

When the uterine artery is identified and ligated during pelvic surgery, the position of the ureter must be considered carefully.

Because the artery crosses above the ureter near the cervix, deep or misplaced ligation can injure or incorporate the ureter.

Hysterectomy

The ureter is particularly important during hysterectomy because surgical dissection and vascular ligation occur close to its pelvic course.

Recognition of the ureter near the uterine artery, cervix, and lateral vaginal fornix helps reduce the risk of inadvertent injury.

Sites of Ureteric Injury in Gynecological Surgery

Potentially vulnerable regions include:

• Near the ovarian vessels at the pelvic brim
• Along the lateral pelvic wall
• Where the uterine artery crosses the ureter
• Near the lateral cervix
• Near the upper vagina
• Close to the ureterovesical junction

Mechanisms of Surgical Injury

Ureteric injury may occur through transection, ligation, crushing, thermal injury, devascularization, or incorporation into sutures.

Because some injuries do not immediately interrupt urine flow completely, clinical manifestations can occasionally appear after the operation.

Relationship to the Ovarian Pedicle

The ureter must also be considered during procedures involving the ovarian pedicle.

The ovarian vessels within the suspensory ligament of the ovary cross anterior to the ureter, so identification of the ureter is important before vascular pedicles are divided or ligated.

Pelvic Masses and Ureteric Relations

Large uterine, ovarian, cervical, or other pelvic masses can displace or compress the ureter.

Consequently, the normal relationship of the ureter to the uterus, cervix, ovary, and pelvic vessels may be significantly altered in patients with pelvic pathology.

Ureteric Obstruction

Compression or invasion of the pelvic ureter can obstruct urinary drainage from the kidney.

Persistent obstruction can cause proximal ureteric dilation and hydronephrosis.

Cervical Disease

The close relationship of the ureters to the cervix and parametrial tissues is clinically significant in advanced cervical disease.

Processes involving the parametrium may compress or involve the ureters and interfere with urinary drainage.

Identification During Pelvic Surgery

The ureter can often be identified along the lateral pelvic wall and followed toward the bladder when its course must be established during surgery.

Direct visualization of the ureter is particularly important when normal anatomical relationships have been distorted by previous surgery, inflammation, endometriosis, adhesions, or pelvic masses.

Ureteric Peristalsis

Visible peristaltic contractions may help identify the ureter intraoperatively.

However, the absence of immediately visible peristalsis does not by itself establish that a tubular structure is not the ureter.

Relationship to Pelvic Autonomic Nerves

The pelvic ureter courses within connective tissue containing autonomic nerve fibers and pelvic vascular structures.

Its close relationship to these structures contributes to the anatomical complexity of deep pelvic dissection.

Female Ureter Course

1. The ureter begins at the renal pelvis.
2. It descends retroperitoneally on the anterior surface of psoas major.
3. The ovarian vessels cross anterior to it.
4. It reaches the pelvic brim near the iliac vessels.
5. It descends along the lateral pelvic wall.
6. It lies posterior and medial to the ovary.
7. It turns anteromedially toward the bladder.
8. It passes lateral to the cervix.
9. The uterine artery crosses superior to it.
10. It passes close to the lateral aspect of the upper vagina.
11. It enters the posterolateral wall of the urinary bladder.
12. It travels obliquely through the bladder wall and opens at the ureteric orifice.

Key Anatomical Features

• The female ureter is predominantly retroperitoneal and extraperitoneal.
• Its abdominal course is broadly similar to that of the male ureter.
• It descends anterior to psoas major.
• The ovarian vessels cross anterior to the ureter.
• The ureter crosses the pelvic brim near the iliac vessels.
• In the pelvis, it descends along the lateral pelvic wall.
• It lies posterior and medial to the ovary.
• It passes lateral to the cervix.
• The uterine artery crosses superior to the ureter near the cervix.
• The uterine artery relationship is remembered as "water under the bridge."
• The terminal ureter lies close to the upper vagina and lateral vaginal fornix.
• It enters the urinary bladder obliquely at its posterolateral aspect.
• Its relationships with the uterine and ovarian vessels are especially important during gynecological surgery.

Clinical Importance

The anatomical relations of the female ureter are particularly important because the ureter passes through regions frequently encountered during gynecological and pelvic surgery. Its relationship to the ovarian vessels, uterine artery, cervix, upper vagina, and bladder places it at risk during hysterectomy, ovarian surgery, cervical procedures, and other operations involving the pelvic sidewall.

The crossing of the uterine artery above the ureter near the cervix is one of the most important relationships to recognize. The phrase "water under the bridge" provides a simple anatomical reminder, but safe surgery depends on direct understanding and identification of the structures, especially when normal anatomy has been distorted.

Understanding the relations of the female ureter provides the anatomical foundation for studying pelvic anatomy, ureteric surgery, hysterectomy, uterine artery ligation, ovarian surgery, ureteric obstruction, pelvic masses, and the relationships between the urinary and female reproductive systems.