Relations in Males

The male ureter is a muscular retroperitoneal tube that transports urine from the renal pelvis to the urinary bladder. Its abdominal course is similar to that of the female ureter, but its pelvic relationships differ because of the presence of the male reproductive organs. Particularly important relationships include those with the ductus deferens, seminal vesicle, iliac vessels, and urinary bladder.

Understanding these relationships is important in pelvic and urological surgery. Near the urinary bladder, the ductus deferens crosses superior to the ureter, creating a characteristic relationship that is frequently compared with the relationship between the uterine artery and ureter in the female.

General Course

Each ureter begins as the continuation of the renal pelvis at the ureteropelvic junction. It descends retroperitoneally through the abdomen, crosses the pelvic brim, and continues along the lateral pelvic wall.

Within the pelvis, the ureter turns anteromedially toward the urinary bladder and enters its posterolateral wall.

Major Portions

The ureter can be divided into two broad anatomical portions:

• Abdominal ureter, extending from the renal pelvis to the pelvic brim
• Pelvic ureter, extending from the pelvic brim to the urinary bladder

Retroperitoneal Position

The abdominal ureter is a retroperitoneal structure and descends posterior to the parietal peritoneum.

After entering the pelvis, it remains largely extraperitoneal as it travels along the pelvic wall and approaches the urinary bladder.

Relationship to Psoas Major

The abdominal ureter descends on the anterior surface of the psoas major muscle.

Psoas major therefore forms one of the most consistent posterior muscular relations of the abdominal ureter.

Genitofemoral Nerve

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

This relationship is useful when identifying structures of the posterior abdominal wall during retroperitoneal dissection.

Gonadal Vessels

The testicular vessels descend retroperitoneally toward the deep inguinal ring and cross anterior to the ureter.

The relationship between the gonadal vessels and ureter is an important landmark during retroperitoneal and urological procedures.

Right Abdominal Ureter

The right ureter descends posterior to structures associated with the right side of the abdominal cavity.

Its anterior relations may include the descending part of the duodenum, root of the mesentery, and intestinal structures, depending on the level being considered.

Left Abdominal Ureter

The left ureter similarly descends retroperitoneally on psoas major.

Its anterior relations include structures associated with the left mesocolon and sigmoid region as it approaches the pelvis.

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.

The iliac vessel crossing is an important anatomical landmark and is traditionally recognized as one of the regions where the ureter is relatively narrow.

Relationship to the Iliac Vessels

At the pelvic brim, the ureter passes anterior to the iliac vessels.

The precise relationship varies with the level of common iliac bifurcation and individual vascular anatomy.

Pelvic Course

After crossing the pelvic brim, the male ureter descends along the lateral pelvic wall.

It then curves anteromedially toward the base of the urinary bladder.

Lateral Pelvic Wall

The pelvic ureter initially follows the lateral wall of the pelvis beneath the pelvic peritoneum.

It is related to branches of the internal iliac vessels, pelvic fascia, and autonomic nerve structures during this portion of its course.

Relationship to the Internal Iliac Vessels

The ureter descends in close relationship to the internal iliac artery and its branches.

These relationships can vary because of differences in the branching pattern of the internal iliac artery.

Turn Toward the Bladder

After descending along the lateral pelvic wall, the ureter turns forward and medially toward the urinary bladder.

This terminal pelvic course brings it into close relationship with structures of the male reproductive system.

Relationship to the Ductus Deferens

The ductus deferens crosses superior to the ureter near the posterolateral aspect of the urinary bladder.

Thus, the terminal ureter passes inferior to the ductus deferens before entering the bladder wall.

Water Under the Bridge in the Male

The male relationship can be remembered using the same general concept of "water under the bridge".

The "water" is urine within the ureter, while the "bridge" is the ductus deferens crossing above it. In the female, the corresponding commonly taught relationship is between the ureter and uterine artery.

Course of the Ductus Deferens Near the Ureter

The ductus deferens enters the pelvis after passing through the inguinal canal and deep inguinal ring.

It courses toward the posterior aspect of the bladder and crosses the ureter before expanding into its ampulla.

Ampulla of the Ductus Deferens

The terminal portion of the ductus deferens enlarges to form the ampulla of the ductus deferens.

The ampulla lies posterior to the bladder and medial to the seminal vesicle, near the terminal course of the ureter.

Relationship to the Seminal Vesicle

The terminal pelvic ureter is closely related to the seminal vesicle.

The ureter approaches the bladder lateral to the region occupied by the seminal vesicle and ductus deferens.

Seminal Vesicles

The seminal vesicles lie posterior to the urinary bladder and anterior to the rectum.

Their position places them near the terminal ureters, although the ureters lie more laterally as they enter the bladder.

Relationship to the Rectum

The rectum occupies the posterior midline of the male pelvis.

The pelvic ureters lie lateral to the rectum during much of their descent and then turn anteriorly and medially toward the urinary bladder.

Relationship to the Urinary Bladder

The ureter reaches the posterolateral wall of the urinary bladder after passing beneath the ductus deferens.

It penetrates the bladder wall obliquely and continues through an intramural segment before opening into the bladder lumen.

Intramural Ureter

The intramural portion of the ureter passes obliquely through the muscular wall of the urinary bladder.

This oblique course helps create a functional valve mechanism that limits retrograde movement of urine during bladder filling and contraction.

Ureteric Orifice

Each ureter opens into the bladder through a ureteric orifice.

The right and left ureteric orifices form the superolateral angles of the trigone of the urinary bladder.

Trigone of the Bladder

The trigone is a smooth triangular region on the internal surface of the bladder base.

Its corners are formed by the two ureteric orifices superiorly and the internal urethral orifice inferiorly.

Important Male Pelvic Relations

Structure	Relationship to the Ureter
Testicular vessels	Cross anterior to the abdominal ureter
Iliac vessels	Ureter crosses anterior to them near the pelvic brim
Rectum	Pelvic ureter lies lateral to it
Ductus deferens	Crosses superior to the terminal ureter
Seminal vesicle	Lies medial to the terminal ureteric region
Urinary bladder	Ureter enters its posterolateral wall obliquely

Comparison with Female Pelvic Relations

Feature	Male	Female
Structure crossing above ureter near bladder	Ductus deferens	Uterine artery
Major reproductive gland or organ nearby	Seminal vesicle	Cervix and upper vagina
Gonadal vessels	Testicular vessels cross anteriorly	Ovarian vessels cross anteriorly
Terminal destination	Posterolateral bladder wall	Posterolateral bladder wall

Peritoneal Relationship

The pelvic ureter remains beneath the pelvic peritoneum as it descends along the pelvic wall.

Its extraperitoneal location is important during surgical approaches to the ureter and pelvic viscera.

Relationship to Pelvic Fascia

The ureter travels within the connective tissue planes of the pelvis as it approaches the urinary bladder.

These fascial relationships become particularly important during pelvic surgery because the ureter may need to be identified and mobilized from surrounding tissues.

Relationship to Pelvic Autonomic Nerves

The pelvic ureter courses near autonomic nerve fibers supplying the pelvic viscera.

The ureter itself receives autonomic fibers through renal, aortic, superior hypogastric, and inferior hypogastric plexuses along different portions of its course.

Physiological Constrictions

Three regions are traditionally described as sites of relative ureteric narrowing:

1. The ureteropelvic junction
2. The region where the ureter crosses the pelvic brim and iliac vessels
3. The ureterovesical junction and intramural ureter

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

Ureteropelvic Junction

The ureteropelvic junction marks the transition from the funnel-shaped renal pelvis to the narrower ureter.

It represents the proximal region of relative narrowing along the urinary drainage pathway.

Iliac Vessel Crossing

The ureter changes its anatomical environment as it crosses the pelvic brim over the iliac vessels.

This region is readily identifiable during surgical exposure and is a useful landmark for tracing the ureter between the abdomen and pelvis.

Ureterovesical Junction

The ureterovesical junction is the region where the ureter enters and traverses the bladder wall.

The narrow intramural segment can impede passage of ureteric calculi and is a frequent site at which stones become lodged.

Ureteric Calculi

Calculi traveling from the kidney toward the bladder may produce obstruction and pain when they encounter relatively narrow portions of the ureter.

The anatomical course and relations of the ureter help explain the distribution and referral patterns of ureteric pain.

Male Pelvic Surgery

Knowledge of the terminal ureter is important during operations involving the urinary bladder, prostate, seminal vesicles, rectum, and other pelvic structures.

Distortion of normal tissue planes by malignancy, inflammation, previous surgery, or fibrosis can increase the risk of ureteric injury.

Relationship During Bladder Surgery

The terminal ureters and ureteric orifices must be considered during operations involving the bladder base and trigone.

Damage or obstruction near the ureterovesical junction can interfere with drainage from the corresponding kidney.

Relationship During Seminal Vesicle Surgery

The close proximity of the seminal vesicles, ductus deferens, and terminal ureters is important during procedures involving the posterior bladder and seminal vesicular region.

Identification of the ureter helps prevent inadvertent injury during deep pelvic dissection.

Relationship During Colorectal Surgery

The pelvic ureters are also important landmarks during operations involving the rectum and sigmoid colon.

Because the ureters descend in the retroperitoneal and extraperitoneal tissue planes lateral to the rectum, they may be vulnerable during extensive pelvic dissection.

Ureteric Injury

Potential mechanisms of ureteric injury include transection, ligation, crushing, thermal damage, devascularization, and incorporation into sutures.

Recognition of the normal course and relationships of the ureter is therefore essential during abdominal, pelvic, colorectal, and urological surgery.

Pelvic Masses

Pelvic tumors, enlarged lymph nodes, inflammatory masses, or fibrosis can compress or displace the ureter.

As a result, the expected relationship between the ureter and surrounding pelvic structures may be altered substantially.

Ureteric Obstruction

Obstruction of the ureter prevents normal drainage of urine from the renal pelvis toward the bladder.

Persistent obstruction may produce hydroureter and hydronephrosis and can eventually compromise renal function.

Retroperitoneal Fibrosis

Retroperitoneal fibrosis can surround and constrict the ureters within the retroperitoneum.

Recognition of their normal retroperitoneal course is important for understanding how fibrotic processes can produce bilateral or unilateral urinary obstruction.

Identification During Surgery

The ureter can be identified by tracing it along the anterior surface of psoas major in the abdomen or along the lateral pelvic wall within the pelvis.

Near the bladder in the male, the relationship with the ductus deferens provides an additional anatomical landmark.

Ureteric Peristalsis

The muscular wall of the ureter produces coordinated peristaltic contractions that propel urine toward the urinary bladder.

Visible peristalsis can sometimes assist with intraoperative identification, although identification should not depend solely on observing contraction.

Male Ureter Course

1. The ureter begins at the renal pelvis.
2. It descends retroperitoneally on the anterior surface of psoas major.
3. The testicular vessels cross anterior to it.
4. It reaches the pelvic brim near the iliac vessels.
5. It crosses anterior to the iliac vessels and enters the pelvis.
6. It descends along the lateral pelvic wall.
7. It lies lateral to the rectum.
8. It turns anteromedially toward the urinary bladder.
9. The ductus deferens crosses superior to the ureter.
10. The terminal ureter lies lateral to the seminal vesicle region.
11. It enters the posterolateral bladder wall.
12. It passes obliquely through the bladder wall.
13. It opens at the ureteric orifice within the trigone.

Key Anatomical Features

• The male ureter is predominantly retroperitoneal and extraperitoneal.
• It begins at the renal pelvis and descends toward the urinary bladder.
• The abdominal ureter lies anterior to psoas major.
• The genitofemoral nerve lies posterior to the ureter on psoas major.
• The testicular vessels cross anterior to the ureter.
• The ureter crosses the pelvic brim near the iliac vessels.
• The pelvic ureter descends along the lateral pelvic wall.
• It lies lateral to the rectum during much of its pelvic course.
• The ductus deferens crosses superior to the terminal ureter.
• The ureter lies lateral to the seminal vesicle region as it approaches the bladder.
• It enters the posterolateral wall of the urinary bladder.
• Its intramural course through the bladder wall is oblique.
• The ureteric orifices form the superolateral corners of the bladder trigone.
• The relationship between the ureter and ductus deferens is particularly important in male pelvic surgery.

Clinical Importance

The anatomical relations of the male ureter are important in urological, colorectal, retroperitoneal, and pelvic surgery. Its course across the iliac vessels, along the lateral pelvic wall, beneath the ductus deferens, and beside the seminal vesicle region places it close to structures commonly encountered during surgical dissection.

The relationship between the ductus deferens and ureter is especially useful near the urinary bladder. The ductus deferens crosses above the ureter before continuing toward its ampulla and the ejaculatory duct system. Identification of this relationship can help orient the surgeon within the deep male pelvis.

Understanding the relations of the male ureter provides the anatomical foundation for studying ureteric surgery, urinary obstruction, ureteric calculi, bladder anatomy, ductus deferens anatomy, seminal vesicle anatomy, pelvic surgery, colorectal surgery, and the relationship between the urinary and male reproductive systems.