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URETERITIS: a CLINICAL SURVEY* Based on 147 Cases Y Dljncan M

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URETERITIS: a CLINICAL SURVEY* Based on 147 Cases Y Dljncan M URETERITIS: A CLINICAL SURVEY* Based on 147 Cases y DlJNCAN M. MORISON, M.C., M.D., F.R.C.S.Ed. ^ " term " ^hic^ Ureteritis is used to designate a lesion of the ureter n0t: Pathoio ^et understood. From the standpoint of that it lesion may be regarded as relatively trivial in ?ftheuJ?ay not cause embarrassment to the conducting system 1 PyeWra ^tract- ^ts recognition by intravenous and retrograde ^"k ^ *s not It is always evident. Usually ^aPParently due to a localised spasm of the ureter and is sPasm jslntermjttent in character. The pain consequent on this the to cause advice to be If areas efficiently. distressing sought. sPasm involve the lower abdominal or Ureter the upper pelvic It attacks of pain offer a diagnostic problem, js n0t frequently teeter >> *ntended in this paper to discuss "stricture of the Wlt^ ^trien, ^brosis and a constant narrowing of the ureteral The ? ^>1?neer worker with regard to ureteral lesions was 0 as lo\yGp early as 1911 drew attention to the similarity U"eteral lesions to those of the urethra. He applied term " Ureteral stricture to cover all areas of localised resistariCe t? Miethe Passage of a bulbed ureteral catheter, irrespective ^ were in nature or of a definite stricture f spasmodic rigid ^e" of considerable ar?se aricj consequence this, confusion observers failed to detect the of the ^eteric le ?lany frequency aS stated Hunner. to overcome this " ^y Later, toAcuity th?nterm " " " ^acilitai- ^ uretero-spasm or ureteritis was applied Keyse,rdlfferentiation.^as simulate the Pr?cess in suggested that ureteritis may ^ Y928)Ve *n arigina ?esophago-spasm, pyloro-spasm, cardio-spasm, ferial and Reynaud's disease, as the structure of the an<^ PelviseCt?r^Sureter and ^eir innervation is similar in many resPects to sVm^ ?,^e ?ther smooth muscle structures also supplied by A ^tem. review ureter of the anatomy and of the Su^ests 1> physiology and to discuss the rec0 ^ before proceeding symptomatology ^nition?u ui * a of theme condition. A ,943 Honyman GiUespie Lecture given in the Royal Infirmary, 5th Angus Duncan M. Morison Anatomy and Physiology with The ureter is a relatively thick-walled muscular tube, , sized which conducts the urine from varying lumen, ^ards to the bladder. From its source the ureter runs down pelvis ^ it and slightly medially across the psoas muscle where Pa_t j5 behind the spermatic or ovarian vessels. From this P?*ntclirve in close relationship to the peritoneum. As the ureters over the common iliac arteries at their bifurcation to ente^^. bony pelvis they are little more than 6 cm. apart, their crossing. approximation till they reach the bladder. After g c iliac arteries each ureter curves outward and backward, ^ to the wall of the bony pelvis alongside the hypogastric ^ the to a point opposite the ischial spine. At this point ^ are furthest from each other. Thereafter, each ureter ^ and medially in front of all the vessels except the uterine of the v supply, close to the side of the cervix and upper part in the female, and beneath the vas deferens and oppoS j ^ seminal vesicle in the male, to enter the bladder obhqu ^ form the trigone. The ureter varies in length from 28 jeft. than in men, the right ureter being usually 1 cm. shorter In women the length of each ureter is slightly shorter. The ureter presents four points of physiological na!"r?r0sSeSit (1) at its origin?the pelvo-ureteral junction, (2) where or the iliac vessels, (3) where it crosses the vas deferens ge vessels, and (4) as it traverses the bladder wall. Between tne ' points of narrowing there are relative spindles. Of nar abdominal spindle between the first and second points of is the largest. At the above zones of ureteral narr?Wl^nCed- circular muscle bundles of the ureteral wall are more prono Structure.?The ureter is composed of three coats anuc0us- fibrous, a middle muscular, and an inner mucous andsr>th The outer fibrous sheath or adventitia envelops tube (calyces, pelvis and ureter) to the bladder and coa consistS main nerves and vascular branches. The middle rTt ^ .^ef of three layers of unstriped muscle fibres, i.e. an ou*er *ke 6 ufeter longitudinal and a middle circular. In the coats elastic fibres of connective tissue are abundant. bla mucosa is of the transitional type similar to the mucosa and submucosa are thrown into longitudin a star ^ped giving the ureteral lumen on transverse section appearance. 662 Ureteritis : A Clinical Survey It Ureter.?The vascular supply is abundant, ariSeg6fSr?m severa-l sources, all of which anastomose freely. branch GS t^le and ?f the renal artery nourish its upper third, branches artery pass to supply the lower third. There a upwards jJ6SlCa^^ree anastomosis of the distribution of these, arteries I W^ich is a<^^e<^ to about the middle third by a branch from the Ocular ?r 0var"ian as well as a smaller vessel arising ^rectly f artery Withir0- lower end of the aorta above its bifurcation. a<^ventitia perforating vessels pass through the Ocular"1 to unite a of size jn !S and form longitudinal plexus pre-capillary * Su^muc?sa. Because of this free anastomosis the nutrition ? f ureter is not of any of the Vessels e J"*16 impaired by ligation ^entit/1 Gr^n^ *ts middle third or by actual disturbance of the ^rain Veins arise from the plexuses in the submucosa, intoltSe^'? Vaginal t^?Se tJle adventitia and thence into the vesical, T^e' ;ter*ne> ^iac, spermatic, lumbar and renal channels. drainage of the ureter is correspondingly COrtlplete renal PhatiCs tiln ^at the upper third passes off into the lym- reach t'he f "diddle third accompanying the vascular branches to aCc0rnpa Um'-)ar chain, and the lower third draining down to those of has been shown a the bladder. Although it Present; ^rnente<^ lymphatic drainage of the ureter is normally Suggest an<^ Wallace, I935)? clinical findings tend to tha^C^enZ^e? Un<^er this rich anastomosis Pefrnit a certain conditions may ^ervePeg"Ureteral ascent of infection. autonornic ?The innervation of the ureter is entirely ?nly S?^ateci cells and a few are in the 1 ganglion ganglia present ^Ventitia /T?West third of the ureter, and these are limited to the The I923"I925)- nerveyntSChak'arises from sources ? three *938) <? SuPPly (Mitchell, 1935 j^eSenteric Lower fibres of the renal plexus or the inter- to the third the / ^?gastricne!iVes Pass*ng upper ; (2) superior 12 exus or the end of the nerve 1 do , upper hypogastric ,?^er > Ist to the middle third ; (3) the encj ? lumbar) passing t^le nerve and the of the ^ hypogastric upper part |nferi0r0 the Plexus (2, 3, 4 sacral) (sympathetic) passing l0vf?gaStric^ aSs?ciateci The inferior ureteric nerves are closely Wl^ which the vas deferens and Sei^inal v ^laments supply Pv esicle. r?rn th e 0 the muscular the Sub adventitia nerves pass through layer At the lower where a diffuse plexus is formed. end?fthemUC0SaUreter this submucosal plexus appears to be accentuated 663 Duncan M. Morison * I ^ i^0 around the ureteral opening and extends over the trigone posterior urethra. a The ureter may be stripped of all its connections t0 nerve and lymphatic?to its full extent from the renal pe ^ the bladder, without apparently causing any alteration ,i been i nutrition and function. Clinically, however, it has g that where persistent pain has previously been present the of the ureter from its intermediate contacts the throughout ^ portion of its length eliminates the sensation of pain (/ ? 1925 ; Wharton, 1932). Jvis Function.?The ureter rena F conducts urine from the ^ j to the bladder by a series of rhythmic peristaltic contra ^ The two ureters not to alter*1 do act in concert but tend ^ their contractions. Further, the rate of contractions vary different segments of the ureter. At the upper end nearef^s pelvis a rate of 4*1 contractions per minute has been noted- ^ whe rate is practically equalled in the juxtavesical portion, ,e the 2 middle third the contractions may be only per ^ The actual mechanism of these contractions, whether truly neurogenic or myogenic, is not yet settled. Symptomatology and Etiology . 1 eflg Irritability of a ureter may be referred to its entire ^ , or be localised in certain zones. It is only in a few marke a that there is a diffuse ureteritis. It is more usual to find j0- of ureteritis referred to those areas of the ureter which P logically show narrowings. t? Ureteral spasm occurring in these zones gives rise ^ which is referred to definite areas of the abdomen 0* 1 (Fig- 0^ from arising Zone 1, pelvo-ureteral junction, is referred ^ subcostal area Pain extending round to the loin behind. j to Zone where the ureter crosses is 2, the iliac vessels, referre^ ^ just below and lateral to the umbilicus. Pain from where the ureter is in apposition with the broad female and the vas in the male, is referred to the inguina^?arneIjtregiol1, 1 Pain from Zone 4, i.e. the portion of ureter which passes ^e the bladder wall, is referred to the area immediately symphysis pubis. For simplicity, these sites of pa"1 referred to subsequently as Zones, 1, 2, 3 and 4. 1 Q Clinically the zones of ureteritis subdivide themselves di e abdominal and pelvic groups. These two groups ? 664 Ureteritis : A Clinical Survey e^ch ' other ln t? ^at the abdomiyial i and be So group (Zones 2) appears w"at ?f f0caj . obscure in its etiology and may be due to sources ?r>whlnfeCti?n outside the urinary tract, whereas the pelvic to lower lnc^udes Zones 3 and 4 has usually a definite reference Pelv' Unnary tract infections, or to pathology associated with Careful01?3"5' enquiry as to the type and time of onset of pain in ? v I .--TV y uh*.
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