F- CLINICAL ASPECTS OF SPINAL CORD INJURIES
309
Anatomical relationship between bladder and ureter
Detailed reviews on the anatomy and physiology of the ureter and its relationship to the
vesico-ureteric and pelvi-ureteric junctions have been published in recent years which
have revealed certain controversial views on this subject (Narath, 1951; Frey & Quenu,
1965; Woodburne, 1967; Bors & Comarr, 1971). Since Waldeyer's description of the
'uretersheath' in 1891 particular attention has been paid by numerous workers to the
anatomical arrangements of the vesico-ureteric junction (McMahon, 1938; Pieper,
1951; Correy & West, 1953; Uhlenhut
et
a/., 1953; Woodburne, 1960; Hutch, 1962;
Tanago & Pugh, 1963). Their and other investigators' findings have clarified the intrinsic
muscular and elastic fibre connections which exist between the intravesical part of the
ureter and the bladder wall, especially the trigone. These intricate connections form the
anatomical basis of an efficient function of the ureteric orifices in preventing vesico-
ureteric reflux and also mutual contamination of urine with seminal fluid excretion, the
latter being prevented by a proper reciprocal function of the close muscular connection
between the ureteric orifices and ejaculatory ducts. On the other hand, it is obvious that
neurogenic dysfunctions of bladder and urethra may adversely aifect this intricate
system of tissue connections at the vesico-ureteric junction and thus the function of the
ureteric orifices. Moreover, these close tissue connections also explain the direct route
of ascending infection from the bladder into the ureters and kidneys. Talbot (1958,1968)
has drawn attention to the continuation of the subepithelial tissue of the bladder with
that of the ureter, renal pelvis and interstitial tissue of the kidney and thus establishing a
direct pathway of bacterial invasion. How far Waldeyer's 'sheath', which according to
Woodburne (1967) is not a connective tissue substratum but a space between detrusor
fascicles and terminal ureter, plays an essential role in the accumulation of infective
material producing early ascending infection, remains to be seen. Having attended a
great number of necropsies of paraplegics who died from ascending infection and pyelo
nephritis, I was always impressed by the continuous and uniform fibrous mass extending
from the bladder and involving the whole upper urinary tract and kidneys which could
represent the final outcome of direct ascending infection. This does not exclude, of
course, other pathways of bacterial spread through lymphogenic and vascular channels,
such as haematogenic origin of renal cortical abscesses, but the direct route of ascending
infection seems to be the most common.
The innervation of the ureter is still a controversial subject, especially concerning
motor function. The ureter receives its innervation from the renal plexus, the upper and
lower end of the intermesenteric plexuses (L2-L5) and from the superior hypogastric
plexus and hypogastric ganglia (Mitchell, 1935, 1950). Lermonth (1931) found that
electrical stimulation of the peripheral end of the presacral nerve produces contraction
of the ureteric orifices in man. Lutzeier (1963) reported a decrease of the tone of the
ureter following sympathectomy which is in accordance with Langworthy's & Murphy's
observation (1939) who found ureteric dilatation following sympathectomy in the cat.
There is difference of opinion amongst authors as to whether spinal anaesthesia had any
influence on tone and contractility of the ureter (Lapides, 1948; Rutishauser, 1962;
Skalol & Morales, 1966). Drugs are known to affect ureteric activity and alpha and beta
