What is the course of the ureter (urine tube) in females?

Course of the Ureter in Females

Anatomical Pathway

The female ureter follows a retroperitoneal course from the renal pelvis to the bladder, descending along the posterior abdominal wall before entering the pelvis and coursing through specific anatomical relationships to reach the bladder base. 1

Upper Course

• The ureter originates at the renal pelvis and descends posterior to the renal vessels at the renal hilum 1
• It travels retroperitoneally along the psoas muscle in the upper abdomen 1

Pelvic Course - Key Surgical Landmarks

The ureter enters the pelvis at the pelvic brim and follows a predictable course relative to three critical anatomical landmarks 2:

At the Ischial Spine

• The ureter lies approximately 3.2 cm above the pelvic floor 2
• This represents the first major pelvic landmark where the ureter can be reliably identified during surgery 2

At the Obturator Canal

• The ureter maintains a distance of approximately 3.2 cm from the pelvic floor 2
• This midpoint helps surgeons track the ureteral course through the lateral pelvic wall 2

At the Arcus Tendineus Insertion on the Pubic Bone

• The ureter descends to approximately 1.6 cm from the pelvic floor 2
• This is the closest approach to the pelvic floor before the ureter turns medially toward the bladder 2

Terminal Course and Bladder Entry

• The ureter courses through the bladder wall in an oblique tunnel before opening at the ureteric orifice 3
• The intramural portion creates a valve mechanism that prevents vesicoureteral reflux 3
• The ureteric muscle merges into a single longitudinal layer at the ureterovesical junction and forms the superficial trigone distally 3
• No direct muscular connection exists between the ureter and bladder musculature - the ureter slides freely through its tunnel during peristalsis 3

Clinical Divisions

The ureter is functionally divided into three segments with distinct surgical implications 1:

• Upper third: Requires ureteroureterostomy for repair if injured 1
• Middle third: Also managed with ureteroureterostomy 1
• Lower third: Requires direct reimplantation (ureteroneocystostomy) when injured 1

Critical Anatomical Relationships in Females

• The ureter passes lateral to the cervix and upper vagina in its terminal pelvic course 2
• The proximity to pelvic organs makes the ureter vulnerable during gynecologic surgery 2
• In females with pelvic fractures, urethral injuries should be suspected when labial edema or blood in the vaginal vault is present on pelvic exam 4

Common Pitfalls

• Surgical injury risk: The ureter's proximity to the pelvic floor (as close as 1.6 cm at the arcus tendineus) makes it vulnerable during pelvic surgery 2
• Vascular supply preservation: Minimal mobilization is essential during any ureteral surgery to avoid devascularization 1
• Imaging considerations: CT urography with both nephrographic and excretory phases is the gold standard for evaluating ureteral anatomy 1