THE BLADDER. 



445 



Attachments. The bladder is fixed at its upper and lower portions. It has 

 true ligaments of fascia and false ligaments of peritoneum. The pelvic fascia is 

 reflected from the levator ani muscles onto the bladder and prostate. Its reflection 

 from the levator ani onto the bladder occurs at its upper portion on each side and is 

 called the lateral trice ligaments (Fig. 450) . The reflection from the anterior part of 

 the bladder and prostate which goes to the posterior surface of the pubes is called the 

 puboprostatic ligament or anterior true ligament of the bladder. The urachus forms a 



Anterior false ligament 

 of peritoneum 



Lateral false ligament _ 

 of peritoneum 



Posterior false ligament 

 of peritoneum 



Urachus or superior 

 ligament 



Puboprostatic ligament 

 Cut edge of peritoneum 

 Lateral true ligament 



FIG. 4So. View of the interior of the male pelvis, showing the bladder attachments. 



superior ligament. The false ligaments are simply the peritoneal reflections. That 

 over the urachus is the anterior false ligament, and those on the sides, which are re- 

 flected from the bladder at about the level of the white line are called the lateral false 

 ligaments. When the urachus above is detached the bladder is comparatively loose. 

 Its firmest attachment is at its neck to the prostate and to the rectum above the pros- 

 tate at the rectovesical pouch. It is this firm attachment which causes the mucous 

 membrane of the base of the bladder to re- 

 main smooth while the rest is corrugated. 



Shape. The shape of the bladder 

 is influenced by its attachments. As we 

 have just seen these are the urachus in 

 front, the neck below, and the rectovesical 

 pouch behind ; therefore, as the bladder 

 collapses it assumes a conical shape with its 

 apex at the neck and its base running from 

 the top of the symphysis anteriorly to the 

 highest point of attachment to the rectum 

 posteriorly. The bladder never sinks en- 

 tirely below the top of the symphysis, be- 

 cause the urachus holds it there; as its top 

 or fundus descends it sinks behind the sym- 

 physis and slopes back to the rectum. If 

 the bladder-walls are actively contracted 

 or much thickened it cannot readily col- 

 lapse, and then retains a more elongated 

 shape. As it distends it becomes oval and rises toward the umbilicus (Fig. 451). 



Peritoneum. In children the bladder is practically an abdominal organ ; 

 when it is empty the peritoneum sinks about to the level of the top of the sym- 

 physis, but when distended it rises from 2.5 to 6.25 cm. (i to 2^ in.) above. In 

 the adult the top of the bladder is held to the top of the symphysis by the urachus, 

 and as it becomes empty the upper surface descends until a curved line is formed 

 from the top of the symphysis downward and backward to the rectovesical pouch, 

 which is opposite the insertion of the ureters and corresponds to a point just below 



FIG. 451. The bladder in its empty and distended 

 state. When distended the peritoneal reflection on the 

 anterior abdominal wall is seen to be raised. The pos- 

 terior or rectovesical reflection remains nearly or quite 

 unchanged. 



