Anatomy of the female pelvic nerves: a macroscopic study of the hypogastric plexus and their relations and variations

Abstract

The autonomic nerves of the lesser pelvis are particularly prone to iatrogenic lesions due to their exposed position during manifold surgical interventions. Nevertheless, the cause of rectal and urinary incontinence or sexual dysfunctions, for example after rectal cancer resection or hysterectomy, remains largely understudied, particularly with regard to the female pelvic autonomic plexuses. This study focused on the macroscopic description of the superior hypogastric plexus, hypogastric nerves, inferior hypogastric plexus, the parasympathetic pelvic splanchnic nerves and the sympathetic fibres. Their arrangement is described in relation to commonly used surgical landmarks such as the sacral promontory, ureters, uterosacral ligaments, uterine and rectal blood vessels. Thirty‐one embalmed female pelvises from 20 formalin‐fixed and 11 Thiel‐fixed cadavers were prepared. In all cases explored, the superior hypogastric plexus was situated anterior to the bifurcation of the abdominal aorta. In 60% of specimens, it reached the sacral promontory, whereas in 40% of specimens, it continued across the pelvic brim until S1. In about 25% of the subjects, we detected an accessory hypogastric nerve, which has not been systematically described so far. It originated medially from the inferior margin of the superior hypogastric plexus and continued medially into the presacral space. The existence of an accessory hypogastric nerve was confirmed during laparoscopy and by histological examination. The inferior hypogastric plexuses formed fan‐shaped plexiform structures at the end of both hypogastric nerves, exactly at the junction of the ureter and the posterior wall of the uterine artery at the uterosacral ligament. In addition to the pelvic splanchnic nerves from S2–S4, which joined the inferior hypogastric plexus, 18% of the specimens in the present study revealed an additional pelvic splanchnic nerve originating from the S1 sacral root. In general, form, breadth and alignment of the autonomic nerves displayed large individual variations, which could also have a clinical impact on the postoperative function of the pelvic organs. The study serves as a basis for future investigations on the autonomic innervation of the female pelvic organs.

Magnetic resonance neuroimaging promotes the preservation of pelvic autonomic nerves in laparoscopic total mesorectal excision: a comparative study

“…Urogenital dysfunction is principally related to injury of the nerve fibers of PANS, which is usually irreversible (19), and great attention needs to be paid to the preservation of the HGN, PSN, and PP due to their variation. Aurore et al (20) revealed that an accessory HGN could be found in 25% of samples, with two main patterns observed. In 56% of samples thick robust nerve bundles were found, while in 44% a rough meshwork of fibers intermingling with blood vessels was seen.…”

The distribution of the inferior hypogastric plexus in female pelvis

“…The plexus has either the aspect of a nerve fiber network or that of a compact lamina of nervous tissue [ 5 ]. The branches are relatively well-organized around the blood vessels that supply the pelvic viscera.…”

Ultrasound of the Uterosacral Ligament, Parametrium, and Paracervix: Disagreement in Terminology between Imaging Anatomy and Modern Gynecologic Surgery

“…In fact, the paracervix and USL contain the pelvic splanchnic nerves, the distal part of the hypogastric nerve, and the IHP ( Figure 7 ). The IHP is composed of sympathetic fibers from the hypogastric nerve and parasympathetic fibers from the splanchnic nerves and nerve anastomoses (which arise from the second-to-fourth sacral roots) [ 27 ]. Efferent fibers from the IHP travel to the rectum, uterus, rectovaginal ligament, and deep vesicouterine ligament.…”