The female inferior hypogastric (= pelvic) plexus: anatomical and radiological description of the plexus and its afferences—applications to pelvic surgery

Abstract

The inferior hypogastric plexus (IHP) is a triangle with a posterior base and an anterior inferior top. It can be described as having three edges and three angles; its inferior edge stretches constantly from the fourth sacral root to the ureter's point of entry into the posterior layer of the broad ligament; its cranial edge is strictly parallel to the posterior edge of the hypogastric artery, along which it runs at a distance of 10 mm; its posterior (dorsal) edge is at the point of contact with the sacral roots, from which it receives its afferences. They most frequently originate from S3 or S4 (60%) and then, in one or two branches, often from S2 (40%), never from S1 and in exceptional cases from S5 (20%). There are sympathetic afferences in 30% of cases, usually through a single branch of the second, third or fourth sacral ganglion. All IHPs have at least one sacral afference and sometimes there may be up to three afferences from the same sacral root. Its dorsal cranial angle, which is superior, comes after the SHP (hypogastric nerve or presacral nerve filament); its anterior inferior angle is located exactly at the ureter's point of entry into the posterior layer of the broad ligament. This is the top of the IHP; its posterior inferior angle is located at the point of contact with the fourth sacral root. At its entrance at the base of the parametrium the pelvic ureter is the anterior, fundamental positional reference for the IHP. The vaginal efferences come out of the top of the IHP through branches leading to the bladder, the vagina and the rectum, which originate through two trunks exactly underneath the crossing point of the ureter and the uterine artery: (i) one trunk leading to the bladder runs along and underneath the ureter and divides into two groups, which are lateral and medial, trigonal. (ii) the trunk leading to the vagina runs along the inferior edge of the uterine artery. At the point of contact with the lateral edge of the vagina, it splits into two groups: anterior thin and posterior voluminous. Some of its branches perforate the posterior wall of the vagina and are distributed to the rectovaginal septum in a tooth comb pattern. The inferior branches, which emerge from the inferior edge of the IHP, reach the rectum directly. The dissection of the 22 specimens allowed us to describe three efferent plexuses: a vaginal rectal plexus, a vesical plexus and a inferior rectal plexus. So the IHP's anterior, fundamental positional reference is the pelvic ureter at the point where it enters at the base of the parametrium, then at the crossing point of the uterine artery. The ureter is the vector for vesical efferences, the uterine artery is the vector for vaginal efferences, which are thus sent into the vesicovaginal septum and the rectovaginal septum. This surgical point of reference is of vital importance in nerve sparing during the course of a simple or extended hysterectomy. Any dissection carried out underneath and outside of the ureter inevitably carries a risk of lesions to its efferent, lateral ...

Pelvic nerve injury negatively impacts female genital blood flow and induces vaginal fibrosis—implications for human nerve‐sparing radical hysterectomy

“…The IHP is an extension of the superior hypogastric plexus that receives fibres from the parasympathetic sacral nerves. 18,19 IHP is less defined in humans than the pelvic plexus is in rats, instead comprising a meshwork of nerve bundles. 20 Taking into account the differences between rat and human pelvic innervation with the specific purpose of developing a model that mirrors post-NSRH genital blood flow dysfunction, we subjected the rats to two different types of nerve crush: (1) PNC, where only the PN was crushed, and (2) CNC, where the PN as well as all bladder, vaginal, and clitoral nerve branches arising from the pelvic plexus were crushed.…”

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“…From the anterior part of the IHP, several groups of fibers are coursed to the pelvic organs and according to their location, we can identify three groups of nerve fibers: a) superior branches, which mostly comming with the ureter and are responsible for the innervation of the urinary bladder; b) central branches, which follow the course of the uterine artery to the uterine cervix; and c) inferior branches, which innervate the inferior part of the rectum and form the neurovascular bundle to the erectile tissue. Vesical efferences have many variations, but most commonly there are two kinds of fibers: ones satellite of the ureter, outside and below of it and another group just under the paracervical tissue, passing through vesicouterine ligament, utero-vesical junction to the bladder wall lateral and medial (8,9,10).…”

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“…This is also a flat structure, which in women is more triangular with a posterior base. The plexus receives irregular afferents from the sacral sympathetic ganglia (108). It lies on the fascia pelvis parietalis interna and the pelvic wall.…”