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Innervation of the Genitalia and the Innervation of the Genitalia and the Pelvic Floor Pelvic Floor
Per BrodalPer BrodalInstitutt for medisinske basalfagInstitutt for medisinske basalfag
Universitetet i OsloUniversitetet i Oslo
9th Semester 20089th Semester 2008
Autonomic Nervous System
2P. Brodal 2008
Preganglionic neurons
Postganglionic neurons
The Autonomic Nervous System
3P. Brodal 2008
Parasympathetic preganglionic neurons (brain stem)
Parasympathetic preganglionic neurons (sacral cord S2-S4)
Intermediolateral column. Preganglionic sympathetic neurons (T1-L2)
Pelvic organs
Sympathetic System
4P. Brodal 2008
Sympathetic trunk
Rami communicantes
Splanchnic nerve
Prevertebral ganglion
The Sympathetic Trunk and Splanchnic Nerves
5P. Brodal 2008
Sympathetic trunk
Communicating rami
Spinal nerve
Splanchnic nerves
Sacral Parasympathetic Division
6P. Brodal 2008
Pelvic splanchnic nerves (nervi erigentes)
BladderRectumGenitals
Pelvic plexus and ganglion
Auntonomic Plexuses in the Pelvis
7P. Brodal 2008 Netter
Sympathetic trunk
Hypogastric plexus
Lumbosacral plexus
Pelvic plexus
Pudendal nerve
Innervation of the Uterus
8P. Brodal 2008
All nerves to the uterus pass through the part of the pelvic plexus lying lateral to the cervix (juxtacervical plexus)
Juxtacervical plexus
Innervation of the Bladder
9P. Brodal 2008
Striated external sphincter – pudendal nerve S2-S4
MOTOR SENSORY
From the bladder neck: traveling with parasympathetic nerves
From main part of the bladder: with sympathetic nerves
S2-S4
L1
L4
To detrusor: preganglionic parasympathetic fibers from S2-S4
Central Control of Micturition
10P. Brodal 2008
Pontine micturition center – coordination of detrusor and sphincter muscles; mediating voluntary control
The Pudendal Nerve (S2-S4)
11P. Brodal 2008Thieme Atlas of Anatomy
The Pudendal Nerve and Internal Pudendal Artery
Benninghoff/Goertler: Lehrbuc der Anatomie des Menschen, Bd. 2
12P. Brodal 2008
Motor Innervation of the Pelvic Floor
Levator ani (diaphragma pelvis): innervation by several small branches from the sacral plexus (L4-S5)
Muscles of the urogenital diaphragm: pudendal nerve (S2-S4)
Striated sphincter muscles: pudendal nerve Mid-positioned disc protrusions affect the
lower sacral nerves: Danger of permanent incontinence!
13P. Brodal 2008
Sensory Innervation of the Perineal Region
Color-shaded area shows distribution of cutaneous pudendal branches
14P. Brodal 2008 Thieme Atlas of Anatomy
Lumbar Plexus Branches to External Genitals
15P. Brodal 2008 Thieme Atlas of Anatomy
Iliohypogastric nerve
Ilioingual nerve
Genitofemoral nerve
Iliohypogastric nerve
Genitofemoral nerve (genital branch)
Ilioingual nerve
Sensory Innervation of the External Genitals
Vulva: anterior-posterior division between lumbar plexus and pudendal nerve – but mainly pdendal
Penis: mainly branches from the pudendal nerve
Scrotum: Aanteriorly branches from the lumbar plexus (L1), dorsally branches from the pudendal nerve (S2)
16P. Brodal 2008
Pain Conduction in Labour
1. stage• Corpus and upper cervix via ”sympathetic pain fibers”
and dorsal roots T10-L2 2. stage• Subperitoneal structures above the pelvic floor,
including upper vagina, via ”parasympathetic pain fibers” and dorsal roots S2-S4
• Pelvic floor and perineum via ”somatic pain fibers” in n. pudendus and dorsal roots S2-S4
17P. Brodal 2008
Perineal Infiltration in the Second Stage of Labour
18P. Brodal 2008Llewellyn-Jones
Fanlike injection of local anesthetic
Genitofemoral nerve
Pudendal nerve
Pudendal Nerve Block
19P. Brodal 2008
Anaesthesia during labour
Infiltration of perineum (skin) Pudendal block (+ block ilioinguinal and posterior
cutaneous of thigh) Paracervical block Sacral (low) epidural anaesthesia (needle in hiatus
sacralis) Lumbar epidural anaesthesia Lumbar subarachnoidal (spinal) block (for sectio)
20P. Brodal 2008