Authors
- Gorniak, Gerard PT, PhD
- King, Patricia M. PT, PhD
Abstract
Purpose: Knowledge of the neuroanatomy of the pelvis, and understanding the potential somatic and visceral sources of pelvic pain, is the foundation for the clinical decision making, differential diagnosis, medical screening, and assessment of treatment responses associated with pelvic pain.
Methods: Flow charts, diagrams, and tables were constructed after reviewing and comparing the literature on pelvic neuroanatomy and pelvic pain.
Results: Pelvic pain manifests from the complex interaction and convergence of visceral and somatic peripheral nerves in the pelvis from several body systems. Multiple sensory and motor signals at each spinal cord level are associated with the pelvic floor, contributing to a clinical presentation of pain patterns and behaviors that confuses and complicates the evaluation, diagnosis, and treatment of pelvic pain.
Conclusion: This article describes the anatomy and convergence of the pelvic peripheral nerves. Afferent and efferent pathways of the pelvic viscera are diagrammed and related to the musculoskeletal innervations of the pelvis and to pelvic pain patterns and behaviors to assist clinicians in understanding and interpreting pelvic pain in women.
Article Content
INTRODUCTION
Potential sources of pelvic pain are numerous and varied.1-43 The many and complex interactions between the pelvic visceral and somatic nerve networks may explain in part the difficulties in describing, diagnosing, and treating pelvic pain.* Women use a wide range of terms and phrases to give a verbal account of the pain they experience. The breadth of descriptors used for pelvic pain is in part a function of the complex biologic nature of the condition. Pain descriptors commonly associated with specific sources of pain are documented in literature and used routinely in the clinic.+ Because visceral and somatic pain can occur concurrently in the pelvis, pain descriptors and patterns can be confusing and misleading, as the interactions of these signals impact the pain presentation.++
Visceral pain is usually described as being poorly localized, dull, and vague. However, it can also be described as sharp, severe, and localized, as well as a pressure, tightness, heaviness, cramping, throbbing, and aching. Somatic afferent pain is described as generally localized, burning, shooting, stabbing, tingling, cutting, and sharp but often the origin of the pain is not clear. Somatic motor pain can be described as dull, heavy, aching, and sore, whereas ligament and joint capsule pain is dull and achy and bone pain is described as dull and achy, and bone pain is deep and dull. Combined visceral and somatic pain descriptions reflect the complex interaction between visceral and somatic afferents. It is important to note that when given the opportunity to describe pelvic pain in a narrative form rather than using a word list of descriptors from a clinical assessment tool,56,64,65,71 women often describe their pain in terms of how it restricts their life as opposed to using sensory adjectives. Acknowledging the role of social and psychological distress in activating the neurologic mechanisms associated with chronic pain may enhance the clinician's ability to manage patients with pelvic pain in addition to a detailed understanding of the neuroanatomy behind the sensory experience of pelvic pain presented here.40,58,60,64
There are complex communicating visceral sympathetic and parasympathetic networks to the pelvic organs, fascia, and vasculature.[S] There are also somatic sources from the muscles, joints, ligaments, and connective tissue associated with the lumbar and sacral spinal nerve plexuses.[P] While visceral and somatic pain can occur separately, these can also occur concurrently. Visceral infections, vascular ischemia, or congestion can also affect the adjacent somatic structures producing this combination of visceral and somatic pain.* Pelvic conditions such as stress urinary incontinence; pelvic organ prolapse; and other prostate, rectal, and urinary bladder pathologies have visceral and musculoskeletal factors and may result in visceral and somatic pain.+ Postural faults, hip and lumbosacral joint dysfunctions, muscle weakness or strain, and compression or entrapment of nerves, vessels, or the sympathetic chain lying in the pelvis can affect visceral structures and produce concurrent visceral and somatic pain.++ At the spinal cord level, the preganglionic sympathetic and parasympathetic neurons are located at the same levels as the origins of the somatic lumbar and sacral plexuses.[S] This localization can result in stimulus overflow between the visceral and somatic afferent signals, producing a mixture of visceral and somatic sensations.
Sources of visceral and somatic pelvic pain are reviewed in the following section. Sources of visceral pain include efferent and afferent pathways to the pelvic organs. Sources of somatic pain include the lumbar and sacral nerve plexuses, pelvic muscles, and pelvic joints. An understanding of the neuroanatomy associated with common visceral and somatic sources of pelvic pain is presented to assist clinicians to evaluate and successfully treat the often frustrating clinical problem of pelvic pain.
VISCERAL SOURCES OF PELVIC PAIN
Autonomic efferent and afferent nerves innervate the organs, fascia, and vasculature in the pelvis. Sympathetic innervations to the pelvic visceral structures travel in lumbar and sacral splanchnic nerves, and parasympathetic innervations travel in pelvic splanchnic nerves (Figure 1).[P] Lumbar splanchnic nerves originate from spinal levels L1-L2 (L3). These travel to the superior hypogastric plexus located below the bifurcation of the abdominal aorta on the ventral surface of the body of L5 (Figure 2). Sympathetic fibers from this plexus form the right and left hypogastric nerves that enter the respective inferior hypogastric plexus lying on the pelvic wall deep to the internal iliac vessels. Parasympathetic fibers from spinal levels S2-S4 leave the sacral nerve plexus on each side as pelvic splanchnic nerves (Figure 1). These nerves enter the respective inferior hypogastric plexus. Sympathetic and parasympathetic fibers from the inferior hypogastric plexus follow the branches of the internal iliac vessels to form other nerve plexuses. In males and females, nerves from the inferior hypogastric plexus give rise to a rectal plexus and a vesical plexus (bladder). In females, these nerves also form an uterovaginal plexus. In males, the nerves from the hypogastric plexus also give rise to the deferential plexus to the vas deferens, epididymis, and the seminal vesicles and the prostatic plexus. The prostatic plexus in males and the vesical plexus in females give rise to the cavernous plexus of the penis and clitoris.
Sympathetic innervations to the ovaries, uterine tubes, and testes are from the T10-L2 spinal levels. Sympathetic fibers from these levels enter the aortic-renal plexus and leave the sympathetic trunk with sacral splanchnic nerves to form ovarian or testicular plexuses. Parasympathetic innervations to the ovaries, uterine tubes, and testes arise from S2-S4 spinal levels of the sacral plexus. These parasympathetic nerves travel with the pelvic splanchnic nerves to the ovarian and testicular plexuses. These plexuses also receive some parasympathetic innervations from the vagus nerve.
Pain from the pelvic viscera would be transmitted through visceral afferent fibers running with sympathetic and parasympathetic efferent fibers innervating the viscera (Figure 3).* As the pelvic organs derive their segmental innervations largely from the lower thoracic, upper lumbar, and sacral nerve root levels, pelvic pain can be transmitted through nerves from the lumbar and sacral plexuses that also innervate pelvic muscles and joints. These pathways containing somatic and visceral signals converge at the spinal cord. This convergence produces a crosstalk interaction that may result in referred pain from the pelvic viscera to the low back, abdominal wall, gluteal region, or thigh.21,32,33,35,61,77 Somatic pain associated with postural, muscle, or joint disorders may refer to the pelvis.+
SOMATIC SOURCES OF PELVIC PAIN
Spinal Nerves in the Pelvis
The lumbar plexus originates from the ventral rami of L1 through L5 spinal nerves in the abdomen and pelvis major (Figure 4; Table 1).72,110,115,116 Only the iliohypogastric nerve from this plexus fails to enter the pelvis. The L1, L2, and sometimes L3 spinal nerves contain preganglionic sympathetic fibers that enter the sympathetic trunk through white rami communicates. Preganglionic fibers from the sympathetic trunk enter gray rami communicates to all the ventral rami from L1-L5. These sympathetic fibers innervate organs and visceral structures in the pelvis.
The sacral plexus consists of the lumbosacral trunk (L4-L5) from the lumbar plexus and ventral rami from S1-S5 spinal nerves (Figures 4 and 5; Table 1).72,110,115,116 These sacral nerves also receive sympathetic fibers through gray rami communicates from the sacral part of the sympathetic trunk and parasympathetic fibers from S2-S4 (Figure 5).
The pudendal nerve from S2-S4 is the primary motor and sensory nerve to the urogenital region.13,33,35,110,115,117 The perineal and dorsal nerves of the penis or clitoris are divisions of the pudendal nerve (Figure 4). The perineal nerve gives off muscular branches to the superficial and deep muscles of the urogenital triangle in the perineum.4,13,110,115 It also gives off posterior scrotal or labial nerves that lie in the superficial perineal space and are cutaneous to the posterior scrotum or posterior labia major (Figure 4). The dorsal nerve of the penis or clitoris enters the deep perineal space to innervate the dorsum and glans of the penis or clitoris.
Muscles of the Pelvis
The urogenital diaphragm (external sphincter urethrae, the compressor urethrae, the bilateral deep transverse perineal, and in females, the urethrovaginal sphincter muscles), bulbospongiosus, ischiocavernosus, superficial transverse perineal muscles, and external anal sphincter muscles of the pelvic floor4,13,110,115 are innervated mainly by the pudendal nerve from S2-S4 and the nerve to the pelvic diaphragm from S3-S4 (Figure 4; Tables 1 and 2). However, there are many muscles that are associated with the pelvis and receive motor and sensory innervations from the lumbar and sacral plexuses (Tables 1 and 2). Some of these lie internally within the bony pelvis and others attach externally to it. These muscles provide afferent signals to the L1-L5 and S1-S4 spinal cord from muscle spindles, Golgi tendon organs, and free nerve endings. The muscle spindles provide input on muscle length and the Golgi tendon organs on muscle force production. The free nerve endings lie throughout the muscle belly and provide nociceptive sensation, as well as input on temperature, pressure, K+ elevation, and lactic acid concentrations.50 Inflammation, infection, injury, metabolic disorders of muscle, and other pathologies of the internal pelvic muscles can produce, refer, and enhance pelvic pain through these muscle afferents. In addition, weakness, tightness, overuse, injury, or other muscle disorders can result in changes in pelvic mechanics that produce and augment pelvic pain. Referred pain patterns to the pelvic area from these muscles have been mapped and described in the literature.1,2,22,25,47,49,81,82
Joints and Ligaments in the Pelvis
In addition to the organs and supporting fascia, nerves, blood vessels, and muscles, the pelvis includes 4 joints and ligaments associated with these joints. The sacroiliac joints and the hip joints are bilateral, but the lumbosacral joint and the pubic symphysis are unilateral midline structures. Sensory outputs from these joints and ligaments travel through nerves of the lumbar and sacral plexuses and thus pain and discomfort from these joints and ligaments may produce or augment symptoms of pelvic pain.
The sacroiliac joint connects the auricular surfaces of the sacrum and ilium (Figure 6). Both surfaces have an irregular pattern of ridges and grooves. The articular surface on the superior part of the joint has fibrous connection with a strong interosseous ligament, whereas the inferior part of the joint is covered with a thin layer of hyaline cartilage. The sacroiliac joints are stabilized by ventral and dorsal sacroiliac ligaments and reinforced by the sacrotuberous and sacrospinous ligaments and to a lesser extent by the iliolumbar ligaments.
Descriptions of the sensory innervations of the sacroiliac joint and ventral, dorsal, and interosseous ligaments vary.* Most of these studies indicate that the sacroiliac joint and the sacroiliac ligaments are innervated by dorsal rami of L4-S3.+ Some studies limit the innervations to dorsal rami from S1-S4, with the S1 being the primary innervations.88,91,93 Another study also includes ventral rami from L4 and L5 and branches from the superior gluteal nerve (L4-S1), obturator nerve (L2-L4), and lumbosacral trunk (L4-L5).101 There are also studies that suggest that the anterior sacroiliac ligaments are innervated from L3-S4 and the posterior ligament from L1-S2.50,85,91,93-95 In general, it does appear that the sacroiliac joint and the ventral, dorsal, and interosseous ligaments are innervated mainly by dorsal rami L4-S3 but there may also be ventral rami innervations from L4-L5. The sacroiliac joint has mechanoreceptors, especially Pacinian pressure receptors, and free nerve endings for pain. Pain from the sacroiliac joint commonly refers to the groin, lumbar spine, buttock, thigh, and lower leg.93,104,105,107
The sacrotuberous ligament connects the ischial tuberosity with the dorsal sacroiliac ligaments, posterior inferior iliac spine, inferior sacrum, and upper coccyx.72,98,108,110,115 It provides attachments for the gluteus maximus, biceps femoris, piriformis, and obturator internus muscles. The sensory innervations for the sacrotuberous ligament are also not clear, but it appears to be by the ventral rami of L5-S2.
The sacrospinous ligament runs from the ischial spine to the lateral sacrum and coccyx where it is continuous with the sacrotuberous ligament.* It lies next to the coccygeus muscle and is innervated by the pudendal nerve (S2-S4) and nerves from the coccygeal plexus (S4-Co1).
The iliolumbar ligament mainly supports the lumbosacral joint (Figure 5). The ligament extends from the transverse processes of L4-L5 in females and L5 in males to the posterior iliac crest and the superior sacroiliac joint.55,72,115 It is innervated by ventral and dorsal rami of L5-S1.
The pubic symphysis connects the 2 bodies of the pubic bone with a fibrocartilage disc and 4 ligaments.72,82,92,96,110,115 The well-developed anterior pubic ligament is continuous with the tendons of rectus abdominis, adductor longus, brevis, and gracilis, and the ischiocavernosus and corpora cavernosa. The posterior pubic ligament is thin and poorly developed. The superior pubic ligament attaches to the disc and the linea alba, whereas the strong inferior pubic (accurate) ligament is a major support structure for this fibrous joint. The pubic symphysis is innervated by the iliohypogastric, ilioinguinal, and genitofemoral nerves from L1-L2 and the pudendal nerve from S2-S4.
The hip joint is formed by the articulation of the femoral head and the acetabulum of the innominate bone (Figure 6). It is supported by the iliofemoral, pubofemoral, and ischiofemoral ligaments and has a round internal ligament that supplies blood to the femoral head.19,51,72,83,86,110,115 The joint capsule and the joint ligaments contain many encapsulated mechanoreceptors for proprioception. The capsule also contains free nerve endings for pain. These pain receptors are dense in the posterior and inferior parts of the capsule. The hip joint and its ligaments have multiple innervations. The obturator nerve (L2-L4) innervates the anterior and middle parts of the joint and the round ligament of the femur. The nerve to the quadratus femoris (L4-S1) innervates the posterior part of the joint. In addition, the hip joint receives innervation from the femoral nerve through the nerve to the pectineus (L2-L3) and the nerves to the rectus femoris and vastus medialis (L2-L4), from the superior gluteal (L5-S2) and inferior gluteal (L4-S1) nerves, and from the nerve to the piriformis (S1).
Afferent Overview of Pelvis
In the preceding description, reference is made to the convergence of visceral and somatic afferents from the pelvis at spinal cord levels. Through the process of neural convergence, signals from each of the separate body system involved in pelvic pain can alter function and pain perception in tissues and structures in the other systems.* The afferent nerve fibers that supply the reproductive, urologic, and gastrointestinal organs are very specific to the tissue these innervate. However, the source of pain in the pelvis is difficult to distinguish, as the innervation pattern from these afferents is one that overlaps and converges prior to cerebral interpretation. Overlapping segmental innervations set up the potential for referred pain, that is, pain perceived in areas without pathology because of painful stimuli traveling to the spinal segmental level that innervates a variety of structures.
Afferent or sensory information traveling from pelvic organs converges with afferents from other structures such as skin and myofascia at the level of the spinal cord. The result is that very specific neurons and nuclei in the spinal cord respond to stimulation from pelvic organs and from skin and other structures. Studies demonstrate that neurons in the thoracic or lumbar spine respond not only to manual contact to the skin and myofascia in that spinal region but also to stimulation of the organs innervated at those same segmental levels.10,32,33,35,72,110,115 In other words, sensory information from the pelvic organs gets blurred at the level of the central nervous system; the sensory information is blurred or merged with not only that from other organs but that from somatic tissues that share segmental, peripheral, and/or autonomic innervations as well. This process of central convergence of neurophysiologic information from visceral organs and musculoskeletal tissues is referred to as "viscera-visceral-somatic convergence."21,32,33,35,61,77 The shared innervations of visceral and peripheral bodily structures render traditional dualistic biomedical assumptions regarding the separation of visceral and somatic sensations inadequate to explain common patterns of pelvic pain.
Convergence Patterns
Table 3 and Figure 7 provide an overview of this convergence by matching the potential sources of afferents to the pelvis and to the spinal cord levels of each source. Each spinal cord level from T10 to S4 appears to have 8 or more converging pelvic afferent sources. L2 and S2 show the highest number of converging sources. There appear to be the following 4 convergent patterns:
1. Convergence to T10-T12 is mainly along sympathetic innervations to the gonads, pelvic organs, and somatic afferents from abdominal muscles.
2. Because most descriptions of the sympathetic origins of preganglionic nerves include the L3 spinal level, convergence to L1-L3 includes sympathetic nerves from pelvic organs, as well as somatic afferents from lumbar paraspinal muscles, flexor and adductor muscles of the hip, and the hip and pubic symphysis joints.
3. Convergence to L4-S1 includes somatic afferents from lumbar paraspinal muscles and hip extensor, rotator, and abductor muscles, as well as hip and the sacroiliac joints and ligaments.
4. Convergence to S2-S4 involves mostly afferents associated with the sacral parasympathetics from the pelvic organs, muscles of the pelvic floor and perineum, sacroiliac joint, and pubic symphysis.
Consequently, dorsal horn neurons in the spinal cord from T10-L3 receive afferent signals from sympathetic nerves to the pelvic organs and from somatic innervations to lumbar spine muscles, hip muscles, hip joint, and pubic symphysis. Dorsal horn neurons from L4-S1 receive somatic afferents from lumbar and hip muscles and the sacroiliac joint and ligaments. Dorsal horn neurons of S2-S4 receive afferents from the parasympathetic nerve to the pelvic organs, pelvic floor and perineal muscles, sacroiliac joint, and pubis. Because of these multiple sensory inputs at each of the spinal cord levels associated with the pelvic, the evaluation, diagnosis, and treatment of pelvic pain are complicated.
SUMMARY
Pelvic pain can be of visceral and/or somatic origin, and the interactions among the visceral and somatic neural stimuli are complex. Because of these complexities, it is important to understand the neuroanatomy of these systems, as these relate to the pelvic organs and musculoskeletal structures. In this article, the neuroanatomy of the visceral and somatic systems of the pelvis is described and levels of afferent convergence are discussed. Knowledge of the neuroanatomy of the pelvis is the foundation for the clinical decision making, differential diagnosis, medical screening, and assessment of pain presentations and treatment responses associated with pelvic pain.
ACKNOWLEDGMENTS
The authors sincerely thank Drs W. Conrad, J. Liphart, and M. Schooley, for their very helpful comments on this article, and the University of St Augustine and East Tennessee State University, for the time and resources to complete this work.
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* References 2, 3, 7, 8, 10, 12-15, 17-23, 25, 26, 32, 34, 37-62. [Context Link]
+ References 12, 20, 23, 33, 37, 48, 55, 56, 58-70. [Context Link]
++ References 5, 12, 14, 15, 20, 22, 25, 31, 34, 46, 52. [Context Link]
[S] References 10, 13, 15-18, 20-26, 28, 30, 31, 35, 38-49, 72-80. [Context Link]
[P] References 2, 6, 12, 13, 15-20, 25, 30, 31, 33, 38, 39, 47, 49-51, 80-108. [Context Link]
* References 9, 12, 24, 39, 40, 42, 46, 61, 109. [Context Link]
+ References 1, 2, 7, 8, 10, 13, 14, 22, 34-37, 40-43, 61, 74, 77, 80, 104. [Context Link]
++ References 1, 2, 5, 6, 15, 27, 31-34, 61, 94, 96, 103, 104. [Context Link]
[S] References 14, 35, 52, 72-74, 78, 80, 83, 110-116. [Context Link]
[P] References 1, 2, 13, 15, 24, 26, 33, 51, 61, 74, 81-88, 99, 103, 112. [Context Link]
* References 10, 17, 26, 33, 35, 37, 44, 57, 73, 74, 76-78, 80, 83, 100, 111-114. [Context Link]
+ References 1, 2, 5, 12, 15, 17, 18, 31, 37, 38, 47, 57, 63. [Context Link]
* References 2, 42, 50, 85, 87-91, 93-95, 99-101, 103-105, 107, 110, 115. [Context Link]
+ References 2, 42, 50, 85, 91, 94, 95, 100, 104, 107. [Context Link]
* References 72, 81, 97, 102, 110, 115, 117. [Context Link]
* References 4, 10, 21, 32, 33, 35, 41-43, 60, 61, 72. [Context Link]
convergence; pelvic floor; peripheral nerves