Visceral Innervation

The reproductive organs have a dual innervation via the sympathetic (thoracolumbar) and parasympathetic (sacral) autonomic, with contributions from the somatic sensory nervous system.6, 7 The visceral afferent fibers travel the same route as their corresponding efferent autonomic fibers (Table 41.1). The afferent innervation of the upper vagina, cervix, uterus, proximal fallopian tubes, upper bladder, terminal ileum, and distal large bowel travels with the thoracolumbar sympathetics through the inferior hypogastric plexus to the hypogastric nerve to the superior hypogastric plexus and on to the lower thoracic and lumber splanchnic nerves which enter the spinal cord at T10-L1. Other pathways of afferent innervation from the pelvis travel via the pelvic (parasympathetic) splanchnic nerves (nervi erigentes) to

Table 41.1 Pelvic structures and their innervations.

Organ

Spinal

Nerves

segment

Outer two-thirds of fallopian tubes, upper ureter T9-10

Ovaries T9-10

Uterine fundus, proximal fallopian tubes, broad T11-12, L1

ligament, upper bladder, cecum, appendix, terminal large bowel Lower abdominal wall L1-2

Perineum, vulva, lower vagina, anus, rectum L1-L2, S2-S4

Upper vagina, cervix, lower uterine segment, posterior S2-S4

urethra, bladder trigone, uterosacral and cardinal ligaments, rectosigmoid, lower ureters

Thoracolumbar splanchnic nerves through mesenteric plexus

Thoracolumbar splanchnic nerves traveling with ovarian vessels via renal and aortic plexus and celiac and mesenteric ganglia Thoracolumbar splanchnic nerves through uterine and hypogastric plexus

Iliohypogastric, ilioninguinal

Pudental, ilioninguinal, genitofemoral, posterior femoral cutaneous, anococcygeal Sacral afferents traveling through the pelvic plexus

S2-4. The perineum, anus, and pelvic floor muscles are supplied by somatic branches of the pudendal nerve (S2-4). Urogenital sinus structures, including the lower vagina, lower bladder, and rectosigmoid, are innervated by both the thoracolumbar and sacral afferents.6

The outer fallopian tube, ovary, and upper ureter are innervated by sympathetic nerves traveling with the ovarian artery, and enter the sympathetic nerve chain at L4, ascend with the chain, and enter the spinal cord at T9 and T10. The afferents from the ovary and outer fallopian tube therefore bypass the inferior hypogastric nerve and superior hypogastric plexus. Visceral conditions are characterized by referred pain to the dermatomes associated with pelvic organ innervation, i.e. T10-L2 (anterior abdominal wall and anterior thighs) and dorsal rami of L1-L2 (lower back).8'9'10 Referred pain is well localized, superficial in location, and appears to arise in the same spinal cord segment receiving the pain input.

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