Pudendal nerve

Not to be confused with Inferior pudendal branch of the Posterior femoral cutaneous nerve.
Pudendal nerve

Pudendal nerve, course and branches in a male.
Details
Latin Nervus pudendi
From
 Sacral nerves S2, S3, S4
To
 Inferior rectal nerves
perineal nerve
dorsal nerve of the penis
dorsal nerve of the clitoris
Identifiers
Gray's p.967
Dorlands
/Elsevier		 _05/12566568
TA A14.2.07.037
FMA 19037
Anatomical terms of neuroanatomy

The pudendal nerve is the main nerve of the perineum.[1]:274 It carries sensation from the external genitalia of both sexes and the skin around the anus and perineum, as well the motor supply to various pelvic muscles, including the male or female external urethral sphincter and the external anal sphincter. If damaged, most commonly by childbirth, lesions may cause sensory loss or fecal incontinence. The nerve may also be temporarily blocked as part of an anaesthetic procedure.

The pudendal canal is also known by the eponymous term "Alcock's canal", after Benjamin Alcock, an Irish anatomist who documented the canal in 1836.

Structure

Image showing the greater sciatic foramen (large foramen), and the lesser sciatic foramen, separated by the sacrospinous ligament. The pudendal nerve exits the pelvis through the greater sciatic foramen, passes over the ligament, and then reenters the pelvis through the lesser sciatic foramen.

The pudendal nerve is paired, meaning there are two nerves, one on the left and one on the right side of the body. Each is formed as three roots immediately above the upper border of the sacrotuberous ligament and the ischiococcygeus muscle.[2] The three roots become two cords when the middle and lower root join to form the lower cord, and these in turn unite to form the pudendal nerve proper just proximal to the sacrospinous ligament.[3] The three roots are derived from the ventral rami of the second, third, and fourth sacral spinal nerves, with the primary contribution coming from the fourth.[2][4]:215[5]:157

The pudendal nerve passes between the piriformis muscle and coccygeus (ischiococcygeus) muscles and leaves the pelvis through the lower part of the greater sciatic foramen.[2] It crosses over the lateral part of the sacrospinous ligament and reenters the pelvis through the lesser sciatic foramen. After reentering the pelvis, it accompanies the internal pudendal artery and internal pudendal vein upwards and forwards along the lateral wall of the ischiorectal fossa, being contained in a sheath of the obturator fascia termed the pudendal canal, along with the internal pudendal blood vessels.[6]:8

Inside the pudendal canal, the nerve divides into branches, first giving off the inferior anal nerve, then the perineal nerve, before continuing as the dorsal nerve of the penis (in males) or the dorsal nerve of the clitoris (in females).[6]:34

Nucleus

The nerve is a major branch of the sacral plexus,[7]:950 with fibers originating in Onuf's nucleus in the sacral region of the spinal cord.[3]

Variation

The pudendal nerve may vary in its origins. For example, the pudendal nerve may actually originate off of the sciatic nerve.[8] Consequently, damage to the sciatic nerve can affect the pudendal nerve as well. Sometimes dorsal rami of the first sacral nerve contribute fibers to the pudendal nerve, and even more rarely S5.[3]

Function

The pudendal nerve has both motor and sensory functions. It does not carry parasympathetic fibers.[9]:1738

The pudendal nerve supplies sensation to the penis in males and the clitoris in females, through the branches dorsal nerve of penis and dorsal nerve of clitoris.[10]:422 The posterior scrotum in males and the labia in females are also supplied, via the posterior scrotal nerves (males) or posterior labial nerves (females). The pudendal nerve is one of several nerves supplying sensation to these areas.[11] Branches also supply sensation to the anal canal.[6]:8 By providing sensation to the penis and the clitoris, the pudendal nerve is responsible for the afferent component of penile erection and clitoral erection.[12] :147

Branches also innervate muscles of the perineum and pelvic floor; namely the bulbospongiosus and ischiocavernosus muscles,[11] the levator ani muscle (including the Iliococcygeus, pubococcygeus, puborectalis and either pubovaginalis in females or pubourethralis in males),[10]:422[13] the external anal sphincter (via the inferior anal branch),[6]:7 and male or female external urethral sphincter.[10]:424–425

As it functions to innervate the External Urethral Sphincter it is responsible for the tone of the sphincter mediated via acetylcholine release. This means that during periods of increased acetylcholine release the smooth muscle in the external urethral sphincter contracts, causing urinary retention. Whereas in periods of decreased acetylcholine release the smooth muscle in the external urethral sphincter relaxes, allowing voiding of the bladder to occur. [14]

Clinical significance

Anesthesia

A pudendal nerve block, also known as a saddle nerve block, is a local anesthesia technique used in a obstetric procedure to anesthetize the perineum during labor.[15] In this procedure, an anesthetic agent such as lidocaine is injected through the inner wall of the vagina about the pudendal nerve.[16]

Damage

The pudendal nerve can be compressed or stretched, resulting in temporary or permanent neuropathy. Irreversible nerve injury may occur when nerves are stretched by 12% or more of their normal length.[6]:655 If the pelvic floor is over-stretched, acutely (e.g. prolonged or difficult childbirth) or chronically (e.g. chronic straining during defecation caused by constipation), the pudendal nerve is vulnerable to stretch-induced neuropathy.[6]:655 Pudendal nerve entrapment, also known as Alcock canal syndrome, is very rare and is associated with professional cycling.[17] Systemic diseases such as diabetes and multiple sclerosis can damage the pudendal nerve via demyelination or other mechanisms.[6]:37 A pelvic tumor (most notably a large sacrococcygeal teratoma), or surgery to remove the tumor, can also cause permanent damage.[18]

Unilateral pudendal nerve neuropathy inconsistently causes fecal incontinence in some, but not others. This is because crossover innervation of the external anal sphincter occurs in some individuals.[6]:34

Imaging

The pudendal nerve is difficult to visualize on routine CT or MR imaging, however under CT guidance, a needle may be placed adjacent to the pudendal neurovascular bundle. The ischial spine, an easily identifiable structure on CT, is used as the level of injection. A spinal needle is advanced via the gluteal muscles and advanced within several millimeters of the ischial spine. Contrast (X-ray dye) is then injected, highlighting the nerve in the canal and allowing for confirmation of correct needle placement. The nerve may then be injected with cortisone and local anesthetic to confirm and also treat chronic pain of the external genitalia (known as vulvodynia in females), pelvic and anorectal pain.[19][20]

Nerve latency testing

The time taken for a muscle supplied by the pudendal nerve to contract in response to an electrical stimulus applied to the sensory and motor fibers can be quantified. Increased conduction time (terminal motor latency) signifies damage to the nerve.[21]:46 2 stimulating electrodes and 2 measuring electrodes are mounted on the examiner's gloved finger ("St Mark's electrode").[21]:46

History

The term pudendal comes from Latin pudenda, meaning external genitals, derived from pudendum, meaning "parts to be ashamed of".[22] The pudendal canal is also known by the eponymous term "Alcock's canal", after Benjamin Alcock, an Irish anatomist who documented the canal in 1836. Alcock documented the existence of the canal and pudendal nerve in a contribution about iliac arteries in Robert Bentley Todd's "The Cyclopaedia of Anatomy and Physiology".[23]

Additional images

See also

This article uses anatomical terminology; for an overview, see anatomical terminology.

References

  1. ↑ AMR Agur, AF Dalley, JCB Grant (2013). Grant's atlas of anatomy (13th ed.). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. ISBN 978-1-60831-756-1.
  2. ↑ 2.0 2.1 2.2 Standring S (editor in chief) (2004). Gray's Anatomy: The Anatomical Basis of Clinical Practice (39th ed.). Elsevier. ISBN 978-0-443-06676-4.
  3. ↑ 3.0 3.1 3.2 Shafik, A; el-Sherif, M; Youssef, A; Olfat, ES (1995). "Surgical anatomy of the pudendal nerve and its clinical implications". Clinical anatomy 8 (2): 110–5. doi:10.1002/ca.980080205. PMID 7712320.
  4. ↑ Moore, Keith L. Moore, Anne M.R. Agur ; in collaboration with and with content provided by Arthur F. Dalley II ; with the expertise of medical illustrator Valerie Oxorn and the developmental assistance of Marion E. (2007). Essential clinical anatomy (3rd ed.). Baltimore, MD: Lippincott Williams & Wilkins. ISBN 978-0-7817-6274-8.
  5. ↑ Russell RM (2006). Examination of peripheral nerve injuries an anatomical approach. Stuttgart: Thieme. ISBN 978-3-13-143071-7.
  6. ↑ 6.0 6.1 6.2 6.3 6.4 6.5 6.6 6.7 Wolff BG et al., ed. (2007). The ASCRS textbook of colon and rectal surgery. New York: Springer. ISBN 0-387-24846-3.
  7. ↑ TL King, MC Brucker, JM Kriebs, JO Fahey (2013). Varney's midwifery (Fifth ed.). Jones & Bartlett Publishers. ISBN 978-1-284-02542-2.
  8. ↑ Nayak, Soubhagya R.; Madhan Kumar, S.J.; Krishnamurthy, Ashwin; Latha Prabhu, V.; D'costa, Sujatha; Jetti, Raghu (November 2006). "Unusual origin of dorsal nerve of penis and abnormal formation of pudendal nerve—Clinical significance". Annals of Anatomy - Anatomischer Anzeiger 188 (6): 565–566. doi:10.1016/j.aanat.2006.06.011.
  9. ↑ Neill, editor-in-chief, Jimmy D. (2006). Knobil and Neill's physiology of reproduction (3rd ed.). Amsterdam: Elsevier. ISBN 0-12-515400-3.
  10. ↑ 10.0 10.1 10.2 Drake, Richard L.; Vogl, Wayne; Tibbitts, Adam W.M. Mitchell; illustrations by Richard; Richardson, Paul (2005). Gray's anatomy for students. Philadelphia: Elsevier/Churchill Livingstone. ISBN 978-0-8089-2306-0.
  11. ↑ 11.0 11.1 Ort, Bruce Ian Bogart, Victoria (2007). Elsevier's integrated anatomy and embryology. Philadelphia, Pa.: Elsevier Saunders. ISBN 978-1-4160-3165-9.|page=Neurovascular Bundles of the Perineum
  12. ↑ Babayan, Mike B. Siroky, Robert D. Oates, Richard K. (2004). Handbook of urology diagnosis and therapy (3rd ed.). Philadelphia, PA: Lippincott Williams & Wilkins. ISBN 978-0-7817-4221-4.
  13. ↑ Guaderrama, Noelani M.; Liu, Jianmin; Nager, Charles W.; Pretorius, Dolores H.; Sheean, Geoff; Kassab, Ghada; Mittal, Ravinder K. (October 2005). "Evidence for the Innervation of Pelvic Floor Muscles by the Pudendal Nerve". Obstetrics & Gynecology 106 (4): 774–781. doi:10.1097/01.AOG.0000175165.46481.a8.
  14. ↑ http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2897743/
  15. ↑ Lynna Y. Littleton, Joan Engebretson (2002). Maternal, Neonatal, and Women's Health Nursing, Volume 1. Cengage Learning. p. 727.
  16. ↑ "Transvaginal Pudendal Nerve Block". WebMD LLC. Retrieved 2 March 2014. |first1= missing |last1= in Authors list (help)
  17. ↑ Mellion MB (January 1991). "Common cycling injuries. Management and prevention". Sports Med 11 (1): 52–70. doi:10.2165/00007256-199111010-00004. PMID 2011683.
  18. ↑ Lim, Jit F.; Tjandra, Joe J.; Hiscock, Richard; Chao, Michael W. T.; Gibbs, Peter. "Preoperative Chemoradiation for Rectal Cancer Causes Prolonged Pudendal Nerve Terminal Motor Latency". Diseases of the Colon & Rectum 49 (1): 12–19. doi:10.1007/s10350-005-0221-7.
  19. ↑ Calvillo O, Skaribas IM, Rockett C.; Skaribas; Rockett (2000). "Computed tomography-guided pudendal nerve block. A new diagnostic approach to long-term anoperineal pain: a report of two cases". Reg Anesth Pain Med 24 (4): 420–3. doi:10.1053/rapm.2000.7620. PMID 10925942.
  20. ↑ Hough DM, Wittenberg KH, Pawlina W, Maus TP, King BF, Vrtiska TJ, Farrell MA, Antolak SJ Jr.; Wittenberg; Pawlina; Maus; King; Vrtiska; Farrell; Antolak Jr (2003). "Chronic perineal pain caused by pudendal nerve entrapment: anatomy and CT-guided perineural injection technique". Am J Roentgenol 181 (2): 561–7. doi:10.2214/ajr.181.2.1810561. PMID 12876048.
  21. ↑ 21.0 21.1 G.A. Santoro, A.P. Wieczorek, C.I. Bartram (editors) (2010). Pelvic floor disorders imaging and multidisciplinary approach to management. Dordrecht: Springer. ISBN 978-88-470-1542-5.
  22. ↑ Harper, Douglas. "Pudendum". Online Etymology Dictionary. Retrieved 28 February 2014.
  23. ↑ Oelhafen, Kim; Shayota, Brian J.; Muhleman, Mitchel; Klaassen, Zachary; Tubbs, R. Shane; Loukas, Marios (September 2013). "Benjamin Alcock (1801-?) and his canal". Clinical Anatomy 26 (6): 662–666. doi:10.1002/ca.22080. PMID 22488487.

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