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Journal of Medicine and Life Jun 2022Elements that comprise the inferior hypogastric plexus are difficult to expose, intricate, and highly variable and can easily be damaged during local surgical...
Elements that comprise the inferior hypogastric plexus are difficult to expose, intricate, and highly variable and can easily be damaged during local surgical procedures. We aimed to highlight, through dissection, the origin, formation, and distribution of the hypogastric nervous structures and follow them in the female pelvis. We performed detailed dissections on 7 female formalin-fixed cadavers, focusing on structures surrounding the pelvic organs. For each hemipelvis, we removed the peritoneum from the pelvic floor, and after we identified the hypogastric nerves, we continued our dissection towards the inferior hypogastric plexuses, following the branches of the latter. Laterorectally, the hypogastric nerves form the inferior hypogastric plexus, a variable structure - nervous lamina, neuronal network (more frequently), or sometimes a combination of them. We identified three components of the inferior hypogastric plexus. The anterior bundle travels towards the base of the urinary bladder, the middle part innervates the uterus and the vagina, and the posterior segment provides the innervation of the rectum. The plexus can be identified after removing the pelvic peritoneum and the subperitoneal adipose tissue. Intraoperatively, the structures can be preserved by using an immediately-subperitoneal dissection plane. The variable branches are relatively well-organized around the pelvic vessels, supplying the urinary bladder, the genital organs, and the rectum. The ureter is surrounded by some branches, especially in its last segment, and it also receives innervation directly from the hypogastric nerve. Close to the viscera, the nerves enter neurovascular plexuses, making the intraoperative separation of the nerves and the vessels virtually impossible.
Topics: Female; Humans; Hypogastric Plexus; Pelvis; Peritoneum; Uterus; Vagina
PubMed: 35928357
DOI: 10.25122/jml-2022-0145 -
Abdominal Radiology (New York) Jul 2020Chronic pelvic pain is an important but underrecognized cause of morbidity in men. While there is abundant literature discussing female pelvic pain and the diagnostic... (Review)
Review
Chronic pelvic pain is an important but underrecognized cause of morbidity in men. While there is abundant literature discussing female pelvic pain and the diagnostic role of imaging, much less attention has been given to imaging of non-gynecologic causes of chronic pelvic pain. Chronic pelvic pain in men can be a challenge to diagnose as pain may arise from visceral, musculoskeletal, or neurovascular pathology. Imaging of the pelvic viscera has been covered in detail elsewhere in this edition and therefore will not be reviewed here. We will focus upon topics less familiar to the abdominal radiologist, including imaging of pelvic floor, musculoskeletal, and neurovascular pathology.
Topics: Abdomen; Diagnostic Imaging; Female; Humans; Male; Pelvic Floor; Pelvic Pain
PubMed: 31834458
DOI: 10.1007/s00261-019-02353-0 -
Zhonghua Wai Ke Za Zhi [Chinese Journal... Jul 2020Pelvic fascia is considered to be one controversial human anatomic structure. According to the characteristics of specialized surgery, colorectal surgeons, gynecologic... (Review)
Review
Pelvic fascia is considered to be one controversial human anatomic structure. According to the characteristics of specialized surgery, colorectal surgeons, gynecologic surgeons and urologic surgeons respectively marked the pelvic fascia, but the naming is not unified. For some specific anatomic structures (such as pelvic plexus), different scholars have different descriptions of their positions. The lack of standard anatomic terms makes it difficult to understand the corresponding anatomic structures, and also hinders the communication between disciplines. Combined with autopsy research, surgical observation and literature review, we discussed the common puzzles of pelvic clinical anatomy. The main points of this article are as follows. (1) Urogenital fascia and vesicohypogastric fascia are the components of visceral fascia. (2) The visceral fascia and fascia propria of rectum are two separate layers. (3) The pelvic plexus is located on the outside of the confluence of visceral fascia and Denonvilliers' fascia. (4) To understand the pelvic lateral ligament from the perspective of layers. (5) To understand pelvic fascia from a holistic perspective.
Topics: Autopsy; Fascia; Female; Humans; Hypogastric Plexus; Pelvis; Peritoneum; Rectum; Urinary Bladder; Urogenital System; Viscera
PubMed: 32610425
DOI: 10.3760/cma.j.cn112139-20191224-00636 -
Radiographics : a Review Publication of... 2020Acute mesenteric ischemia (AMI) is a life-threatening condition with a high mortality rate. The diagnosis of AMI is challenging because patient symptoms and laboratory... (Review)
Review
Acute mesenteric ischemia (AMI) is a life-threatening condition with a high mortality rate. The diagnosis of AMI is challenging because patient symptoms and laboratory test results are often nonspecific. A high degree of clinical and radiologic suspicion is required for accurate and timely diagnosis. CT angiography of the abdomen and pelvis is the first-line imaging test for suspected AMI and should be expedited. A systematic "inside-out" approach to interpreting CT angiographic images, beginning with the bowel lumen and proceeding outward to the bowel wall, mesentery, vasculature, and extraintestinal viscera, provides radiologists with a practical framework to improve detection and synthesis of imaging findings. The subtypes of AMI are arterial and venoocclusive disease, nonocclusive ischemia, and strangulating bowel obstruction; each may demonstrate specific imaging findings. Chronic mesenteric ischemia is more insidious at onset and almost always secondary to atherosclerosis. Potential pitfalls in the diagnosis of AMI include mistaking pneumatosis as a sign that is specific for AMI and not an imaging finding, misinterpretation of adynamic ileus as a benign finding, and pseudopneumatosis. Several enterocolitides can mimic AMI at CT angiography, such as inflammatory bowel disease, infections, angioedema, and radiation-induced enterocolitis. Awareness of pitfalls, conditions that mimic AMI, and potential distinguishing clinical and imaging features can assist radiologists in making an early and accurate diagnosis of AMI. RSNA, 2020.
Topics: Computed Tomography Angiography; Diagnosis, Differential; Humans; Mesenteric Ischemia
PubMed: 32125953
DOI: 10.1148/rg.2020190122 -
Menopause (New York, N.Y.) Jun 2022A common symptom of genitourinary syndrome of menopause (GSM) is dyspareunia, attributed to vulvovaginal atrophy. Our objective was to systematically describe the pain...
OBJECTIVE
A common symptom of genitourinary syndrome of menopause (GSM) is dyspareunia, attributed to vulvovaginal atrophy. Our objective was to systematically describe the pain characteristics and anatomic locations of tenderness in a cohort with moderate/severe dyspareunia likely due to GSM.
METHODS
This cross-sectional study reports the baseline data of postmenopausal women with dyspareunia screened for an intervention trial of topical estrogen. Postmenopausal women not using hormone therapy who had moderate or severe dyspareunia were eligible if estrogen was not contraindicated. Biopsychosocial assessments were performed using the Vulvar Pain Assessment Questionnaire, and participants underwent a systematic vulvovaginal examination that included a visual assessment and cotton swab testing for tenderness rated using the Numerical Rating Scale (0-10). Vaginal pH and mucosal sensitivity were assessed; pelvic floor muscles and pelvic viscera were palpated for tenderness.
RESULTS
Fifty-five eligible women were examined between July 2017 and August 2019. Mean age was 59.5 ± 6.8 years, and duration of dyspareunia was 6.2 ± 4.3 years. The mean intercourse pain score was 7.3 ± 1.8, most often described as "burning" and "raw." Ninety-eight percent had physical findings of vulvovaginal atrophy. Median pain scores from swab touch at the vulvar vestibule (just outside the hymen) were 4 to 5/10, and topical lidocaine extinguished pain. Median vaginal mucosal pain was zero.
CONCLUSIONS
Participants described their pain as "burning" and "dry." Tenderness was most severe and most consistently located at the vulvar vestibule. Correlating the symptom of dyspareunia with genital examination findings may further our understanding of treatment outcomes for GSM.
Topics: Aged; Atrophy; Cross-Sectional Studies; Dyspareunia; Estrogens; Female; Humans; Middle Aged; Pelvic Pain; Postmenopause; Syndrome; Vagina
PubMed: 35231008
DOI: 10.1097/GME.0000000000001956 -
Clinics and Practice Dec 2023The internal iliac artery (IIA) is the main arterial vessel of the pelvis. It supplies the pelvic viscera, pelvic walls, perineum, and gluteal region. In cases of severe... (Review)
Review
The internal iliac artery (IIA) is the main arterial vessel of the pelvis. It supplies the pelvic viscera, pelvic walls, perineum, and gluteal region. In cases of severe obstetrical or gynecologic hemorrhage, IIA ligation can be a lifesaving procedure. Regrettably, IIA ligation has not gained widespread popularity, primarily due to limited surgical training and concerns regarding possible complications, including buttock claudication, impotence, and urinary bladder and rectum necroses. Nowadays, selective arterial embolization or temporary balloon occlusion are increasingly utilized alternatives, which can be applied preoperatively or intraoperatively for threatening severe genital or pelvic bleeding. However, IIA ligation retains its relevance, as the previously described procedures are not always available and have limitations. This article provides a step-by-step guide to the IIA ligation procedure and its possible complications. It also includes a detailed description of the anatomy of the IIA and pelvic arterial anastomoses. This review highlights the importance of a thorough understanding of pelvic anatomy as a prerequisite for safe IIA ligation and posits that training in this procedure should be an integral part of obstetrics and gynecology curricula.
PubMed: 38248429
DOI: 10.3390/clinpract14010005 -
American Journal of Physical... Sep 2020Obstetric demands have long been considered in the evolution of the pelvis, yet consideration of the interaction of pregnancy, the pelvis, and the gastrointestinal tract...
OBJECTIVES
Obstetric demands have long been considered in the evolution of the pelvis, yet consideration of the interaction of pregnancy, the pelvis, and the gastrointestinal tract (gut) is lacking. Here, we explore sex differences in the relationship of gut volume with body size and pelvic dimensions.
MATERIALS AND METHODS
Computed tomography (CT) scans of living adult Homo sapiens (46 females and 42 males) were obtained to measure in vivo gut volume (GV) and to extract 3D models of the pelvis. We collected 19 3D landmarks from each pelvis model to acquire pelvic measurements. We used ordinary least squares regression to explore relationships between GV and body weight, stature, and linear pelvic dimensions.
RESULTS
The gut-pelvis relationship differs between males and females. Females do not exhibit significant statistical correlations between GV and any variable tested. GV correlates with body size and pelvic outlet size in males. GV scales with negative allometry relative to body weight, stature, maximum bi-iliac breadth, inferior transverse outlet breadth, and bispinous distance in males.
DISCUSSION
The lack of association between GV and body size in females may be due to limits imposed by the anticipation of accommodating a gravid uterus and/or the increased plasticity of the pelvis. The pattern of relationship between GV and the pelvic outlet suggests the role of the bony pelvis in supporting the adominal viscera in females may be small relative to its role in childbirth. We conclude that gut size inference in fossil hominins from skeletal proxies is limited and confounded by sexual dimorphism.
Topics: Adult; Anatomic Landmarks; Anthropology, Physical; Anthropometry; Female; Gastrointestinal Tract; Humans; Male; Pelvis; Pregnancy; Sex Characteristics
PubMed: 32519366
DOI: 10.1002/ajpa.24084 -
American Journal of Obstetrics and... Aug 2020Laparoscopic or robotic procedures involving extensive dissection of the posterior cul-de-sac and pelvic sidewalls often require the surgeon and assistants to manipulate...
Laparoscopic or robotic procedures involving extensive dissection of the posterior cul-de-sac and pelvic sidewalls often require the surgeon and assistants to manipulate the uterus and adnexa to optimize intraoperative visualization and access pathology. This is especially true during excision of endometriosis surgeries. Temporary oophoropexy and uteropexy improve intraoperative visualization and decrease the necessity for additional ports and surgical assistants. These procedures can be efficiently completed by using a Keith needle and suture passed suprapubically (uteropexy) or through the bilateral lower quadrants (oophoropexy) (Figure), through the target viscera, and back through the abdominal wall. The suture is then secured at the level of the abdominal wall. A video was included to describe and demonstrate these procedures. Temporary oophoropexy and uteropexy free the assistant to provide countertraction, irrigation, and removal of specimens rather than limiting the assistant to the sole duty of retraction. This can in turn improve operating room efficiency and safety.
Topics: Endometriosis; Female; Gynecologic Surgical Procedures; Humans; Laparoscopy; Ovary; Peritoneal Diseases; Robotic Surgical Procedures; Uterus
PubMed: 32360845
DOI: 10.1016/j.ajog.2020.04.027