Skip to main content

Advertisement

SpringerLink
Log in

Innervation of the levator ani muscles: description of the nerve branches to the pubococcygeus, iliococcygeus, and puborectalis muscles

  • Original Article
  • Published:
International Urogynecology Journal Aims and scope Submit manuscript

Abstract

We described the innervation of the levator ani muscles (LAM) in human female cadavers. Detailed pelvic dissections of the pubococcygeus (PCM), iliococcygeus (ICM), and puborectalis muscles (PRM) were performed on 17 formaldehyde-fixed cadavers. The pudendal nerve and the sacral nerves entering the pelvis were traced thoroughly, and nerve branches innervating the LAM were documented. Histological analysis of nerve branches entering the LAM confirmed myelinated nerve tissue. LAM were innervated by the pudendal nerve branches, perineal nerve, and inferior rectal nerve (IRN) in 15 (88.2%) and 6 (35.3%) cadavers, respectively, and by the direct sacral nerves S3 and/or S4 in 12 cadavers (70.6%). A variant IRN, independent of the pudendal nerve, was found to innervate the LAM in seven (41.2%) cadavers. The PCM and the PRM were both primarily innervated by the pudendal nerve branches in 13 cadavers (76.5%) each. The ICM was primarily innervated by the direct sacral nerves S3 and/or S4 in 11 cadavers (64.7%).

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5
Fig. 6
Fig. 7
Fig. 8

Similar content being viewed by others

References

  1. De Lancey JOL (1997) Surgical anatomy of the female pelvis (Chapter 6). In: Rock JA, Thompson JD (eds) Te Linde’s operative gynecology, 8th edn. Lippincott Williams and Wilkins, Philadelphia, pp 63–93

    Google Scholar 

  2. Petros PP (2004) The female pelvic floor: function, dysfunction and management according to the integral theory (Chapter 2). The anatomy and dynamics of pelvic floor function and dysfunction. Springer, Heidelberg, Germany, pp 14–47

    Google Scholar 

  3. Strohbehn K (1998) Normal pelvic floor anatomy. Obstet Gynecol Clin North Am 25:683–705

    Article  PubMed  CAS  Google Scholar 

  4. Retzky SS, Rogers RM, Richardson AC (1996) Anatomy of female pelvic support. In: Brubaker L, Saclarides T (eds) The female pelvic floor: disorders of function and support. FA Davis, Philadelphia, pp 3–21

    Google Scholar 

  5. Mundy AR (2005) True pelvis, pelvic floor and perineum (Chapter 108). In: Stranding S, Ellis H, Healy JC, Johnson D, Williams A (eds) Gray’s anatomy, 39rd edn. Elsevier, London, pp 1357–1370

    Google Scholar 

  6. Lawson JO (1974) Pelvic anatomy: I. Pelvic floor muscles. Ann R Coll Surg Engl 54:244–252

    PubMed  CAS  Google Scholar 

  7. Shafik A (1995) Surgical anatomy of the pudendal nerve and its clinical implications. Clin Anat 8:110–115

    Article  PubMed  CAS  Google Scholar 

  8. Shafik A, Doss S (1999) Surgical anatomy of the somatic terminal innervation to the anal and urethral sphincters: role in anal and urethral surgery. J Urol 161:85–89

    Article  PubMed  CAS  Google Scholar 

  9. Guaderrama NM, Liu J, Nager CW, Pretorius DH, Sheean G, Kassab G, Mittal RK (2005) Evidence for the innervation of pelvic floor muscles by the pudendal nerve. Obstet Gynecol 106:774–781

    PubMed  Google Scholar 

  10. Barber MD, Bremer RE, Thor KB, Dolber PC, Kuehl TJ, Coates KW (2002) Innervation of the female levator ani muscles. Am J Obstet Gynecol 187:64–71

    Article  PubMed  Google Scholar 

  11. Pierce LM, Reyes M, Thor KB, Dolber PC, Bremer RE, Kuehl TJ, Coates KW (2005) Immunohistochemical evidence for the interaction between levator ani and pudendal motor neurons in the coordination of pelvic floor and visceral activity in the squirrel monkey. Am J Obstet Gynecol 192:1506–1515

    Article  PubMed  Google Scholar 

  12. Percy JP, Neill ME, Swash M, Parks AG (1981) Electrophysiological study of motor nerve supply of pelvic floor. Lancet 1(8210):16–17

    Article  PubMed  CAS  Google Scholar 

  13. Vanderhorst VG, Holstege G (1997) Organization of lumbosacral motoneuronal cell groups innervating hindlimb, pelvic floor, and axial muscles in the cat. J Comp Neurol 382:46–76

    Article  PubMed  CAS  Google Scholar 

  14. Wall LL (1993) The muscles of the pelvic floor. Clin Obstet Gynecol 36:910–925

    Article  PubMed  CAS  Google Scholar 

  15. Parkkinen A, Karjalainen E, Vartiainen M, Penttinen J (2004) Physiotherapy for female stress urinary incontinence: individual therapy at the outpatient clinic versus home-based pelvic floor training: a 5 year follow-up study. Neurourol Urodyn 23:643–648

    Article  PubMed  CAS  Google Scholar 

  16. Bo K, Talseth T, Holme I (1999) Single blind, randomised controlled trial of pelvic floor exercises, electrical stimulation, vaginal cones and no treatment in management of genuine stress incontinence in women. BMJ 318:487–493

    PubMed  CAS  Google Scholar 

  17. Bidmead J, Mantle J, Cardozo L, Hextall A, Boos K (2002) Home electrical stimulation in addition to conventional pelvic floor exercises: a useful adjunct or expensive distraction? (abstract 68). Neurourol Urodyn 21:372–373

    Google Scholar 

  18. Klutke JJ, Bergman A (2003) Nonsurgical treatment of stress urinary incontinence (Chapter 28). In: Bent AE, Ostergard DR, Cundiff GW, Swift SE (eds) Ostergard’s urogynecology and pelvic floor dysfunction, 5th edn. Lippincott Williams and Wilkins, Philadelphia, pp 447–455

    Google Scholar 

  19. Wallner C, Maas CP, Dabhoiwala NF, Lamers WH, DeRuiter MC (2006) Innervation of the pelvic floor muscles: a reappraisal for the levator ani nerve. Obstet Gynecol 108:529–534

    PubMed  Google Scholar 

  20. Anderson RS (1984) A neurogenic element to urinary genuine stress incontinence. Br J Obstet Gynaecol 91:41–45

    PubMed  CAS  Google Scholar 

  21. Smith AR, Hosker GL, Warrell DW (1989) The role of partial denervation of the pelvic floor in the aetiology of genitourinary prolapse and stress incontinence of urine: a neurophysiological study. Br J Obstet Gynaecol 96:24–28

    PubMed  CAS  Google Scholar 

  22. Wedell-Smith CP, Wilson PM (1991) The vulva, vagina and urethra and the musculature of the pelvic floor (Chapter 8). In: Philipp E, Setchell M, Ginsburg J (eds) Scientific foundations of obstetrics and gynaecology, 4th edn. Butterworth-Heinemann, Oxford, pp 84–100

    Google Scholar 

  23. Juenemann KP, Lue TF, Schmidt A, Tanagho EA (1988) Clinical significance of sacral and pudendal nerve anatomy. J Urol 139:74–77

    PubMed  CAS  Google Scholar 

  24. Olsen AL, Ross M, Stansfield RB, Kreiter C (2003) Pelvic floor nerve conduction studies: Establishing clinically relevant normative data. Am J Obstet Gynecol 189:1114–1119

    Article  PubMed  Google Scholar 

  25. Roberts WH, Taylor WH (1973) Inferior rectal nerve variations at it relates to pudendal block. Anat Rec 177:461–463

    Article  PubMed  CAS  Google Scholar 

  26. Mahakkanukrauh P, Surin P, Vaidhayakarn P (2005) Anatomical study of the pudendal nerve adjacent to the sacrospinous ligament. Clin Anat 18:200–205

    Article  PubMed  Google Scholar 

  27. Sato K (1980) A morphological analysis of the nerve supply of the sphincter ani externus, levator ani and coccygeus. Acta Anat Nippon 55:187–223

    PubMed  CAS  Google Scholar 

  28. Gosling JA (1985) The structure of the female lower urinary tract and pelvic floor. Urol Clin North Am 12:207–214

    PubMed  CAS  Google Scholar 

  29. Lawson J (1987) The innervation of the muscles of continence. Ann R Coll Surg Engl 69:144

    PubMed  CAS  Google Scholar 

  30. Swash M, Snooks SJ, Henry MM (1985) Unifying concept of pelvic floor disorders and incontinence. J R Soc Med 78:906–11

    PubMed  CAS  Google Scholar 

  31. Allen RE, Hosker GL, Smith AR, Warrell DW (1990) Pelvic floor damage and childbirth: a neurophysiological study. Br J Obstet Gynaecol 97:770–779

    PubMed  CAS  Google Scholar 

  32. Bump RC, Norton PA (1998) Epidemiology and natural history of pelvic floor dysfunction. Obstet Gynecol Clin North Am 25:723–746

    Article  PubMed  CAS  Google Scholar 

  33. DeLancey JO, Kearney R, Chou Q, Speights S, Binno S (2003) The appearance of levator ani muscle abnormalities in magnetic resonance images after vaginal delivery. Obstet Gynecol 101:46–53

    Article  PubMed  Google Scholar 

  34. Hoyte L, Jakab M, Warfield SK, Shott S, Flesh G, Fielding JR (2004) Levator ani thickness variations in symptomatic and asymptomatic women using magnetic resonance-based 3-dimensional color mapping. Am J Obstet Gynecol 191:856–861

    Article  PubMed  Google Scholar 

  35. Mahakkanukrauh P, Somsarp V (2002) Dual innervation of the brachialis muscle. Clin Anat 15(3):206–209

    Article  PubMed  Google Scholar 

  36. Terzis JK (1989) Pectoralis minor: a unique muscle for correction of facial palsy. Plast Reconstr Surg 83(5):767–776

    Article  PubMed  CAS  Google Scholar 

  37. Bhadra N, Keith MW, Peckham PH (1999) Variations in innervation of the flexor digitorum profundus muscle. J Hand Surg 24:700–703

    Article  CAS  Google Scholar 

Download references

Acknowledgments

We are grateful to Radma S. Mahmood, Ph.D., and Rani Sellers, D.V.M., Ph.D., Department of Pathology, at the Albert Einstein College of Medicine, Bronx, New York, for assistance with histological analysis. We thank Tatyana Harris, Graphic Artist at the Albert Einstein College of Medicine, Graphic Arts Center, Bronx, New York, for her illustrations.

Author information

Authors and Affiliations

  1. Division of Female Pelvic Medicine and Reconstructive Surgery, Department of Obstetrics and Gynecology and Women’s Health, Montefiore Medical Center, Albert Einstein College of Medicine, 3332 Rochambeau Ave., Bronx, NY, 10467, USA

    Bogdan A. Grigorescu, George Lazarou, Kenneth Powers, Wilma Markus Greston & Magdy S. Mikhail

  2. Department of Anatomy and Structural Biology, Albert Einstein College of Medicine, Bronx, NY, USA

    Todd R. Olson & Sherry A. Downie

Authors
  1. Bogdan A. Grigorescu
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. George Lazarou
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Todd R. Olson
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Sherry A. Downie
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Kenneth Powers
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Wilma Markus Greston
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Magdy S. Mikhail
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Bogdan A. Grigorescu.

Additional information

Reprint requests: Magdy S. Mikhail, M.D.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Grigorescu, B.A., Lazarou, G., Olson, T.R. et al. Innervation of the levator ani muscles: description of the nerve branches to the pubococcygeus, iliococcygeus, and puborectalis muscles. Int Urogynecol J 19, 107–116 (2008). https://doi.org/10.1007/s00192-007-0395-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00192-007-0395-8

Keywords

Search

Navigation