International Urogynecology Journal

, Volume 23, Issue 11, pp 1483–1494

Anatomy and histology of apical support: a literature review concerning cardinal and uterosacral ligaments

  • Rajeev Ramanah
  • Mitchell B. Berger
  • Bernard M. Parratte
  • John O. L. DeLancey
Review Article

DOI: 10.1007/s00192-012-1819-7

Cite this article as:
Ramanah, R., Berger, M.B., Parratte, B.M. et al. Int Urogynecol J (2012) 23: 1483. doi:10.1007/s00192-012-1819-7


The objective of this work was to collect and summarize relevant literature on the anatomy, histology, and imaging of apical support of the upper vagina and the uterus provided by the cardinal (CL) and uterosacral (USL) ligaments. A literature search in English, French, and German languages was carried out with the keywords apical support, cardinal ligament, transverse cervical ligament, Mackenrodt ligament, parametrium, paracervix, retinaculum uteri, web, uterosacral ligament, and sacrouterine ligament in the PubMed database. Other relevant journal and textbook articles were sought by retrieving references cited in previous PubMed articles. Fifty references were examined in peer-reviewed journals and textbooks. The USL extends from the S2 to the S4 vertebra region to the dorsal margin of the uterine cervix and/or to the upper third of the posterior vaginal wall. It has a superficial and deep component. Autonomous nerve fibers are a major constituent of the deep USL. CL is defined as a perivascular sheath with a proximal insertion around the origin of the internal iliac artery and a distal insertion on the cervix and/or vagina. It is divided into a cranial (vascular) and a caudal (neural) portions. Histologically, it contains mainly vessels, with no distinct band of connective tissue. Both the deep USL and the caudal CL are closely related to the inferior hypogastric plexus. USL and CL are visceral ligaments, with mesentery-like structures containing vessels, nerves, connective tissue, and adipose tissue.


Apical supportsUterosacral ligamentCardinal ligamentAnatomyHistologyImaging



Cardinal ligament


Uterosacral ligament


Pelvic organ prolapse


Inferior hypogastric plexus or pelvic plexus


Magnetic resonance


Computed tomography

Copyright information

© The International Urogynecological Association 2012

Authors and Affiliations

  • Rajeev Ramanah
    • 1
    • 3
  • Mitchell B. Berger
    • 2
    • 3
  • Bernard M. Parratte
    • 4
  • John O. L. DeLancey
    • 2
    • 3
    • 5
  1. 1.Department of Obstetrics and GynecologyBesancon University Medical CenterBesanconFrance
  2. 2.Department of Obstetrics and GynecologyUniversity of MichiganAnn ArborUSA
  3. 3.Pelvic Floor Research GroupUniversity of MichiganAnn ArborUSA
  4. 4.Anatomy InstituteUniversity of Franche-ComteBesanconFrance
  5. 5.L4000 Women’s Hospital1500 E. Medical Center DriveAnn ArborUSA