Pelvic Nerve Research Articles

Vaginismus: Results from Treatment with the PRM Protocol™

Background/Aim: Vaginismus, a condition characterized by involuntary pelvic floor muscle spasms, presents considerable challenges in diagnosis and treatment, impacting sexual health and quality of life. This study evaluates the efficacy of a novel pelvic peripheral nerve block and trigger point injection protocol (the PRM Protocol™) in addressing vaginismus. Materials/Methods: A retrospective chart review of 961 patients diagnosed with vaginismus, aged 18-76, was conducted. Participants underwent a 6-week treatment protocol involving neuromuscular treatment and physical therapy. Results: Outcome measures included the Visual Analog Scale (VAS) pain scale, the Functional Pelvic Pain Scale (FPPS), and the modified Sexual Function Profile (SFP). Post-treatment, there were notable decreases in VAS by 46%, FPPS by 51% and a 25% improvement in SFP. Additionally, opioid use decreased by 22%, ER visits decreased by 18%, and absenteeism and presenteeism decreased by 56% and 68%, respectively. No adverse events were reported. Conclusion: The study highlights the comprehensive efficacy of the PRM Protocol™ in alleviating vaginismus symptoms and improving patient outcomes. Implementation of this protocol offers a transformative opportunity to enhance patient care and optimize resource allocation in managing vaginismus, warranting further research and clinical application.

32 - Expression and mechanism of action of PIEZO1 in bladder dysfunction Caused by pelvic nerve injury

32 - Expression and mechanism of action of PIEZO1 in bladder dysfunction Caused by pelvic nerve injury

Case Report: Delorme Technique for the Treatment of Giant Non-Reducible Rectal Prolapse at the Second Level of Care

Rectal prolapse is an invagination of the rectum that causes it to protrude through the anus. Irreducible rectal prolapse is an unusual condition; in most cases, the prolapse reduces spontaneously. Non-surgical treatment alternatives have been noted, such as the use of sugar, which reduces rectal prolapse. The results have not yet been compared against surgical treatment, so they cannot yet be considered the preferred option. Given the many techniques and procedures, it should be considered that the best procedure must be chosen not only to correct the prolapse but also to restore defecatory function and to improve fecal incontinence throughout the patient's lifetime. The Delorme procedure is a transanal technique that addresses complete rectal prolapse with a low surgical risk and minimal morbidity (less damage to pelvic and hypogastric nerves compared to abdominal procedures). It is associated with a significant improvement in anal continence, low recurrence rates, short hospital stays, and patient comfort.

The Anatomy, Histology, and Function of the Major Pelvic Ganglion.

This review provides a comprehensive analysis of the pelvic plexus and its regulation across various mammalian species, including rats, cats, dogs, and pigs. The pelvic and hypogastric nerves play crucial roles in regulating pelvic functions such as micturition, defecation, and erection. The anatomical organization of these nerves varies, forming either well-defined ganglia or complex plexuses. Despite these variations, the neurons within these structures are consistently regulated by key neurotransmitters, norepinephrine and acetylcholine. These neurons also possess receptors for testosterone and prolactin, particularly in rats, indicating the significant role of these hormones in neuronal function and development. Moreover, neuropeptides such as vasoactive intestinal peptide (VIP), substance P, neuropeptide Y (NPY), somatostatin (SOM), galanin (GAL), and calcitonin gene-related peptide (CGRP) are co-released with neurotransmitters to modulate pelvic functions. This review highlights the complex interplay between neurotransmitters, neuropeptides, and hormones in regulating pelvic physiology and emphasizes the importance of hormonal regulation in maintaining the functionality and health of the pelvic plexus across different species.

Comparison of surgical outcomes between robot-assisted and conventional laparoscopic nerve-sparing modified radical hysterectomy for deep endometriosis.

Drug resistance and severe pelvic pain often warrant surgical intervention for treating deep endometriosis (DE); however, damage to the autonomic nervous system can occur because of anatomical considerations. We aimed to investigate the advantages of robotic technology in enabling precise dissection, even in DE. We retrospectively compared the surgical outcomes of robot-assisted (RA) and conventional laparoscopic (CL) nerve-sparing modified radical hysterectomies (NSmRHs) for DE. Between the two groups (RA-NSmRH group, n = 50; CL-NSmRH group, n = 18), no differences were identified based on patient demographics, such as age, body mass index, previous surgery, revised American Society of Reproductive Medicine classification, Enzian classification, uterine weight, number of removed DE lesions, and concomitant procedures. All patients in both groups achieved complete removal of the DE lesions with complete bilateral pelvic autonomic nerve preservation. The mean operative time (OT) was significantly longer (130 ± 46 vs. 98 ± 22min, p < 0.01), and estimated blood loss (EBL) was lower (35 ± 44 vs. 131 ± 49ml, p < 0.01) in the RA-NSmRH group than in the CL-NSmRH group. The hospitalization days (4.3 ± 1.3 vs. 4.1 ± 0.2days, p = 0.45) and perioperative complications with Clavien-Dindo classification ≥ grade III (0% vs. 0%) were not significant in both the groups. None of the patients required self-catheterization after surgery. Compared with CL-NSmRH, RA-NSmRH was associated with longer OT and lower EBL, whereas the number of hospitalization days and complications were similar in both groups. Our results imply that nerve-sparing surgery can be safely and reproducibly performed using conventional or robotic laparoscopic modalities to treat DE.

Understanding the anatomy of pelvic fascia: implications for regional anesthesia.

The fascia, a continuous structure around the whole body across various anatomical locations, remains underexplored in regional anesthesia. The pelvic fascia is a particularly controversial and complicated anatomical structure. It holds significant relevance not only for surgeons but also in the realms of regional anesthesia and pain management. Many regional nerve blocking techniques in the pelvis are closely related to fascial anatomy, such as fascia iliaca compartment block, circum-psoas block, inferior hypogastric plexus block, and ganglion impar block. The continuity of fascia and interfascial spaces profoundly influences both the efficacy of blockades and the incidence of complications. A thorough understanding of pelvic fascia anatomy is crucial for understanding the potential pathways and barriers for spread of local anesthetics, enhancing analgesia, and minimizing side effects. Currently, a systematic discussion of pelvic fascia from the perspective of regional anesthesia and pain therapy is notably absent. This narrative review aims to consolidate knowledge on the anatomy of pelvic fascia pertinent to regional anesthesia and pain management, detailing relevant pelvic nerves, and associated peripheral nerve blocking techniques.

Applied anatomy study and preliminary clinical application of hyper selective neurectomy of triceps branches combined with partial neurotomy of S 2 nerve root to relieve spastic equinus foot

To observe the possibility of hyper selective neurectomy (HSN) of triceps branches combined with partial neurotomy of S 2 nerve root for relieving spastic equinus foot. Anatomical studies were performed on 12 adult cadaveric specimens. The S 2 nerve root and its branches were exposed through the posterior approach. Located the site where S 2 joined the sciatic nerve and measured the distance to the median line and the vertical distance to the posterior superior iliac spine plane, and the S 2 nerve root here was confirmed to have given off branches of the pelvic splanchnic nerve, the pudendal nerve, and the posterior femoral cutaneous nerve. Between February 2023 and November 2023, 4 patients with spastic equinus foot were treated with HSN of muscle branches of soleus, gastrocnemius medial head and lateral head, and cut the branch where S 2 joined the sciatic nerve. There were 3 males and 1 female, the age ranged from 5 to 46 years, with a median of 26 years. The causes included traumatic brain injury in 2 cases, cerebral hemorrhage in 1 case, and cerebral palsy in 1 case. The disease duration ranged from 15 to 84 months, with a median of 40 months. The triceps muscle tone measured by modified Ashworth scale (MAC) before operation was grade 3 in 2 cases and grade 4 in 2 cases. The muscle strength measured by Daniels-Worthingham manual muscle test (MMT) was grade 2 in 1 case, grade 3 in 1 case, and 2 cases could not be accurately measured due to grade 4 muscle tone. The Holden walking function grading was used to evaluate lower limb function and all 4 patients were grade 2. After operation, triceps muscle tone, muscle strength, and lower limb function were evaluated by the above grading. The distance between the location where S 2 joined the sciatic nerve and median line was (5.71±0.53) cm and the vertical distance between the location and posterior superior iliac spine plane was (6.66±0.86) cm. Before joining the sciatic nerve, the S 2 nerve root had given off branches of the pelvic splanchnic nerve, the pudendal nerve, and the posterior femoral cutaneous nerve. All the 4 patients successfully completed the operation, and the follow-up time was 4-13 months, with a median of 7.5 months. At last follow-up, the muscle tone of the patients decreased by 2-3 grades when compared with that before operation, and the muscle strength did not decrease when compared with that before operation. Holden walking function grading improved by 1-2 grades, and there was no postoperative hypoesthesia in the lower limbs. HSN of triceps branches combined with partial neurotomy of S 2 nerve root can relieve spastic equinus foot without damaging other sacral plexus nerves.

Clinical Anatomy of the Sacral Nerve Roots and Its Relevance to Their Reconstruction After Sacrectomy.

En bloc sacrectomy is associated with sacral root transection causing loss of urinary bladder, rectum, and sexual function. The aim of the study was to determine the position of the pudendal branches (sensorimotor) and pelvic splanchnic nerves (parasympathetic) on the sacral roots relative to the sacrum, and the minimal and maximal defects in the sacral roots that can be reconstructed by grafting after various types of sacrectomy. Five cadaveric pelves were dissected bilaterally. The lengths and widths of the S1-S4 roots and their branches were measured. Then, the minimal and maximal defects between the proximal and distal stumps of the sacrificed roots were measured following 3 models of sacrectomy (below S2, below S1, and total sacrectomy). The mean distance of the splanchnic nerves from the S2 and S3 anterior sacral foramina was 17.7 ± 7.3 and 23.6 ± 11.1 mm, respectively, and the mean distance of the pudendal S2 and S3 branches was 36.8 ± 13.7 and 30.2 ± 10.8 mm, respectively. The mean widths of the S2 and S3 roots were 9.3 ± 1.9 and 5.4 ± 1.2 mm, respectively. The mean maximal defects in S2 and S3 roots after various types of sacrectomies were between 61.8 ± 16.3 and 100.7 ± 14.3 mm and between 62.7 ± 20.2 and 84.7 ± 25.1 mm, respectively. There were no statistically significant differences between sides or sexes for all obtained measurements. The reconstruction of the S2-S3 roots is anatomically feasible after partial or total sacrectomies in which the resection of the soft tissue does not extend further than approximately 1.5 to 2 cm ventrally from the sacrum.

Intraoperative pelvic neuromonitoring based on bioimpedance signals: a new method analyzed on 30 patients

PurposeIncreasing importance has been attributed in recent years to the preservation of the pelvic autonomic nerves during rectal resection to achieve better functional results. In addition to improved surgical techniques, intraoperative neuromonitoring may be useful.MethodsThis single-arm prospective study included 30 patients who underwent rectal resection performed with intraoperative neuromonitoring by recording the change in the tissue impedance of the urinary bladder and rectum after stimulation of the pelvic autonomic nerves. The International Prostate Symptom Score, the post-void residual urine volume and the Low Anterior Resection Syndrome Score (LARS score) were assessed during the 12-month follow-up period.ResultsA stimulation-induced change in tissue impedance was observed in 28/30 patients (93.3%). In the presence of risk factors such as low anastomosis, neoadjuvant radiotherapy and a deviation stoma, an average increase of the LARS score by 9 points was observed 12 months after surgery (p = 0,04). The function of the urinary bladder remained unaffected in the first week (p = 0,7) as well as 12 months after the procedure (p = 0,93).ConclusionThe clinical feasibility of the new method for pelvic intraoperative neuromonitoring could be verified. The benefits of intraoperative pelvic neuromonitoring were particularly evident in difficult intraoperative situations with challenging visualization of the pelvic nerves.

Essential knowledge and technical tips for total mesorectal excision and related procedures for rectal cancer.

Total mesorectal excision (TME) has greatly improved rectal cancer surgery outcomes by reducing local recurrence and enhancing patient survival. This review outlines essential knowledge and techniques for performing TME. TME emphasizes the complete resection of the mesorectum along embryologic planes to minimize recurrence. Key anatomical insights include understanding the rectal proper fascia, Denonvilliers fascia, rectosacral fascia, and the pelvic autonomic nerves. Technical tips cover a step-by-step approach to pelvic dissection, the Gate approach, and tailored excision of Denonvilliers fascia, focusing on preserving pelvic autonomic nerves and ensuring negative circumferential resection margins. In Korea, TME has led to significant improvements in local recurrence rates and survival with well-adopted multidisciplinary approaches. Surgical techniques of TME have been optimized and standardized over several decades in Korea, and minimally invasive surgery for TME has been rapidly and successfully adopted. The review emphasizes the need for continuous research on tumor biology and precise surgical techniques to further improve rectal cancer management. The ultimate goal of TME is to achieve curative resection and function preservation, thereby enhancing the patient's quality of life. Accurate TME, multidisciplinary-based neoadjuvant therapy, refined sphincter-preserving techniques, and ongoing tumor research are essential for optimal treatment outcomes.

Dissection layer selection based on an understanding of pelvic fascial anatomy in transanal total mesorectal excision.

This study aimed to review the historical transition of rectal cancer surgery and recent evidence regarding transanal total mesorectal excision (TaTME). Additionally, it outlined the anatomical landmarks and technical considerations essential for successful TaTME. Anatomical studies and surgical techniques were analyzed to identify key landmarks and procedural steps crucial for TaTME. TaTME offers improved visibility and maneuverability even in the deep and narrow pelvis and is expected to contribute to tumor radical cure rates. By securing the circumferential resection margin and distal margin while preserving pelvic autonomic nerve function, TaTME holds promise for maintaining postoperative urinary and sexual functions. Key anatomical landmarks include the endopelvic fascia posteriorly, the S4-pelvic splanchnic nerve laterally, and the prostate or posterior vaginal wall anteriorly. Selecting the appropriate dissection layer based on tumor depth and ensuring precise incision of the tendinous arch of the pelvic fascia contributes to successful TaTME outcomes. TaTME represents a significant advancement in rectal cancer surgery, offering improved outcomes through meticulous attention to anatomical detail and precise dissection techniques. Understanding the historical context of rectal cancer surgery alongside recent evidence on TaTME is essential for optimizing patient outcomes and expanding the safe implementation of this innovative approach.

Revisiting Querleu-Morrow Radical Hysterectomy: How to Apply the Anatomy of Parametrium and Pelvic Autonomic Nerves to Cervical Cancer Surgery?

In 2008, Querleu and Morrow proposed a novel classification of radical hysterectomy, which was quickly accepted by the professional oncogynecological community. The Querleu and Morrow (Q-M) classification of radical hysterectomy has provided a unique opportunity for uniform surgical and anatomical terminology. The classification offers detailed explanations of anatomical landmarks and resection margins for the three parametria of the uterus. However, there are still some disagreements and misconceptions regarding the terminology and anatomical landmarks of the Q-M classification. This article aims to highlight the surgical anatomy of all radical hysterectomy types within the Q-M classification. It discusses and illustrates the importance of anatomical landmarks for defining resection margins of the Q-M classification and reviews the differences between Q-M and other radical hysterectomy classifications. Additionally, we propose an update of the Q-M classification, which includes the implementation of parauterine lymphovascular tissue, paracervical lymph node dissection, and Selective-Systematic Nerve-Sparing type C2 radical hysterectomy. Type D was modified according to current guidelines for the management of patients with cervical cancer. The detailed explanation of the surgical anatomy of radical hysterectomy and the proposed update may help achieve surgical harmonization and precise standardization among oncogynecologists, which can further facilitate accurate and comparable results of multi-institutional surgical clinical trials.

Parametrium ultrasound in patients with deep endometriosis

Parametrial endometriosis is a severe form of the disease associated with the involvement of the ureters and pelvic nerves, which leads to sexual, urinary, and intestine dysfunction. Surgery in such cases requires a complex multidisciplinary approach, which can be planned only with a detailed preoperative diagnosis. The article presents a review of current international guidelines for parametrium ultrasound. The capabilities of ultrasound are demonstrated by our own ultrasound images of normal parametrium and in deep endometriosis.

(037) VESTIBULODYNIA SECONDARY TO LUMBOSACRAL ANNULAR TEAR-INDUCED SACRAL RADICULOPATHY

Abstract Introduction Vestibulodynia is a prevalent problem in individuals with vulvas, with as many as 30% reporting complaints consistent with entry dyspareunia. Distinctive vestibulodynia pathophysiologies may include psychosocial factors, pelvic floor muscle dysfunction, dermatologic disorders, inflammatory disorders, hormonal deficiencies, neuroproliferative pathology, and pudendal neuropathy. Sacral radiculopathy is considered an inflammatory irritation of S2-S3 nerve roots in the cauda equina by various pathologies such as lumbosacral annular tear. S2-S3 nerve roots are formed by the convergence of the pelvic, pudendal, and sciatic nerves and genito-pelvic clinical symptoms may result from inflammatory involvement of the sensory fields of these nerves. Vestibulodynia may occur from sacral radiculopathy since the somatic and visceral afferent innervation of the vestibule occurs via the pudendal and pelvic nerves, respectively; however, to the best of our knowledge, there has not been a case series of such patients previously reported. Objective To perform a chart review of patients with vestibulodynia secondary to lumbosacral annular tear-induced sacral radiculopathy. Methods Vestibulodynia patients who presented to our sexual medicine clinic were evaluated by detailed history, vulvoscopy, vestibular anesthesia testing, neurogenital testing and lumbosacral MRI. When these tests warranted it, a transforaminal epidural spinal injection with 1 ml lidocaine 1% was performed to substantiate the diagnosis. If appropriate, spine surgery was performed. Improvement was assessed using the Patient Global Impression of Improvement (PGI-I). Results Four patients, 3 cis-gender women and 1 trans-man, mean age 33 years (range 25-42), were diagnosed with vestibulodynia secondary to lumbosacral annular tear-induced sacral radiculopathy. Concomitant sacral radiculopathy symptoms included: clitoral hypersensitivity (50%), bladder urgency/frequency (75%), umbilical hypersensitivity (75%), vaginal dysesthesia (25%), vulvar itching (50%), low back pain (100%), and sciatica (75%). Vulvoscopy was performed to exclude other forms of vestibulodynia. All patients had: a) positive cotton-tipped swab testing throughout the entire vestibule; b) negative vestibular anesthesia testing; c) abnormal neurogenital testing; d) lumbosacral MRI that revealed surgically treatable lumbosacral annular tear (L5-S1, L4-L5); e) transforaminal epidural spinal injection resulting in clinically significant symptom reduction. Lumbar endoscopic spine surgery resulted in improvement in 75% reporting PGI-I 1-3 (very much better - somewhat better). Conclusions We report the first series of patients with vestibulodynia resulting from lumbosacral annular tear-induced sacral radiculopathy. Clinicians should be aware that bothersome vestibulodynia in patients with vulvas can occur from cauda equina pathology (Region 3) outside the genitals (Region 1) and/or pelvis/perineum (Region 2). Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Elliquence.

(084) PERSISTENT GENITAL AROUSAL DISORDER/GENITO-PELVIC DYSESTHESIA (PGAD/GPD) SECONDARY TO TARLOV CYST-INDUCED SACRAL RADICULOPATHY

Abstract Introduction Persistent Genital Arousal Disorder/Genito-Pelvic Dysesthesia (PGAD/GPD) is characterized by persistent, unwanted genital arousal and/or other dysesthesia, including burning, itch and/or pain in the genito-pelvic area such as clitoris, vulva, perineal region and/or peri-anal region (pudendal nerve), umbilicus, urethra, bladder, vagina, and/or rectum (pelvic nerve) and also including the lower extremity buttock, thigh, calf, foot (sciatic nerve). Patients with PGAD/GPD are significantly bothered/distressed, and catastrophization and suicidal ideation are common. In 2012 Komisaruk reported that PGAD/GPD could result from Tarlov cyst-induced sacral radiculopathy. We developed a multidisciplinary step-care management algorithm with specialists in sexual medicine, spine surgery, sex therapy, physical therapy, and neurophysiology to diagnose and treat Tarlov cyst-induced sacral radiculopathy. Objective To utilize a multidisciplinary step-care management algorithm to identify PGAD/GPD patients with Tarlov cyst-induced sacral radiculopathy who could benefit from Tarlov cyst spine surgery and to evaluate long-term safety and efficacy of the surgery. Methods Clinical data were collected on PGAD/GPD patients who underwent Tarlov cyst spine surgery between 2016 and 2020 with at least 1-year follow-up. The management algorithm used to identify and treat Tarlov cyst-induced sacral radiculopathy involves: detailed psychosocial assessment and medical history; non-invasive diagnostic assessments for sacral radiculopathy; sacral MRI with Tarlov cyst protocol; targeted diagnostic caudal epidural injection; and if appropriate, Tarlov cyst spine surgery using minimally invasive surgery techniques. Treatment outcome was based on the validated Patient Global Impression of Improvement (PGI-I) measured at regular intervals post-operatively. Results Ten patients (8 women, 2 men), mean age 40 years (range 19-66), met inclusion criteria. Patients were discharged the same day or following morning post-operatively. No serious complications occurred. Follow-up was &amp;gt;12 months (range 13-22 months). Seven (70%) patients reported post-operative clinical improvement on PGI-I at last follow up: two patients reported “very much better”, three patients reported “much better” and two patients reported “little better”. Two patients had no improvement. Only one patient was much worse, however we believe that the PGI-I score of 6 reflected the worsening of the PGAD/GPD condition and not specifically the result of the surgical procedure. Conclusions Distressing PGAD/GPD symptoms can be caused by Tarlov cyst-induced sacral radiculopathy. A multidisciplinary step-care management algorithm allows selection of appropriate surgical candidates. To the best of our knowledge, this is the largest case series of patients with PGAD/GPD treated with Tarlov cyst spine surgery with at least 1 year follow-up. Using minimally invasive spine surgery techniques, spine surgery on the Tarlov cyst was associated with clinical improvement in 70% of select patients. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Elliquence.

(082) DELAYED ORGASM CAN RESULT FROM LUMBOSACRAL DISC DISEASE DISRUPTING GENITAL SENSORY TRANSMISSION IN THE CAUDA EQUINA: A REVIEW

Abstract Introduction Delayed orgasm may be considered an unwanted, atypically long latency during most genital/sexual activity despite sexual stimulation, causing significant distress to the individual and/or partner, persisting for at least 6 months. Delayed orgasm is reported to affect 6.9% of women. It is associated with negative effects on sexual function, sexual satisfaction, and relationship satisfaction. Pharmacologic, endocrinologic, and neurobiological pathophysiological factors have been identified as possible etiologies of delayed orgasm, but an under-researched etiology is lumbosacral disc disease, specifically lumbosacral annular tear-induced sacral radiculopathy. The pelvic, pudendal, and sciatic nerves all merge at the S2-4 foramina where they coalesce to form the S2-4 nerve roots. These sacral spinal nerve roots (S2-4) ascend to the first synapse in the conus medullaris. During their ascent, they can be irritated mechanically by impingement/compression or chemically by exposure to the extruded nucleus pulposus from lumbosacral annular tears, and thereby disrupt genital sensory transmission with resultant delayed orgasm. The new evidence that delayed orgasm can be successfully treated by endoscopic spine surgery supports the association of delayed orgasm with sacral radiculopathy. There is still a paucity of research regarding delayed orgasm from lumbosacral disc disease. Objective To review the existing literature concerning the contribution of lumbosacral disc disease to delayed orgasm. Methods A literature search on delayed orgasm, its impacts and possible etiologies was performed. The following keywords were searched on Pubmed individually and in combination, related to the association between delayed orgasm and lumbosacral disc disease: delayed orgasm, delayed ejaculation, sexual dysfunction, anorgasmia, and persistent genital arousal disorder. Current definitions were compiled, and overall epidemiology, anatomy, and biopsychosocial factors of delayed orgasm were explored. Results There are a number of publications (n = 19) demonstrating the development of sexual dysfunction after damage to the sacral spinal nerve roots. Furthermore, several studies (n = 4) and case reports (n = 1) have demonstrated that treating lumbosacral disc disease reduces sexual dysfunction including improvement in delayed or reduced ejaculation. While delayed ejaculation encompasses the experience of delayed orgasm for some individuals, the literature fails to address delayed orgasm comprehensively in relation to lumbosacral disc disease, and thus fails to address treatment of lumbosacral disc disease and subsequent resolution of delayed orgasm. People with vulvas are particularly underrepresented in the literature studying the connection between lumbosacral disc disease and delayed orgasm. Conclusions While lumbosacral disc disease has many side effects that may impede daily function, sexual side effects can further detract from one’s personal life and relationship satisfaction. Thus, improving clinician awareness of sexual side effects, particularly delayed orgasm, can help improve treatment for individuals especially as they age. Further research is needed to strengthen the understanding of the effect of sacral radiculopathy on delayed orgasm as well as other sexual dysfunctions. Disclosure No.

Adrenergic relaxations in an in situ urinary bladder model evoked by stimulation of sensory pelvic and pudendal nerves in the rat

Urinary bladder dysfunction might be related to disturbances at different levels of the micturition reflex arc. The current study aimed to further develop and evaluate a split bladder model for detecting and analysing relaxatory signalling in the rat urinary bladder. The model allows for discrimination between effects at the efferent and the afferent side of the innervation. In in vivo experiments, the stimulation at a low frequency (1 Hz) of the ipsilateral pelvic nerve tended to evoke relaxation of the split bladder half (contralateral side; −1.0 ± 0.4 mN; n = 5), in contrast to high frequency-evoked contractions. In preparations in which the contralateral pelvic nerve was cut the relaxation occurred at a wider range of frequencies (0.5–2 Hz). In separate experiments, responses to 1 and 2 Hz were studied before and after intravenous injections of propranolol (1 mg/kg IV). The presence of propranolol significantly shifted the relaxations into contractions. Also, electrical stimulation of the ipsilateral pudendal nerve evoked relaxations of similar magnitude as for the pelvic stimulations, which were also affected by propranolol. In control in vitro experiments, substances with β-adrenoceptor agonism, in contrast to a selective α-agonist, evoked relaxations. The current study shows that the split bladder model can be used for in vivo studies of relaxations. In the model, reflex-evoked sympathetic responses caused relaxations at low intensity stimulation. The involvement of β-adrenoceptors is supported by the sensitivity to propranolol and by the in vitro observations.

Effects of intrarenal pelvic infusion of tumour necrosis factor-α and interleukin 1-β on reno-renal reflexes in anaesthetised rats.

Reno-renal reflexes are disturbed in cardiovascular and hypertensive conditions when elevated levels of pro-inflammatory mediators/cytokines are present within the kidney. We hypothesised that exogenously administered inflammatory cytokines tumour necrosis factor alpha (TNF-α) and interleukin (IL)-1β modulate the renal sympatho-excitatory response to chemical stimulation of renal pelvic sensory nerves. In anaesthetised rats, intrarenal pelvic infusions of vehicle [0.9% sodium chloride (NaCl)], TNF-α (500 and 1000 ng/kg) and IL-1β (1000 ng/kg) were maintained for 30 min before chemical activation of renal pelvic sensory receptors was performed using randomized intrarenal pelvic infusions of hypertonic NaCl, potassium chloride (KCl), bradykinin, adenosine and capsaicin. The increase in renal sympathetic nerve activity (RSNA) in response to intrarenal pelvic hypertonic NaCl was enhanced during intrapelvic TNF-α (1000 ng/kg) and IL-1β infusions by almost 800% above vehicle with minimal changes in mean arterial pressure (MAP) and heart rate (HR). Similarly, the RSNA response to intrarenal pelvic adenosine in the presence of TNF-α (500 ng/kg), but not IL-1β, was almost 200% above vehicle but neither MAP nor HR were changed. There was a blunted sympatho-excitatory response to intrapelvic bradykinin in the presence of TNF-α (1000 ng/kg), but not IL-1β, by almost 80% below vehicle, again without effect on either MAP or HR. The renal sympatho-excitatory response to renal pelvic chemoreceptor stimulation is modulated by exogenous TNF-α and IL-1β. This suggests that inflammatory mediators within the kidney can play a significant role in modulating the renal afferent nerve-mediated sympatho-excitatory response.

3D MR neurography with gadolinium contrast to improve the visualization of pelvic nerves and the branches

ObjectiveTo evaluate the effectiveness of 3D NerveVIEW sequence with gadolinium contrast on the visualization of pelvic nerves and their branches compared to that without contrast.MethodsParticipants were scanned twice using 3D NerveVIEW sequence with and without gadolinium contrast to acquire pelvic nerve images. The signal-to-noise ratio (SNR), contrast-to-noise ratio (CNR) and contrast ratio of the nerves were calculated and compared to determine the quality of images. To subjectively assess, using a 3-point scale, branch nerves critical to therapeutic decision-making, including the pelvic splanchnic nerve and pelvic plexus, the superior gluteal nerve, and the pudendal nerve.ResultsIn the 32 eligible participants after using contrast, the CNRs of the images of nerve-to-bone and nerve-to-vessel significantly increased (p &amp;lt; 0.05). The CR of the images with contrast of all nerve-to-surrounding tissues (i.e., bone, muscle, blood vessels, and fat) were also found significantly higher (p &amp;lt; 0.05). The assessment of observers also shows higher scores for images with contrast compared to images without contrast.ConclusionThe 3D NerveVIEW sequence combined with gadolinium contrast improved vascular suppression, increased the contrast between pelvic nerves and surrounding tissue, and enhanced the visualization of nerves and their branches. This study may be helpful for the technically challenging preoperative planning of pelvic diseases surgery.

Key Anatomical Concepts, Landmarks, and Proposed Terminology for Nerve-Sparing Gynecologic Surgery: A Narrative Review

ObjectiveTo synthesize the terminology utilized in nerve-sparing surgical literature and propose standardized and nonconflicting terms to allow for consistent vocabulary. DesignWe performed a literature search on PubMed using the search terms “pelvis” and “nerve-sparing.” Nongynecologic surgery and animal studies were excluded. A narrative review was performed, focusing on nerves, fasciae, ligaments, and retroperitoneal spaces. Terms from included papers were discussed by all authors, who are surgeons versed in nerve-sparing procedures and one anatomist, and recommendations were made regarding the most appropriate terms based on the frequency of occurrence in the literature and the possibility of overlapping names with other structures. Results224 articles were identified, with 81 included in the full-text review. Overall, 48% of articles focused on cervical cancer and 26% on deeply infiltrating endometriosis. Findings were synthesized both narratively and visually. Inconsistencies in pelvic anatomical nomenclature were prevalent across publications. The structure with the most varied terminology was the rectal branch of the inferior hypogastric plexus with 14 names. A standardized terminology for pelvic autonomic nerve structures, fasciae, ligaments, and retroperitoneal spaces was proposed to avoid conflicting terms. ConclusionSurgeons and anatomists should use consistent terminology to facilitate increased uptake of nerve-sparing techniques in gynecologic surgery through a better understanding of surgical technique description. We have proposed a standardized terminology believed to facilitate this goal.