Autonomic Plexuses of the Female Sexual Organs Travel Within Pubocervical and Rectovaginal [Endopelvic] Fascia: A Rationale for ‘Nerve‐Aware’ Vaginal Prolapse Repair

The connective tissue support of female pelvic viscera-endopelvic fascia-has been studied in fetal and immunohistochemical models to demonstrate its relationship with the autonomic nerves of the female pelvis. Due to a paucity of literature examining the gross anatomical relationships between endopelvic fascia and autonomic nerves in adult female pelvises, it remains unknown whether defects in endopelvic fascia predisposing pelvic organ prolapse and/or manipulation of endopelvic fascia during prolapse repair may be the cause of prolapse-related pelvic pain and sexual dysfunction. Through the dissection of formalin-fixed hemipelvises (n = 10) the present study aimed to map the loci of the visceral branches of the inferior hypogastric plexus and associate them with endopelvic fascia of the female pelvis. In all specimens, two gross bundles of autonomic nerves were identified within pubocervical fascia traveling caudally to innervate the clitoral crura, vestibular bulbs, and anterior vaginal wall. Moreover, a distinct bundle was found traveling within the rectovaginal septum innervating the posterior vaginal wall. Immunohistochemical staining for S100 protein confirmed the presence of nerves and ganglia within pubocervical fascia that were localized near the vaginal arteries. Additionally, our dissections revealed that the visceral branches of the inferior hypogastric plexus can be stratified to correspond to different named components of endopelvic fascia. Clinically, our results provide a robust anatomical characterization that will inform the development of surgical approaches to reduce the risk of pelvic neuropathy during vaginal prolapse surgery.