Pudendal nerve

Pudendal nerve
Nerve: Pudendal nerve

Pudendal nerve, course and branches in a male.

Latin Gray's From To Nervus pudendus p.967 [1]

Sacral nerves S2, S3, S4 Inferior rectal nerves perineal nerve dorsal nerve of the penis

The pudendal nerve is the main nerve of the perineum.:274 It carries sensation from the external genitalia of both sexes and the skin around the anus and perineum, as well the motor supply to various pelvic muscles, including the external urethral sphincter and the external anal sphincter.

Pudendal nerve

Structure
The pudendal nerve is a paired structure, with one on either side, termed the left and right pudendal nerves respectively. Each is formed as three roots immediately above the upper border of the sacrotuberous ligament and the ischiococcygeus muscle. The three roots become two cords when the middle and lower root join to form the lower cord, and these in turn unite to form the pudendal nerve proper just proximal to the sacrospinous ligament. The three roots are derived from the ventral rami of the second, third, and fourth sacral spinal nerves, with the primary contribution coming from the fourth.:215:157 The pudendal nerve passes between the piriformis muscle and ischiococcygeus muscles and leaves the pelvis through the lower part of the greater sciatic foramen. It crosses over the lateral part of the sacrospinous ligament and reenters the pelvis through the lesser sciatic foramen. After reentering the pelvis, it accompanies the internal pudendal artery and internal pudendal vein upwards and forwards along the lateral wall of the ischiorectal fossa, being contained in a sheath of the obturator fascia termed the pudendal canal, along with the internal pudendal blood vessels.:8

Inside the pudendal canal, the nerve divides into branches, first giving off the inferior anal nerve, then the perineal nerve, before continuing as the dorsal nerve of the penis (in males) or the dorsal nerve of the clitoris (in females).:34

Image showing the greater sciatic foramen (large foramen), and the lesser sciatic foramen, separated by the sacrospinous ligament. The pudendal nerve exits the pelvis through the greater sciatic foramen, passes over the ligament, and then reenters the pelvis through the lesser sciatic foramen.

Nucleus
The nerve is a major branch of the sacral plexus,:950 with fibres originating in Onuf's nucleus in the sacral region of the spinal cord.

Variation
The pudendal nerve may vary in its origins. For example, the pudendal nerve may actually originate off of the sciatic nerve. Consequently, damage to the sciatic nerve can affect the pudendal nerve as well. Sometimes dorsal rami of the first sacral nerve contribute fibers to the pudendal nerve, and even more rarely S5.

Function
The pudendal nerve has both motor and sensory functions. It does not carry parasympathetic fibres.:1738 The pudendal nerve supplies sensation to the penis in males and the clitoris in females, through the branches dorsal nerve of penis and dorsal nerve of clitoris.:422 The posterior scrotum in males and the labia in females are also supplied, via the posterior scrotal nerves (males) or posterior labial nerves (females). The pudendal nerve is one of several nerves supplying sensation to these areas.[2] Branches also supply sensation to the anal canal.:8 By providing sensation to the penis, the pudendal nerve is responsible for the afferent component of penile erection. :147 Branches also innervate muscles of the perineum and pelvic floor; namely the bulbospongiosus and ischiocavernosus muscles, the levator ani muscle (including the Iliococcygeus, pubococcygeus, puborectalis and either pubovaginalis in females or pubourethralis in males),:422 the external anal sphincter (via the inferior anal branch),:7 and external urethral sphincter.:424425

Pudendal nerve

Clinical significance
Anesthesia
A pudendal nerve block, also known as a saddle nerve block, is a local anaesthesia technique used in a obstetric procedure to anesthetize the perineum during labor. In this procedure, an anaesthetic agent such as lidocaine is injected through the inner wall of the vagina into the pudendal nerve.

Damage
The pudendal nerve can compressed or stretched, resulting in temporary or permanent neuropathy. Irreversible nerve injury may occur when nerves are stretched by 12% or more of their normal length.:655 If the pelvic floor is over-stretched, acutely (e.g. prolonged or difficult childbirth) or chronically (e.g. chronic straining during defecation caused by constipation), the pudendal nerve is vulnerable to stretch-induced neuropathy.:655 Pudendal nerve entrapment, also known as Alcock canal syndrome, is very rare and is associated with professional cycling. Systemic diseases such as diabetes and multiple sclerosis can damage the pudendal nerve via demyelination or other mechanisms.:37 A pelvic tumor (most notably a large sacrococcygeal teratoma), or surgery to remove the tumor, can also cause permanent damage. Unilateral pudendal nerve neuropathy inconsistently causes fecal incontinence in some, but not others. This is because crossover innervation of the external anal sphincter occurs in some individuals.:34 Imaging The pudendal nerve is difficult to visualize on routine CT or MR imaging, however under CT guidance, a needle may be placed adjacent to the pudendal neurovascular bundle. The ischial spine, an easily identifiable structure on CT, is used as the level of injection. A spinal needle is advanced via the gluteal muscles and advanced within several millimeters of the ischial spine. Contrast (X-ray dye) is then injected, highlighting the nerve in the canal, confirming correct needle placement. The nerve may then be injected with cortisone and local anaesthetic to confirm and also treat chronic pain of the external genitalia (known as vulvodynia in females), pelvic and anorectal pain In rare cases, the nerve may be destroyed with either alcoholic or radiofrequency ablation. Nerve latency testing The time taken for a muscle supplied by the pudendal nerve to contract in response to an electrical stimulus applied to the sensory and motor fibers can be quantified. Increased conduction time (terminal motor latency) signifies damage to the nerve.:46 2 stimulating electrodes and 2 measuring electrodes are mounted on the examiner's gloved finger ("St Mark's electrode").:46 Prolonged motor latency can be an indicator of the extent of idiopathic or obstetric neurological damage, and can provide some indication regarding potential recovery or response to surgery.

Pudendal nerve

History
The term pudendal comes from Latin pudenda, meaning external genitals, derived from pudendum, meaning "parts to be ashamed of". The pudendal canal is also known by the eponymous term "Alcock's canal", after Benjamin Alcock, an Irish anatomist who documented the canal in 1836. Alcock documented the existence of the canal and pudendal nerve in a contribution about iliac arteries in Robert Bentley Todd's "The Cyclopaedia of Anatomy and Physiology".

Additional images

The male pelvis, showing the pudendal nerve (centre right).

Schematic showing the structures innervated by the pudendal nerve.

Diagram of the course of the pudendal nerve in the male pelvis

Notes
[1] http:/ / archive. org/ stream/ anatomyofhumanbo1918gray#page/ 967/ mode/ 2up [2] |page=Neurovascular Bundles of the Perineum

References External links

SUNY Figs 41:04-11 (http://ect.downstate.edu/courseware/haonline/figs/l41/410411.htm) - "Inferior view of female perineum, branches of the internal pudendal artery." figures/chapter_32/32-2.HTM (http://www.dartmouth.edu/~humananatomy/figures/chapter_32/32-2.HTM) Basic Human Anatomy at Dartmouth Medical School figures/chapter_32/32-3.HTM (http://www.dartmouth.edu/~humananatomy/figures/chapter_32/32-3.HTM) Basic Human Anatomy at Dartmouth Medical School Cross section at UV pelvis/pelvis-female-17 (http://www.univie.ac.at/anatomie2/pelvis/ pelvis-female-17-text.html) Diagnosis and treatment at www.nervemed.com (http://www.nervemed.com/nerve-pudendal.html) www.pudendal.com (http://www.pudendal.com) Pudendal nerve entrapment at chronicprostatitis.com (http://www.chronicprostatitis.com/pne.html) CT sequence showing a pudendal nerve block. (http://www.melbourneradiology.com.au/ interventional-radiology/nerve-blocks.html)

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