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Distraction is essential during hip arthroscopy to allow for adequate working space during central and peripheral compartment procedures. Pudendal posts are frequently used with traction boots to achieve distraction, but use of these posts is believed to be associated with the iatrogenic pudendal area and perineal nerve injuries seen with hip arthroscopy. Current post-free distraction tables are costly and cumbersome. The pink pad positioning device allows for post-free distraction through the creation of friction between the patient, the pad, and the bed. This device can be used with a standard hip arthroscopy table, is easy to learn, allows for adequate distraction, and allows for greater access to the femoral neck during osteochondroplasty, as there is less restriction of the patient’s range of motion without a post present. The purpose of this Technical Note is to describe a method of post-free distraction using the pink pad positioning device., Technique Video Video 1 This video describes the key aspects of use of the pink pad positioning device during left hip arthroscopy. The pink pad is placed on top of a standard hip arthroscopy bed, with the widest portion of the pad matching up with the widest portion of the bed attachment. After the distal portion of the pad is secured to the bed attachment using the wide purple Velcro straps, the remainder of the pad is secured to the Bucky arms of the bed using the thin white Velcro straps. A draw sheet is placed onto of the bed, and safety straps are attached to the Bucky arms. The patient is moved onto the bed, anesthetized, and moved in the caudad direction until the anterior superior iliac spine is in line with the widest portion of the pad. The draw sheet is removed from under the patient, and the patient’s arms are secured in position with tape and safety straps. The arms may both be folded across the chest, or the arm contralateral to the surgery side may rest on an arm board. The patient’s feet are placed in traction boots, and the operative side is secured with Coban. The patient is placed in 10-15° Trendelenburg position with the leg adducted and the foot internally rotated. After a clear fluoroscopic field is confirmed with a C-arm, the patient is prepped and draped in sterile fashion. An air arthrogram is performed to disrupt the suction seal under fluoroscopy. Maximum traction is then achieved through adjustment of the distal traction arm. An interportal capsulotomy is created, and central compartment procedures (rim trimming, labral repair) are performed. Traction is released, and a T-capsulotomy is created to access the peripheral compartment. The procedure is completed with capsular and portal closure.

Pelvic floor muscle stretch injury during pregnancy and birth is associated with the incidence of stress urinary incontinence (SUI), a condition that affects 30–60% of the female population and is characterized by involuntary urine leakage during physical activity, further exacerbated by aging. Aging and multiparous rabbits suffer pelvic nerve and muscle damage, resulting in alterations in pelvic floor muscular contraction and low urethral pressure, resembling SUI. However, the extent of nerve injury is not fully understood. Here, we used electron microscopy analysis of pelvic and perineal nerves in multiparous rabbits to describe the extent of stretch nerve injury based on axon count, axon size, myelin-to-axon ratio, and elliptical ratio. Compared to young nulliparous controls, mid-age multiparous animals showed an increase in the density of unmyelinated axons and in myelin thickness in both nerves, albeit more significant in the bulbospongiosus nerve. This revealed a partial but sustained damage to these nerves, and the presence of some regenerated axons. Additionally, we tested whether electrical stimulation of the bulbospongiosus nerve would induce muscle contraction and urethral closure. Using a miniature wireless stimulator implanted on this perineal nerve in young nulliparous and middle age multiparous female rabbits, we confirmed that these partially damaged nerves can be acutely depolarized, either at low (2–5 Hz) or medium (10–20 Hz) frequencies, to induce a proportional increase in urethral pressure. Evaluation of micturition volume in the mid-age multiparous animals after perineal nerve stimulation, effectively reversed a baseline deficit, increasing it 2-fold (p = 0.02). These results support the notion that selective neuromodulation of pelvic floor muscles might serve as a potential treatment for SUI.

OBJECTIVE To develop and validate a novel perineal nerve block approach for transperineal prostate biopsy. PATIENTS AND METHODS Five adult male cadavers were dissected to delineate the superficial and deep branches of the perineal nerve. Afterwards, 90 out of 115 patients were selected and randomly assigned to receive periprostatic, periapical triangle, or branches of perineal nerve (BPN) block. The primary outcome was the maximal pain intensity associated with transperineal prostate biopsy, which was assessed by the 10-point visual analog scale. The secondary outcomes included the number of biopsy with visual analog scale of ≥4 in each biopsy procedure, and the incidences of complications. RESULTS On the horizontal line of the upper anal border, the locations of the superficial branch of perineal nerve on the left and right sides were 1.87 ± 0.05 cm and 1.86 ± 0.06 cm, respectively; and the deep branch were 2.15 ± 0.07 cm and 2.16 ± 0.06 cm, respectively, from the midline, and lied between the deep layer of superficial fascia and prostate capsule. The number of cases finally enrolled in data analysis in periprostatic block, periapical triangle block, and BPN block groups were 26, 27, and 30, respectively. The maximal pain intensities were 3.4 (3.1-3.7), 3.3 (3.0-3.6), and 1.8 (1.5-2.2) in the 3 groups, respectively, and the numbers of biopsy with the pain intensity of ≥4 were 4.0 (3.2-4.9), 4.2 (3.3-5.2), and 0.7 (0.1-1.2), respectively. There were 4, 3 and 4 cases developing hematuria, and 1, 1 and 2 burdened with urine retention after biopsy in the 3 groups, respectively. CONCLUSION Collectively, BPN block is a safe, effective and repeatable local anesthesia approach for transperineal prostate biopsy.

Study Design: Narrative review with a case illustration.Purpose: The purpose of this study was to evaluate the pathogenesis and outcome of therapy for walking-evoked erection in patients with lumbar degenerative diseases.Overview of Literature: Cauda equina compression due to lumbar degenerative diseases rarely cause a walking-evoked erection; however, no review has been undertaken of walking-evoked erection in patients with lumbar degenerative diseases.Methods: A total of 1,570 male patients with lumbar degenerative diseases, who underwent surgery between April 2003 and June 2017, were evaluated; from these patients, participants with walking-evoked erection were selected. Preoperative clinical data of walking-evoked erection, paresthesia, and bladder and bowel function were assessed. In our study, the neurological status and the erectile function of each participant were retrospectively evaluated before and after surgery using the Japanese Orthopedic Association score and the Overactive Bladder Symptom Score.Results: Among the 1,570 male patients screened in our department, eight patients (0.51%, 8/1,570) presented with walking-evoked erection accompanied by cauda equina symptoms. In six of the patients, the erectile symptoms were associated with paresthesia in the genitalia or perianal region. Of the six patients evaluated for bladder dysfunction, all were diagnosed with prostatic hyperplasia, while four were diagnosed with an overactive bladder. In all patients, walking-evoked erection disappeared entirely after surgery.Conclusions: This study comprises the first review of walking-evoked erection in patients with lumbar degenerative diseases. We speculate that sensory input, such as paresthesia in the genitalia or perianal region stimulates the pelvic or perineal nerves through the pudendal nerve and induces reflexogenic erections.

Introduction: Transperineal prostate biopsy is as effective as the transrectal biopsy in detecting prostate cancer and has a lower risk of infection. However, concerning the procedural pain of the transperineal route, a higher level of anaesthesia is needed, which prevents this approach from being widely used. Although several methods of local anaesthesia to relieve pain during transperineal biopsy have been described, few well-designed trials have been conducted to assess the efficacy of local anaesthesia.Methods: This is a prospective, multicentre, randomised controlled study in men suspected of having prostate cancer and planning to undergo transperineal prostate biopsy. The aim of this trial is to determine whether the perineal nerve block and periprostatic block relieve pain to different extents in men undergoing transperineal biopsy. The main inclusion criteria are men aged between 18 and 80 years old, a prostate-specific antigen (PSA) level of 4–20 ng/ml, or/and suspicious rectal examination findings. A sample size of 190 participants, accounting for a 10% loss, is required. All participants will be randomly allocated at a ratio of 1:1 to the perineal nerve block (n = 95) and periprostatic block groups (n = 95). The primary outcome will be the level of the worst pain experienced during the transperineal prostate biopsy procedure, which will be measured by a numerical rating scale (NRS). The key secondary outcomes will include the pain severity score at 1, 6, and 24 h after prostate biopsy.Results: The primary outcome is the level of the worst pain experienced during the prostate biopsy procedure. The main secondary outcomes are as follows: (1) Post-biopsy pain severity score at 1, 6, and 24 h after the prostate biopsy; (2) Changes in blood pressure, heart rate and breathing rate during the biopsy procedure; (3) External manifestations of pain during biopsy; (4) Anaesthesia satisfaction; (5) The detection rate for clinically significant prostate cancer and any prostate cancer.Conclusion: Anaesthesia in PROstate biopsy Pain Obstruction Study (APROPOS) is randomised controlled trial aiming to determine the efficacy of the perineal nerve block in controlling pain in patients undergoing prostate biopsy via the transperineal approach.Clinical Trial Registration:www.ClinicalTrials.gov, identifier: NCT04501055.

Episiotomy is the surgical incision of the vaginal orifice and perineum to ease the passage of an infant’s head while crowning during vaginal delivery. Although episiotomy remains one of the most frequently performed surgeries around the world, short- and long-term complications from the procedure are not uncommon. We performed midline and mediolateral episiotomies with the aim of correlating commonly diagnosed postepisiotomy complications with risk of injury to perineal neuromuscular and erectile structures. We performed 61 incisions on 47 female cadavers and dissected around the incision site. Dissections revealed that midline incisions did not bisect any major neuromuscular structures, although they did increase the risk of direct and indirect injury to the subcutaneous portion of the external anal sphincter. Mediolateral incisions posed greater risk of iatrogenic injury to ipsilateral nerve, muscle, erectile, and gland tissues. Clinician discretion is advised when weighing the potential risks to maternal perineal anatomy during vaginal delivery when episiotomy is indicated. If episiotomy is warranted, an understanding of perineal anatomy may benefit diagnosis of postsurgical complications.

Neonatal seizures are frequent in neonatal intensive care and the most common cause is perinatal asphyxia. Among other causes, toxin exposure is rare. We present a boy with an uneventful vaginal birth, who presented one hour after birth with apnea, hypotonia, mydriasis, tongue fasciculation, and tonic seizures. There was no hypoxic ischemic encephalopathy and brain imaging was normal. Toxicology screening revealed a toxic concentration of lidocaine in his blood. The intoxication was transplacental, as a cord blood sample confirmed the toxic level. This was probably due to maternal perineal nerve block with lidocaine. Perineal local infiltration of lidocaine is not without risk for the newborn. Toxicology screen remains an important tool in the work-up of neonatal seizures and sudden unexpected postnatal collapse.

Modern anatomical and surgical references illustrate perineal muscles all innervated by branches of the pudendal nerve but still organized into anatomically distinct urogenital and anal triangles with muscles inserting onto a central perineal body. However, these conflict with the anatomy commonly encountered during dissection. We used dissections of 43 human cadavers to characterize the anatomical organization of the human perineum and compare our findings to standard references. We found bulbospongiosus and the superficial portion of the external anal sphincter (EAS) were continuous anatomically with a common innervation in 92.3% of specimens. The superficial transverse perineal muscle inserted anterior and lateral to the midline, interdigitating with bulbospongiosus. The three EAS subdivisions were anatomically discontinuous. Additionally, in 89.2% of our sample the inferior rectal nerve emerged as a branch of S3 and S4 distinct from the pudendal nerve and innervated only the subcutaneous EAS. Branches of the perineal nerve innervated bulbospongiosus and the superficial EAS and nerve to levator ani innervated the deep EAS. In conclusion, we empirically demonstrate important and clinically relevant differences with perineal anatomy commonly described in standard texts. First, independent innervation to the three portions of EAS suggests the potential for functional independence. Second, neuromuscular continuity between bulbospongiosus and superficial EAS suggests the possibility of shared or overlapping function of the urogenital and anal triangles. Clin. Anat. 29:1053-1058, 2016. © 2016 Wiley Periodicals, Inc.

Background: The objective was to describe clinical findings and outcomes of patients with pudendal neuralgia in relation with the anatomical segment affected. Methods: Fifty-one consecutive patients with chronic perineal pain (CPP) located in the areas supplied by the pudendal nerve (PN), from January 2011 to June 2012, were analyzed. Results: The distribution of pain at perineal, dorsal clitoris and inferior anal nerves was 92.2, 31.4 and 25.5% respectively. The duration of pain was longer when the dorsal clitoris nerve (DCN) was affected (p < 0,003). The pain in the pudendal canal was frequently associated with the radiation of pain to the inferior members (p < 0.043). Conclusion: CPP and radiation of pain to lower limbs suggest a disorder at the second segment of PN. A positive Tinel sign in the third segment indicates a nerve entrapment. In terminal branches, pain was more frequent at the perineal nerve and more persistent at the DCN.

The aim of this study was to develop and evaluate a procedure for equine pudendal nerve block using a peripheral nerve locator. In the first experiment, six ponies were used to determine the relationship between elicited muscle contractions (anal, perineal or both) and nerves serving the perineal region (pudendal, caudorectal and perineal nerves) when methylene blue dye was injected using the electrolocation technique. This experiment showed that the pudendal nerve was approached effectively when both anal and perineal twitch were elicited during electrolocation. In a second experiment, seven Thoroughbred horses were used to evaluate the appropriate volume of anaesthetic solution for the nerve block. Immediately after euthanasia, lidocaine/methylene blue solution was injected after positive electrolocation. A stained segment of 2 cm or more of the nerve was considered effective and this was evaluated after dissection. Both 10 and 20 mL per injection site resulted in effective nerve staining. Finally, pudendal nerve block was performed and evaluated in 27 horses admitted for selected reproductive surgical procedures including perineoplasty, urethroplasty, clitorectomy in mares and penile examination, phallectomy and urethrostomy in geldings. Surgical time varied from several minutes to 3 h. The choice between lidocaine, mepivacaine or bupivacaine was based on the duration of analgesia required. In mares and males, a volume of 20 mL and 10 mL, respectively, was injected per site. The use of a peripheral nerve stimulator-guided pudendal nerve block is a feasible, safe and reliable alternative for both epidural and general anaesthesia, to provide peri-operative analgesia in clinical equine patients undergoing specific reproductive surgeries.

Introduction: In this study we aimed to determine whether high-resolution ultrasound (US) can identify the pudendal nerve and its terminal branches. We also attempted to identify the best approach for visualizing these structures. Methods: Normal anatomy of the pudendal nerve was evaluated in 3 cadavers and 20 healthy volunteers proximally at the level of the ischial spine and distally with low-frequency (2–5-MHZ) and high-frequency (12–7-MHZ and 17–5-MHZ) transducers. Two musculoskeletal radiologists performed the examinations and evaluations. Volunteers were placed in 3 different positions, which allowed different approaches (posterior, medial, and anterior transperineal). A 0–3 scale was used to assess nerve visibility. Results: Visualization of the pudendal nerve at the ischial spine was best when using a medial approach (P < 0.004); the terminal branches were seen best with the anterior approach (P < 0.002). Conclusion: High-resolution ultrasound (US) can identify the pudendal nerve and its terminal branches. Muscle Nerve 47:403-408, 2013

Background: The pudendal nerve block is widely used in patients undergoing gyaenecologic, obstetric and penile surgery. But in some cases, the pudendal nerve block may fail and be ineffective. This may be due to failure of localization of the pudendal nerve or anatomical variations in its origin, course or branching pattern. Aim of the work was to study the anatomical variations of the pudendal nerve and the accurate localization of the pudendal nerve in relation to surface landmarks such as the ischial spine. Materials and Methods: This study was carried out on thirteen dissected human Egyptian pelves, gluteal regions and perineums (11 males and 2 females). Results: According to our examinations, the roots and trunks of the pudendal nerve could be grouped into four types: In Type I, the pudendal nerve arose from s3&4 in the form of one trunk (19.2%). This trunk divided into inferior rectal nerve, perineal nerve and dorsal nerve of the penis. In Type II, the pudendal nerve arose from s2,3&4 in the form of two trunks (34.6%). The medial trunk continued as the inferior rectal nerve, while the lateral trunk divided into perineal nerve and dorsal nerve of penis. In Type III, the pudendal nerve arose from s2&3 in the form of two trunks (15.5%). The lateral trunk got connected with the sciatic nerve, while the medial trunk divided into the perineal nerve and dorsal nerve of the penis. The inferior rectal nerve arose directly from the 3rd sacral nerve. In Type 1V, the pudendal nerve arose from s2&3 in the form of one trunk (30.8%). The origin of the inferior rectal nerve was variable. In 50%, it arose as a branch from the pudendal nerve after passing through the greater sciatic foramen. In 34.6%, the inferior rectal nerve was the continuation of the medial trunk of the pudendal nerve. In 15.4%, it arose directly from S3 and never joined the pudendal nerve. The dorsal nerve of the penis divided into two branches (medial and lateral) in 81.8% and three branches (medial, lateral and ventral) in18.2%. The medial branches of both sides communicated with each other to form a plexus behind the corona glandis to supply the glans. The ischial spine was an essential bony landmark for localization of the pudendal nerve. In the gluteal region, the point of the tip of the ischial spine represented the junction between the upper 2/3 and the lower 1/3 of a line extending between the posterior superior iliac spine and the ischial tuberosity. The point of crossing of the pudendal nerve to the sacrospinous ligament lay 1±0.5 cm medial to the point of the tip of the ischial spine. The surface line of the pudendal nerve divided equally the line extending between the base of the coccyx and the ischial tuberosity.

Knowledge of penile embryology and anatomy is essential to any pediatric urologist in order to fully understand and treat congenital anomalies. Sex differentiation of the external genitalia occurs between the 7thand 17thweeks of gestation. The Y chromosome initiates male differentiation through the SRY gene, which triggers testicular development. Under the influence of androgens produced by the testes, external genitalia then develop into the penis and scrotum. Dorsal nerves supply penile skin sensation and lie within Buck's fascia. These nerves are notably absent at the 12 o'clock position. Perineal nerves supply skin sensation to the ventral shaft skin and frenulum. Cavernosal nerves lie within the corpora cavernosa and are responsible for sexual function. Paired cavernosal, dorsal, and bulbourethral arteries have extensive anastomotic connections. During erection, the cavernosal artery causes engorgement of the cavernosa, while the deep dorsal artery leads to glans enlargement. The majority of venous drainage occurs through a single, deep dorsal vein into which multiple emissary veins from the corpora and circumflex veins from the spongiosum drain. The corpora cavernosa and spongiosum are all made of spongy erectile tissue. Buck's fascia circumferentially envelops all three structures, splitting into two leaves ventrally at the spongiosum. The male urethra is composed of six parts: bladder neck, prostatic, membranous, bulbous, penile, and fossa navicularis. The urethra receives its blood supply from both proximal and distal directions.

Background To describe a new surgical technique for the repair of bulbar urethral strictures to preserve the bulbospongiosum muscle and its perineal innervation. Objective Surgical steps of muscle- and nerve-sparing bulbar urethroplasty are described. The outcome is provided regarding semen sequestration and postvoiding dribbling. Design, Setting, and Participants We performed the procedure in 12 patients (average age: 43.58 yr) with bulbar urethral strictures (average stricture length: 4.47cm). Surgical Procedure Six patients underwent urethroplasty using a ventral oral mucosal onlay graft, and six patients underwent urethroplasty using a dorsal oral mucosal onlay graft. In all patients, the surgical approach to the bulbar urethra was made avoiding dissection of the bulbospongiosum muscle from the corpus spongiosum and leaving the central tendon of the perineum intact. Measurements Clinical outcome was considered a failure when any postoperative instrumentation was needed. The primary outcome examined the technical feasibility of the muscle- and nerve-sparing bulbar urethroplasty. The secondary outcome examined the presence or absence of postoperative postvoid dribbling and semen sequestration using a nonvalidated questionnaire (Appendix). Results and Limitations In all patients, postoperative voiding cystourethrography was performed 3 wk after surgery and no urethral sacculation was evident. Urethrography were repeated after 6 mo and 12 mo. No postvoid dribbling or semen sequestration was demonstrated in all patients at 6 mo and 12 mo after surgery. No patient showed stricture recurrence. The average follow-up was 15.25 mo (range 12 mo to 26 mo, median 13.5 mo). Conclusions Bulbar urethroplasty preserving the bulbospongiosum muscle, the central tendon of the perineum, and the perineal nerves is a safe, feasible, minimally invasive alternative to traditional bulbar urethroplasty.

OBJECTIVE To further define neural pathways and mechanisms responsible for the arousing properties of the epithelium of the clitoris as well as related neural pathways associated with sexual arousal in a murine model. MATERIALS AND METHODS Adult female C57B1/6 mice were used for gross dissection, facilitated by resin injection of the vascular system, and silver staining, and immunostaining for S-100 and neuronal nitric oxide synthase (nNOS). We also comprehensively reviewed relevant published clinical and histological material from both human and non-human vertebrate studies. RESULTS The distal innervation consists of three nerve bundles: one related to the perineal region, one through the corpus cavernosum, and the third between the dorsal part of the clitoris and the urethra. Communicating nerve fibres were identified between the perineal, the corpus cavernous nerve (CN) and the dorsal nerve of the clitoris. Immunostaining for nNOS showed that the CN sends nNOS-positive fibres to join the dorsal nerve of the clitoris. In the same distal area of the clitoris, the connecting branches between the perineal nerve and the dorsal nerve of the clitoris are also nNOS positive. CONCLUSIONS A rich network of nerve bundles and terminal branches were identified and associated with nNOS immunostaining in the cavernosal tissue of the body of clitoris. NO control of vasodilatation and neuronal signalling between the CN and the dorsal nerve of the clitoris could contribute to the engorgement and subsidence of clitoral tissue. This supports the initiation of sexual arousal by tactile stimuli. The distribution pattern of the general and peptidergic innervation in the murine clitoris is similar to that of the penis.

Objective The purpose of this study was to determine the increase in pudendal nerve branch lengths using a 3D computer model of vaginal delivery. Study design The main inferior rectal and perineal branches of the pudendal nerve were dissected in 12 hemi-pelves from 6 adult female cadavers. Their 3D courses were digitized in the 4 specimens with the most characteristic nerve branching pattern, and the data were imported into a published 3D computer model of the pelvic floor. Each nerve branch was then represented by a stretchable cord with a fixation point at the ischial spine. The length change in each branch was then quantified as the fetal head descended through the pelvic floor. The maximum nerve strains ([final length minus original length/original length] × 100) were calculated for 5 degrees of perineal descent: reference descent from the literature, 1.25 cm and 2.5 cm caudal and cephalad. The effect of alternative fixation points on resultant nerve strain was also studied. Results The inferior rectal branch exhibited the maximum strain, 35%, and this strain varied by 15% from the scenario with the least perineal descent to that with the most perineal descent. The strain in the perineal nerve branch innervating the anal sphincter reached 33%, while the branches innervating the posterior labia and urethral sphincter reached values of 15% and 13%, respectively. The more proximal the nerve fixation point, the greater the nerve strain. Conclusion During the second stage: (1) nerves innervating the anal sphincter are stretched beyond the 15% strain threshold known to cause permanent damage in appendicular peripheral nerve, and (2) the degree of perineal descent is shown to influence pudendal nerve strain.

Background: This study documents the anatomy of the pudendal nerve, which has a major role in maintaining faecal continence. Unexpected faecal incontinence can develop following perineal surgery even when the anal sphincters are not damaged. In addition, injury to the pudendal nerve might be encountered during pelvic procedures such as a sacrospinous colpopexy. Methods: An anatomical study on 28 cadavers was conducted to examine the course of the pudendal nerve and its branches in the perineum. Results: In five of the 28 cadavers dissected (four male, one female), a nerve plexus was found within the ischiorectal fossa in close proximity to the anal sphincters. The plexus received contributions from interconnecting branches of the inferior rectal and perineal nerves to innervate the external anal sphincter. In 11 of the 28 cadavers (five female, six male) an additional nerve arose from the medial aspect of the pudendal nerve at the level of the sacrotuberous and sacrospinous ligaments. This nerve continued distally and gave several branches to the perineum and the levator ani muscle. Conclusion: A sound knowledge of the anatomical variations of the pudendal nerve and its branches is essential for all surgeons operating in the perineal region.

Objective To describe the topography of the perineal nerves from their pudendal origin to their course into the male genitalia, with specific attention on the course of the perineal nerve along the ventral penis, including branches into bulbospongiosus muscle and corpus spongiosum. Materials and methods The study comprised 18 normal human fetal penile specimens at 17.5-38 weeks of gestation (determined by fetal heel-to-toe length). Specimens were fixed in formalin, embedded in paraffin wax and serially sectioned at 6 micro m. The penile specimens contained the whole penis from the glans to the crural bodies, beneath the pubic arch and the perineum up to the anal verge. Immunocytochemistry was assessed on selected sections with antibodies against the neuronal markers S-100 and nitric oxide synthase (nNOS). Three-dimensional computer reconstruction of serial sections allowed an in-depth analysis of the neuroanatomy of the fetal penis, perineum and surrounding structures. Results After the pudendal nerve leaves the pudendal canal it gives rise to the perineal nerve branches in the ischiorectal fossa. Perineal nerves travel alongside the ischiocavernous and bulbospongiosus muscles and before reaching the latter, nerve branches course into the bulbospongiosus muscle. During its pathway within this muscle, fine nerve fibres course into the corpus spongiosum by piercing through the junction of the muscle. At the penoscrotal area, the perineal nerves give branches to the scrotum, funnelling into the interscrotal septum. Perineal nerves continue their pathway over the ventral side of penis covering the ventral surface of corpus spongiosum. Branches of the dorsal nerve of the penis at the junction of corpus cavernosum and corpus spongiosum assemble into a network with the perineal nerves. All perineal nerves from their main trunk at the ischiorectal fossa until their interaction with dorsal nerve of penis at the base of penis were nNOS negative. After the interaction with the dorsal nerve of penis, they become nNOS positive. Conclusion Integrating neuroanatomical knowledge about the perineal nerves and their communication with the dorsal nerve of penis should facilitate a strategic approach to reconstructive procedures on the penis. Special care should be taken at the junction between the corpora cavernosa and spongiosa, where the dorsal nerve joins the perineal nerve, and at the proximal bulbospongiosus muscle, thereby protecting the fine nerves piercing into the cavernosa spongiosa.

The developmental neuroanotomy of the human scrotum may not have been evaluated up to now, but the authors from San Francisco report here on an outstanding study in foetuses of this important area of interest. They have helped to define clearly the neuroanotomy of this region, which will be useful in planning surgery to the scrotum and penis in children. The group from the Hospital for Sick Children in Toronto have evaluated the safety and efficacy of toleterodine in children who have previously failed to tolerate oxybutinin. They found that toleterodine is well tolerated in children, and 77% of patients were able to continue this treatment without significant side effects in this subgroup who could not tolerate oxybutinin. OBJECTIVE To define the scrotal nerve origin and distribution with respect to surrounding structures in male human fetuses, by using neuronal-specific markers and three-dimensional (3D) imaging techniques, as the developmental neuroanatomy of the human scrotum has not been studied in detail and an explicit description of nerve derivation and distribution in the human scrotum is germane to genital reconstructive surgery. MATERIALS AND METHODS Sixteen normal human fetal penile specimens at 17.5–38 weeks of gestation were studied. Specimens were fixed in formalin, embedded in paraffin wax, serially sectioned at 6 µm and stained with the neuronal marker S-100. All of the specimens contained the whole penis and scrotum from glans to anal verge. The gestational age of the fetuses was determined by fetal heel-to-toe length. 3D-computer reconstruction of serial sections allowed a detailed analysis of the neuroanatomy of the fetal penis and scrotum. RESULTS The nerves innervating the ventral side of the proximal penis and scrotum originated mainly from the perineal nerves arising from pudendal nerves. The nerves travelling along the ventral side of penis coalesced at the penoscrotal area to be directed into the interscrotal septum. At the penoscrotal junction, nerves on both sides of the ventral penis shifted to the interscrotal septum in a triangular fashion. The interscrotal septum was densely occupied by nerve fibres. Nerves were distributed horizontally to both hemiscrotal walls through this interscrotal septum. Both hemiscrota seem primarily to be innervated separately. CONCLUSION The interscrotal septum has a dense innervation. Both hemiscrota were innervated mainly by horizontally distributed nerve fibres arising from the interscrotal septum. Any procedure violating the penoscrotal and interscrotal septal area may jeopardize scrotal innervation.

Background: Although a range of cytomegalovirus (CMV)-induced cutaneous manifestations is described in AIDS patients, skin involvement in immunocompromised patients is rare, and intraneural CMV inclusions or CMV neuritis has not been documented in skin biopsies. Methods and results: Cutaneous biopsies of CMV lesions were collected prospectively for 12 months. The morphology, sites and symptomatology of the individual lesions, associated systemic illnesses, treatment schedules and disease outcome were recorded. A total of nine biopsies were obtained from three females who presented with extensive painful perineal ulceration and disseminated cutaneous ulcers, nodules and plaques. Clinically, herpes simplex virus (HSV) ulceration was diagnosed and treatment with acyclovir was initiated after biopsies from the natal cleft, perineum and neck were obtained. All were superficial and demonstrated HSV infection. Only the natal cleft biopsy demonstrated coexistent CMV inclusions. Suboptimal healing necessitated two further biopsies from each patient, none of which demonstrated HSV inclusions. Three of four deep perineal biopsies demonstrated CMV inclusions within nerves attended by a lymphocytic infiltrate and architectural disturbances. Two deep cutaneous biopsies of the trunk and abdominal wall confirmed CMV in extraneural locations only. One superficial perineal biopsy did not demonstrate any viral inclusion. Conclusions: In documenting CMV neuritis in painful perineal ulcers, the histopathological spectrum of perineal CMV ulcers is expanded, a cutaneous neurotropic characteristic of CMV is presented and a direct role for CMV in the pathogenesis of pain is suggested. CMV latency within perineal nerves is also revisited as another potential site of CMV reactivation in immunocompromised patients, and another potential site for possible venereal transmission of CMV infection. The exclusive presence of HSV in initial superficial biopsies highlights the need for optimally biopsied tissue to confirm the coexistence of CMV infection.

Little information is available on the participation of the perineal striated muscles in female reproductive processes. Here, we describe the gross anatomy and innervation of two striated perineal muscles in the female rabbit, the bulbospongiosus (BSM) and ischiocavernosus (ISM), and analyze their reflex electromyographic (EMG) activity in response to stimulation of the perigenital skin and vaginal tract. Twenty-four mature chinchilla-breed rabbit does were used: 12 to describe the anatomy and innervation of the muscles, 9 to determine reflex EMG activity of the muscles in response to stimulation of the perigenital skin and specific levels of the vaginal tract and 3 to analyze the effect of contraction of the muscles on intravaginal pressure. Both muscles were well developed, with their fibers originating at the ischiadic arch and inserting onto the ligamentum suspensorium clitoridis. Branches of the clitoral and perineal nerves innervated the BSM and ISM, respectively. Bilateral electrical stimulation of these nerves provoked retraction of the clitoral sheath and an increase in intravaginal pressure at the level of the perineal vagina. Whereas neither muscle responded to stimulation of the perigenital skin, both were reflexively activated during mechanical stimulation of the inner walls of the perineal vagina. Prolonged cervical stimulation inhibited this reflex. Thus, in reproductive processes such as copulation and/or parturition, the contraction of these muscles may be induced during stimulation of the perineal vagina.

Effective anesthetic coverage with regional anesthesia for any procedure involves a fundamental knowledge of several key ideas. This chapter will discuss regional anesthesia used for in-office gynecological procedures. It will review local anesthetics, their mechanism of action, and the means to which they can be augmented for nerve blocks. The basic anatomy of cervical and perineal nerves will also be discussed. In addition, proper equipment and regional techniques that can be utilized for office procedures is a key topic in this chapter. This chapter will try to familiarize the reader with the proper equipment and medications needed to provide a safe and effective regional anesthetic. Finally, the various complications that can arise from performing a nerve block will be reviewed.

Purpose: To investigate the site of pudendal nerve compression and the relation between traction force and abduction angle regarding pressure levels at setup for hip arthroscopy. Methods: A total of 17 hips from 9 fresh-frozen cadavers (6 male and 3 female cadavers) were used. The pudendal nerves were dissected, and 3 FlexiForce force sensors (Tekscan, Boston, MA) were implanted on the pudendal nerve where the inferior rectal nerve, perineal nerve, and dorsal nerve of the clitoris/penis emerge. A custom-made traction table in a supine position was used with a padded perineal post of 9 cm. Recordings were made at 0, 10, 20, 30, and 40 kg of traction at varying hip abduction angles of 0 � ,1 5 � ,3 0 � , and 45 � . Results: The tuber ischiadicum (perineal nerve) and genital region (dorsal nerve of penis/clitoris) had statistically higher pressure values when compared with the pudendal canal (inferior rectal nerve) (P < .05). There was a significant increase in forces acting on the pudendal nerve with increasing application of 0 to 40 kg of traction in steps of 10 kg, with the exception of the pudendal canal sensor and reading of the perineal nerve sensor at 45 � of hip abduction (P < .004 with Bonferroni correction for significant values). On the contrary, hip abduction angle had no statistically significant effect on pudendal nerve compression. (All specific P values with Bonferroni correction were greater than .003.) Conclusions: To avoid nerve palsy completely, the etiopathogenesis of compressive neuropathy should be identified. The location for compression and relation between different traction positions and forces are clarified in this study. This information can be used for further research and prevention. Clinical Relevance: This study adds objective data on the etiopathogenesis of pudendal nerve compression, which potentially contributes to prevention of pudendal nerve palsy as a common complication of hip arthroscopy.

Objective To determine the somatic reflex innervation of the bulbocavernosus muscle (BCM) and to illustrate the role of the perineal nerve in BCM contraction, using electrophysiological techniques. Subjects and methods Ten healthy, potent men underwent genital electrophysiological testing. Stimuli were applied to the dorsal nerve of the penis at the base of the penis, glans and anterior urethra, and the perineal nerve branch to the BCM. The electromyographic (EMG) responses of the BCM were recorded and onset latencies measured at baseline, both after anaesthetising the perineal nerve and after recovery from the anaesthetic. Results A reflex BCM contraction was elicited from all stimulation sites. Anaesthetizing the perineal nerve resulted in alterations of the EMG response. After the anaesthetic effect wore off, the responses returned to baseline values. Conclusions Three distinct somatic bulbocavernosus reflexes were detected which are components of normal ejaculation. BCM contraction can be elicited after stimulating the dorsal penile nerve at the glans and the anterior urethra; these are the flexor responses of the bulbocavernosus reflex. BCM contraction can also be induced on stimulating the perineal nerve, which is the pathway through which the stretch and the tendon organ reflexes are carried to mediate muscle tone. The motor innervation of the BCM for all reflexes is carried through a branch of the perineal nerve. The findings may be relevant to the evaluation of ejaculatory disorders.

Pelvic cancer causes several types of pain, i.e., visceral, neuropathic, and somatic pain. Somatic pain is due to stimulation of nociceptors in the integument and supporting structures, namely, striated muscles, joints, periosteum, bones, and nerve trunks by direct extension through fascial planes and their lymphatic supply. In 60% of patients with malignant disease of soft tissues, nerve trunk, and sacral invasion from carcinoma of the cervix, uterus, vagina, colon, rectum, and other tissues in women, and from penile, prostate, and colorectal carcinoma and sarcoma in men, they have neuropathic pain. The infiltration of the perineal nerves results in lumbosacral plexopathies and complete destruction of the nerve, including perineural lymphatic invasions producing symptomatic sensory loss, causalgia, and deafferentation. Visceral pain is the result of spasms of smooth muscles of hallow viscus; distortion of capsule of solid organs; inflammation; chemical irritation; traction or twisting of mesentery; and ischemia, or necrosis, and encroachment of pelvis and presacral tumors. Pain of these types is managed by different modalities depending on the age of the patient, the expected life expectancy, availability of invasive and non-invasive pain control modalities, and the resources of the patient, community, and health care agencies. Patients with pelvic cancer can live with less pain due to better pain-control modalities that are available today with the help of dedicated and caring algologists.

The micturition reflex pathway is a supraspinal pathway. Anatomical tracing evidence is compatible with an involvement of the periaqueductal gray (PAG) in the ascending limb of this reflex. We tested the involvement of the PAG in receiving urinary tract- or perineum-related information and attempted to characterize this ascending path in terms of what type of information is being conveyed. Electrical stimulation of the pelvic nerves, which carry afferent information from the urinary bladder, evoked maximum field potentials in the caudal third of the PAG, primarily in the dorsal part of the lateral PAG and in the ventrolateral PAG. Since the regions activated by pelvic nerve stimulation differed from those activated by stimulation of the sensory pudendal or superficial perineal nerves, it is possible that specific pathways for different nerve inputs to the PAG exist. Sacral spinal cord neurons ascending to the PAG were identified by antidromic activation and then tested for inputs from pelvic, sensory pudendal or superficial perineal nerves. Of 18 units identified, only five received inputs from any of the peripheral nerves tested and only two projecting neurons received a pelvic nerve input. Thus the PAG may receive inputs from bladder and perineum, but the small proportion of cells with direct projections to the PAG receiving inputs from our test nerves implies that the major part of this pathway is not directly related to lower urinary tract function.

The cat has been used extensively as an animal model for urogenital studies involving the pudendal nerve. However, discrepancies persist in the literature regarding the origin of the dorsal nerve of the penis (DNP). This study used gross dissections and serial histological cross sections to demonstrate that the DNP arises from the deep perineal nerve and not the sensory afferent branch as previously reported. This finding indicates a better than previously appreciated neuroanatomical homology between the cat and human.

Objectives The external striated urethral sphincter (rhabdosphincter) is a tubular muscle sleeve that extends from the prostato-membranous urethra and perineal membrane to the bladder neck. The male rhabdosphincter neuroanatomy remains unclear, and a better understanding of its innervation may provide insight into potential modifications of radical pelvic surgery to improve urinary continence. Methods Fresh cadaveric dissections of 12 male hemipelves were undertaken to investigate the neuroanatomy of the urinary rhabdosphincter. Results Neuroanatomic courses of the nerve supply to the rhabdosphincter revealed that, in the perineum, the perineal nerve (a terminal branch of the pudendal nerve) provided branches directly to the bulbospongiosus muscle and the urinary rhabdosphincter. In the pelvis, the course of the pelvic nerve was as follows: (1) arising from the inferior hypogastric plexus, it had a weblike course beneath the muscle fascia of the levator ani muscle; (2) traveling posterolateral to the rectum, it gave many branches that perforated into the lateral rectum; and (3) at the level of the prostatic apex, still beneath the levator ani muscle fascia (superior fascia), it sent multiple direct branches to the inferolateral aspect of urinary rhabdosphincter. The pudendal nerve traversed the pelvis in the pudendal canal, and, before leaving the pelvis to enter the perineum, it gave an intrapelvic branch that courses with the pelvic nerve to innervate the rhabdosphincter. Conclusions Our understanding of the neuroanatomy of what may be the continence nerves has been improved by fresh cadaveric dissection. The rhabdosphincter receives nerve fibers from the pelvic nerve and dual innervation from an intrapelvic branch and a perineal branch of the pudendal nerve. Better understanding of these anatomic findings may have potential surgical significance with respect to improvement in post-operative urinary continence.

OBJECTIVE To investigate the feasibility, tolerability, safety and efficacy of using a new surgical technique for the repair of anterior urethral strictures to preserve vascular supply to the urethra and its entire muscular and neurogenic support. PATIENTS AND METHODS In all, 24 patients (mean age 46 years) underwent a new one-sided anterior dorsal oral mucosal graft urethroplasty while preserving the lateral vascular supply to the urethra, the central tendon of the perineum, the bulbospongiosum muscle and its perineal innervation. The cause of stricture was instrumentation in three cases (12%), unknown in five (21%), infection in four (17%), and lichen sclerosus in 12 (50%). The stricture site was bulbar in 12 cases (50%) and panurethral in 12 (50%). The mean stricture length was 4.2 cm in patients with bulbar strictures and 10 cm in patients with panurethral strictures. Of 24 patients, 20 patients (83%) had received previous treatments. Clinical outcome was considered a failure when any postoperative instrumentation was needed, including dilatation. RESULTS The overall mean (range) follow-up was 22 (12-55) months. Of the 24 patients, 22 (92%) had a successful outcome and two (8%) were failures. One failure was treated using definitive perineal urethrostomy and another failure underwent successful internal urethrotomy. CONCLUSIONS The preservation of the one-sided vascular supply to the urethra and its entire muscular and neurogenic support should represent a slight but significant step toward perfecting the surgical technique of urethral reconstruction using a minimally invasive approach.

The effect of inferior rectal nerve (IRN) stimulation on sphincteric control of the rectal neck was studied in eight dogs. With the dog under anesthesia, the IRN was exposed through para-anal incision, and a bipolar electrode was applied to it. Response of the rectal and rectal neck pressures as well as external and sphincter (EAS) EMG activity to IRN stimulation was determined. IRN stimulation resulted in increase in both the rectal neck pressure (P0.01) and the EMG activity of EAS (P0.01). Response increased with increasing stimulation frequency up to 50 Hz, above which no more response occurred. Rectal pressure showed no change (P0.05). Both the latency and the duration of response decreased with increased stimulation. The response was resumed after an off-time of twice the stimulation phase. Long-term activation has not been associated with an impairment of nerve responsiveness or with electrode migration or break. To conclude, a stimulus of 50 Hz evokes the most adequate EAS contraction and RN pressure elevation. Chronic electrostimulation of the perineal nerve may restore EAS tone.

A urodynamic study was done on 14 normal subjects and 24 with stress urinary incontinence (SUI), aiming to elucidate SUI etiology. All were multiparous women; 8 of the SUI patients also had partial fecal incontinence. The investigations comprised measuring the vesical and urethral pressures before and after testing external urethral sphincter anesthesia, determination of the functional urethral length and recording of the external urethral sphincter EMG, the straining-urethral reflex and the perineal nerve terminal motor latency (PNTML). The results in both normal and SUI subjects showed that coughing caused both vesical and urethral pressure increase, while an increase in vesical pressure only on external urethral sphincter anesthesia. In SUI patients, the urethral pressure at rest and on coughing was significantly lower (P

Complete or full-thickness rectal prolapse is defined as protrusion of the entire rectal wall through the anal canal. Symptoms may include bowel protrusion during lifting or coughing, need for manual replacement, mucous discharge, and rectal bleeding. Fecal incontinence and/or constipation are frequently associated with rectal prolapse. Fecal incontinence may be related to stretch injury to the anal sphincter muscles, and/or pudendal and perineal nerves. Incarcerated rectal prolapse is an uncommon complication and may lead to bowel strangulation.

OBJECTIVES To report the surgical anatomy of the muscles of the urogenital diaphragm and the pattern of its vessels in the classic exstrophy bladder and incontinent epispadias. METHODS A total of 11 patients, 9 with unoperated classic exstrophy and 2 with incontinent epispadias, who were >5 years old at presentation, were selected for the present study. Magnetic resonance imaging of the pelvis was performed using a 3.0 T magnetic resonance imaging scanner and an 8-channel coil. Computed tomography was performed for 5 patients using a multidetector row helical computed tomography scanner. Angiograms of the vessels of the urogenital diaphragm were also obtained using magnetic resonance imaging and computed tomography. RESULTS A central perineal body was seen in all the patients, with attachment of the bulbospongiosus anteriorly, superficial transverse perinei laterally, and anal sphincter posteriorly. At the root of corpora, the ischiocavernosus muscle was also seen. The triangle among the ischiocavernosus, bulbospongiosus, and superficial transverse perinei muscle was accentuated and contained the perineal artery, indirectly indicating the course of the perineal nerve. The dorsal penile artery was nearer to the posterior edge of the ischiopubic ramus, before coursing on the lateral aspect of the anterior segment of the corpora. The deep transverse perinei muscle and laid open external urethral sphincter were also seen in the proximal planes of the urogenital diaphragm. CONCLUSIONS First, all the muscles of the urogenital diaphragm, including the external urethral sphincter, were present in the exstrophy bladder. Second, the perineal artery and its sphincteric branches were in the triangular space between the ischiocavernosus, bulbospongiosus, and superficial transverse perinei muscle. Finally, the dorsal penile artery ran along the inner edge of the ischiopubic ramus before lying on lateral aspect of the corpora.

The dorsal root origins of cutaneous nerves supplying the feline pelvic limb were determined electrophysiologically in 11 cats. Cutaneous nerves were surgically exposed and the presence or absence of an evoked potential in response to stimulation of individual dorsal roots was noted. The dorsal cutaneous branches of L3-L5 and S3, and the lateral cutaneous branch of L3 each arose solely from their parent spinal nerves. The L7, S1, and S2 dorsal cutaneous branches had multiple dorsal root origins. The lateral cutaneous femoral nerve originated from L3-L6 dorsal roots in 4 patterns of origin, and the saphenous nerve originated from L4-L6 dorsal roots in 2 patterns of origin. The lateral and caudal cutaneous sural nerves originated from L6-S1 roots in 2 and 3 patterns, respectively. The lateral and medial plantar nerves arose from L6-S2 roots in 4 and 2 patterns, respectively. The superficial and deep peroneal nerves originated from L6-S1 roots in 2 and 3 patterns, respectively. The caudal cutaneous femoral nerve or its branches arose from L7-S3 in 8 origin patterns. The dorsal nerve of the penis and the superficial perineal nerve arose from L7-S3 and S1-S3 roots, respectively, each in 4 patterns. A subtle correlation between plexus type and dorsal root origins of the cutaneous nerves was noted.

Detailed dissections were performed on some primates and adult cadavers to provide more accurate morphological data on the composition of the pelvic diaphragm, pudendal plexus and sacral autonomic nerves.1) The pelvic diaphragm is generally divided into 2 parts, the ventral iliopubococcygeus (levator ani: man) and the dorsal ischiococcygeus (coccygeus: man). This laminate arrangement is distinct in macaque monkeys. In man it becomes obscure and 2 parts are blended into one sheet. Some fibers of the pubococcygeus become attached to the rectal wall and form the levator ani. This attachment has been observed in chimpanzees and gibbons. 2) The pudendal plexus is divided into 2 parts, medial and lateral at their origin. From the 2 parts, 3 nerves originate respectively. In primates as in man a laminate arrangement exists among the 3 nerves from the medial: The pelvic splanchnic nerves (PSN) are situated ventrally, the nerve to the ischiococcygeus dorsally, the nerve to the iliopubococcygeus in between. The same laminate arrangement exists among the 3 nerves from the lateral: The dorsal nerve of the penis (or clitoris) is situated ventrally, the inferior rectal nerve dorsally, the perineal nerve in between. In the macaque monkey, no obvious laminate arrangement exists and in the gibbon and chimpanzee tends to be more distinct, but is not as obvious as in man. 3) Sacral autonomic nerves are composed of PSN (parasympathetic) and sacral splanchnic nerves (SSN) (sympathetic). PSN exist always in man and primates. But, SSN are observed in 21 out of 60 pelvic halves (35.0%) in man, and none are observed in primates with the only exception of chimpanzees. SSN in primates can be considered part of PSN, and in man they have developed to become independent nerves.

Electrical stimulation of pudendal nerve sensory pathways can evoke excitatory bladder reflexes. However, the precise peripheral innervation pattern of these somatic fibers remains unclear. In adult male cats, we investigated pudendal nerve innervation of the lower urinary tract (LUT) by employing anatomical (Sihler's stain) and electrophysiological (selective electrical nerve stimulation) techniques. The stained specimens revealed differential innervation of the proximal and distal urethrae by fibers derived from the sensory branch of the pudendal nerve. Cranial sensory branch fibers penetrated the prostate to terminate along the intraluminal surface of the urethra, whereas the dorsal nerve of the penis primarily innervated the glans penis. Further examination of the proximal urethra showed a separate pathway (deep perineal nerve) that inserted directly into the external urethral sphincter. These observations were confirmed electrophysiologically by the measured urethral sphincter activity evoked in response to selective nerve stimulation. Electrical activation of the sensory pathway evoked only reflex (latency = 8.9 ± 1.1 ms) contractions of the urethral muscle, whereas stimulation of the perineal pathway elicited direct (latency = 1.3 ± 0.1 ms) responses. Our findings identify specific pudendal nerve sensory pathways that can be used potentially to restore bladder function in persons with spinal cord injury and also treat LUT symptoms such as urinary retention.

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%).

Vaginal surgery performed for pelvic floor relaxation, genuine stress incontinence or both can have intended and unintended effects on the lower urinary tract. Intended effects are restoration of anatomy and urinary continence; unintended effects include operative injury, recurrent prolapse, persistent or unmasked stress incontinence, and voiding difficulties. Objective long-term follow-up and new investigational techniques have led to a critical reexamination of standard and time-honoured vaginal operations, particularly anterior colporrhaphy. This review addresses the effects of different vaginal operations on the lower urinary tract and conduction studies of the perineal nerve.

Reflexes mediated by urethral sensory pathways are integral to urinary function. This study investigated the changes in bladder pressure and urethral sphincter activity resulting from electrical stimulation of afferents in the deep perineal nerve (DP), which innervates the urethra and surrounding muscles, before and after acute spinal cord transection (SCT) in cats anesthetized with α-chloralose monitored by blood pressure and heart rate. DP stimulation elicited bladder contractions before and after SCT but only if the bladder contained a sufficient volume of fluid (78% of the volume needed to cause distention-evoked reflex contractions). The volume dependency was mediated by a neuronal mechanism in the lumbosacral spinal cord and was not attributable to length-tension properties of the detrusor muscle. Stimulation at 2–40 Hz initiated bladder contractions, but 20–40 Hz was more effective than lower frequencies in evoking and sustaining bladder contractions for the duration of the stimulus train. Decreases in urethral sphincter activity occurred during sustained bladder contractions evoked by 20- to 40-Hz stimulation before and within 16 h after SCT. After SCT, average bladder pressure increases evoked by DP stimulation were smaller than those evoked before SCT, but in some animals, bladder pressures elicited by DP stimulation continued to increase as time after SCT increased and reached pretransection amplitudes at 8–16 h posttransection. These data confirm the presence of a spinal circuit that can mediate coordinated bladder–sphincter responses and show that afferents from the DP can activate this circuit under appropriate conditions.

Spinal cord injury (SCI) eliminates voluntary control of bladder function. This study examined the ability to elicit and sustain bladder contractions with deep perineal nerve (DP) stimulation in 3 cats. The DP was stimulated at 2, 10, 20, 33, and 40 Hz over a range of bladder volumes before and after SCI. DP stimulation elicited bladder contractions pre- and post-spinal transection and was dependent on bladder volume and stimulation frequency. Bladder contractions were only evoked above a threshold bladder volume, which decreased post-spinalization. Both pre- and post-transection, bladder contractions were evoked at stimulation frequencies (2 Hz - 40 Hz), however frequencies of 20 Hz or greater were more effective at sustaining contractions. Post-transection, stimulation frequencies of 33 Hz or greater evoked greater bladder pressures than lower frequencies. Stimulation of the proximal, but not distal DP after DP-transection elicited contractions, demonstrating that the response was afferent mediated. Neural prostheses able to evoke sustained bladder contractions could restore bladder control and provide substantial clinical benefit to individuals with SCI.