Superior hypogastric plexus
The superior hypogastric plexus, also commonly known as the presacral nerve, is a network of nerves situated just anterior to the fifth lumbar vertebral body, the sacral promontory and aortic bifurcation. It receives sympathetic contributions from the lower two lumbar splanchnic nerves (L3, L4); parasympathetic from the pelvic splanchnic nerves (S2-S4) and both parasympathetic and sympathetic contributions from the aortic plexus. From the superior hypogastric plexus, two main nervous trunks (right and left hypogastric nerves) and several smaller branches descend into the pelvis.
The main function of the superior hypogastric plexus is to carry the parasympathetic, and sympathetic innervation for the pelvic viscera and bowel (distal to the left colonic flexure), as well as visceral afferent fibers from these structures to the spinal cord. This is why the dysfunction of this plexus can cause reproductive, urinary and bowel dysfunction.
This article will discuss the anatomy and function of the superior hypogastric plexus.
|Location||Anterior to the vertebral body L5 and sacral promontory|
|Branches||Left and right hypogastric nerves|
|Supply||Both sexes: Distal colon, distal ureter, urinary bladder, reproductive tract, associated accessory glands and blood vessels
Males: Epididymis, ductus deferens, prostate, seminal vesicles
Females: Uterus, uterine tubes, ovaries and vagina
- Origin and course
- Branches and innervation
- Clinical relations
Origin and course
The superior hypogastric plexus is a primary retroperitoneal structure located in the midline of the lower abdomen. More specifically, it is situated anterior to the vertebral body of the inferiormost lumbar vertebrae (L5) and the bifurcation of the abdominal aorta, between the left and right common iliac arteries. It is formed by nerve fibers that originate from the three main sites:
- Aortic plexus
- Lumbar splanchnic nerves (L3, L4)
- Pelvic splanchnic nerves (S2-S4)
These contributing nerve fibers interconnect in the plexus together with the visceral afferent fibers. Nerve impulses are carried out of the plexus by a series of branches that usually convey information to other subsidiary nerve plexuses.
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Branches and innervation
The two main branches that carry information to and out of the superior hypogastric plexus are the left and right hypogastric nerves. The hypogastric nerves carry sympathetic fibers from the superior hypogastric plexus to the inferior hypogastric plexus. At the same time, they carry parasympathetic fibers from the inferior hypogastric plexus to the superior hypogastric plexus.
The superior hypogastric plexus also gives off several smaller branches which convey innervation to the ureteric, gonadal and common iliac nerve plexuses, as well as the mesentery of the rectum (mesorectum) which accompany the superior rectal artery.
The prime function of the superior hypogastric plexus is to carry autonomic innervation to and receive visceral afferent fibers from the pelvic viscera and the distal bowel. More specifically, the superior hypogastric plexus provides the innervation for the distal rectum, distal portion of ureter, urinary bladder, reproductive tract and associated accessory glands, and blood vessels in both sexes. In males, it contributes to the innervation of the epididymis, ductus deferens, prostate and seminal vesicles. In females, it innervates the ovaries, uterine tubes, uterus and vagina. For this reason, the plexus plays a key role in continence (urinary and fecal) and the maintenance of normal sexual function, including erection and ejaculation.
Superior hypogastric plexus block
The superior hypogastric plexus block is a commonly used pain management technique for malignant and nonmalignant pain syndromes that originate from the pelvic cavity. This procedure cuts off the pain pathway and is usually performed laparoscopically. Some of its indications include severe dysmenorrhea, endometriosis, testicular pain, genital tumors, etc. Due to its common side effects, this procedure is typically performed only when medication and other therapy modalities fail.
Presacral neurectomy is a common surgical laparoscopic procedure in which the superior hypogastric plexus is excised so that the pain pathway is cut off from the spinal column.
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