Innervation of the Pelvic Floor Muscles

A Reappraisal for the Levator Ani Nerve

Christian Wallner, Cornelis P. Maas, Noshir F. Dabhoiwala, Wouter H. Lamers,
and Marco C. DeRuiter

OBJECTIVE: We investigated the clinical anatomy of the

levator ani nerve and its topographical relationship with
the pudendal nerve.
T he innervation of the pelvic floor remains contro-
versial. Many well-regarded medical texts and
review articles state that the pelvic floor muscles are
METHODS: Ten female pelves were dissected and a innervated both by the pudendal nerve and by direct
pudendal nerve blockade was simulated. The course of branches of the third and fourth sacral motor nerve
the levator ani nerve and pudendal nerve was described roots.1 Such direct branches are more prone to dam-
quantitatively. The anatomical data were verified using age during childbirth or surgical interventions. The
(immuno-)histochemically stained sections of human fe- effect of a pudendal nerve blockade on pelvic floor
tal pelves. muscle function was recently reported in this journal.2
RESULTS: The levator ani nerve approaches the pelvic- The study tested whether the pudendal nerve does
floor muscles on their visceral side. Near the ischial spine, indeed innervate the levator ani muscle. A blockade
the levator ani nerve and the pudendal nerve lie above with 10 mL lidocaine of the pudendal nerve of
and below the levator ani muscle, respectively, at a nulliparous asymptomatic women without anal or
distance of approximately 6 mm from each other. The urinary incontinence decreased intravaginal pressure,
median distance between the levator ani nerve and the
increased the length of the urogenital hiatus, and
point of entry of the pudendal blockade needle into the
decreased electromyography activity of the puborec-
levator ani muscle was only 5 mm.
talis muscle. The authors therefore concluded that
CONCLUSION: The levator ani nerve and the pudendal these results provide strong evidence that the puden-
nerve are so close at the level of the ischial spine that a
dal nerve innervates the levator ani muscle.2 We
transvaginal “pudendal nerve blockade” would, in all
would like to challenge their conclusions. Direct
probability, block both nerves simultaneously. The clini-
branches from S3 to S5, which lie on the visceral side
cal anatomy of the levator ani nerve is such that it is
of the pelvic floor and which are completely indepen-
prone to damage during complicated vaginal childbirth
and surgical interventions.
dent of the pudendal nerve, have been unambigu-
(Obstet Gynecol 2006;108:529–34) ously documented.3 In anatomical textbooks this di-
rect innervation is termed the “nerve to the levator
LEVEL OF EVIDENCE: II-3
ani” or “levator ani nerve.”4,5 We hypothesized that
the anatomical relationship between the levator ani
nerve and the pudendal nerve in the area of the
ischial spine is so close that a pudendal nerve block-
ade affects both the pudendal nerve and the levator
From the Departments of Anatomy & Embryology and Urology, Academic
ani nerve. We, therefore, investigated the topography
Medical Center, University of Amsterdam, Amsterdam, The Netherlands; and
the Departments of Anatomy & Embryology and Gynaecology, Leiden University of the levator ani nerve from the perspective of
Medical Center, Leiden University, Leiden, The Netherlands. obstetricians and gynecologists. We measured the
Christian Wallner is supported by a grant from the John L. Emmett Foundation, distance between the levator ani nerve and pudendal
The Netherlands. nerve in the area of the ischial spine and positioned a
Corresponding author: M. C. DeRuiter, PhD, Department of Anatomy & mock pudendal nerve block to assess whether such a
Embryology, Leiden University Medical Center, Building 2, S-1-P, P.O. BOX
9600, 2300 RC Leiden, The Netherlands; e-mail: M.C.DeRuiter@lumc.nl.
block can also affect the levator ani nerve. To verify
© 2006 by The American College of Obstetricians and Gynecologists. Published
our anatomical conclusions, we also studied (im-
by Lippincott Williams & Wilkins. muno-)histochemically stained sections of human fe-
ISSN: 0029-7844/06 tal pelves.

VOL. 108, NO. 3, PART 1, SEPTEMBER 2006 OBSTETRICS & GYNECOLOGY 529
MATERIALS AND METHODS standard clinical practice.2 The needle was inserted
Ten pelves of female cadavers without signs of pelvic transvaginally through the pelvic floor approximately
surgery were dissected. The dissections were com- 8 mm medial to the ischial spine to a depth of 1 cm.
pleted in a timeframe of 3 months, September to No anesthetic fluid was injected. After dissection, the
November 2005. The women were all postmeno- seven measurements shown in Figure 1 were taken
pausal. The cadavers were preserved by injection into (results are presented as median and 95% confidence
the femoral artery of embalming fluid, which con- intervals).
sisted of a mixture of formaldehyde, ethanol, glycerin, To further help characterize the anatomical rela-
phenol, K2SO4, Na2SO4, NaHCO3, NaNO3, and tionship of the LAN and the pudendal nerve, we also
Na2SO3. All pelves were transected midsagittally. The studied (immuno-)histochemically stained sections of
distal rectum was carefully detached from the pelvic human fetal pelves. The fetuses were obtained after
floor to expose the sacral plexus, the pudendal nerve, legal abortion, and the study was approved by the
and the levator ani nerve. The pudendal nerve was medical-ethical committee of the Leiden University
also dissected by a gluteal approach. The topograph- Medical Center. Two female fetal pelves (female, 14
ical relationship between the pudendal nerve and the and 19 weeks of gestation) were stained for the
levator ani nerve in the area of the ischial spine was presence of striated muscle tissue, using a monoclonal
systematically studied. A mock transvaginal “puden- antibody directed against myosin heavy chain (clone
dal blockade” was positioned in the specimens by an A4.1025; Upstate Cell Signaling Solutions, Char-
experienced clinician (C.P.M.) following guidelines of lottesville, VA), and for the presence of nerve tissue,

Fig. 1. Schematic overview of the measurements taken in the female pelves. A. Superior view into the lesser pelvis. B.
Enlarged view of frame in panel. 1, the shortest distance from the levator ani nerve (LAN) to the midsagittal plane at the level
of the ischial spine; 2, the shortest distance from the LAN to the tip of the coccyx measured perpendicular to the midsagittal
plane; 3, the shortest distance from the point of entry of the main branch of the LAN into the levator ani muscle to the
midsagittal plane; 4, the shortest distance from the ischial spine to the LAN, measured perpendicular to the midsagittal
plane; 5, the shortest distance between the pudendal nerve and the LAN at the level of the ischial spine; 6, the shortest
distance between the LAN and the point of penetration of the needle through the levator ani muscle during a mock
transvaginal pudendal nerve blockade; 7, the shortest distance between the point of entry of the main branch of the LAN
into the levator ani muscle and to the point where the LAN passes the ischial spine. C, coccyx; CM, coccygeal muscle; IS,
ischial spine; LAM, levator ani muscle; OIM, obturator internus muscle; PM, piriformis muscle; PN, pudendal nerve; PS,
pubic symphysis; R, rectum; S, sacrum; S1, S2, S3, sacral nerve trunks 1–3; U, urethra; V, vagina; X, point of needle
penetration through the levator ani muscle during mock pudendal nerve blockade. The interrupted lines represent the
pudendal nerve inferior to the coccygeal and levator ani muscle. Note that the distance between the point of needle
injection and the ischial spine is approximately 8 mm.
Wallner. Levator Ani Nerve. Obstet Gynecol 2006.

530 Wallner et al Levator Ani Nerve OBSTETRICS & GYNECOLOGY

using a polyclonal antibody directed against neuro- symphysis to enter the muscle in its puborectalis
filament 68 kD (AB1983; Chemicon International, portion 48 mm (95% CI 36 – 60 mm) distal to the
Temecula, CA), as well as with hematoxylin-azo- point of passage of the ischial spine and 40 mm (95%
phloxin. To verify the data obtained from these two CI 18 – 60 mm) lateral to the midsagittal plane (Fig. 2).
fetuses, we also undertook investigations on existing In all cases the levator ani nerve was covered by the
fetal pelvic sections from the collections of the depart- pelvic parietal fascia.
ments of Anatomy & Embryology, Leiden University The pudendal nerve, by contrast, coursed behind
Medical Center, and from the Academic Medical the sacrospinous ligament and the overlying coccy-
Center, Amsterdam. These fetuses (11 females and 7 geal muscle before passing around the ischial spine.
males, ranging from 65 mm crown-rump length In the area of the ischial spine, the distance between
[CRL, 10 weeks of gestation] to 260 mm CRL [27 the pudendal nerve and levator ani nerve (positioned
weeks of gestation]) were stained with hematoxylin
inferior and superior to the levator ani muscle, respec-
and either azophloxin or eosin. Male fetuses were
tively) was 6 mm (95% CI 4 –11 mm). The tip of the
used to show that the levator ani nerve is present in both
needle, inserted during the mock pudendal nerve
sexes. Three-dimensional reconstructions were pre-
blockade maneuver, effectively reached the pudendal
pared using Amira 3.0 (TGS Template Graphics Soft-
ware, San Diego, CA; available at: http://www.tgs.com). nerve in all specimens. The distance between the
levator ani nerve and the passage of the needle
RESULTS through the levator ani muscle was 5 mm (95% CI
The levator ani nerve originated from sacral foramina 1– 8 mm). In the fetuses the close topographic rela-
S3 and/or S4. Its trajectory is on the visceral surface of tionship of the levator ani nerve and the pudendal
the coccygeal and levator ani muscles and was situ- nerve as found in the adult specimens could be
ated 45 mm (95% confidence interval [CI] 40 – 49 confirmed and elegantly demonstrated by using nerve
mm) lateral to the midsagittal plane at the level of the and striated muscle–specific immunohistochemistry
ischial spine, 45 mm (95% CI 35–50 mm) lateral to the (Fig. 3).
tip of the coccyx, and 8 mm (95% CI 3–20 mm) The levator ani nerve, originating from the third
medio-caudal to the ischial spine. The main branch of and/ or fourth sacral foramen and innervating the
the levator ani nerve entered the levator ani muscle at levator ani muscle on its visceral side, was demonstra-
the level of the ischial spine in four pelves. In six ble in female as well as male fetal pelves (Fig. 4A).
pelves it continued its course further on the visceral Figure 4B shows the course of the nerves in a female
surface of the muscle in the direction of the pubic fetal pelvis in a three-dimensional reconstruction.

Fig. 2. The course of the levator ani

nerve on the pelvic floor. A. Over-
view of a pelvis in which the main
branch of the levator ani nerve (LAN,
arrowheads) courses on the levator
ani muscle in the direction of the
pubic symphysis before entering the
puborectalis portion of the muscle. B.
Detail of the pelvis shown in panel A.
C. Overview of a pelvis in which the
main branch of the LAN (arrowhead)
enters the levator ani muscle at the
level of the ischial spine. D. Detail of
the pelvis shown in panel C. BL,
bladder; LAM, levator ani muscle; R,
rectum; S, sacrum; V, vagina; PS,
pubic symphysis. In all images a
white pinhead marks the position of
the ischial spine.
Wallner. Levator Ani Nerve. Obstet
Gynecol 2006.

VOL. 108, NO. 3, PART 1, SEPTEMBER 2006 Wallner et al Levator Ani Nerve 531
Fig. 3. Topographical relation between the levator ani nerves and pudendal nerves. Immunohistochemically stained
transverse sections of a 19-week-old female pelvis just caudal to the ischial spine. Note that parts of the pelvic bone became
detached during the staining procedure. A. Overview of striated muscles, with the arrowheads showing the ventral and
dorsal borders of the levator ani muscle (bar⫽1 mm). B. Magnification of frame in panel A, showing the dorsal part of the
levator ani muscle (bar⫽0.2 mm). C. Serial section stained for neural tissue and showing the branches of the levator ani
nerve (arrowheads) and the pudendal nerve (arrows) (bar⫽0.2 mm). I, Ischium; LAM, levator ani muscle; OIM, obturator
internus muscle; R, rectum; U, urethra; V, vagina.
Wallner. Levator Ani Nerve. Obstet Gynecol 2006.

Fig. 4. The levator ani nerve (LAN), innervating the levator ani muscle on its visceral side. A. Transverse section (stained with
hematoxylin-azophloxin) of an 11-week-old male fetus showing the LAN (arrowheads) on the visceral side of the levator ani
muscle (bar⫽0.2 mm). B. Frontal view of three-dimensional reconstruction of the levator ani and pudendal nerves and
levator ani muscle of a 14-week-old female fetus. Note the close topographical relationship of the LAN (arrowhead) and the
pudendal nerve (arrow) at the level of the ischial spine (asterisk) (bar⫽1 mm). EAS, external anal sphincter; LAM, levator ani
muscle; R, rectum; S, sacrum; SN, sciatic nerve; SP, sacral plexus.
Wallner. Levator Ani Nerve. Obstet Gynecol 2006.

DISCUSSION only 6 mm. This close relationship is also demonstra-

Our study provides strong and objective evidence ble in the fetal sections. Because the 95% CI of the
that both the levator ani nerve and the pudendal distance between the penetrating needle and the
nerve can be simultaneously blocked by a transvagi- levator ani nerve ranges from 1 mm to 8 mm, while
nal “pudendal nerve blockade.” We have docu- the injection of 10 mL of fluid theoretically forms a
mented that the levator ani nerve lies only 8 mm sphere with a radius of approximately 13 mm, a
medio-caudal from the ischial spine and that the pudendal blockade with 10 mL anesthetic that does
shortest distance between the pudendal nerve and the not affect the levator ani nerve is virtually impossible.
levator ani nerve at the level of the ischial spine is These data throw considerable doubt on an earlier

532 Wallner et al Levator Ani Nerve OBSTETRICS & GYNECOLOGY

report2 that innervation of the levator ani muscle by Our findings confirm and extend earlier findings.
the pudendal nerve can be deduced from a transvag- Several studies argue that direct sacral branches are
inal lidocaine blockage of the nerve near the ischial responsible for innervation of the levator ani muscle
spine. Clearly, the physiological parameters, mea- on its visceral side and that the pudendal nerve
sured clinically in that study, demonstrated that the innervates the external anal sphincter only.3,7,8 This
pudendal nerve was blocked. In agreement, the tip of pattern is also seen in other primates9 –11 and in rats.12
the needle in the mock transvaginal “pudendal nerve Furthermore, neurectomy of the levator ani nerve or
block” that we performed effectively reached the the pudendal nerve in rats12 and squirrel monkeys9
pudendal nerve in all tries. Guaderrama et al2 in their shows that only denervation of the levator ani nerve
discussion also mentioned that the transvaginal “pu- affects the levator ani muscle, whereas denervation of
dendal nerve block” might affect both the direct the pudendal nerve affects the external anal sphincter.
branches of sacral nerve roots S3 and S4 and the Neurostimulation of the levator ani nerve or the
pudendal nerve. However, they ruled out the possi- pudendal nerve in humans also shows muscle-specific
bility of double blockade by explaining that the effects on the levator ani and the external anal
amount of lidocaine is too small to affect the direct sphincter, respectively.7,13 Together, these studies
branches and the pudendal nerve simultaneously. convincingly demonstrate that the levator ani muscle
In contrast, our anatomical data reveal that the and the external anal sphincter are innervated by
topographical relation of the levator ani nerve to the different nerves.
pudendal nerve is so close at the point of injection that The clinical implications of the innervation of the
even the small amount of lidocaine that is used pelvic floor are evident: denervation of the pelvic
reaches both nerves. Moreover, literature data show floor muscles and the accompanying muscle dysfunc-
the distribution area of anesthetics administered tion could cause urinary and/or anal incontinence,
through pudendal nerve blockade to be large. A study and pelvic organ prolapse. The concept of neural
in which spread of anesthetics during transvaginal damage due to stretching and pressure during com-
pudendal nerve blockade was visualized with X-rays plicated vaginal childbirth or pelvic surgical proce-
showed that anesthetics spread widely. The X-rays dures is more easily conceivable with the nerve to the
showed diffusion retrogradely up to the sacral roots of levator ani muscle being located on the superior,
origin of the pudendal nerve.6 visceral side of the pelvic floor. In contrast, the
A limitation of our analysis could be that we pudendal nerve is better protected in these situations
studied cadavers as opposed to live subjects. One because it lies on the inferior side of the pelvic floor,
might argue that the age of our cadavers may have within Alcock’s canal. The same considerations apply
influenced the thickness of the pelvic floor muscles, to transvaginal sacrospinous ligament fixation for
because the pelvic floor in the elderly is frequently vault prolapse. One or more permanent stitches are
less functional, and that our assessment of the distance put through the ligament by placing them 1 cm
between the levator ani nerve and the pudendal nerve medial to the ischial spine.14 As can be concluded
in cadavers is therefore an underestimate. Because the from our morphological findings, this procedure
pelvic floor, both in the fetus and the adult, consists of holds a risk of levator ani nerve entrapment or
one layer of muscle bundles only, we think that the disruption, either immediately or as a delayed re-
possible differences in thickness in the pelvic floor are sponse to surgery. Documentation of recurrence rates
marginal. Also, although embalming of cadavers can of vaginal vault prolapse after sacrospinous ligament
cause distortion of anatomical relations, this distortion fixation is poor due to lack of follow-up studies with
is probably minimal in the area of the ischial spine standardized parameters14,15 but is repeatedly men-
and the sacrospinous ligament because these are firm tioned in the literature as a clinical problem associ-
structures that resist the pressures created in embalming. ated with this surgical procedure.3,14,15 Pelvic floor
A second argument against our hypothesis could muscle denervation due to disruption of the levator
be that the levator ani muscle functions as an effective ani nerve could explain these recurrent prolapses.
diaphragm and divides the space above and below Given the clinical impact of a denervation of the
the pelvic floor into separate compartments, which levator ani muscles, all obstetricians, gynecologists,
inhibits diffusion of lidocaine to the levator ani nerve. and pelvic surgeons should be aware of the levator ani
Only a study in which the diffusion pattern of the nerve and its clinical anatomy. Although we fully
anesthetic is assessed could clarify whether the levator realize that the functional assessment of the levator
ani muscle does indeed prevent spreading of the ani nerve is not trivial, our data clearly show that a
anesthetic to the levator ani nerve. pudendal blockade with an anesthetic is not the

VOL. 108, NO. 3, PART 1, SEPTEMBER 2006 Wallner et al Levator Ani Nerve 533
proper approach because it fails to distinguish be- 8. Juenemann KP, Lue TF, Schmidt RA, Tanagho EA. Clinical
significance of sacral and pudendal nerve anatomy. J Urol
tween the pudendal and the levator ani nerves.
1988;139:74–80.
9. Pierce LM, Reyes M, Thor KB, Dolber PC, Bremer RE, Kuehl
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534 Wallner et al Levator Ani Nerve OBSTETRICS & GYNECOLOGY