Sacrospinous colpopexy: management of postoperative pudendal nerve entrapment

Comparison between anterior and posterior vaginal approach in apical prolapse repair in relation to anatomical structures and points of fixation to the sacrospinous ligament in fresh postmenopausal female cadavers

INTRODUCTION AND HYPOTHESIS

The high prevalence of pelvic organ prolapse (POP) in women requires attention and constant review of treatment options. Sacrospinous ligament fixation (SSLF) for apical prolapse has benefits, high efficacy, and low cost. Our objective is to compare anterior and posterior vaginal approach in SSLF in relation to anatomical structures and to correlate them with body mass index (BMI).

METHODS

Sacrospinous ligament fixation was performed in fresh female cadavers via anterior and posterior vaginal approaches, using the CAPIO®SLIM device (Boston Scientific, Natick, MA, USA). The distances from the point of fixation to the pudendal artery, pudendal nerve, and inferior gluteal artery were measured.

RESULTS

We evaluated 11 cadavers with a mean age of 70.1 ± 9.9 years and mean BMI 22.4 ± 4.6 kg/m². The mean distance from the posterior SSLF to the ischial spine, pudendal artery, pudendal nerve, and inferior gluteal artery were 21.18 ± 2.22 mm, 17.9 ± 7.3 mm, 19.2 ± 6.8 mm, and 18.9 ± 6.9 mm respectively. The same measurements relative to the anterior SSLF were 19.7 ± 2.7 mm, 18.6 ± 6.7 mm, 19.2 ± 6.9 mm, and 18.3 ± 6.7 mm. Statistical analysis showed no difference between the distances in the two approaches. The distances from the fixation point to the pudendal artery and nerve were directly proportional to the BMI.

CONCLUSIONS

There was no difference in the measurements obtained in the anterior and posterior vaginal approaches. A direct correlation between BMI and the distances to the pudendal artery and pudendal nerve was found.

Anatomical Study of the Variants of Extrapelvic Part of the Pudendal Nerve

Background

A comprehensive understanding of the anatomy of the extra pelvic course of the pudendal nerve and its variations is crucial when undertaking perineal and perirectal procedures to safeguard the integrity of the extrapelvic segment of the pudendal nerve and its branches. So we aimed to identify the changes in the pudendal nerve's extrapelvic branching pattern before it enters the pudendal canal and its relationships and connections.

Materials and Methods

A cross-sectional descriptive study was carried out on 26 formalin embalmed adult human cadavers between 20 to 65 years (16 male and 10 female) of north Indian origin. Anatomical course, variations, and connections of the pudendal nerve before entering the pudendal canal were noted.

Results

The extrapelvic course of the pudendal nerve was examined in 52 hemipelves (26 cadavers) after meticulous dissection. Single pudendal nerve trunk (type I) was identified in 51.9% of hemipelves. Two trunked pudendal nerve with inferior gluteal nerve piercing the sacrospinous ligament (type IIa) was observed in 13.5% of hemipelves. 23.1% of hemipelves exhibited two trunked pudendal nerves with inferior gluteal nerve not piercing the sacrospinous ligament(type IIb). Three trunked pudendal nerve (type III) was observed in 11.5% of hemipelves. In 14/52 hemipelves (26.9%), communication with the sciatic nerve was noted, whereas, in 38/52 hemipelves (73.1%), no communication with the sciatic nerve was present.

Conclusion

The extrapelvic course of the pudendal nerve may present with an earlier subdivision or even an aberrant connection with the sciatic nerve. These anatomical variations of the extra pelvic course of the pudendal nerve, its variations, and connections are essential for all surgeons and anesthetists operating in the perineal and perirectal region to avoid unwanted complications.

Surgical management of pudendal nerve entrapment after sacrospinous ligament fixation

Objective

To analyse the efficacy of sacrospinous ligament (SSL) suture removal on the reduction of pain symptoms in the case of suspected pudendal nerve entrapment after sacrospinous ligament fixation (SSLF).

Design

Retrospective cohort study.

Setting

Tertiary referral centre, the Netherlands.

Population

A cohort of 21 women having their SSLF sutures removed because of SSLF‐related pain symptoms.

Methods

Clinical record review.

Main outcome measures

The primary outcome was reduction of pain after SSL suture removal. Secondary outcome measures were time interval between suture placement and suture removal, complete suture removal, adverse events and recurrence of pelvic organ prolapse (POP).

Results

A total of 21 women underwent SSL suture removal for severe and/or persistent pain, which was confirmed on clinical examination: 95% of the women (20/21) reported pain reduction after suture removal, and 57% reported complete pain relief. The time interval between suture placement and suture removal was at a median of 414 days (range 8–1855 days). Sutures could be completely removed in 86% of cases (18/21). One woman had excessive blood loss (520 ml) without blood transfusion. At 6–8 weeks after surgery, 10% of the women (2/21) had renewed symptomatic POP, stage ≥ 2, for which additional POP surgery was indicated.

Conclusions

When performed by an experienced clinician, SSL suture removal is feasible and efficacious, with low morbidity. In addition, the risk of recurrent POP in the short term appeared to be low.

Tweetable abstract

The surgical removal of sacrospinous ligament sutures is safe and efficacious for pain relief, even remote from initial placement.

The surgical removal of sacrospinous ligament sutures is safe and efficacious for pain relief, even remote from initial placement.

Pudendal nerve entrapment syndrome caused by ganglion cysts along the pudendal nerve

Pudendal nerve entrapment (PNE) syndrome refers to the condition in which the pudendal nerve is entrapped or compressed. Reported cases of PNE associated with ganglion cysts are rare. Deep gluteal syndrome (DGS) is defined as compression of the sciatic or pudendal nerve due to a non-discogenic pelvic lesion. We report a case of PNE caused by compression from ganglion cysts and treated with steroid injection; we discuss this case in the context of DGS. A 77-year-old woman presented with a 3-month history of tingling and burning sensations in the left buttock and perineal area. Ultrasonography showed ganglion cystic lesions at the subgluteal space. Magnetic resonance imaging revealed cystic lesions along the pudendal nerve from below the piriformis to the Alcock’s canal and a full-thickness tear of the proximal hamstring tendon. Aspiration of the cysts did not yield any material. We then injected steroid into the cysts, which resolved her symptoms. Steroid injection into a ganglion cyst should be considered as a treatment option for PNE caused by ganglion cysts.

Topography and landmarks for the nerve supply to the levator ani and its relevance to pelvic floor pathologies

The aim of this study was to explore the anatomical variations of the nerve to the levator ani (LA) and to relate these findings to LA dysfunction. One hundred fixed human female cadavers were dissected using transabdominal, gluteal, and perineal approaches, resulting in two hundred dissections of the sacral plexus. The pudendal nerve and the sacral nerve roots were traced from their origin at the sacral foramina to their termination. All nerves contributing to the innervation of the LA were considered to be the nerve to the LA. Based on the spinal nerve components, the nerve to the LA was classified into the following categories: 50% (n = 100) originated from S4 and S5 (type I); 19% (n = 38) originated from S5 (type II); 16% (n = 32) originated from S4 (type III); 11% (n = 22) originated from S3 and S4 (type IV); 4% (n = 8) originated from S3, S4, and S5 (type V). Two patterns of nerve termination were observed. In 42% of specimens, the nerve to the LA penetrated the coccygeus muscle and assumed an external position along the inferior surface of the LA muscle. In the remaining 58% of specimens, the nerve crossed the superior surface of the coccygeus muscle and continued along the superior surface of the iliococcygeus muscle. Damage to the nerve to LA has been associated with various pathologies. In order to minimize injuries during surgical procedures, a thorough understanding of the course and variations of the nerve to the LA is extremely important.

The Pudendal Nerve and Its Branches in Relation to Richter's Procedure

OBJECTIVE

Variations in the branching pattern of the pudendal nerve (PN) have been described in the literature. This study investigated these variations in order to comment on a safe area for the placement of a Richter's stitch.

METHODS

Richter's procedure was performed on nine unembalmed female cadavers and followed by dissection. PN dissections were done on another 20 embalmed female cadavers. Variations in the branching pattern of the PN were noted and the distance between the Richter's stitch placed and the PN/or the inferior rectal nerve (IRN) measured.

RESULTS

The IRN entered the gluteal region as a separate structure in 6/29 cases. The separate IRN was found to pass between 4.1 and 14.45 mm medial to the ischial spine in 18/29 cases. In one case, the Richter's stitch was found to pierce the IRN. The distance between the stitch and the PN and/or the IRN ranged from 0 to 17.8 mm.

CONCLUSIONS

To minimize the risk of nerve damage or entrapment, the Richter's stitch should be placed >20 mm from the ischial spine. This recommended area should be revised for different population groups, as variations might exist between groups.

Modern role of sacrospinous ligament fixation for pelvic organ prolapse surgery--a systemic review

Pelvic organ prolapse (POP) is a common condition in women. Women with POP often experience pelvic discomfort, urinary and fecal problems, sexual dysfunction, and an overall decrease in their quality of life. Surgical treatment is a feasible option if conservative management fails. Various surgical techniques have been proposed to correct POP with or without the use of graft material. Owing to recent U.S. Food and Drug Administration warnings about mesh-related complications, sacrospinous ligament fixation (SSF), as a traditional vaginal procedure, may play an important role again. To answer this question and evaluate quantitatively the efficacy of SSF in POP, we conducted a systemic review of the available data about SSF and POP. Interventions had to include SSF as a point of attachment. To eliminate confounding bias and effect modification, at least one arm must include SSF without mesh or graft. All follow-up periods were allowed. Information on the following parameters was extracted and entered into a database: study design, type of intervention, number of patients, follow-up in months, cure rate, recurrence rate, intra/postoperative complications, and/or uni/bilateral, preventive/therapeutic, or concomitant procedures. Published papers from the years 1995 to 2011 were selected for analysis.

Sensory neuropathy following suspension of the vaginal apex to the proximal uterosacral ligaments

INTRODUCTION AND HYPOTHESIS

Reports of sensory neuropathy attributed to uterosacral ligament suspension (USLS) have emerged. The objectives of this study were to assess the rate of sensory neuropathy symptoms following transvaginal USLS at a single institution during a 5-year period and to describe the evaluation, management, and outcomes in these patients.

METHODS

A retrospective review of records identified 278 women who underwent transvaginal USLS during the study period. Inpatient and outpatient records within the first 4 weeks postsurgery were reviewed. Women with new-onset buttock and/or lower-extremity pain, numbness, weakness or a combination of these symptoms were identified. Demographic data, intraoperative data, and management modalities and outcomes were collected.

RESULTS

Nineteen (6.8 %) women met criteria for inclusion. The most common symptom was buttock pain (73.7 % of cases). Pain radiation to the ipsilateral posterior thigh was present in 11 cases (57.9 %). The majority of women (73.7 %) reported pain symptoms on the right side. Conservative treatment modalities were initially implemented in all women. Four women (21 %) underwent suture removal a median of 1.75 months after USLS. Full symptom resolution was reported in 13 (68.4 %) women a median of 6 months after USLS. The remaining women experienced partial symptom resolution with ongoing conservative management.

CONCLUSIONS

Sensory neuropathy is common in women who undergo transvaginal USLS. As quality of life may be significantly affected, any symptoms of buttock or lower-extremity pain in the immediate postoperative period warrant a thorough evaluation and close follow-up, with early suture removal consideration.

Persistent pelvic pain following transvaginal mesh surgery: a cause for mesh removal

OBJECTIVE

Persistent pelvic pain after vaginal mesh surgery is an uncommon but serious complication that greatly affects women's quality of life. Our aim was to evaluate various procedures for mesh removal performed at a tertiary referral center in cases of persistent pelvic pain, and to evaluate the ensuing complications and outcomes.

STUDY DESIGN

A retrospective study was conducted at the University Hospital of Caen, France, including all patients treated for removal or section of vaginal mesh due to pelvic pain as a primary cause, between January 2004 and September 2009.

RESULTS

Ten patients met the inclusion criteria. Patients were diagnosed between 10 months and 3 years after their primary operation. Eight cases followed suburethral sling procedures and two followed mesh surgery for pelvic organ prolapse. Patients presented with obturator neuralgia (6), pudendal neuralgia (2), dyspareunia (1), and non-specific pain (1). The surgical treatment to release the mesh included: three cases of extra-peritoneal laparoscopy, four cases of complete vaginal mesh removal, one case of partial mesh removal and two cases of section of the suburethral sling. In all patients with obturator neuralgia, symptoms were resolved or improved, whereas in both cases of pudendal neuralgia the symptoms continued. There were no intra-operative complications. Post-operative Retzius hematoma was observed in one patient after laparoscopy.

CONCLUSIONS

Mesh removal in a tertiary center is a safe procedure, necessary in some cases of persistent pelvic pain. Obturator neuralgia seems to be easier to treat than pudendal neuralgia. Early diagnosis is the key to success in prevention of chronic disease.

Gynecologic management of neuropathic pain

Obstetrician/gynecologists often are the initial management clinicians for pelvic neuropathic pain. Although treatment may require comprehensive team management and consultation with other specialists, there are a few critical and basic steps that can be performed during an office visit that offer the opportunity to improve quality of life significantly in this patient population. A key first step is a thorough clinical examination to map the pain site physically and to identify potentially involved nerves. Only limited evidence exists about how best to manage neuropathic pain; generally, a combination of surgical, manipulative, or pharmacologic methods should be considered. Experimental methods to characterize more precisely the nature of the nerve dysfunction exist to diagnose and treat neuropathic pain; however, additional scientific evidence is needed to recommend these options unanimously. In the meantime, an approach that was adopted from guidelines of the International Association for the Study of Pain has been tailored for gynecologic pain.

[Management of chronic postoperative pelvic and perineal pain due to parietal somatic nerve damage]

INTRODUCTION

All surgical procedures require an incision with a risk of nerve damage at the site of the scar or as a result of fibrotic scar tissue. The purpose of this article is to describe the management of chronic postoperative pelvic and perineal pain due to parietal somatic nerve damage.

PATIENTS AND METHODS

A comprehensive review of the literature was performed by searching PUBMED for articles on the management of chronic postoperative pelvic and perineal pain due to parietal somatic nerve damage.

RESULTS

Postoperative lesions of parietal somatic nerves (ilioinguinal, iliohypogastric, genitofemoral, pudendal, obturator, femoral) are frequent after pelvic surgery. Clinical examination of the scars (trigger zone) and detailed analysis of the topography and type of pain are essential elements in the analysis of this pain. Infiltration of local anaesthetic at the trigger point or along the nerve has a diagnostic value. Corticosteroid infiltrations and minimally invasive treatments such as pulsed radiofrequency have provided more or less lasting improvement of the symptoms. Surgical nerve release together with resection of fibrosis and removal of prosthetic material provides good long-term results. The surgical approach depends on the nerve concerned and the level of the lesion.

CONCLUSION

The management of chronic postoperative pelvic and perineal pain due to parietal somatic nerve damage is based on local infiltration of anaesthetics and corticosteroids. Nerve release surgery with resection of fibrosis provides the best long-term results.

Anatomic variations of the pelvic floor nerves adjacent to the sacrospinous ligament: a female cadaver study

Our objective was to document variations in the topography of pelvic floor nerves (PFN) and describe a nerve-free zone adjacent to the sacrospinous ligament (SSL). Pelvic floor dissections were performed on 15 female cadavers. The course of the PFN was described in relation to the ischial spine (IS) and the SSL. The pudendal nerve (PN) passed medial to the IS and posterior to the SSL at a mean distance of 0.6 cm (SD = +/-0.4) in 80% of cadavers. In 40% of cadavers, an inferior rectal nerve (IRN) variant pierced the SSL at a distance of 1.9 cm (SD = +/-0.7) medial to the IS. The levator ani nerve (LAN), coursed over the superior surface of the SSL-coccygeus muscle complex at a mean distance of 2.5 cm (SD = +/-0.7) medial to the IS. Anatomic variations were found which challenge the classic description of PFN. A nerve-free zone is situated in the medial third of the SSL.

Neurosurgical treatment of perineal neuralgias

Perineal pain is the basis of presentation to different specialities. This pain is still rather unknown and leads the different teams to inappropriate treatments which may fail. For more than twenty years, we have seen these patients in a multidisciplinary consultation. Our anatomical works have provided a detailed knowledge of the nervous supply of the perineum which allowed us to propose the description of an entrapment syndrome of the pudendal nerve. Other disturbances of different origins were highlighted helping colleagues to a better analysis of this enigmatic painful syndrome. Cadaveric studies have been done to guide treatments by blocks and surgery if necessary according to well defined criteria. A randomized prospective study validated the surgery. The retrospective study concluded that two thirds of the patients improved after treatment. New anatomical concepts are leading us to enlarge the field of this type of surgery, with the hope of improving the success rate.

Relationship of the uterosacral ligament to the sacral plexus and to the pudendal nerve

We describe the anatomy of the uterosacral ligament with respect to the sacral plexus. In six adult female embalmed cadavers, we identified the uterosacral ligament and its lateral nerve relations. Using the ischial spine as the starting point and measuring along the axis of the uterosacral ligament, we noted that the S1 trunk of the sacral plexus passes under the ligament 3.9 cm [95% confidence interval (CI), 2.1-5.8 cm] superior to the ischial spine. The S2 trunk passes under the ligament at 2.6 cm (95% CI; 1.5, 3.6 cm), the S3 trunk passes under the ligament at 1.5 cm (95% CI; 0.7, 2.4 cm), and the S4 trunk passes under the ligament at 0.9 cm (95% CI; 0.3, 1.5 cm) superior to the ischial spine. The pudendal nerve forms lateral to the uterosacral ligament. Our data demonstrate that the S1-S4 trunks of the sacral plexus, not the pudendal nerve, are vulnerable to injury during uterosacral ligament suspension.

Pudendal nerve decompression in perineology: a case series

BACKGROUND

Perineodynia (vulvodynia, perineal pain, proctalgia), anal and urinary incontinence are the main symptoms of the pudendal canal syndrome (PCS) or entrapment of the pudendal nerve. The first aim of this study was to evaluate the effect of bilateral pudendal nerve decompression (PND) on the symptoms of the PCS, on three clinical signs (abnormal sensibility, painful Alcock's canal, painful "skin rolling test") and on two neurophysiological tests: electromyography (EMG) and pudendal nerve terminal motor latencies (PNTML). The second aim was to study the clinical value of the aforementioned clinical signs in the diagnosis of PCS.

METHODS

In this retrospective analysis, the studied sample comprised 74 female patients who underwent a bilateral PND between 1995 and 2002. To accomplish the first aim, the patients sample was compared before and at least one year after surgery by means of descriptive statistics and hypothesis testing. The second aim was achieved by means of a statistical comparison between the patient's group before the operation and a control group of 82 women without any of the following signs: prolapse, anal incontinence, perineodynia, dyschesia and history of pelvi-perineal surgery.

RESULTS

When bilateral PND was the only procedure done to treat the symptoms, the cure rates of perineodynia, anal incontinence and urinary incontinence were 8/14, 4/5 and 3/5, respectively. The frequency of the three clinical signs was significantly reduced. There was a significant reduction of anal and perineal PNTML and a significant increase of anal richness on EMG. The Odd Ratio of the three clinical signs in the diagnosis of PCS was 16,97 (95% CI = 4,68 - 61,51).

CONCLUSION

This study suggests that bilateral PND can treat perineodynia, anal and urinary incontinence. The three clinical signs of PCS seem to be efficient to suspect this diagnosis. There is a need for further studies to confirm these preliminary results.

Sacro-spinous ligament fixation peri-operative complications in 195 cases: visual approach versus digital approach of the sacro-spinous ligament

OBJECTIVE

To evaluate sacro-spinous ligament fixation (SLF) peri-operative complications.

STUDY DESIGN

Monocentric, retrospective study. Department of Gynecology, SIHCUS-CMCO, University Hospital, Strasbourg, France. Between January 1990 and December 2000, 195 women, mean age 63.2 years old (40-90), underwent a vaginal SLF. Ninety point eight percent of women were post-menopaused and 27.9% of these had a hormonal substitution. About 24% of patients had prior hysterectomy, 20% vaginal prolapse repair and 22% urinary stress incontinence repair. SLF was performed in 1.5% of cases without any other procedures and it was combined with the following: rectocele and elytrocele repair in 89.2%, hysterectomy in 72.3%, cystocele repair in 52.8% and stress incontinence repair in 15.3% of cases. In 107 cases, the SLF attachment was placed under digital control and in 88 cases under visual control.

RESULTS

The mean hospitalisation stay was of 8.5 +/- 2.6 days (4-26). About 41% of women presented a complication. Major complications were represented by 3.6% of bladder injury, 0.5% of uretero-vaginal fistula, 0.5% of vascular injuries, 0.5% of thromboembolic events. In 38% of cases patients had minor complications: urinary tract infections (29%), temporary urinary retention (5.6%), local complications (4.5%), and other complications (3%). The only specific SLF complication in this data was a vascular injury and in this case the SLF was performed under digital control.

CONCLUSIONS

The global peri-operative complication frequency of SLF is high. It is mainly represented by non-specific complications, secondary to the combined procedures and not to the SLF itself. The specific complications due to SLF, all of which are major ones, can be avoided or diagnosed earlier, by using the visual approach technique.

Anatomy of the pudendal nerve and its terminal branches: a cadaver study

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.

A review of 165 cases of transvaginal sacrospinous colpopexy performed by the Endo Stitch technique

The Endo Stitch technique has been in use in Geelong since 1994 as the method of performing transvaginal sacrospinous colpopexy (TSC). This article looks at the outcome of 165 of these procedures as assessed by a questionnaire. As the operation is technically easy, has a low complication rate and a high level of patient satisfaction we suggest that the Endo Stitch technique may be the method of choice for TSC.

Sacrospinous ligament fixation and modified McCall culdoplasty during vaginal hysterectomy for advanced uterovaginal prolapse

OBJECTIVE

Our purpose was to compare anatomic and functional results of 2 procedures performed at vaginal hysterectomy for vaginal vault suspension in patients with advanced uterovaginal prolapse.

STUDY DESIGN

A retrospective case-control study was designed comparing 62 patients who underwent sacrospinous ligament fixation and 62 members of a matched control group who underwent modified McCall culdoplasty during vaginal hysterectomy and reconstructive pelvic surgery. The 62 pairs were matched for grade of uterine prolapse, age, parity, dystocia, menopause, body mass index, previous prolapse surgery, heavy work, constipation, and chronic cough.

RESULTS

Operative time and blood loss were significantly greater (P < .001) in the group with sacrospinous suspension. With a follow-up from 4 to 9 years, 17 (27%) patients receiving sacrospinous suspension had prolapse recurrence at any vaginal site compared with 9 (15%) patients receiving modified McCall culdoplasty (P = .14). Recurrent vault prolapse was recorded in 5 (8%) and 3 (5%) subjects, respectively (P = .72). Thirteen (21%) and 4 (6%) patients, respectively, had recurrent cystocele (matched odds ratio 4.1, 95% confidence interval 1.3 to 14.2, P = .04). No significative difference was observed in postoperative sexual function.

CONCLUSION

Sacrospinous ligament fixation is not recommended as a prophylactic measure at vaginal hysterectomy in patients with uterovaginal prolapse.

Intraligamentous nerves as a potential source of pain after sacrospinous ligament fixation of the vaginal apex

The aim of the study was to investigate the histology of the sacrospinous ligament to determine whether nerve fibers exist within the substance of the sacropinous ligament itself. Six sacrospinous ligaments were removed from 4 fixed female cadavers. Representative segments were taken from the lateral (ischial), middle and medial (sacral) portions of these specimens, sectioned by microtome, mounted, and stained with hematoxylin and eosin dyes. The fixed and stained sections were then examined using light microscopy. Nerve tissue was found to be concentrated in the medial portions of the sacrospinous ligaments, but nerves were found in all segments of the ligament. It was concluded that, nervous tissue is present and widely distributed within the body of the sacrospinous ligament. A wide variety of sizes and thicknesses are also demonstrated, suggesting a variety of functions, including possible pain reception. This fact should be taken into consideration when planning operative procedures for pelvic prolapse.