Int Urogynecol J (2008) 19:107–116

DOI 10.1007/s00192-007-0395-8

ORIGINAL ARTICLE

Innervation of the levator ani muscles: description

of the nerve branches to the pubococcygeus, iliococcygeus,
and puborectalis muscles
Bogdan A. Grigorescu & George Lazarou &
Todd R. Olson & Sherry A. Downie & Kenneth Powers &
Wilma Markus Greston & Magdy S. Mikhail

Received: 8 January 2007 / Accepted: 1 May 2007 / Published online: 13 June 2007
# International Urogynecology Journal 2007

Abstract We described the innervation of the levator ani Keywords Levator ani muscles . Pubococcygeus muscle .
muscles (LAM) in human female cadavers. Detailed pelvic Iliococcygeus muscle . Puborectalis muscle . Inferior rectal
dissections of the pubococcygeus (PCM), iliococcygeus nerve . Pudendal nerve
(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
Introduction
nerve branches innervating the LAM were documented.
Histological analysis of nerve branches entering the LAM
The levator ani muscles (LAM) are comprised of the
confirmed myelinated nerve tissue. LAM were innervated by
iliococcygeus (ICM), the pubococcygeus (PCM), and the
the pudendal nerve branches, perineal nerve, and inferior
puborectalis (PRM) muscles, which, together with the coccy-
rectal nerve (IRN) in 15 (88.2%) and 6 (35.3%) cadavers,
geus muscle and the perineal membrane, constitute the pelvic
respectively, and by the direct sacral nerves S3 and/or S4 in 12
floor. The LAM, composed mainly of type-I (slow-twitch)
cadavers (70.6%). A variant IRN, independent of the pudendal
muscle fibers and, to a smaller extent, type-II (fast-twitch)
nerve, was found to innervate the LAM in seven (41.2%)
fibers, play an essential role in urinary and fecal continence and
cadavers. The PCM and the PRM were both primarily
provide support to the pelvic organs [1, 2].
innervated by the pudendal nerve branches in 13 cadavers
LAM innervation has been debated for many years [3].
(76.5%) each. The ICM was primarily innervated by the direct
This is not surprising, given the complexity of the pelvic
sacral nerves S3 and/or S4 in 11 cadavers (64.7%).
floor anatomy and the difficulty of dissection and access to
this area of the human body. Standard anatomy textbooks
Reprint requests: Magdy S. Mikhail, M.D. and journal articles indicate that the LAM are dually
innervated by pudendal nerve branches and by direct
Oral presentation at the 31st Annual International Urogynecological
Association Meeting, Athens, Greece, September 6–9, 2006—The branches from the sacral nerve roots S3 and/or S4 [1, 4,
Best Oral Poster Presentation Award. 5]. Dual LAM innervation from the sacral and pudendal
B. A. Grigorescu (*) : G. Lazarou : K. Powers : W. M. Greston :
nerves was confirmed by several investigators. In a study of
M. S. Mikhail fetal and neonatal pelvic anatomy, Lawson [6] found
Division of Female Pelvic Medicine and Reconstructive Surgery, evidence of dual LAM innervation from branches of the
Department of Obstetrics and Gynecology and Women’s Health, pudendal nerve that coursed posterior to the pelvic floor to
Montefiore Medical Center, Albert Einstein College of Medicine,
supply the inferior surface of the LAM and from the sacral
3332 Rochambeau Ave.,
Bronx, NY 10467, USA nerves S3–S5 that directly penetrated the superior (pelvic)
e-mail: grigorba@yahoo.com surface of the LAM. Shafik [7] and Shafik and Doss [8]
described that the inferior rectal nerve (IRN) entered the
T. R. Olson : S. A. Downie
inferior surface of the LAM but did not elaborate on the
Department of Anatomy and Structural Biology, Albert Einstein
College of Medicine, specific innervation of each muscle of the LAM group.
Bronx, NY, USA Furthermore, pudendal nerve blockade studies provided
108
evidence for pudendal nerve innervation of the LAM [9].
However, other studies have contradicted the pudendal
nerve role in LAM innervation. Barber et al. [10] studied 12
fresh-frozen cadavers and found no evidence of pudendal
innervation of the LAM. They described the LAM
innervation as originating solely from the sacral nerve roots
S3, S4, and/or S5, which entered the superior surface of the
LAM. In a nonhuman primate model of the pelvic floor
musculature and continence, Pierce et al. [11] used neuro-
tracers in the female squirrel monkey and provided
evidence to suggest that LAM innervation received little
or no contribution from the pudendal nerve. Moreover,
other nonhuman nerve conduction studies [12] and neuro-
anatomic tracer studies [13] also suggested that the LAM
were innervated by the sacral nerves S3 and/or S4 from the
pelvic side of the muscles with no contribution from
pudendal nerve branches.
The purpose of this study is to describe the innervation
of each of the muscles that comprise the LAM (the PCM,
the ICM, and the PRM) in fixed female cadavers.
Materials and methods
The study protocol was submitted to the Institutional
Review Board and was deemed exempted. The cadavers
were obtained from the Department of Anatomy and
Structural Biology at the Albert Einstein College of
Medicine, Bronx, New York. Detailed pelvic dissections
were performed, with photo documentation for illustrative
purposes. We exposed the pelvic floor, the coccygeus
muscle, sacrospinous ligament, the ICM, PCM, and PRM,
the pudendal nerve, and the sacral nerve roots in 17
formaldehyde-fixed female cadavers, aged 62–95, using
abdominal, gluteal, and perineal approaches. The cadavers
were maintained with daily wetting with a solution of 10%
fabric softener and water. To facilitate dissection, all
cadavers were hemisected. The pudendal nerve, its
branches (IRN, perineal nerve, and dorsal nerve of the
clitoris), and all the sacral nerves that entered the pelvis
were traced in an anterograde fashion from their origin at
the anterior sacral foramina to their termination. To identify
the pelvic floor nerves, the entire course of all the nerves
was traced, while gradually dissecting each of the muscles
that constitute the LAM.
We identified pudendal nerve branches by the following
method: The pudendal nerve branches innervating the
clitoris were identified as the dorsal nerve of the clitoris,
the pudendal nerve branches terminating in the external
anal sphincter were named the IRN (“classical” IRN), and
the pudendal nerve branches terminating in the perineum
and innervating the perineal muscles and the urethra were
identified as the perineal nerve. All nerve fibers found to
Int Urogynecol J (2008) 19:107–116
innervate the LAM were identified according to their origin
in the sacral plexus.
The PCM was identified as the part of the LAM that
originated on the dorsal surface of the symphysis pubis that
passed posterior and caudal and inserted into the anococcy-
geal raphe and the coccyx. The ICM was identified as the
component muscle of the LAM attached to the ischial spine
and arcus tendineus levator ani laterally that passed medially
to form a midline raphe attached to the sacrum and coccyx.
The PRM was identified as the vertically oriented LAM
fibers, which originated medial to the PCM and ran inferior
to this muscle. The external anal sphincter, associated
closely with the anal canal, was located inferior to the
PRM and was attached to the perineal body. We further
distinguished PRM from the anal sphincter complex by
transilluminating one side of the dissected specimen with
bright light. The point at which it was not possible to shine
light through the muscle was determined to be the superior
aspect of the anal sphincter complex with its fascia and
associated tissue. Superior to this, the fiber direction of the
PRM and the PCM was transparent to the light.
All cadavers were dissected meticulously using a
magnifying lens, bright light, and standard surgical instru-
ments. All dissections were independently verified by two
of the authors (Olson and Downie).
To confirm our findings microscopically, specimens from
the first three dissected cadavers measuring 5 mm in length
were obtained from suspected nerve branches proximal to
their entry into the LAM. These biopsies were fixed in 4%
paraformaldehyde and embedded in paraffin. Sections were
stained with hematoxylin and eosin and Luxol Fast Blue and
were submitted for histological analysis.
Results
Cadaver characteristics
The mean cadaver age was 76.2 (SD=±11.7) years, the mean
cadaver height was 161.7 cm (SD=±15.3), and the mean
cadaver weight was 69.6 kg (SD=±11.6). In all 17 dissected
cadavers, we noted no difference between the left and right
hemipelves of the structures studied. With the exception of four
cadavers with evidence of a previous hysterectomy, all cadavers
had grossly normal pelves.
Pudendal nerve and its branches
In all 17 cadavers, the pudendal nerve originated from the
ventral divisions of the second, third, and fourth sacral
rami (S2, S3, and S4). The pudendal nerve then passed
between the piriformis and coccygeus muscles and exited
the pelvis through the greater sciatic foramen, posterior to
Int Urogynecol J (2008) 19:107–116
the sacrospinous ligament, and medial to the pudendal
artery. The pudendal nerve then entered the pudendal
canal where it divided into the perineal nerve and the
dorsal nerve of the clitoris branches in all cadavers. In ten
cadavers (58.8%), the pudendal nerve also branched into
the IRN (“classical” IRN), as described in the following
paragraph (Figs. 1, 2). After it exited the pudendal canal,
the perineal nerve extended branches that entered the PCM,
ICM, and PRM as described below (Table 1, Figs. 1, 2, 6a–
c). The dorsal nerve of the clitoris was not observed to send
branches to the LAM in any of the cadavers examined.
“Classical” IRN
In ten cadavers (58.8%), the IRN originated from the
pudendal nerve (“classical” IRN) in the proximal part of the
Fig. 1 Schematic diagram illustrating two patterns of innervation of the
levator ani muscles (LAM)—superior view. The nerves traveling on the
superior surface of LAM are shown as a continuous line and the nerves
coursing inferior to LAM are illustrated by a dashed line. a “Classical”
IRN distribution. LAM innervation in cadavers where the inferior
rectal nerve (IRN) originated from the pudendal nerve (PN, shown in
green). The PN branches into the dorsal nerve of the clitoris, perineal
nerve, and the IRN. The perineal nerve and the IRN send branches that
enter the inferior surface of the iliococcygeus (ICM), pubococcygeus
(PCM), and puborectalis (PRM) muscles. The dorsal nerve of the
clitoris terminates in the clitoris (not shown). b Variant IRN
distribution. LAM innervation in cadavers with an IRN variant (shown
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pudendal canal (Figs. 1a, 2). It reached the external anal
sphincter and the perianal skin in all ten cadavers by
traveling through the ischioanal fossa in an inferior-medial
direction. The nerve extended branches to LAM in six
cadavers (35.3%), which entered the inferior surface of the
PCM, ICM, and PRM in two (11.8%), two (11.8%), and six
(35.3%) cadavers, respectively (Table 1).
Variant IRN
In seven cadavers (41.2%), an anatomically variant IRN,
independent from the pudendal nerve, originated directly
from the S3 and/or S4 roots of the sacral plexus (Figs. 1b,
3a, b): from the S3 alone in two cadavers, from the S4
alone in three cadavers, and from both the S3 and S4 in two
cadavers. The variant IRN passed superior to the coccygeus
in blue) that originates directly from the sacral nerve plexus (S3 and/or
S4 roots). The IRN variant courses superior to the coccygeus muscle,
sends branches to the superior surface of the ICM, and penetrates the
coccygeus–sacrospinous ligament complex. The variant IRN then
travels inferior to the LAM and sends branches to the inferior surfaces
of PCM and PRM. PN divides into the dorsal nerve of the clitoris and
the perineal nerve with distribution similar to that shown in a. The
levator ani nerve (LAN) arises directly from S3 and/or S4 sacral nerve
roots (shown in yellow) and travels on the superior surface of the LAM
to innervate the ICM, PCM, and PRM. The LAN has the same
distribution in a and b. OIM Obturator internus muscle
110 Int Urogynecol J (2008) 19:107–116

nous ligament–coccygeus muscle complex (Figs. 1a, b, 3a,

b, 5a). In three cadavers, the nerves originated from the
sacral nerve root S3 (Fig. 3a, b), in three cadavers, the nerves
originated from the sacral nerve root S4, and in five cadavers,
the nerves originated from both the S3 and S4. The S3 and/or
S4 nerves passed over the superior surface of the ICM and
sent branches that entered directly into the superior surface of
the LAM, as described below (Table 1, Figs. 1a, b, 3a, b, 5a).
No direct LAM innervation from the sacral nerves that
entered the pelvis was observed to originate from the sacral
roots S1, S2, or S5 in any of the dissected cadavers.

LAM innervation

Fig. 2 Perineal view of puborectalis muscle (PRM) innervation by Pudendal nerve branches innervated the LAM in 15
perineal nerve branches. Left hemipelvis shown after removal of the cadavers (88.2%). The perineal and the IRN branches of
skin, subcutaneous tissues, and gluteus muscles. The pudendal canal the pudendal nerve innervated the LAM in 15 (88.2%) and
was opened to reveal the pudendal nerve branches. Within the
pudendal canal, the pudendal nerve branches into inferior rectal nerve
in 6 (35.3%) cadavers, respectively. We noted exclusive
(IRN) and perineal nerve (Perineal n.). The perineal nerve sends LAM innervation from the pudendal nerve branches in four
branches that enter the inferior (perineal) surface of the puborectalis
muscle (PRM). A metal probe was placed through the levator ani
muscles to demarcate the border between the pubococcygeus and the Table 1 Innervation of the levator ani muscles, the pubococcygeus,
PRM. The IRN is seen on its course to the external anal sphincter iliococcygeus, and puborectalis muscles
muscle (EASM). IT Ischial tuberosity
Cadaver PCM ICM PRM
Number
muscle in a lateral and caudal direction and extended nerve
branches that entered the superior surface of the ICM in 1 Perineal N+IRN* S3–S4 Perineal N+
three cadavers (17.6%; Figs. 1b, 3a, b). Next, the variant IRN*
IRN pierced the mid-portion of the sacrospinous ligament– 2 S3–S4 – Perineal N+
coccygeus muscle complex (Figs. 1b, 3a, b). After exiting IRN
the inferior surface of the sacrospinous ligament–coccygeus 3 Perineal N – Perineal N
4 Perineal N – Perineal N+
muscle complex, the variant IRN traveled on the inferior
IRN
surface of the ICM, entered the ischioanal fossa in a medial 5 Perineal N S3–S4 Perineal N+
and caudal direction, and ultimately extended nerve IRN
branches to the external anal sphincter and the perianal 6 Perineal N S3–S4 IRN*
skin (Figs. 6a–c). The variant IRN sent nerve branches to 7 S3–S4+IRN* S3–S4 S3–S4
six cadavers that entered the inferior surface of the PCM 8 Perineal N+IRN IRN IRN
and the PRM in four (23.5%) and five (29.4%) cadavers, 9 Perineal N+IRN* Perineal N+ Perineal N+
IRN* IRN*
respectively (Table 1, Figs. 4a, c). Cadavers with the variant
10 – S3–S4 S3–S4
IRN had no identifiable “classical” IRN branch originating 11 Perineal N+IRN+ IRN+S3–S4 Perineal N+
from the main trunk of the pudendal nerve (Figs. 1b, 6a). S3–S4 IRN
Conversely, cadavers with a “classical” IRN pattern had no 12 Perineal N S3–S4 Perineal N+
identifiable IRN variant present (Figs. 1a, 2). In one IRN*
cadaver, the perineal nerve extended a communicating 13 Perineal N+IRN*+ IRN*+ Perineal N+
branch, which joined the main trunk of the IRN variant S3–S4 S3–S4 IRN*
(Fig. 6b, c). Cadavers that displayed an IRN variant had 14 Perineal N+S3–S4 S3–S4 S3–S4
15 Perineal N Perineal N IRN
separate identifiable direct sacral S3 and/or S4 nerve
16 Perineal N+S3–S4 S3–S4 Perineal N
branches that innervated the LAM as described below. 17 IRN*+S3–S4 IRN*+ Perineal N
S3–S4
Direct sacral nerves S3 and/or S4 (levator ani nerve)
PCM Pubococcygeus muscle, ICM iliococcygeus muscle, PRM
puborectalis muscle, S3, S4, sacral nerves originating from sacral roots
In 12 cadavers (70.6%), nerve branches originating from S3 and/or S4 (levator ani nerve), Perineal N perineal nerve, IRN
the sacral roots S3 and/or S4 entered the pelvis, merged, “classical” inferior rectal nerve, IRN* variant inferior rectal nerve, – no
and coursed over the superior–medial surface of sacrospi- innervation was observed for the particular component muscle of LAM
Int Urogynecol J (2008) 19:107–116
Fig. 3 Nerve distribution across superior surface of right pelvic floor
in a cadaver with an inferior rectal nerve variant (IRN variant).
a Sagittal view of the right hemipelvis with bladder reflected anterior
out of view. Photograph of the levator ani nerve (LAN) and IRN
variant. b This is an outline drawing of the relevant structures shown
in a. Nerves from the S3 root extend branches that form the LAN, IRN
variant, and a nerve to the coccygeus muscle. The LAN courses
cadavers (23.5%). Variant IRN entered the LAM in seven
(41.2%) cadavers. Direct branches from the sacral nerves
S3 and/or S4 entered the LAM in 12 cadavers (70.6%). In
one cadaver (5.9%), the LAM were innervated exclusively
by direct branches from the sacral nerves S3 and/or S4.
Dual LAM innervation from both the pudendal nerve and
direct branches from the sacral nerves S3 and/or S4 were
noted in ten cadavers (58.8%; Table 1).
PCM innervation
The PCM received innervation from branches of the
pudendal nerve in 13 cadavers (76.5%). These branches
Fig. 4 Perineal view of pubococcygeus muscle (PCM) innervation by
inferior rectal nerve variant (IRN variant) branches. a This is a
photograph of the left hemipelvis. The skin, subcutaneous tissues, and
gluteus muscles have been removed, the sacrotuberous and the
sacrospinous ligaments have been dissected, and the pudendal canal
opened. The IRN variant originates independent of the pudendal nerve,
enters the ischioanal fossa, and sends branches to the PCM. The
perineal nerve (Perineal n) emerges from the pudendal canal and
enters the ischioanal fossa. b Sagittal view of the left hemipelvis. The
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superior to the coccygeus muscle (CM)–sacrospinous ligament (SSL)
complex and sends branches that enter the iliococcygeus muscle
(ICM). The IRN variant extends branches that enter the superior
surface of the CM and the ICM and then pierces the CM–SSL
complex. L5, S1, S2, S3, S4 Nerve roots originating from lumbar and
sacral foraminas
entered the inferior surface of the PCM. The perineal and
the IRN branches of the pudendal nerve innervated the
PCM in 13 (76.5%) and in 2 (11.8%) cadavers, respectively
(Fig. 1a, b). Variant IRN entered the PCM in five (29.4%)
cadavers (Figs. 1b, 4a, c). The PCM was innervated by
direct branches from the S3 and/or S4 nerves in seven
cadavers (41.2%) that entered the superior (pelvic) surface
of the PCM (Figs. 1a, b, 5a). Dual PCM innervation, from
both pudendal nerve and direct sacral nerves S3 and/or S4,
was observed in four cadavers (23.5%; Table 1). We could
not identify nerve branches to the PCM in one cadaver.
Table 2 shows the PCM innervation in the cadavers that
demonstrated the “classical” IRN versus the variant IRN.
bladder is reflected anterior; the rectum and the coccygeus muscle–
sacrospinous ligament complex were dissected. A metal probe is
inserted through the pelvic floor to mark the location of the pelvic
floor muscle innervated by the IRN variant in a. c Magnified perineal
view of the same left hemipelvis as in a and b with slight tensioning of
the IRN variant by pickups to illustrate small perforating nerve
branches entering the inferior surface of the PCM at the site of the
metal probe. IT Ischial tuberosity
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Fig. 5 Levator ani nerve on superior surface of the levator ani
muscles (LAM). a Sagittal view of the same left hemipelvis as in Fig.
4. The bladder is reflected further anterior to reveal the superior
surface of the LAM; the rectum and the coccygeus muscle–
sacrospinous ligament complex were dissected. The levator ani nerve
is shown innervating the superior surface of the LAM. Magnified
photograph of the same felt hemipelvis as in a. A metal probe was
inserted to mark the border between the pubococcygeus (PCM) and
the puborectalis muscles
ICM innervation
The ICM received innervation from branches of the
pudendal nerve in four cadavers (23.5%). These branches
entered the inferior surface of the ICM. The perineal and
the IRN branches of the pudendal nerve innervated the ICM
in two (11.8%) and in two (11.8%) cadavers, respectively
(Fig. 1a, b). Variant IRN entered the ICM in three (17.6%)
cadavers (Figs. 1b, 3a, b). In 11 cadavers (64.7%), the ICM
received innervation from the direct sacral nerves S3 and/or S4
(Figs. 3a, b, 5a). These nerve branches entered the superior
surface of the ICM. Dual ICM innervation, from both
pudendal nerve and direct sacral nerve branches S3 and/or
S4, was observed in one cadaver (5.9%; Table 1). We could
not identify nerve branches to the ICM in three dissected
cadavers. Table 2 shows the ICM innervation in the cadavers
that demonstrated the “classical” IRN versus the variant IRN.
Table 2 The pubococcygeus, iliococcygeus and puborectalis muscle innervation in cadavers with “classical” inferior rectal nerve versus cadavers
with variant inferior rectal nerve
Cadavers with “classical” inferior rectal nerve (n=10)
Pubococcyeus Iliococcygeus
muscle n (%) muscle n (%)
Perineal nerve 8 (80) 1 (10)
Inferior rectal nerve 2 (20) 2 (20)
S3 and/or S4 nerves 4 (40) 5 (50)
(levator ani nerve)
Int Urogynecol J (2008) 19:107–116
PRM innervation
The PRM received innervation from branches of the
pudendal nerve in 13 cadavers (76.5%). These nerves
entered the inferior surface of the PRM. The perineal and
the IRN branches of the pudendal nerve innervated the
PRM in 11 (64.7%) and in 6 (35.3%) cadavers, respectively
(Figs. 1a, b, 2, 6a–c). Variant IRN entered the PRM in five
(29.4%) cadavers (Fig. 1a, b). In three cadavers (17.6%),
the PRM received innervation directly from the sacral
nerves S3 and/or S4 (Figs. 1a, b, 5a). These branches
entered the superior surface of the PRM. There were no
cadavers that exhibited dual PRM innervation from both the
pudendal nerve and the direct sacral nerves S3 and/or S4
(Table 1). Table 2 shows the PRM innervation in the
cadavers that demonstrated the “classical” IRN versus the
variant IRN.
Histological analysis
An anatomic pathologist examined the tissue biopsies
submitted and confirmed that all the tissue samples entering
the LAM were myelinated nerves (Figs. 7, 8).
Lastly, there was complete agreement between our two
anatomists on all of the findings.
Discussion
During human evolution, the pelvic floor assumed the
inferior pole of the pelvic cavity. The human pelvic floor
evolved into a strong fibromuscular structure that met the
needs for reproduction, parturition, normal urination, and
defecation while resisting the downward pressure of the
abdomino-pelvic organs [1]. Despite its essential function
in the maintenance of continence (urinary, fecal) and
normal pelvic organ position, the pelvic floor and, in
particular, the LAM are few of the least studied and least
understood parts of the human anatomy [14].
Cadavers with variant inferior rectal nerve (n=7)
Puborectalis Pubococcyeus Iliococcygeus Puborectalis
muscle n (%) muscle n (%) muscle n (%) muscle n (%)
6 (60) 5 (71.4) 1 (14.3) 5 (71.4)
6 (60) 5 (71.4) 3 (42.9) 5 (71.4)
2 (20) 3 (42.9) 6 (85.7) 1 (14.3)
Int Urogynecol J (2008) 19:107–116
Fig. 6 Perineal view of inferior rectal nerve variant (IRN variant) and
perineal nerve (Perineal n.) on the inferior surface of the pelvic floor.
a This is a photograph of the same left hemipelvis as shown in Figs. 4
and 5. The skin, subcutaneous tissues, and gluteus muscles have been
removed, the sacrotuberous and the sacrospinous ligaments have been
dissected, and the pudendal canal opened. The ischioanal fossa has
been dissected to reveal the entire course of the nerves described in
Fig. 4. The perineal nerve (Perineal n) emerges from the pudendal
canal, enters the ischioanal fossa, and sends branches that curve back
to enter the inferior surface of the puborectalis muscle (PRM). The
metal probe is inserted at the border between the pubococcygeus
muscle and the PRM (see Fig. 5b). The IRN variant originates
Precise knowledge of LAM innervation could have
clinical implications for the management of stress urinary
incontinence. Pelvic floor physiotherapy with active pelvic
floor exercises in conjunction with pelvic electrical stimu-
lation and biofeedback has been shown to have variable
effectiveness in the conservative treatment of patients with
stress urinary incontinence [15–17]. One of the techniques
for pelvic electrical stimulation consists of active pudendal
nerve stimulation at the ischial spine by a 1-mm-thick
intravaginally placed electrode attached to the gloved index
finger of the examiner (e.g., St. Mark’s pudendal electrode,
Medtronic, Minneapolis, MN). Pudendal nerve electrical
Fig. 7 Histological analysis confirms nerve branch innervating
levator ani muscles. Microscope (5×) photograph of tissue biopsy
specimen fixed with 4% paraformaldehyde and embedded in paraffin.
Hematoxylin and eosin stain demonstrates nerve fiber (arrowheads).
Schwann cell nucleus (arrow) is visible
113
independent of the pudendal nerve, enters the ischioanal fossa, and
sends branches to the external anal sphincter. b Magnified section of
the same view as in Fig. 5a. This is a photograph showing the terminal
branches of the Perineal n and the IRN variant. The IRN variant is held
medially to show the Perineal n branches entering the PRM. c This is
an outline drawing of the relevant structures from Fig. 5b. The Perineal
n branches curve to enter the inferior surface of the PRM. The external
anal sphincter muscle (EASM) is distinguished from the PRM by its
location inferior to the PRM fibers and its close association with the
anal canal. The IRN variant nerve fibers innervate the EASM and the
perianal skin. A small communicating nerve from the Perineal n joins
the IRN variant
stimulation causes contraction of the striated periurethral
and pelvic floor muscles, helps strengthen LAM contrac-
tion, and results in increased urethral pressure [18]. In order
for electrical stimulation to be effective, the pelvic floor
musculature must have at least partial innervation from the
pudendal nerve. According to Barber et al. [10], the levator
ani nerve crossed the superior surface of the coccygeus
muscle and the LAM, at a mean distance of 3.2 cm medial
from the ischial spine. However, in view of the data
recently published by Wallner et al. [19] who suggests that
the levator ani nerve lies 8 mm medial to the ischial spine,
the courses of the pudendal and the levator ani nerves at the
Fig. 8 Histological analysis confirms myelinated nerve branch
innervating levator ani muscles. Microscope (5×) photograph of the
same biopsy specimen as in Fig. 7. Luxol Fast Blue stain, specific for
myelinated nerve tissue, demonstrates myelinated nerve fiber (arrow-
heads). Myelin-producing Schwann cell nucleus (arrow) is apparent
114
sacrospinous ligament may be too close to stimulate one
without stimulating the other.
The strong association between pudendal neuropathy
and pelvic floor dysfunction is well documented in the
literature. Several studies provide supporting evidence that
denervation of the LAM occurs in women with stress
urinary incontinence and prolapse and denervation of the
pudendal nerve may contribute to stress incontinence. In a
study of 11 women asymptomatic for urinary or fecal
incontinence, Anderson [20] performed single-fiber elec-
tromyography of the external anal sphincter in women with
stress urinary incontinence but without fecal incontinence
and found evidence of partial denervation. In a pudendal
nerve conduction study of 129 women, Smith et al. [21]
found that women with stress urinary incontinence had
delayed pudendal nerve conduction to both the striated
urethral muscle and to the PCM. Moreover, they found that
women with genitourinary prolapse and normal urine
control had comparable pudendal conduction times to the
striated urethral sphincter muscle but exhibited clear
evidence of pudendal denervation injury to the PCM.
Our findings demonstrate that in most cadavers studied,
the LAM received innervation mainly from the perineal and
the IRN branches of the pudendal nerve, and in the majority
of dissections, the LAM were also innervated by the direct
sacral nerves S3 and/or S4. We noted a variant IRN, which
innervated the LAM in more than one third of the cadavers
dissected. We did not observe direct LAM innervation from
the pelvic sacral nerves S1 or S5 in any of the dissected
cadavers. Our dissections are in agreement with the
majority of studies performed on LAM innervation, which
is described to originate from the second, third, and fourth
(S2, S3, and S4) spinal sacral segments. Thus, Mundy [5]
and Wedell-Smith and Wilson [22] showed that LAM
innervation originates from the S2, S3, and S4 sacral nerve
roots. Juenemann et al. [23] found that LAM were
innervated by nerves from S2, S3, and S4 and found no
evidence of S5 innervation. Wallner et al. [19] found that
the levator ani nerve originated from sacral nerve roots S3
and/or S4 with no contribution from S5. Consequently, it
may be suggested that injury to the pudendal nerve, the
direct sacral nerves S3 and/or S4, and/or the variant IRN
sustained during pelvic reconstructive surgery may affect
the innervation of the LAM.
Our study has some limitations. First, our sample size is
small, and therefore, our results should be regarded as
preliminary. However, our sample size of 17 cadavers is
comparable to other cadaver studies in the literature [7, 10,
11]. Second, in four cadavers, innervation to a certain part
of the LAM was not observed. This could be explained by
anatomic variations that exist in pelvic floor innervation [7,
22], or by possible nerve atrophy secondary to advanced
age, parturition [24], or pelvic surgery (in four of the
Int Urogynecol J (2008) 19:107–116
dissected cadavers). Nevertheless, we found evidence of
LAM innervation in all cadavers dissected. (Table 1). Third,
our cadaver population was exclusively female, and
therefore, our findings may not apply to the male anatomy.
However, our study of female cadavers renders any
conclusion regarding the LAM innervation in women more
applicable. Lastly, the cadavers we studied were formalde-
hyde fixed, and the effect of such fixation on anatomical
relationships is unknown.
Our dissections demonstrated variations of the IRN
origin and course. These IRN variations may be clinically
significant for pelvic reconstructive surgery and have also
been evidenced in other studies. Roberts and Taylor [25]
showed that IRN variants occurred in 20% of the 40 pelves
dissected where the IRN originated independently from the
sacral plexus and it pierced midway through the sacrospi-
nous ligament. Moreover, in an anatomical study of 37
cadavers, Mahakkanukrauh et al. [26] demonstrated that a
variant IRN, independent from the pudendal nerve, origi-
nated from the S4 root in 15 cadavers, and in 11%, the IRN
perforated through the fibers of the sacrospinous ligament,
1 cm medial to the ischial spine. We observed IRN variants
in 41% of the cadavers we dissected, where the IRN
originated independently from the sacral roots S3 and/or
S4, and perforated the mid-portion of the sacrospinous
ligament. Consequently, this renders the variant IRN
particularly liable to injury during sacrospinous ligament
(SSL) fixation procedures. Validation of our findings of an
IRN variant is supported by the innervation of the external
anal sphincter from the variant IRN nerve branches, the
demonstration of separate direct branches from the S3 and/
or S4 nerves innervating the LAM, and by the absence of
an identifiable “classical” IRN branch originating from the
main trunk of the pudendal nerve in the same cadavers.
Verification of anatomic dissections by two experienced
anatomists further supports our findings.
Variations also exist with regards to documented LAM
innervation [21]. Thus, somatic motor nerves innervating
the LAM may travel either with autonomic nerves from the
inferior hypogastric plexus [27], with autonomic fibers
from the pelvic splanchnic nerves [28], in branches of the
nerve to the anterior levator ani [29], or in direct nerve
branches from the sacral plexus [22]. Several cadaver
studies [10, 29] described a “levator ani nerve” originating
from the sacral nerves S3, S4, and/or S5, or from the sacral
nerve roots S3 and/or S4 [19, 23]. This is consistent with
our finding of direct sacral nerves S3 and/or S4 innervating
LAM in the majority of our dissections. While our study
contrasts to several recent dissections, which found no
evidence of LAM innervation by the pudendal nerve [10,
14], our findings are in agreement with many other
anatomical, physiological, and functional studies, which
confirm pudendal nerve innervation of the LAM and dual
Int Urogynecol J (2008) 19:107–116
innervation of the LAM from both direct sacral nerves and
pudendal nerve branches. Anatomic studies by Shafik [7]
and Shafik and Doss [8] found evidence that branches of
the pudendal nerve and IRN entered the inferior surface of
the LAM. Moreover, several studies found evidence of dual
LAM innervation from both direct sacral nerve branches
(levator ani nerve) and also from pudendal nerve branches
that were distributed to the undersurface of the LAM. Thus,
Lawson [6] found evidence that the pudendal nerve
branches innervated the inferior surface of LAM and the
direct sacral nerves entered the superior surface of LAM.
Sato [27] found evidence that LAM were innervated by a
pelvic sacral plexus nerve, but he noted that branches of the
perineal nerve and IRN entered the PRM segment of the
LAM. Physiological studies by Guaderrama et al. [9] found
that pudendal nerve blockade significantly decreased the
electromyographic activity of the PRM and vaginal
pressures and increased the length of urogenital hiatus,
thus providing evidence for LAM innervation by the
pudendal nerve. Electrophysiological studies by Smith et
al. [21] found strong evidence for pudendal nerve innerva-
tion of the PCM. While variations in pudendal nerve fibers
and, in particular, IRN variations were documented in the
literature [25, 26], to our knowledge, our study is the only
one describing LAM innervation in cadavers with an IRN
variant. These findings may account for some differences in
LAM innervation from other anatomic studies.
Damage to the pelvic floor, in particular by parturition,
has been postulated to result in denervation injury to the
LAM [2, 30, 31] and consequent pelvic organ prolapse and
urinary and fecal incontinence [32]. DeLancey et al. [33]
performed a magnetic resonance imaging (MRI) study of
the LAM and found no LAM abnormality in nulliparous
women, while 20% of parous women had visible LAM
defects on MRI. Hoyte et al. [34] compared pelvic floor
three-dimensional color mapping MRI images of asymp-
tomatic women with images of women with pelvic organ
prolapse and found that asymptomatic women had bulkier
PRM. Potential causes for these findings include LAM
atrophy resulting from denervation injury.
While the mechanism(s) by which obstetrical trauma from
vaginal childbirth affects pudendal and sacral innervation of
the LAM is unclear, a dual nerve supply might provide the
LAM with added protection against pelvic organ prolapse
and/or urinary and fecal incontinence. We observed dual
LAM innervation from both the pudendal and the direct
sacral nerves S3 and/or S4 in more than half of the cadavers
studied. There is ample evidence in the medical literature of
muscles with dual somatic nerve innervation: brachialis
muscle [35], pectoralis minor [36], and flexor digitorum
profundus [37] among others. Furthermore, the perineal
nerve and the “classical” IRN (originating from the
pudendal nerve in the pudendal canal) entered the inferior
115
surface of all muscles that constitute the LAM, while the
variant IRN (originating directly from the sacral plexus)
entered the superior surface of the ICM and the inferior
surface of the PCM and the PRM. In addition, direct
branches of the sacral nerves S3 and/or S4 also entered the
superior surface of the LAM. It may be suggested that a
positional difference in LAM innervation from the superior
and inferior surfaces of the pelvic floor may influence the
degree of vulnerability to parturition-induced nerve injury.
This postulation may deserve further study.
Finally, our findings demonstrated that individual muscle
components of the human LAM received different contri-
butions from the pudendal nerve, the direct sacral nerves S3
and/or S4 (levator ani nerve), or the variant IRN. Cadavers
that displayed the “classical” IRN and the cadavers that
showed the variant IRN had a constant LAM innervation
pattern: The PCM was primarily innervated by the perineal
nerve, while the PRM was equally innervated by the perineal
nerve and the IRN. Conversely, the ICM was mainly
innervated by the direct S3 and/or S4 nerves (levator ani
nerve) in both cadaver types. Overall, our study consistently
showed that the PCM were mainly innervated by the
pudendal nerve and secondarily by the direct S3 and/or S4
nerves (levator ani nerve) and the PRM were primarily
innervated by the pudendal nerve branches, while the ICM
was mainly innervated by the direct sacral nerves S3 and/or
S4 (levator ani nerve). As a result, nerve injury sustained
during parturition or pelvic reconstructive surgery may
selectively damage one and spare other LAM component
muscles. It may be suggested that the proportional difference
and/or variations in innervation of the PCM, PRM, and ICM
from the pudendal nerve and from the direct sacral nerves S3
and/or S4 may contribute to the observation that some
women tend to experience pelvic organ prolapse, while
others may be affected by urinary and/or fecal incontinence
after nerve injury. Caution should be exercised in extrapo-
lating our cadaver findings into clinical applications, and
therefore, our conclusions should be regarded as provisional.
Further studies are needed in this area.
Acknowledgments We are grateful to Radma S. Mahmood, Ph.D.,
and Rani Sellers, D.V.M., Ph.D., Department of Pathology, at the
Albert Einstein College of Medicine, Bronx, New York, for assistance
with histological analysis. We thank Tatyana Harris, Graphic Artist at
the Albert Einstein College of Medicine, Graphic Arts Center, Bronx,
New York, for her illustrations.
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