OJOG  Vol.4 No.7 , May 2014
The Perineal Membrane: Its Composite Fibers and Nerve Content, and Relationship to the Levator Ani and Deep Transverse Perineal Muscles
ABSTRACT

The perineal membrane (PM) is a thick, elastic fiber-rich, smooth muscle-poor membrane extending along the vestibule and lower vaginal wall and embedding the urethrovaginal sphincter and compressor urethrae muscles. To provide a better understanding of the topographical relationship between the PM and the levator ani muscle, we examined histological sections from 15 female cadavers. The composite fibers of the PM were usually continuous with that of a fascia covering the inferior or lateral surface of the levator ani (fascia diaphragmatis pelvis inferior) rather than the endopelvic fascia covering the superior or medial surface of the latter muscle. However, this fascial connection was sometimes interrupted by a venous plexus. The deep transverse perineal muscle was consistently adjacent to the posterolateral aspect of the PM, but whether it extended superficially or deeply to the PM depended on size of the muscle. In contrast to the endopelvic fascia embedding abundant middle-sized nerves (cavernous and sphincter nerves; 0.05 - 0.1 mm in thickness), the PM contained very thin nerves: many in 10 cadavers but few in 5 cadavers. Most of the nerves seemed to be sensory on the basis of immunohistochemistry. The levator ani muscle was considered likely to provide traction force to the PM, but active elevation appeared to be difficult because of the highly elastic nature of the PM and the interrupting venous plexus. Loss of nerves in the PM might be one of a number of factors that can accelerate pelvic organ prolapse.


Cite this paper
Kurokawa, T. , Hinata, N. , Sasaki, H. , Murakami, G. , Fujisawa, M. , Abe, S. and Yosida, Y. (2014) The Perineal Membrane: Its Composite Fibers and Nerve Content, and Relationship to the Levator Ani and Deep Transverse Perineal Muscles. Open Journal of Obstetrics and Gynecology, 4, 405-415. doi: 10.4236/ojog.2014.47061.
References
[1]   DeLancey, J.O. (1999) Structural Anatomy of the Posterior Pelvic Compartment as It Relates to Rectocele. American Journal of Obstetrics & Gynecology, 180, 815-823.
http://dx.doi.org/10.1016/S0002-9378(99)70652-6

[2]   Stein, T.A. and DeLancey, J.O. (2008) Structure of the Perineal Membrane in Females: Gross and Microscopic Anatomy. Obstetrics & Gynecology, 111, 686-893.
http://dx.doi.org/10.1097/AOG.0b013e318163a9a5

[3]   Kato, M., Matsubara, A., Murakami, G., et al. (2008) Female Perineal Membrane: A Study Using Pelvic Floor Semiserial Sections from Elderly Nulliparous and Multiparous Women. International Urogynecology Journal, 19, 1663-1670. http://dx.doi.org/10.1007/s00192-008-0701-0

[4]   Hinata, N., Murakami, G., Abe, S., et al. (2012) Detailed Histological Investigation of the Female Urethra: Application to Radical Cystectomy. The Journal of Urology, 187, 451-456.
http://dx.doi.org/10.1016/j.juro.2011.10.037

[5]   Sasaki, H., Hinata, N., Kurokawa, T. and Murakami, G. (2014) Supportive Tissues of the Vagina with Special Reference to a Fibrous Skeleton in the Perineum: A Review. Open Journal of Obstetrics and Gynecology, 144-157.

[6]   Standring, S. (2008) Gray’s Anatomy: The Anatomical Basis of Clinical Practice. Churchill Livingstone/Elsevier, Edinburgh.

[7]   Oelrich, T.M. (1983) The Striated Urogenital Sphincter Muscle in the Female. The Anatomical Record, 205, 223-232. http://dx.doi.org/10.1002/ar.1092050213

[8]   Fritsch, H., Lienemann, A., Brenner, E. and Ludwikowski, B. (2004) Clinical Anatomy of the Pelvic Floor. Advances in Anatomy, Embryology and Cell Biology, 175, 1-64. http://dx.doi.org/10.1007/978-3-642-18548-9

[9]   Hinata, N., Hieda, K., Sasaki, H., et al. (2014) Topohistology of Sympathetic and Parasympathetic Nerve Fibers in Branches of the Pelvic Plexus: An Immunohistochemical Study Using Donated Elderly Cadavers. Anatomy & Cell Biology, 47, 55-65. http://dx.doi.org/10.5115/acb.2014.47.1.55

[10]   Hinata, N., Hieda, K., Sasaki, H., et al. (2014) Nerves and Fasciae in and around the Paracolpium or Paravaginal Tissue: An Immunohistochemical Study Using Elderly Donated Cadavers. Anatomy & Cell Biology, 47, 44-54. http://dx.doi.org/10.5115/acb.2014.47.1.44

[11]   World Medical Association (2013) World Medical Association Declaration of Helsinki: Ethical Principles for Medical Research Involving Human Subjects. Journal of the American Medical Association, 310, 2191-2194. http://dx.doi.org/10.1001/jama.2013.281053

[12]   Hinata, N. and Murakami, G. (2014) The Urethral Rhabdosphincter, Levator Ani Muscle, and Perineal Membrane: A Review. BioMed Research International, 2014, Article ID: 906921.

[13]   Betschart, C., Scheiner, D., Maake, C., et al. (2008) Histomorphological Analysis of the Urogenital Diaphragm in Elderly Women: A Cadaver Study. International Urogynecology Journal, 19, 1477-1481. http://dx.doi.org/10.1007/s00192-008-0669-9

[14]   Arakawa, T., Murakami, G., Nakajima, F., et al. (2004) Morphologies of the Interfaces between the Levator Ani Muscle and Pelvic Viscera, with Special Reference to Muscle Insertion into the Anorectum in Elderly Japanese. Anatomical Science International, 79, 72-81. http://dx.doi.org/10.1111/j.1447-073x.2004.00069.x

[15]   Dingemans, K.P., Teeling, P., Lagendijk, J.H. and Becker, A.E. (2000) Extracellular Matrix of the Human Aortic Media: An Ultrastructural Histochemical and Immunohistochemical Study of the Adult Aortic Media. The Anatomical Record, 258, 1-14. http://dx.doi.org/10.1002/(SICI)1097-0185(20000101) 258:1<1::AID-AR1>3.0.CO;2-7

[16]   Hahn, M.S., Kobler, J.B., Starcher, B.C., Zeitels, S.M. and Langer, R. (2006) Quantitative and Comparative Studies of the Vocal Fold Extracellular Matrix. I: Elastic Fibers and Hyaluronic Acid. Annals of Otology, Rhinology, and Laryngology, 115, 156-164.

[17]   Korn, G.P., Martins, J.R., Park, S.W., Mendes, A., Kobayashi, E.Y., Nader, H.B., et al. (2011) Concentration of Hyaluronic Acid in Human Vocal Folds in Young and Old Subjects. Otolaryngology—Head and Neck Surgery, 145, 981-986. http://dx.doi.org/10.1177/0194599811419457

[18]   Kawase, T., Shibata, S., Katori, Y., Ohtsuka, A., Murakami, G. and Fujimiya, M. (2012) Elastic Fiber-Mediated Enthesis in the Human Middle Ear. Journal of Anatomy, 221, 331-340.
http://dx.doi.org/10.1111/j.1469-7580.2012.01542.x

[19]   Hinata, N., Murakami, G., Abe, S., Shibata, S., Morizane, S., Honda, M., et al. (2013) Coexistence of Elastic Fibers with Hyaluronic Acid in the Human Urethral Sphincter Complex: A Histological Study. The Journal of Urology, 190, 1313-1319. http://dx.doi.org/10.1016/j.juro.2013.04.023

[20]   Stecco, C., Porzionato, A., Macchi, V., Tiengo, C., Parenti, A., Aldegheri, R., et al. (2006) Histological Characteristics of the Deep Fascia of the Upper Limb. Italian Journal of Anatomy and Embryology, 111, 105-110.

[21]   Ochala, J., Frontera, W.R., Dorer, D.J., Van Hoecke, J. and Krivickas, L.S. (2007) Single Skeletal Muscle Fiber Elastic and Contractile Characteristics in Young and Older Men. The Journals of Gerontology Series A: Biological Sciences and Medical Sciences, 62, 375-381.
http://dx.doi.org/10.1016/j.juro.2013.04.023

[22]   Hayes, M.A. (1950) Abdominopelvic Fasciae. American Journal of Anatomy, 87, 119-161. http://dx.doi.org/10.1002/aja.1000870105

[23]   Nakajima, F., Takenaka, A., Uchiyama, E., Hata, F., Suzuki, D. and Murakami, G. (2007) Macroscopic and Histotopographic Study of the Deep Transverse Perineal Muscle (Musculus Transversus Perinei Profundus) in Elderly Japanese. Annals of Anatomy, 189, 65-74.
http://dx.doi.org/10.1002/aja.1000870105

[24]   Takenaka, A., Kawada, M., Murakami, G., Hisasue, S., Tsukamoto, T. and Fujisawa, M. (2005) Interindividual Variation in Distribution of Extramural Ganglion Cells in the Male Pelvis: A Semi-Quantitative and Immunohistochemical Study Concerning Nerve-Sparing Pelvic Surgery. European Urology, 48, 46-52.

[25]   Takenaka, A., Hara, R., Soga, H., Murakami, G. and Fujisawa, M. (2005) A Novel Technique for Approaching the Endopelvic Fascia in Retropubic Radical Prostatectomy, Based on an Anatomical Study of Fixed and Fresh Cadavers. BJU International, 95, 766-771.
http://dx.doi.org/10.1111/j.1464-410X.2005.05397.x

[26]   Hoyle, C.H., Stones, R.W., Robson, T., Whitley, K. and Burnstock, G. (1996) Innervation of Vasculature and Microvasculature of the Human Vagina by NOS and Neuropeptide-Containing Nerves. Journal of Anatomy, 188, 633-644.

[27]   Andres, K.H., von Düring, M. and Schmidt, R.F. (1985) Sensory Innervation of the Achilles Tendon by Group III and IV Afferent Fibers. Anatomy and Embryology (Berlin), 172, 145-156.
http://dx.doi.org/10.1007/BF00319597

[28]   Arruda, E.M., Calve, S, Dennis, R.G., Mundy, K. and Baar, K. (2006) Regional Variation of Tibialis Anterior Tendon Mechanics Is Lost Following Denervation. Journal of Applied Physiology, 101, 1113-1117. http://dx.doi.org/10.1152/japplphysiol.00612.2005

[29]   Ackermann, P.W., Ahmed, M. and Kreicbergs, A. (2002) Early Nerve Regeneration after Achilles Tendon Rupture—A Prerequisite for Healing? A Study in the Rat. Journal of Orthopaedic Research, 20, 849-856. http://dx.doi.org/10.1016/S0736-0266(01)00159-0

[30]   Carlsson, O., Schizas, N., Li, J. and Ackermann, P.W. (2011) Substance P Injections Enhance Tissue Proliferation and Regulate Sensory Nerve Ingrowth in Rat Tendon Repair. Scandinavian Journal of Medicine and Science in Sports, 21, 562-569. http://dx.doi.org/10.1111/j.1600-0838.2009.01080.x

[31]   Bonnet, P., Waltregny, D., Reul, O. and de Leval, J. (2005) Transobturator Vaginal Tape Inside out for the Surgical Treatment of Female Stress Urinary Incontinence: Anatomical Considerations. The Journal of Urology, 173, 1223-1228. http://dx.doi.org/10.1097/01.ju.0000148364.13525.7b

[32]   Vaze, A., Goldman, H., Jones, J.S., Rackley, R., Vasavada, S. and Gustafson, K.J. (2008) Determining the Course of the Dorsal Nerve of the Clitoris. Urology, 72, 1040-1043.
http://dx.doi.org/10.1016/j.urology.2008.07.029

[33]   Montoya, T.I., Calver, L., Carrick, K.S., Prats, J. and Corton, M.M. (2011) Anatomic Relationships of the Pudendal Nerve Branches. American Journal of Obstetrics and Gynecology, 205, 504.

[34]   Range, R.L. and Woodburne, R.T. (1964) The Gross and Microscopic Anatomy of the Transverse Cervical Ligament. American Journal of Obstetrics and Gynecology, 90, 460-467.

[35]   Kato, T., Murakami, G. and Yabuki, Y. (2002) Does the Cardinal Ligament of the Uterus Contain a Nerve That Should Be Preserved in Radical Hysterectomy? Anatomical Science International, 77, 161-168. http://dx.doi.org/10.1046/j.0022-7722.2002.00023.x

 
 
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