Superior hypogastric plexus !
The superior hypogastric plexus is a flat band of nerves in front of the lowest lumbar vertebra; it supplies the pelvic organs, including for ejaculation.
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What it is
A network of autonomic nerves in front of L5 and the sacrum, below the aortic split.
What it does
Helps control the bladder, bowel and sexual function.
Key facts
- Roots
- Aortic plexus plus lumbar splanchnic nerves (L1–L2); lies in front of L5 and the sacral promontory, between the common iliac arteries
- Moves
- Sympathetic to pelvic viscera via hypogastric nerves to the inferior hypogastric plexus; internal urethral sphincter, emission of semen
- Feeling from
- Visceral pain from pelvic organs above the pelvic pain line; injury in anterior L5–S1 approach can cause retrograde ejaculation
Relations
- In front
- Parietal peritoneum; the root of the sigmoid mesocolon and the superior rectal vessels to its left
- Behind
- Body of L5, the L5–S1 disc and the sacral promontory; the left common iliac vein and the median sacral vessels
- Lateral
- The common iliac arteries on each side, with the ureters further out crossing the pelvic brim
- Above
- Continuous with the intermesenteric (aortic) plexus at the aortic bifurcation (about L4)
- Below
- The hypogastric nerves, running into the pelvis to the inferior hypogastric plexuses, where the pelvic splanchnic nerves (S2–S4) join
How to find it
In an anterior approach to L5–S1 it lies in the loose retroperitoneal tissue over the disc, just below the aortic bifurcation; surgeons sweep it aside bluntly rather than cutting it or using electrocautery there.
On imaging
Not seen on imaging. It lies in front of the L5 vertebral body and the sacral promontory, just below the aortic bifurcation, and these are the landmarks. Fluoroscopy or CT guides the needle for a neurolytic block in pelvic cancer pain. Its position also explains a risk of anterior lumbar spine surgery at L5-S1: injury here can cause retrograde ejaculation.
Common problems
- Pain from pancreatic cancer can be eased by blocking it with an injection (celiac plexus block).
Clinical notes
- Retrograde ejaculation after anterior lumbar interbody fusion at L5–S1; cloudy urine after orgasm is the clue
- Superior hypogastric plexus block: for chronic pain from cancers of the uterus, cervix, bladder, prostate or rectum
- Presacral neurectomy (cutting the plexus) has been used for severe midline pelvic pain, such as from dysmenorrhoea or endometriosis
- Damage during rectal cancer surgery, together with the hypogastric nerves, causes ejaculatory and bladder dysfunction
Anatomical variants
- Its form varies: a single flat band, a network of strands or two or three parallel nerves; it often lies a little to the left of the midline (texts vary)
Test yourself
Think of the answer, then tap the question to see it.
Where is the superior hypogastric plexus?
In front of L5 and the sacral promontory, below the aortic bifurcation and between the common iliac arteries; it is sometimes called the presacral nerve.
What is the classic consequence of injuring the superior hypogastric plexus in anterior L5–S1 spine surgery?
Retrograde ejaculation, as its sympathetic fibres close the bladder neck during ejaculation; cloudy urine after orgasm is the clue.
How does the superior hypogastric plexus continue into the pelvis?
It splits into the right and left hypogastric nerves, which run to the inferior hypogastric plexuses, where the pelvic splanchnic nerves (S2–S4) join.
What is a superior hypogastric plexus block used for?
Chronic pain from cancers of the uterus, cervix, bladder, prostate or rectum.
Educational information, not medical advice. For any symptom, see a health professional.
Its names
- Official Latin (TA2)
- plexus hypogastricus superior TA2 6711
- Official Spanish (DeCS)
- Plexo hipogástrico superior DeCS D007001
- English (TA2)
- Superior hypogastric plexus
- Also called
- presacral nerve · plexus hypogastricus
Sources: Terminologia Anatomica (TA2); DeCS; Anatomy, Abdomen and Pelvis: Inferior Hypogastric Plexus; Anatomy, Abdomen and Pelvis, Nerves.
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Representative model, for educational purposes only.
