Uterosacral injuries, or, "defects"

The consequences of vaginal delivery on the posterior axis of pelvic support along the uterosacral-rectovaginal-perineal axis, may not have been fully appreciated. At most laparoscopy lists you will see examples of avulsion, attenuation or asymmetry of uterosacral ligaments in women with chronic pelvic pain (Fig 1 & 2). The left uterosacral ligament is missing, the right is pulled out of its sheath, there is evidence of scarring - almost rupture - of the posterior aspect of the uterus, and, there are extensive varices
.

Treatment with GnRH provided temporary, though incomplete, relief. Immunohistochemistry of the uterine isthmus and uterosacral insertions showed extensive reinnervation. The pain was largely relieved after hysterectomy.

Attribution of pain is always controversial. Abnormal innervation inevitably contributes to pain - and it frequently recurs despite removal of all pelvic organs. The extent of the contribution of other injuries is less certain.