Research Article
The arterial blood supply of the symphysis pubis – Spatial orientated and highly variable

https://doi.org/10.1016/j.aanat.2020.151649Get rights and content

Abstract

Background

Open surgical treatment of the pubic region and adductor related pathologies require an exact knowledge of the arterial blood supply of the symphysis pubis that seems furthermore important to explain the hematogenous occurrence of symphysitis. Pubic bone marrow oedema (PBME) is a frequent occurring magnetic resonance imaging finding in groin pain. However, even asymptomatic athletes present PBME and a correlation to the physical activity or higher blood flow was suggested. Data on the vascular anatomy of the symphysis pubis are rare.

Methods

Ten formaldehyde-embalmed cadavers were dissected, and the arterial blood supply was investigated and photographically documented.

Results

In the majority of cases the following pattern was determined: superior–inferior epigastric artery (n = 12 hemipelves), inferior - dorsal artery of the penis/dorsal artery of the clitoris (n = 16), posterior- obturator artery (n = 16 hemipelves), anterior- deep external pudendal artery (n = 14 hemipelves). Besides variations for the deep external pudendal artery anteriorly, we observed a highly variable arterial supply, especially superior. Superior in 4/10 cadavers, inferior in 0/10 cadavers, posterior in 2/10 cadavers and anterior in 5/10 cadavers side variations were found.

Conclusion

The symphysis pubis has a spatial and rich organized arterial blood supply with several variations. Despite the symphysis pubis is recognized as bradytroph, the high number of vessels is presumably required in stress situations for example in heavy training.

Introduction

The varying pathologies of the symphysis pubis ranging from traumatic or postpartum disruptions (Osterhoff et al., 2012, Gill et al., 2017, Moed et al., 2019) as well as osteomyelitis as a complication after urological and gynaecological procedures (Degheili et al., 2018, Frederick et al., 2004, Ross and Hu, 2003) underline the interdisciplinary role and increasing interest in this region. Even in sports medicine the groin pain is the leading symptom of symphysis pubis pathologies related to bony, ligamentous or muscular affections (Weir et al., 2015, Sa et al., 2016).

Magnetic resonance imaging (MRI) is the radiological examination method of choice to detect groin pathologies (Brennan et al., 2005, Larbi et al., 2016, Sheen et al., 2014). Nonetheless, some assumed pathological findings like pubic bone marrow oedema (PBME) were high frequently found in asymptomatic athletes (Branci et al., 2013, Paajanen et al., 2008, Paajanen et al., 2019). PBME is characterized by an increased signal in fluid sensitive MRI sequences extending from the pubic bones to the symphysis pubis (Larbi et al., 2016, Branci et al., 2013, Verrall et al., 2001) probably as a sign of ligament instability. The involvement of the symphysis pubis was interpreted as mechanical overuse or subclinical contact injury (Paajanen et al., 2019). PBME might occur in asymptomatic athletes during heavy training (Paajanen et al., 2008). During a sports season, in 14% of investigated professional runners PBME occurred without a clinical consequence (Kornaat et al., 2014). But so far, the reason for PBME, especially in asymptomatic athletes, remains unclear. A higher arterial perfusion was suspected to induce PBME in a similar way that was reported for the patellar tendon (Proft et al., 2016). Furthermore, in a correlation study of MRI findings and histology the authors found neovascularization and in more severe cases cell migration and repair processes in pubic-related groin pain (Larbi et al., 2016).

Currently, the vascular anatomy of the symphysis in humans is sparsely examined. Data from an animal study (Da Rocha et al., 2004) yielded a high vascularization of the pubic ligaments. To re-evaluate earlier studies, we hypothesized a spatial distributed arterial blood supply orientated to the pubic ligaments as reported by Fick (Fick, 1904). Special attention has been directed to the spatial distribution and course variations of arteries.

Section snippets

Material and methods

Pelves were obtained from ten formaldehyde-embalmed cadavers (mean age, 82.8 years; range, 55–102 years; six males, four females, Supplemental Table 1) who signed for body donation for education and medical research according to the Japanese law (“Act on Body Donation for Medical and Dental Education”) during life. The study was approved by the Tokyo Medical University, Institutional Review Board (approval number: T2020-0050). The signed consents are available on reasonable request (Masahiro

Results

Results are summarized in Fig. 1 for the main findings and the spatial arterial distribution for each cadaver are summarized in Supplemental Table 2.

Discussion

Persisting groin pain involving the pubic region is a central reason for interrupting sport activities in athletes. Notably and in general, 80% of groin pathologies in athletes require surgery and approximately 40% of those are near or directly related to the symphysis pubis (Sa et al., 2016). In 70% of cases open surgical procedures are chosen to treat athletic pubalgia. Furthermore, open procedures are preferred for interventions on the adductor longus (Sa et al., 2016, Larbi et al., 2016).

Author contribution

Philipp Pieroh: Conceptualization, Methodology, Validation, Formal analysis, Investigation, Data curation, Writing – Original Draft, Visualization, Writing – Review & Editing.

Zhong-Lian Li: Methodology, Investigation, Writing – Review & Editing.

Shinichi Kawata: Methodology, Investigation, Writing – Review & Editing.

Yuki Ogawa: Resources, Validation, Writing – Review & Editing.

Christoph Josten: Supervision, Project administration, Writing – Review & Editing.

Hanno Steinke: Conceptualization,

Funding

The present study was funded by the Ichiro Kanehara Foundationwith the Chihiro and Kiyoko Yokochi Fund.

Ethical statement

Pelves were collected from cadavers who signed informed consent for agreement for body donation for education and medical research during life. The study was performed accordingly to the Japanese law (“Act on Body Donation for Medical and Dental Education”) and approved by the Tokyo Medical University, Institutional Review Board (approval number: T2020-0050). Signed consents are available on reasonable request from Masahiro Itoh.

Competing interest

The Ichiro Kanehara Foundation had no role in the design of the study, in the collection, analyses, or interpretation of data, in the writing of the manuscript, and in the decision to publish the results. The authors declare no further conflict of interest.

Data availability statement

The datasets generated during and/or analyzed during the current study are available from the first author on reasonable request.

Acknowledgment

The authors would like to thank the Ichiro Kanehara Foundation for funding and Hidenobu Miyaso, Kenta Nagahori, Takuya Omotehara for their help and interesting discussions. The authors thank Dr.med. Mara Sandrock for the illustration of Fig. 1.

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