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Recommended standardized anatomic terminology of the posterior female pelvis and vulva based on a structured medical literature review

Published:March 08, 2021DOI:https://doi.org/10.1016/j.ajog.2021.02.033

      Background

      Anatomic terminology in both written and verbal forms has been shown to be inaccurate and imprecise.

      Objective

      Here, we aimed to (1) review published anatomic terminology as it relates to the posterior female pelvis, posterior vagina, and vulva; (2) compare these terms to “Terminologia Anatomica,” the internationally standardized terminology; and (3) compile standardized anatomic terms for improved communication and understanding.

      Study Design

      From inception of the study to April 6, 2018, MEDLINE database was used to search for 40 terms relevant to the posterior female pelvis and vulvar anatomy. Furthermore, 11 investigators reviewed identified abstracts and selected those reporting on posterior female pelvic and vulvar anatomy for full-text review. In addition, 11 textbook chapters were included in the study. Definitions of all pertinent anatomic terms were extracted for review.

      Results

      Overall, 486 anatomic terms were identified describing the vulva and posterior female pelvic anatomy, including the posterior vagina. “Terminologia Anatomica” has previously accepted 186 of these terms. Based on this literature review, we proposed the adoption of 11 new standardized anatomic terms, including 6 regional terms (anal sphincter complex, anorectum, genital-crural fold, interlabial sulcus, posterior vaginal compartment, and sacrospinous-coccygeus complex), 4 structural terms (greater vestibular duct, anal cushions, nerve to the levator ani, and labial fat pad), and 1 anatomic space (deep postanal space). In addition, the currently accepted term rectovaginal fascia or septum was identified as controversial and requires further research and definition before continued acceptance or rejection in medical communication.

      Conclusion

      This study highlighted the variability in the anatomic nomenclature used in describing the posterior female pelvis and vulva. Therefore, we recommended the use of standardized terminology to improve communication and education across medical and anatomic disciplines.

      Key words

      Introduction

      Anatomic knowledge and the understanding of pathology, affecting specific vital structures in the human body, are crucial to the practice of medicine. Inaccurate use of anatomic terms, particularly in surgical procedures, can lead to confusion about key steps and ambiguity about surgical procedures, ultimately affecting patient care and safety.
      • Greathouse D.G.
      • Halle J.S.
      • Dalley 2nd, A.F.
      Terminologia Anatomica: revised anatomical terminology.
      • Hirsch B.E.
      Does the Terminologia Anatomica really matter?.
      • Leonard R.J.
      • Acland R.D.
      • Cahill D.R.
      • et al.
      The clinical anatomy of several invasive procedures.
      Clear, standardized definitions of anatomic terms are necessary for the transfer of knowledge in medicine, health education, and research.

      Why was this study conducted?

      This study aimed to reconcile the widespread clinical use of anatomic terms, such as the vulva and posterior female pelvic anatomy, including the posterior vagina, with internationally accepted standardized anatomic terminology to facilitate clear communication among healthcare providers.

      Key findings

      We identified anatomic structures in the posterior female pelvis and vulva and provided a list of preferred terms along with a proposal of new terms.

      What does this add to what is known?

      This study provides a standardized anatomic terminology guide for unambiguous communication among healthcare providers, relating to the posterior female pelvis and vulva.
      In an effort to consolidate and improve communication about anatomy, the “Basle Terminologia Anatomica” was published in 1895 and significantly reduced the number of anatomic terms from 50,000 to 5000.
      • Gobée O.P.
      • Jansma D.
      • DeRuiter M.C.
      AnatomicalTerms.info: heading for an online solution to the anatomical synonym problem hurdles in data-reuse from the Terminologia Anatomica and the foundational model of anatomy and potentials for future development.
      In 1998, the Federative Committee on Anatomical Terminology, with broad representation from various anatomic organizations, published “Terminologia Anatomica” (TA) designed to be the international reference standard of anatomic terms.
      • Gobée O.P.
      • Jansma D.
      • DeRuiter M.C.
      AnatomicalTerms.info: heading for an online solution to the anatomical synonym problem hurdles in data-reuse from the Terminologia Anatomica and the foundational model of anatomy and potentials for future development.
      ,
      Federative Committee of Anatomical Terminology
      Terminológia anatomica: international anatomical terminology.
      However, TA has several limitations, such as lacking definitions for certain structures, not having precise descriptions of landmarks and planes used in surgical practice, and being written by a small number of experts with little transparency about the process of selecting terms.
      • Tunn R.
      • DeLancey J.O.
      • Quint E.E.
      Visibility of pelvic organ support system structures in magnetic resonance images without an endovaginal coil.
      ,
      • Butler-Manuel S.A.
      • Buttery L.D.
      • A’Hern R.P.
      • Polak J.M.
      • Barton D.P.
      Pelvic nerve plexus trauma at radical hysterectomy and simple hysterectomy: the nerve content of the uterine supporting ligaments.
      Updated in 2011, TA lacks information from imaging modalities and laboratory studies that have furthered the understanding of anatomy.
      Currently, the body of knowledge of female pelvic anatomy is described in several perspectives, including anatomy, radiology, and surgery.
      The Society of Gynecologic Surgeons (SGS) Pelvic Anatomy Group (PAG) was formed in 2016 to create a standardized list of terms for female pelvic anatomy and to address the limitations in current references, such as TA. The standardization of anatomic terms can help unify the medical literature and improve communication among researchers and clinicians. Previously, this group published the results of 2 reviews of anatomic terms and recommended standardized terminology for the anterior compartment
      • Jeppson P.C.
      • Balgobin S.
      • Washington B.B.
      • et al.
      Recommended standardized terminology of the anterior female pelvis based on a structured medical literature review.
      and apical segment
      • Balgobin S.
      • Jeppson P.C.
      • Wheeler 2nd, T.
      • et al.
      Standardized terminology of apical structures in the female pelvis based on a structured medical literature review.
      of the female pelvis. The primary aim of the current study was to review the literature, clarify ambiguous terms, reconcile multiple terms used for singular structures, and provide a list of new, clearly defined terms specific to the vulva and posterior female pelvis, including the posterior vagina.

      Materials and Methods

      The SGS PAG consists of gynecologic surgeons with extensive clinical, anatomic, surgical, and imaging expertise and physicians with vast experience in systematic review methodology. Based on our previous work on the anterior female pelvis
      • Jeppson P.C.
      • Balgobin S.
      • Washington B.B.
      • et al.
      Recommended standardized terminology of the anterior female pelvis based on a structured medical literature review.
      and apical structures in the female pelvis,
      • Balgobin S.
      • Jeppson P.C.
      • Wheeler 2nd, T.
      • et al.
      Standardized terminology of apical structures in the female pelvis based on a structured medical literature review.
      an extensive literature search was undertaken to identify relevant terms to the posterior female pelvis, posterior vagina, and vulva.
      The posterior pelvis was defined as the area inferior to the superior aspect of the sacrum, area dorsal to the posterior vaginal wall, area medial to the wing of the ilium, and area extending inferiorly to the perineum. The posterior margin extended to the skin but did not include the dermal layers of the skin. The vulva was defined as the area from the mons pubis to the anus and medial to the genital-crural folds, not extending proximally beyond the pubic bone. However, we excluded the adjacent pelvic viscera (ie, the rectum and anal anatomy superior to the pectinate line).
      For review of the literature, all study types were accepted, including primary clinical studies, narrative review articles, case reports, and studies that described surgical, cadaveric, and radiologic anatomies. Radiologic studies utilized computed tomography, magnetic resonance, sonography, and fluoroscopy. In addition, 11 textbook chapters were selected for review.
      • Walters M.D.
      • Karram M.M.
      Anatomy of the lower urinary tract, pelvic floor, and rectum.
      • Nichols D.H.
      • Randall C.L.
      Pelvic anatomy of the living.
      • Hansen J.T.
      Pelvis and perineum.
      • Baggish M.S.
      • Karram M.
      Advanced pelvic anatomy.
      • Baggish M.S.
      • Karram M.
      Basic pelvic anatomy.
      • Clarke-Pearson D.
      • Nichols D.
      Pelvic anatomy for the gynecologic surgeon.
      • Reiffenstuhl G.R.
      • Platzer W.
      • Batke F.
      Anatomical description.
      • Brant W.E.
      • Helms C.A.
      CT: MRI, and radiographic imaging.
      • Drake R.L.
      • VW
      • Mitchell A.W.M.
      • Vogl A.W.
      Pelvis and perineum.
      • Araghizadeh F.
      • Abdelnaby A.
      Anatomy and physiology.
      • Sutton D.
      Gynecologic imaging.
      The book chapters were selected to include relevant anatomic, surgical, and imaging terms from various medical disciplines and anatomy experts to ensure a broad representation of anatomic terminology. All terms were then compared with the terms in TA.
      Federative Committee of Anatomical Terminology
      Terminológia anatomica: international anatomical terminology.
      As our focus was on normal, adult female anatomy, literature and terms related to the following were excluded: (1) male anatomy, (2) subjects <18 years of age, (3) obstetrical- or postpartum-related anatomy, (4) histology, (5) cytology, (6) congenital anomalies, and (7) oncologic pathology. Furthermore, we excluded non-English manuscripts, meeting abstracts, video abstracts, and abstracts without full-text manuscripts.
      From inception of the study to April 6, 2018, MEDLINE was used to search the following terms, including MeSH terms when possible: ala, anal sphincter, Bartholin’s gland, bulbospongiosus, central tendon, clitoris, coccygeus, coccyx, Denonvillier’s, dorsal nerve, female genitalia, gluteal artery or vein, gluteus muscle, hymen, iliac crest, iliac spine, iliacus, introitus, ischiocavernosus, perineal muscle, perineal body, perineal membrane, perineal nerve, perineal artery or vein, piriformis, posterior vaginal wall, puborectalis, pudendal canal, sacrospinous ligament, sacrotuberous ligament, sacrum, sciatic nerve, Skene’s duct or gland, urogenital diaphragm, vestibule or vestibular, and vulva. As this was a review of previously published data, institutional review board approval was not required.
      Abstracts were screened by 11 reviewers using a computer software program, Abstrackr (http://abstrackr.cebm.brown.edu).
      • Wallace B.C.
      • Trikalinos T.A.
      • Lau J.
      • Brodley C.
      • Schmid C.H.
      Semi-automated screening of biomedical citations for systematic reviews.
      Based on the patterns of accepts or rejects, the software uses machine learning to identify the most relevant citations. Screening was completed in 2 phases owing to the large number of accepted abstracts. Book chapters were reviewed individually by reviewers.
      Phase 1 consisted of “mapping” in which abstracts were screened and common anatomic terms were identified. Each accepted abstract was grouped under a common anatomic term, randomly selected, and assigned to individual group members for review. An iterative approach was undertaken in which groups of 10 to 15 articles were reviewed concurrently. Consequently, we identified 14 common terms: anal sphincter, clitoris, labia or labium, perineum, pudendal, puborectalis, rectovaginal, sacrospinous, vulva, piriformis, Bartholin’s, sciatic, inferior gluteal artery, introitus, and “other.” Once a common term was deemed “saturated” (ie, appearing in 12 accepted manuscripts), it was excluded from further screening and extraction. To ensure adequate representation of the rarer terms, abstracts that were not initially assigned to a common anatomic term were selected for review at twice the rate of the common terms. This process was repeated until approximately 200 articles had been selected for full extraction. Based on our previous work
      • Jeppson P.C.
      • Balgobin S.
      • Washington B.B.
      • et al.
      Recommended standardized terminology of the anterior female pelvis based on a structured medical literature review.
      ,
      • Balgobin S.
      • Jeppson P.C.
      • Wheeler 2nd, T.
      • et al.
      Standardized terminology of apical structures in the female pelvis based on a structured medical literature review.
      and group consensus, inclusion of 200 articles seemed to offer a representative sample of the published literature while allowing for feasibility of the study.
      Phase 2 included full extraction of each article and book chapter distributed among the 11 reviewers. The following variables were collected in a standardized extraction form, including reported anatomic terms, author’s proposed definitions if available, publication year, country of origin, and study type. Anatomic terms were then matched to terms referenced in TA. Terms that did not have a corresponding term were recorded for further group review and discussion. Based on group consensus, these terms were identified and accepted as “proposed” new terms, rejected terms, or controversial terms that require further information. Anatomic terms that were identified as histologic entities (eg, fascia) were captured for planned future reviews. Finally, anatomic terms that were previously discussed in the anterior compartment and apical segment projects and not relevant to the posterior pelvis were excluded.
      • Jeppson P.C.
      • Balgobin S.
      • Washington B.B.
      • et al.
      Recommended standardized terminology of the anterior female pelvis based on a structured medical literature review.
      ,
      • Balgobin S.
      • Jeppson P.C.
      • Wheeler 2nd, T.
      • et al.
      Standardized terminology of apical structures in the female pelvis based on a structured medical literature review.
      In addition, 2 pelvic anatomy experts (M.M.C and J.D.) were consulted throughout the process.
      The preliminary findings were presented at the SGS 45th Annual Scientific Meeting in April 2019 in Tucson, AZ. Our complete results and drafted article were then submitted to the SGS Board of Directors for review and approval. Additional reviewers included both colorectal and urologic surgeons. Lastly, the project was subsequently distributed to the SGS membership community, which includes general and subspecialty gynecologists, for review.

      Results

      The literature search identified 22,872 abstracts of which 19,938 were excluded via an initial round of abstract review. After phase 1 review and “saturation” of common anatomic terms, full extraction was performed on 222 full-text articles and 11 book chapters. We rejected 15 full-text articles because of inability to isolate female-specific anatomic terms, terms related to malignancy, and the absence of predefined anatomic terms relevant to this review. A total of 486 separate terms were identified, and after group consensus, 222 terms were rejected because of being nondescriptive or outside of the scope of the posterior pelvis or vulva (Figure 1). The remaining 264 terms were then categorized into previously accepted terms in TA (Table 1) and proposed new terms (Table 2). Table 1 lists previously accepted terms in TA along with the nonpreferred synonyms noted in this review. Table 2 summarizes the proposed new terms and definitions that were developed on the basis of published literature and group consensus. Anatomic illustrations were included to further highlight posterior pelvic and vulvar anatomy along with incorporation of key proposed terms (Figures 2 and 3).
      Figure thumbnail gr1
      Figure 1Literature flow
      The asterisk indicates articles that were rejected if they contained male anatomy and abnormal pathology and/or lacked predefined anatomic terms.
      TA, Terminologia Anatomica.
      Hill et al. Standardized terminology of the posterior female pelvis and vulva. Am J Obstet Gynecol 2021.
      Table 1Accepted “Terminologia Anatomica” terms
      EnglishLatinUnique identification numberNumber of publications that used the English or Latin termNonpreferred synonyms (number of publications that used this term)
      Vulva
      Anterior commissureCommissura labiorum anteriorA09.2.01.0042
      Bulb of vestibuleBulbus vestibuliA09.2.01.01311Clitoral bulb (2)
      Greater vestibular glandGlandula vestibularis majorA09.2.01.0164Bartholin’s gland (19), major vestibular gland (1), vestibular gland (3)
      Perineal bodyCorpus perineale; centrum perineiA09.5.00.00535Central tendon (3)
      Clitoral bodyCorpus clitoridisA09.2.02.00314
      Clitoral crusCrus clitoridisA09.2.02.0023
      Clitoral frenulumFrenulum clitoridisA09.2.01.0108
      Clitoral glansGlans clitoridisA09.2.02.00418
      Clitoral prepucePreputium clitoridisA09.2.01.00914Clitoral hood (8)
      ClitorisClitorisA09.2.02.00127
      Corpora cavernosaCorpus cavernosum clitoridisA09.2.02.0055
      Crura or crurasCrus clitoridisA09.2.02.0026
      Paraurethal ductsDuctus paraurethralesA09.2.03.0152Skene’s gland ducts (2)
      Female external genitaliaOrgana genitalia feminine externaA09.2.00.0012
      Vestibular fossaFossa vestibuli vaginaeA09.2.01.0120Fossa navicularis (3)
      Labium majusLabium majus pudendiA09.2.01.0039Labia majora (30), greater labia (1)
      HymenHymenA09.1.04.00816Hymenal ring (8)
      Vaginal orificeOstium vaginaeA09.2.01.0153Introitus (41), vaginal entrance (1), vaginal opening (1), vaginal outlet (1)
      Labium minusLabium minus pudendiA09.2.01.0074Labia minora (31)
      Mons pubisMons pubisA09.2.01.0028
      Hymenal caruncleCaruncle hymenalesA09.1.04.0098
      Lesser vestibular glandsGlandulae vestibulares minoresA09.2.01.0170Paraurethral glands (2), Skene’s glands (2)
      PerineumPerineumA09.5.00.00152
      Perineal membraneMembrana perineiA09.5.03.00212Superficial perineal membrane (4)
      Posterior commissureCommissura labiorum posteriorA09.2.01.0045
      FourchetteFrenulum labiorum pudendiA09.2.01.0083Posterior fourchette (9), vaginal fourchette (2)
      VulvaVulva; pudendumA09.2.01.00143
      Suspensory ligamentLigamentum fundiforme clitoridisA04.5.02.0194
      Urogenital hiatusHiatus urogenitalisA04.5.04.0104
      VestibuleVestibulum vaginaeA09.2.01.01220Vulvar vestibule (2)
      Musculoskeletal
      Ala of sacrumAla ossis sacriA02.2.05.0041
      Pudendal canalCanalis pudendalisA09.5.04.00313Alcock’s canal (13)
      Superior gemellusMusculus gemellus superiorA04.7.02.0132
      Perineal musclesMusculi perineiA04.5.05.0011
      Anterior sacral foramenForamina sacralia anterioraA02.2.05.0123Sacral foramen (1)
      Bulbospongiosus muscleMusculus bulbospongiosusA09.5.02.00510Bulbocavernosus (16)
      Coccygeus muscleMusculus ischiococcygeus; musculus coccygeusA04.5.04.1118
      CoccyxOs coccygisA02.2.06.00122
      Gluteus maximus muscleMusculus gluteus maximusA04.7.02.00615
      Gluteus medius muscleMusculus gluteus mediusA04.7.02.0078
      Greater sciatic foramenForamen ischiadicum majusA03.6.03.00816Sciatic foramen (1), infrapiriform foramen (1)
      Greater sciatic notchIncisura ischiadica majorA02.5.01.00911Sciatic notch (1)
      IliumOs ilium; iliumA02.5.01.10111
      Iliac crestCrista iliacaA02.5.01.1065
      Iliac fossaFossa iliacaA02.5.01.1153
      IliacusIliacusA04.7.02.0031
      Iliococcygeus muscleMusculus iliococcygeusA04.5.04.00819
      Inferior gemellus muscleMusculus gemellus inferiorA04.7.02.0142
      Pubic tubercleTuberculum pubicumA02.5.01.3031
      Inguinal canalCanalis inguinalissA04.5.01.0262
      Pubovesicalis muscleMusculus pubovesicalisA04.5.03.0141
      Ischial ramiRamus ossis ischiiA02.5.01.2032
      Ischiocavernosus muscleMusculus ischiocavernosusA09.5.02.00411
      IschiumOs ischii; ischiumA02.5.01.20111
      Lesser sciatic foramenForamen ischiadicum minusA03.6.03.00911
      Pelvic parietal peritoneumPeritoneum parietaleA10.1.02.0051Peritoneum of the cul de sac (1)
      Pelvic inletApertura pelvis superiorA02.5.02.0081
      Pelvic outletApertura pelvis inferiorA02.5.02.0091
      Piriformis muscleMusculus piriformisA04.7.02.01138
      Posterior superior iliac spineSpina iliaca posterior inferiorA02.5.01.1148
      Posterior sacral foramenForamina sacralia posterioraA02.2.05.0151
      PromontoryPromontoriumA02.2.05.0031Sacral promontory (5)
      Psoas muscleMusculus psoas majorA04.7.02.0044
      Musculus psoas minorA04.7.02.005
      Rectococcygeus muscleMusculus rectococcygeusA05.7.04.0112
      Quadratus femoris muscleMusculus quadratus femorisA04.7.02.0152
      SacrumOs sacrum; vertebrae sacralesA02.2.05.00131Sacral body (1)
      Sacral baseBasis ossis sacriA02.2.05.0021
      Sacral canalCanalis sacralisA02.2.05.0191
      Sacrococcygeal jointArticulatio sacroiliacaA03.6.03.00110
      Sacral hiatusHiatus sacralisA02.2.05.0201
      Superficial transverse perineal muscleMusculi transversus perinei superficialisA09.5.02.00321
      External anal sphincter muscleMusculus sphincter ani externusA04.5.04.01261
      Subcutaneous external anal sphincter muscleMusculus sphincter ani externus pars subcutaneaA04.5.04.0134
      Internal anal sphincter muscleMusculus sphincter ani internusA05.7.05.01134
      Superficial external anal sphincter muscleMusculus sphincter ani externus pars superficialisA04.5.04.0145
      Anus
      AnusAnusA05.7.05.01311Anal orifice (2), anal aperture (1)
      Anal canalCanalis analisA05.7.05.00128
      Anocutaneous lineLinea anocutaneaA05.7.05.008Anal verge (1)
      Pectinate linePecten analisA05.7.0091Dentate line (1)
      Vagina
      Posterior vaginal fornixFornix vaginae pars posteriorA09.1.04.0041
      Posterior vaginaParies posteriorA09.1.04.00733
      Ligaments or fascia
      Rectovaginal fascia; rectovaginal septumFascia rectovaginalis; septum rectovaginaleA04.5.03.00433Denovillier’s fascia (7), rectogenital fascia (1), rectogenital septum (1), prerectal fascia (1)
      Iliococcygeal rapheRaphe musculi iliococcygeiA04.5.04.0182
      Inguinal ligamentLigamentum inguinale; arcus inguinalisA04.5.01.0091
      Anococcygeal body; anococcygeal ligamentCorpus anococcygeum; ligamentum anococcygeumA04.5.04.0166Anococcygeal raphe (1)
      Anterior sacrococcygeal ligamentLigamentum sacrococcygeum anterius or ligamentum sacrococcygeum anterius ventraleA03.2.08.0041
      Sacrococcygeal jointArticulatio sacroccocygealA03.2.08.0011
      Sacrospinous ligamentLigamentum sacrospinaleA03.6.03.00738
      Sacrotuberous ligamentLigamentum sacrotuberaleA03.6.03.00525
      Vasculature
      Perineal arteryArteria perinalisA12.2.15.04010Artery to the bulbocavernosus (1)
      Deep artery of the clitorisArteria profunda clitoridisA12.2.15.0450Clitoral artery (6)
      Anterior labial arteryLabiales anterioresA12.2.16.0151Labial artery (3), labial branch (1), labial minora artery (1)
      Posterior labial arteryLabiales posterioresA12.2.15.0414
      Artery to the bulbArteria bulbi vestibuliA12.2.15.0435
      Circumflex gluteal arteryArteria circumflexa ilium profundaA12.2.16.0081
      Coccygeal arteryGlomus coccygeumA12.2.12.0113
      Common iliac arteryArteria iliaca communisA12.2.14.0012
      Deep dorsal vein of the clitorisVenae dorsalis profunda clitoridisA12.3.10.0143Dorsal vein of the clitoris (2)
      Deep external pudendal arteryArteria pudenda externa profundaA12.2.16.0141
      Dorsal artery of the clitorisArteria dorsalis clitoridisA12.2.15.0448
      Inferior rectal arteryArteria rectalis inferiorA12.2.15.0397External hemorrhoidal artery (1), inferior hemorrhoidal artery (1)
      Inferior rectal veinVenae rectales inferioresA12.3.10.0216External hemorrhoidal vein (1), inferior rectal venous plexus (1)
      Iliolumbar arteryArteria iliolumbalisA12.2.15.0033
      Inferior gluteal arteryArteria glutaea inferiorA12.2.15.01821
      Inferior gluteal veinVenae gluteae inferioresA12.3.10.0063
      Internal pudendal arteryArteria pudenda internaA12.2.15.03826Inferior pudendal artery (1)
      Internal iliac arteryArteria iliaca internaA12.2.15.0015
      Internal iliac veinVena iliaca internaA12.3.10.0042
      Internal pudendal veinVenae pudenda internaA12.3.10.0198
      Lateral sacral arteriesArteria sacrales lateralesA12.2.15.0060Sacral artery (4)
      Vaginal arteryArteria vaginalisA12.2.15.0351
      Median sacral arteryArteria sacralis medianaA12.2.12.082
      Middle rectal arteryArteria rectalis mediaA12.2.15.0367Middle hemorrhoidal artery (1)
      Middle rectal veinsVenae rectales mediaeA12.3.10.0183Middle hemorrhoidal vein (1)
      Obturator arteryArteria obturatoriaA12.2.15.0084
      Obturator veinVenae obturatoriaeA12.3.10.0072
      Posterior labial veinVenae labiales posterioresA12.3.10.0222
      Superior gluteal arteryArteria glutea superiorA12.2.15.01310
      Superior gluteal veinVenae gluteae superioresA12.3.10.0052
      Superior rectal arteryArteria rectalis superiorA12.2.12.0732Superior hemorrhoidal artery (8)
      Superior rectal veinVenae rectalis superiorA12.3.12.0351Superior hemorrhoidal vein (3)
      Vaginal arteryArteria vaginalisA12.2.15.0356
      Vaginal venous plexusPlexus venosus vaginalisA12.3.10.0172Vaginal vein (2)
      Vein of the bulb of the vestibuleVenae bulbi vestibuliA12.3.10.0231
      Sacral venous plexusPlexus venosus sacralisA12.3.10.0091
      Regions or spaces
      Anal triangleRegio analisA01.2.06.0022
      Anorectal junctionJunctio anorectalisA05.7.05.0034
      Urogenital peritoneumPeritoneum urogenitaleA10.01.02.0510Cul de sac peritoneum (2)
      Intersphincteric grooveSulcus intersphinctericusA05.7.05.0122
      Female genital systemSystema genitale femininumA09.0.00.0013Genital tract (1)
      Urogenital triangleRegio urogenitalisA01.2.06.0033
      Deep perineal pouch; deep perineal spaceSaccus profundus perinei; spatium profundum perineiA09.5.03.0011
      Ischioanal fossaFossa ischioanalisA09.5.04.00110Ischiorectal fossa (17), ischiorectal space (2)
      Rectouterine pouchExcavatio rectouterinaA10.1.02.5125Pouch of Douglas (2)
      Rectouterine foldPlica rectouterinaA10.1.02.5111
      Superficial perineal pouch; superficial perineal compartment; superficial perineal spaceCompartimentum superficial perinei; spatium superficiale perineiA09.5.02.0011
      Nerves or lymph
      Sacral nerveNervi sacralesA14.2.06.00111Sacral roots (3), sacral segments (1)
      Sacral splanchnic nervesNervi splanchnici sacralesA14.3.01.0363
      Sacral gangliaGanglia sacraliaA14.3.01.035Sacral ventral trunk (1), sacral parasympathetic plexus (1)
      Perineal nerveNervi perinealesA14.2.07.03916Accessory nerve to the perineal muscles (1)
      Inferior anal nerves; inferior rectal nerveNervi anales inferiories; nervi rectales inferioresA14.2.07.03817Anal branch of pudendal nerve (1), inferior hemorrhoidal nerve (1)
      Dorsal nerve of the clitorisNervi dorsalis clitoridisA14.2.07.04216Clitoral nerve (2), anterior nerve branch of the clitoris (2)
      Coccygeal nerveNervi coccygeusA14.2.07.0432
      Coccygeal plexusPlexus coccygeusA14.2.07.0442
      Deep inguinal lymph nodesNodi inguinales profundiA13.05.0072
      Ganglion imparGanglion imparA14.3.01.0371
      Genital branch of the genitofemoral nerveNervi genitofemoralis genitalisA14.2.07.0091
      Femoral branch of the genitofemoral nerveNervi genitofemoralis femoralisA14.2.07.0101
      Genitofemoral nerveNervi genitofemoralisA14.2.07.0084
      Hypogastric nerveNervi hypogastricusA14.3.03.0475
      Iliohypogastric nerve; iliopubic nerveNervi iliohypogastricus; nervi iliopubicusA14.2.07.0032
      Ilioinguinal nerveNervi ilioinguinalisA14.2.07.0065
      Inferior gluteal nerveNervi gluteus inferiorA14.2.07.0328Posterior gluteal nerve (1)
      Inferior hypogastric plexus; pelvic plexusPlexus hypogastricus inferior; Plexus pelvicusA14.3.03.04812
      Posterior labial nervesNervi labiales posterioresA14.2.07.0401
      Obturator nerveNervi obturatoriusA14.2.07.129
      Pelvic gangliaGanglia pelvicaA14.3.02.0171Pelvic autonomic plexus (1)
      Pelvic splanchnic nerve; parasympathetic rootNervi splanchnici pelvici; radix parasympathicaA14.3.02.188
      Perforating cutaneous nerveNervi cutaneus perforansA14.2.07.0361
      Perineal branch of the posterior cutaneous nerve of the thighNervi cutaneus femoralis posterior perinealesA14.2.07.0351
      Sacral plexusPlexus sacralisA14.2.07.02711
      Sciatic nerveNervus ishciadicusA14.2.07.04634
      Anococcygeal nerveNervi anococcygeusA14.2.07.0451
      Superficial inguinal lymph nodesNodi inguinales superficialesA13.3.05.0035
      Superior gluteal nerveNervi gluteus superiorA14.2.07.0314
      Superior hypogastric plexus; presacral nervePlexus hypogastricus superior; nervi presacralisA14.3.03.0462
      External iliac lymph nodesNodi lymphodei iliaci externiA13.3.04.0092
      Inferior gluteal lymph nodesNodi gluteales inferiorsA13.3.04.0191
      Inguinal lymph nodesNodi lymphoidei inguinalesA13.3.05.0027Inguinofemoral lymph nodes (3)
      Interiliac nodesNodi interiliaciA13.3.04.0164
      Hill et al. Standardized terminology of the posterior female pelvis and vulva. Am J Obstet Gynecol 2021.
      Table 2Proposed terms
      Regional termsNonpreferred synonyms (number of publications that used this term)Definition
      EnglishNumber of publications that used the term
      Anal sphincter complex4A descriptive term to include all portions of the external and internal anal sphincter musculature
      Anorectum6Area where the rectum fuses with the anal canal during embryologic development
      Genital-crural fold1Groin crease, genital-femoral foldThe indentation between the upper medial thigh and the lateral aspect of the labium majus
      Interlabial sulcus1Labial sulcus (1)The groove where the medial aspect of the labium majus and lateral aspect of the labium minus intersect
      Posterior vaginal compartment6A region that includes the posterior vaginal wall from the perineal body epithelium distally to the rectouterine peritoneal fold proximally. It extends dorsally to the anterior rectal and anal walls and laterally to where the lateral walls of the posterior vagina join the connective tissue that attach to the bony pelvis
      Sacrospinous-coccygeus complex4A descriptive term to include both the sacrospinous ligament and overlying coccygeus muscle
      Structural terms
      Greater vestibular gland duct2Bartholin’s gland duct (2)A duct that supplies the greater vestibular gland
      Anal cushions2Endovascular cushions (1)Mucosal vascular prominences formed by clusters of veins surrounding the anal canal
      Nerve to the levator ani6A nerve originating from the sacral foramina (S3–S5) that supplies the levator ani muscles
      Labial fat pad1Bulbocavernosus fat pad (1)The fat that underlies the labium majus and is used during creation of the Martius labial interposition flap for pelvic surgery
      Spaces
      Deep postanal space1The space between the levator ani and the anococcyeal body. The anterior border is the deep external anal sphincter, the superior border is the levator ani, and the inferior border is the superficial anal sphincter as it inserts to the coccyx via the anococcygeal ligament. The space is contiguous with the ischioanal fossa
      Hill et al. Standardized terminology of the posterior female pelvis and vulva. Am J Obstet Gynecol 2021.
      Figure thumbnail gr2
      Figure 2Inferior view of the female perineum and vulvar structures
      Contents in the superficial pouch of the urogenital triangle and anal triangle are shown.
      Hill et al. Standardized terminology of the posterior female pelvis and vulva. Am J Obstet Gynecol 2021.
      Figure thumbnail gr3
      Figure 3Sagittal view of the female posterior pelvis
      Superficial pouch of the urogenital triangle with perineal muscles shown on the left and removed on the right. The perineal membrane separates the superficial pouch of the urogenital triangle from the deep pouch.
      Hill et al. Standardized terminology of the posterior female pelvis and vulva. Am J Obstet Gynecol 2021.

      Proposed new terms

      Regional terms

      These generalized terms describe an anatomic region rather than a definitive anatomic structure.
      • 1.
        Anal sphincter complex appeared in 4 citations
        • Shobeiri S.A.
        • White D.
        • Quiroz L.H.
        • Nihira M.A.
        Anterior and posterior compartment 3D endovaginal ultrasound anatomy based on direct histologic comparison.
        • Aigner F.
        • Zbar A.P.
        • Ludwikowski B.
        • Kreczy A.
        • Kovacs P.
        • Fritsch H.
        The rectogenital septum: morphology, function, and clinical relevance.
        • Karram M.
        • Maher C.
        Surgery for posterior vaginal wall prolapse.
        • Morgan D.M.
        • DeLancey J.O.
        • Guire K.E.
        • Fenner D.E.
        Symptoms of anal incontinence and difficult defecation among women with prolapse and a matched control cohort.
        from 3 countries (Australia, Austria, and the United States) from 2004 to 2013. A synonym noted was “anal sphincter muscles.” The anal sphincter complex is a grouping term that can be used when describing all portions of the external and internal anal sphincter muscles.
      • 2.
        Anorectum was used in 6 citations
        • Woodman P.J.
        • Graney D.O.
        Anatomy and physiology of the female perineal body with relevance to obstetrical injury and repair.
        • Volloyhaug I.
        • Wong V.
        • Shek K.L.
        • Dietz H.P.
        Does levator avulsion cause distension of the genital hiatus and perineal body?.
        • Abendstein B.
        • Petros P.E.
        • Richardson P.A.
        • Goeschen K.
        • Dodero D.
        The surgical anatomy of rectocele and anterior rectal wall intussusception.
        • Rao S.S.
        Pathophysiology of adult fecal incontinence.
        • Farouk R.
        • Bartolo D.C.
        The clinical contribution of integrated laboratory and ambulatory anorectal physiology assessment in faecal incontinence.
        • Shek K.L.
        • Dietz H.P.
        Pelvic floor ultrasonography: an update.
        from 1993 to 2013 from 4 countries (Austria, Australia, Norway, and the United States). As this term was not specifically defined in the selected articles, we propose this term as the area where the rectum fuses with the anal canal during embryologic development. This was primarily described in radiographic imaging studies and in gross anatomy reviews.
      • 3.
        Genital-crural fold appeared in 1 citation
        • Spear S.L.
        • Pellegrino C.J.
        • Attinger C.E.
        • Potkul R.K.
        Vulvar reconstruction using a mons pubis flap.
        from 1994 from the United Sates. This term describes the groove between the superior medial thigh and the lateral aspect of the labium majus. A nonpreferred synonym was “groin crease.”
      • 4.
        Interlabial sulcus was used in 1 citation
        • Placik O.J.
        • Arkins J.P.
        A prospective evaluation of female external genitalia sensitivity to pressure following labia minora reduction and clitoral hood reduction.
        from 2015 from the United Sates. A nonpreferred synonym noted was “labial sulcus.” This term describes the groove where the medial aspect of the labium majus and the lateral aspect of the labium minus intersect.
      • 5.
        Posterior vaginal compartment was used in 6 citations
        • Shobeiri S.A.
        • White D.
        • Quiroz L.H.
        • Nihira M.A.
        Anterior and posterior compartment 3D endovaginal ultrasound anatomy based on direct histologic comparison.
        ,
        • Shek K.L.
        • Dietz H.P.
        Pelvic floor ultrasonography: an update.
        ,
        • Campagna G.
        • Panico G.
        • Morciano A.
        • et al.
        Vaginal mesh repair SYSTEMS for pelvic organ prolapse: anatomical study comparing transobturator/trangluteal versus single incision techniques.
        • Huebner M.
        • Rall K.
        • Brucker S.Y.
        • Reisenauer C.
        • Siegmann-Luz K.C.
        • DeLancey J.O.
        The rectovaginal septum: visible on magnetic resonance images of women with Mayer-Rokitansky-Kuster-Hauser syndrome (Mullerian agenesis).
        • Rovner E.S.
        • Ginsberg D.A.
        Posterior vaginal wall prolapse: transvaginal repair of pelvic floor relaxation, rectocele, and perineal laxity.
        • Bureau M.
        • Carlson K.V.
        Pelvic organ prolapse: a primer for urologists.
        from 2001 to 2018 from 5 countries (Australia, Canada, Italy, Germany, and the United States). This region is defined as that includes the posterior vaginal wall from the epithelium of the perineal body distally to the rectouterine peritoneal fold proximally. It extends dorsally to the anterior rectal and anal canal walls and laterally to where the lateral walls of the posterior vagina join the connective tissue that attach to the bony pelvis.
      • 6.
        Sacrospinous-coccygeus complex appeared in 3 citations
        • Florian-Rodriguez M.E.
        • Hare A.
        • Chin K.
        • Phelan J.N.
        • Ripperda C.M.
        • Corton M.M.
        Inferior gluteal and other nerves associated with sacrospinous ligament: a cadaver study.
        • Maldonado P.A.
        • Carrick K.S.
        • Montoya T.I.
        • Corton M.M.
        Posterior vaginal compartment anatomy: implications for surgical repair.
        • Pollak J.
        • Takacs P.
        • Medina C.
        Complications of three sacrospinous ligament fixation techniques.
        from 2007 to 2016 from 1 country (the United States). The sacrospinous-coccygeus complex includes both the sacrospinous ligament and overlying coccygeus muscle. These structures have the same attachment points and represent the apical fixation point during sacrospinous ligament fixation procedures.

      Structural terms

      • 1.
        Greater vestibular duct appeared in 2 citations
        • Jacobson P.
        Vulvovaginal (Bartholin) cyst treatment by marsupialization.
        ,
        • Apostolis C.A.
        • Von Bargen E.C.
        • DiSciullo A.J.
        Atypical presentation of a vaginal epithelial inclusion cyst.
        from 1950 to 2012 from 1 country (the United States). The nonpreferred synonym noted in the literature was “Bartholin’s gland duct.” This term is used to describe a duct that supplies the greater vestibular gland.
      • 2.
        Anal cushions was used in 2 citations
        • Rao S.S.
        Pathophysiology of adult fecal incontinence.
        ,
        • Nicholls M.J.
        • Dunham R.
        • O’Herlihy S.
        • Finan P.J.
        • Sagar P.M.
        • Burke D.
        Measurement of the anal cushions by transvaginal ultrasonography.
        from 2004 to 2006 from 2 countries (the United Kingdom and United States). The nonpreferred synonym identified in the literature was “endovascular cushions.” This term describes the mucosal vascular prominences formed by clusters of veins surrounding the anal canal.
      • 3.
        Nerve to levator ani appeared in 6 citations
        • Walters M.D.
        • Karram M.M.
        Anatomy of the lower urinary tract, pelvic floor, and rectum.
        ,
        • Florian-Rodriguez M.E.
        • Hare A.
        • Chin K.
        • Phelan J.N.
        • Ripperda C.M.
        • Corton M.M.
        Inferior gluteal and other nerves associated with sacrospinous ligament: a cadaver study.
        ,
        • Yeung J.
        • Pauls R.N.
        Anatomy of the vulva and the female sexual response.
        • Wallner C.
        • Maas C.P.
        • Dabhoiwala N.F.
        • Lamers W.H.
        • DeRuiter M.C.
        Innervation of the pelvic floor muscles: a reappraisal for the levator ani nerve.
        • Barber M.D.
        • Bremer R.E.
        • Thor K.B.
        • Dolber P.C.
        • Kuehl T.J.
        • Coates K.W.
        Innervation of the female levator ani muscles.
        • Katrikh A.Z.
        • Ettarh R.
        • Kahn M.A.
        Cadaveric nerve and artery proximity to sacrospinous ligament fixation sutures placed by a suture-capturing device.
        from 2006 to 2018 from 2 countries (the Netherlands and the United States). This nerve is described as originating from the third through fifth sacral nerve roots (S3–S5) and supplying the levator ani muscles from their superior or pelvic surface.
      • 4.
        Labial fat pad was used in 1 citation
        • Le A.
        • Shan L.
        • Wang Z.
        • Dai X.
        • Xiao T.
        • Shen Y.
        Transvaginal repair of rectovaginal fistula by filling with bulbocavernosus fat pad and retaining scar tissue.
        in 2013 from China. The nonpreferred synonym was “bulbocavernosus fat pad.” This term is used to describe the fat that underlies the labium majus and is used during creation of the Martius labial interposition flap for pelvic surgery.

      Anatomic spaces

      • 1.
        Deep postanal space was used in 1 citation
        • Apostolis C.A.
        • Von Bargen E.C.
        • DiSciullo A.J.
        Atypical presentation of a vaginal epithelial inclusion cyst.
        from 2012 from the United States. This space is described as the region between the levator ani and the anococcygeal body, including the pubococcygeal tendon, iliococcygeal raphe, and attachment of the superficial external anal sphincter. The anterior border is the deep part of the external anal sphincter, the superior border is the inferior surface of the levator ani muscles, and the inferior border is the superficial part of the anal sphincter as it inserts to the coccyx via the anococcygeal body. This space can be relevant in location and treatment of anal fistulas and/or abscesses.

      Controversial term

      • 1.
        Rectovaginal fascia or rectovaginal septum was described in 33 citations
        • Nichols D.H.
        • Randall C.L.
        Pelvic anatomy of the living.
        • Hansen J.T.
        Pelvis and perineum.
        • Baggish M.S.
        • Karram M.
        Advanced pelvic anatomy.
        ,
        • Clarke-Pearson D.
        • Nichols D.
        Pelvic anatomy for the gynecologic surgeon.
        ,
        • Reiffenstuhl G.R.
        • Platzer W.
        • Batke F.
        Anatomical description.
        ,
        • Shobeiri S.A.
        • White D.
        • Quiroz L.H.
        • Nihira M.A.
        Anterior and posterior compartment 3D endovaginal ultrasound anatomy based on direct histologic comparison.
        ,
        • Karram M.
        • Maher C.
        Surgery for posterior vaginal wall prolapse.
        ,
        • Woodman P.J.
        • Graney D.O.
        Anatomy and physiology of the female perineal body with relevance to obstetrical injury and repair.
        ,
        • Abendstein B.
        • Petros P.E.
        • Richardson P.A.
        • Goeschen K.
        • Dodero D.
        The surgical anatomy of rectocele and anterior rectal wall intussusception.
        ,
        • Shek K.L.
        • Dietz H.P.
        Pelvic floor ultrasonography: an update.
        ,
        • Campagna G.
        • Panico G.
        • Morciano A.
        • et al.
        Vaginal mesh repair SYSTEMS for pelvic organ prolapse: anatomical study comparing transobturator/trangluteal versus single incision techniques.
        ,
        • Huebner M.
        • Rall K.
        • Brucker S.Y.
        • Reisenauer C.
        • Siegmann-Luz K.C.
        • DeLancey J.O.
        The rectovaginal septum: visible on magnetic resonance images of women with Mayer-Rokitansky-Kuster-Hauser syndrome (Mullerian agenesis).
        ,
        • Bureau M.
        • Carlson K.V.
        Pelvic organ prolapse: a primer for urologists.
        ,
        • Onodera H.
        • Nagayama S.
        • Kohmoto I.
        • Maetani S.
        • Imamura M.
        Novel surgical repair with bilateral gluteus muscle patching for intractable rectovaginal fistula.
        • Cundiff G.W.
        • Weidner A.C.
        • Visco A.G.
        • Addison W.A.
        • Bump R.C.
        An anatomic and functional assessment of the discrete defect rectocele repair.
        • Ghafar M.A.
        • Chesson R.R.
        • Velasco C.
        • Slocum P.
        • Winters J.C.
        Size of urogenital hiatus as a potential risk factor for emptying disorders after pelvic prolapse repair.
        • Milani R.
        • Frigerio M.
        • Vellucci F.L.
        • Palmieri S.
        • Spelzini F.
        • Manodoro S.
        Transvaginal native-tissue repair of vaginal vault prolapse.
        • Richardson A.C.
        The rectovaginal septum revisited: its relationship to rectocele and its importance in rectocele repair.
        • Stecco C.
        • Macchi V.
        • Porzionato A.
        • et al.
        Histotopographic study of the rectovaginal septum.
        • Barbalat Y.
        • Tunuguntla H.S.
        Surgery for pelvic organ prolapse: a historical perspective.
        • Fowler Jr., R.
        Landmarks and legends of the anal canal.
        • Nano M.
        • Ferronato M.
        • Solej M.
        • D’Amico S.
        A novel technique for rectocele repair in elderly women.
        • Mercês R.L.
        • Pisi P.H.
        • Balestrim Filho A.
        • Braga T.A.
        • Rocha J.J.
        • Féres O.
        Surgical treatment of traumatic cloaca.
        • Merchea A.
        • Larson D.W.
        • Hubner M.
        • Wenger D.E.
        • Rose P.S.
        • Dozois E.J.
        The value of preoperative biopsy in the management of solid presacral tumors.
        • Stricker J.W.
        • Schoetz Jr., D.J.
        • Coller J.A.
        • Veidenheimer M.C.
        Surgical correction of anal incontinence.
        • Baker H.W.
        Dyspareunia due to conditions of the introitus.
        • Lukacz E.S.
        • Luber K.M.
        Rectocele repair: when and how?.
        • Miklos J.R.
        • Kohli N.
        • Moore R.
        Levatorplasty release and reconstruction of rectovaginal septum using allogenic dermal graft.
        • Angioni S.
        • Pontis A.
        • Dessole M.
        • Surico D.
        • De Cicco Nardone C.
        • Melis I.
        Pain control and quality of life after laparoscopic en-block resection of deep infiltrating endometriosis (DIE) vs. incomplete surgical treatment with or without GnRHa administration after surgery.
        • Stadnik H.
        • Kościński T.M.
        Prosthetic materials for treating posterior vaginal wall prolapse and rectocele—own experience.
        from 11 countries (Australia, Austria, Brazil, Canada, Germany, Italy, Japan, Poland, Switzerland, the United Kingdom, and the United States) from 1996 to 2018. Nonpreferred synonyms included Denonvillier’s fascia,
        • Clarke-Pearson D.
        • Nichols D.
        Pelvic anatomy for the gynecologic surgeon.
        ,
        • Araghizadeh F.
        • Abdelnaby A.
        Anatomy and physiology.
        ,
        • Woodman P.J.
        • Graney D.O.
        Anatomy and physiology of the female perineal body with relevance to obstetrical injury and repair.
        ,
        • Richardson A.C.
        The rectovaginal septum revisited: its relationship to rectocele and its importance in rectocele repair.
        ,
        • Lukacz E.S.
        • Luber K.M.
        Rectocele repair: when and how?.
        ,
        • Tamakawa M.
        • Murakami G.
        • Takashima K.
        • Kato T.
        • Hareyama M.
        Fascial structures and autonomic nerves in the female pelvis: a study using macroscopic slices and their corresponding histology.
        ,
        • Kraima A.C.
        • West N.P.
        • Treanor D.
        • et al.
        Whole mount microscopic sections reveal that Denonvilliers’ fascia is one entity and adherent to the mesorectal fascia; implications for the anterior plane in total mesorectal excision?.
        rectogenital fascia,
        • Aigner F.
        • Zbar A.P.
        • Ludwikowski B.
        • Kreczy A.
        • Kovacs P.
        • Fritsch H.
        The rectogenital septum: morphology, function, and clinical relevance.
        rectogenital septum,
        • Aigner F.
        • Zbar A.P.
        • Ludwikowski B.
        • Kreczy A.
        • Kovacs P.
        • Fritsch H.
        The rectogenital septum: morphology, function, and clinical relevance.
        and prerectal fascia.
        • Rovner E.S.
        • Ginsberg D.A.
        Posterior vaginal wall prolapse: transvaginal repair of pelvic floor relaxation, rectocele, and perineal laxity.
        TA recognizes this as an anatomic structure, and it has been widely used in anatomic literature. However, more recent investigations have failed to identify a distinct dense fibroconnective tissue “fascial” layer between the anterior rectal wall and posterior vaginal wall.
        • Maldonado P.A.
        • Carrick K.S.
        • Montoya T.I.
        • Corton M.M.
        Posterior vaginal compartment anatomy: implications for surgical repair.
        Further histologic investigation is needed, as there is insufficient evidence to support or refute continued use of this term.

      Comment

      Principal findings

      The purpose of this review was to identify, describe, and standardize anatomic terms in the literature related to the posterior female pelvis and vulva. Similar to our group’s previous work, we identified the lack of standardized anatomic terminology and notable inconsistencies in the medical literature.

      Results

      After review, we proposed 6 new regional terms (anal sphincter complex, anorectum, genital-crural fold, interlabial sulcus, posterior vaginal compartment, and sacrospinous-coccygeus complex), 4 anatomic terms (greater vestibular duct, anal cushions, nerve to levator ani, and labial fat pad), 1 anatomic space (deep postanal space), and 1 controversial term (rectovaginal fascia; rectovaginal septum).

      Clinical implications

      Throughout this review, as with our previous reviews, the use of eponyms was notable. Eponyms, or terms named after their discoverers, are prevalent throughout medical communication and education. In obstetrics and gynecology, eponyms exist in many domains, including anatomic structures, surgical instruments, surgical procedures, incisions, disease states, scoring systems, physical examination findings, and diagnostic tests.
      • Baskett T.
      On the shoulders of giants: eponyms and names in obstetrics and gynecology.
      For example, 2 particular terms, “Bartholin’s gland” and “Fallopian tube,” are in such common use and have become so entrenched in the anatomic lexicon that they are often spelled without capitalization.
      • Balgobin S.
      • Jeppson P.C.
      • Wheeler 2nd, T.
      • et al.
      Standardized terminology of apical structures in the female pelvis based on a structured medical literature review.
      ,
      • Baskett T.
      On the shoulders of giants: eponyms and names in obstetrics and gynecology.
      Although such terms may add historic significance and a more human side to the technical aspects of medicine, they are often a source of confusion. For example, the term “Bartholin’s gland” appears in the TA index of eponymous terms, a listing designed to assist readers in identification of appropriate noneponymous terms.
      Federative Committee of Anatomical Terminology
      Terminológia anatomica: international anatomical terminology.
      The corresponding TA term for this eponym is greater vestibular gland. In addition, “Bartholin’s duct” appears in the TA index but is not the duct of the greater vestibular gland as would be expected by a women’s health practitioner but rather the major sublingual salivary gland duct, a term for which Caspar Bartholin is also credited.
      • Lydiatt D.D.
      • Bucher G.S.
      The historical evolution of the understanding of the submandibular and sublingual salivary glands.
      Thus, our proposal for “greater vestibular duct” was not arbitrary but designed to circumvent such confusion and promote consistency in the use of these terms. Similar confusion exists surrounding the Fallopian (uterine) tube nomenclature, where Gabriele Falloppio has been credited with naming other parts of the human body—“Fallopian” (facial) canal, “Fallopian” (inguinal) ligament, “Fallopian” muscle (pyramidalis), and “Fallopian” (ileocecal) valve.
      • Mortazavi M.M.
      • Adeeb N.
      • Latif B.
      • et al.
      Gabriele Fallopio (1523-1562) and his contributions to the development of medicine and anatomy.
      Thus, although we acknowledge the challenges in eliminating such prominent terms from our vocabulary, we recommend avoiding eponyms and advise adherence to unique standardized terms in medical communications.
      In review of vulvar anatomy, various terms, groupings, and nonpreferred synonyms were encountered. Knowledge of vulvar anatomy is essential for surgical procedures and has also crossed into the medicolegal and sociocultural domains, highlighting the need for terminologic standards. With the growing popularity of female genital cosmetic surgery, including reduction of the clitoral prepuce, alteration of the labial minora and majora, hymenal reconstruction, or amplification of the “G-spot,”
      Elective female genital cosmetic surgery: ACOG Committee Opinion, number 795.
      preferred and accepted terminology is paramount.

      Research implications

      Although rectovaginal fascia or rectovaginal septum is an accepted TA term, it has been classified as a controversial term in this focused evaluation of the posterior compartment. Rectovaginal fascia or rectovaginal septum or various synonyms were identified in 33 selected publications for review, and the term was commonly used in both anatomic and surgical arenas. However, additional studies have been inconclusive about whether a rectovaginal fascia or rectovaginal fascia septum is a distinct entity.
      • Maldonado P.A.
      • Carrick K.S.
      • Montoya T.I.
      • Corton M.M.
      Posterior vaginal compartment anatomy: implications for surgical repair.
      ,
      • Stecco C.
      • Macchi V.
      • Porzionato A.
      • et al.
      Histotopographic study of the rectovaginal septum.
      ,
      • DeLancey J.O.
      Structural anatomy of the posterior pelvic compartment as it relates to rectocele.
      • Zhai L.D.
      • Liu J.
      • Li Y.S.
      • Yuan W.
      • He L.
      Denonvilliers’ fascia in women and its relationship with the fascia propria of the rectum examined by successive slices of celloidin-embedded pelvic viscera.
      • Kleeman S.D.
      • Westermann C.
      • Karram M.M.
      Rectoceles and the anatomy of the posteriorvaginal wall: revisited.
      • Dariane C.
      • Moszkowicz D.
      • Peschaud F.
      Concepts of the rectovaginal septum: implications for function and surgery.
      Redefining a standard TA term represents a departure from previous work from this group
      • Jeppson P.C.
      • Balgobin S.
      • Washington B.B.
      • et al.
      Recommended standardized terminology of the anterior female pelvis based on a structured medical literature review.
      ,
      • Balgobin S.
      • Jeppson P.C.
      • Wheeler 2nd, T.
      • et al.
      Standardized terminology of apical structures in the female pelvis based on a structured medical literature review.
      but epitomizes and highlights our purpose to compile, clarify, and update, if indicated, standard anatomic terms for the female pelvis. In TA, the same unique identifying number is used for “rectovaginal fascia,” “rectovaginal septum,” and “rectovesical septum.” However, 6 common anatomic and surgical textbooks in this study describe a fascial condensation between the vagina and rectum that is surgically important for posterior vaginal repair, vaginal reconstruction, and rectal mobilization during colorectal procedures. Given the potential of this structure, further research is necessary to resolve the discrepancy between surgical and histologic findings and to inform future terminology recommendations.

      Strengths and limitations

      The strengths of this study included a broad comprehensive review of current literature, including surgical manuscripts, cadaveric descriptions, radiographic imaging modalities, gross anatomy textbooks, and pathologic studies. Although not technically a systematic review, as it was not feasible to extract terms from >22,000 manuscripts, we clarified anatomic terminology of the posterior female pelvis and vulva using standardized extraction. All terms were compared with the standard referent TA, and when applicable, we used group consensus.
      Limitations of our work included restricting analysis to only those terms published in the English language. In addition, it is possible that by excluding non-English studies, meeting abstracts, rare anatomy, and obstetrical or postpartum anatomy, we may have overlooked less commonly used terminology or unique anatomic descriptions. Ultimately, the focus of this review was on normal anatomy for the posterior female pelvis and vulva; therefore, we excluded abnormal pathology, such as malignancy and congenital anomalies. Finally, most group members are gynecologic specialists. Therefore, we sought the input and review of other pelvic specialists, such as colorectal surgeons and urologists.

      Conclusion

      Through expert review and group consensus, we presented a list of recommended terms for the posterior female pelvis and vulva and proposed new anatomic terms to be considered for adoption. As with our previous work, we recommended using the English or Latin accepted term and minimizing the use of nonpreferred synonyms and/or eponyms. Use of standardized terminology in both written and verbal communications will lead to less confusion and improved understanding between clinicians, surgeons, anatomists, and students.

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