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Uterosacral ligament

The uterosacral ligament is a strong fibrous band of connective tissue that provides posterolateral support to the uterus and cervix. It extends from the cervix and upper vagina to the sacrum, anchoring the uterus within the pelvis and contributing to pelvic organ stability. It is a clinically significant structure in gynecology and radiology due to its role in pelvic support disorders, endometriosis, and gynecologic surgery.

Synonyms

  • Sacrouterine ligament

  • Posterior cervical ligament

  • Rectouterine ligament (in some texts)

Attachments, Course, and Termination

  • Attachments: Arises from the posterolateral aspect of the cervix and the upper vagina

  • Course: Extends posterolaterally along the pelvic wall within the rectouterine fold of peritoneum, running toward the sacrum

  • Termination: Inserts into the anterior surface of the sacrum around S2–S4 vertebral levels

Relations

  • Anteriorly: Cervix, upper vagina, rectouterine pouch (pouch of Douglas)

  • Posteriorly: Sacrum, presacral fascia

  • Laterally: Pelvic ureters, hypogastric nerves, uterine arteries

  • Superiorly: Broad ligament of the uterus

  • Inferiorly: Rectum and pelvic floor fascia

Function

  • Provides posterolateral support to the uterus and cervix

  • Helps maintain the anteverted position of the uterus

  • Prevents downward displacement of pelvic organs

  • Acts as a stabilizer of the uterine axis during pregnancy and childbirth

Clinical Significance

  • Common site of deep infiltrating endometriosis

  • Shortening or scarring may cause pelvic pain or dyspareunia

  • Important surgical landmark in hysterectomy and uterine suspension procedures

  • Weakening may contribute to uterine prolapse and pelvic floor disorders

MRI Appearance

T1-weighted images:

  • Ligament appears as a low-signal-intensity band between the cervix and sacrum

  • Fibrosis or endometriosis may appear as thickened, irregular, or mildly high-signal areas

T2-weighted images:

  • Ligament appears as a dark, low-signal-intensity band

  • Endometriotic implants or scarring appear as focal thickening with bright or mixed signal intensity

STIR (Short Tau Inversion Recovery):

  • Normal ligament remains dark

  • Pathological involvement (inflammation, endometriosis, scarring) shows bright hyperintensity

T1 Fat-Sat Post-Contrast:

  • Normal ligament shows minimal or no enhancement

  • Pathology enhances irregularly: endometriosis and neoplastic infiltration show heterogeneous enhancement; fibrosis enhances mildly

CT Appearance

Non-Contrast CT:

  • Ligament not well delineated; appears as part of soft tissue planes between uterus and sacrum

  • Thickening or calcification may be visible in advanced pathology

Post-Contrast CT:

  • Ligament enhancement is usually subtle or indistinguishable in normal cases

  • Endometriosis, tumor spread, or pelvic inflammation may cause irregular thickening and heterogeneous enhancement

MRI image

Uterosacral ligament MRI axial anatomy image-img-00000-00000

MRI image

Uterosacral ligament MRI coronal anatomy image-img-00000-00000

CT image

Uterosacral ligament ct axial anatomy image-img-00000-00000