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BRS Pelvis Questions

Terms in this set (63)

1. A 68-year-old woman with uterine carcinoma
undergoes surgical resection. This cancercan spread directly to the labia majora in
lymphatics that follow which of the followingstructures?(A) Pubic arcuate ligament
(B) Suspensory ligament of the ovary (C) Cardinal (transverse cervical) ligament(D) Suspensory ligament of the clitoris
(E) Round ligament of the uterus
1. The answer is E. The round ligament of the uterus runs laterally from the uterus through thedeep inguinal ring, inguinal canal, and superficial inguinal ring and becomes lost in the subcutaneous
tissues of the labium majus. Thus, carcinoma of the uterus can spread directly to thelabium majus by traveling in lymphatics that follow the ligament.
2. A 17-year-old boy suffers a traumatic groin
injury during a soccer match. The urologistnotices tenderness and swelling of the boy's left
testicle that may be produced by thrombosis inwhich of the following veins?(A) Left internal pudendal vein (B) Left renal vein
(C) Inferior vena cava(D) Left inferior epigastric vein (E) Left external pudendal vein
2. The answer is B. A tender swollen left testis may be produced by thrombosis in the left renalvein because the left testicular vein drains into the left renal vein. The right testicular vein drainsinto the inferior vena cava. The left internal pudendal vein empties into the left internal iliacvein. The left inferior epigastric vein drains into the left external iliac vein, and the left externalpudendal vein empties into the femoral vein.
3. On a busy Saturday night in Chicago, a
16-year-old boy presents to the emergency departmentwith a stab wound from a knife that entered the pelvis above the piriformis muscle.
Which of the following structures is most likelyto be damaged?(A) Sciatic nerve
(B) Internal pudendal artery(C) Superior gluteal nerve(D) Inferior gluteal artery(E) Posterior femoral cutaneous nerve
3. The answer is C. The superior gluteal nerve leaves the pelvis through the greater sciatic foramen,above the piriformis. The sciatic nerve, internal pudendal vessels, inferior gluteal vessels
and nerve, and posterior femoral cutaneous nerve leave the pelvis below the piriformis.
4. A 22-year-old woman receives a deep cut
in the inguinal canal lateral to the pubictubercle. Which of the following ligaments is
lacerated within the inguinal canal? (A) Suspensory ligament of the ovary (B) Ovarian ligament(C) Mesosalpinx(D) Round ligament of the uterus(E) Rectouterine ligament
4. The answer is D. The round ligament of the uterus is found in the inguinal canal along itscourse. The other ligaments do not pass through the inguinal canal.
5. A 29-year-old carpenter sustains severe
injuriesof the pelvic splanchnic nerve by a deeppuncture wound, which has become contaminated.The injured parasympathetic preganglionicfibers in the splanchnic nerve are most likelyto synapse in which of the following ganglia?(A) Ganglia in or near the viscera or pelvicplexus(B) Sympathetic chain ganglia(C) Collateral ganglia(D) Dorsal root ganglia(E) Ganglion impar
5. The answer is A. The pelvic splanchnic nerves carry preganglionic parasympathetic generalvisceral efferent fibers that synapse in the ganglia of the inferior hypogastric plexus and in terminal
ganglia in the muscular walls of the pelvic organs. The sympathetic preganglionic fiberssynapse in the sympathetic chain (paravertebral) ganglia or in the collateral (prevertebral)
ganglia. The dorsal root ganglia contain cell bodies of general somatic afferent (GSA) and generalvisceral afferent (GVA) fibers and have no synapsis. The two sympathetic trunks unite and
terminate in the ganglion impar (coccygeal ganglion), which is the most inferior, unpaired ganglionlocated in front of the coccyx.
6. A 59-year-old woman comes to a local hospital
for uterine cancer surgery. As the uterineartery passes from the internal iliac artery to the
uterus, it crosses superior to which of the followingstructures that is sometimes mistakenly
ligated during such surgery? (A) Ovarian artery(B) Ovarian ligament(C) Uterine tube
(D) Ureter(E) Round ligament of the uterus
6. The answer is D. The ureter runs under the uterine artery near the cervix; thus, the ureter issometimes mistakenly ligated during pelvic surgery. The other structures mentioned are not
closely related to the uterine artery near the uterine cervix.
7. A 29-year-old woman is admitted to a hospital
because the birth of her child is several daysoverdue. Tearing of the pelvic diaphragm during
childbirth leads to paralysis of which of thefollowing muscles?(A) Piriformis
(B) Sphincter urethrae(C) Obturator internus(D) Levator ani(E) Sphincter ani externus
7. The answer is D. The pelvic diaphragm is formed by the levator ani and coccygeus, whereas theurogenital diaphragm consists of the sphincter urethrae and deep transverse perinei muscles.
The piriformis passes through the greater sciatic notch and inserts on the greater trochanter ofthe femur. The obturator internus forms the lateral wall of the ischiorectal fossa. The sphincter
ani externus is composed of three layers, including the subcutaneous (corrugator cutis ani),superficial, and deep portions, and maintains a voluntary tonic contracture.
8. A 37-year-old small business manager receivesa gunshot wound in the pelvic cavity, resulting in a lesion of the sacral splanchnicnerves. Which of the following nerve fiberswould primarily be damaged?(A) Postganglionic parasympathetic fibers(B) Postganglionic sympathetic(C) Preganglionic sympathetic fibers (D) Preganglionic parasympathetic fibers(E) Postganglionic sympathetic and parasympatheticfibers
8. The answer is C. The sacral splanchnic nerves consist primarily of preganglionic sympatheticneurons and also contain GVA fibers. None of the other fibers listed are contained in these
nerves.
. A young couple is having difficulty conceiving
a child. Their physician at a reproductionand fertility clinic explains to them that
(A) The ovary lies within the broad ligament(B) The glans clitoris is formed from the corpus
spongiosum(C) Erection of the penis is a sympatheticresponse(D) Ejaculation follows parasympatheticstimulation(E) Fertilization occurs in the infundibulum orampulla of the uterine tube
. The answer is E. Fertilization takes place in the infundibulum or ampulla of the uterine tube.The glans clitoris is derived from the corpora cavernosa, whereas the glans penis is the expanded
terminal part of the corpus spongiosum. Erection of the penis is caused by parasympatheticstimulation, whereas ejaculation is mediated via the sympathetic nerve. The ovaries
are not enclosed in the broad ligament, but their anterior surface is attached to the posteriorsurface of the broad ligament
10. A 46-year-old woman has a history of
infectionin her perineal region. A comprehensiveexamination reveals a tear of the superiorboundary of the superficial perineal space.Which of the following structures would mostlikely be injured?(A) Pelvic diaphragm(B) Colles fascia(C) Superficial perineal fascia(D) Deep perineal fascia(E) Perineal membrane
10. The answer is E. The superior (deep) boundary of the superficial perineal space is the perinealmembrane (inferior fascia of the urogenital diaphragm). Colles fascia is the deep membranous
layer of the superficial perineal fascia. The deep perineal fascia essentially divides the superficialperineal space into a superficial and deep compartment. The pelvic diaphragm consists of
the levator ani and coccygeus muscles.
11. A 58-year-old man is diagnosed as having
a slowly growing tumor in the deep perinealspace. Which of the following structures would
most likely be injured? (A) Bulbourethral glands (B) Crus of penis(C) Bulb of vestibule(D) Spongy urethra(E) Great vestibular gland
11. The answer is A. The deep perineal space contains the bulbourethral (Cowper) glands. Thecrus of the penis, bulb of the vestibule, spongy urethra, and great vestibular gland are found in
the superficial perineal space.
12. An elderly man with a benign enlargement
of his prostate experiences difficulty inurination,urinary frequency, and urgency. Which of the following lobes of the prostate
gland is commonly involved in benign hypertrophythat obstructs the prostatic urethra? (A) Anterior lobe(B) Middle lobe(C) Right lateral lobe(D) Left lateral lobe(E) Posterior lobe
12. The answer is B. The middle lobe of the prostate gland is commonly involved in benignprostatichypertrophy, resulting in obstruction of the prostatic urethra, whereas the posterior
lobe is commonly involved in carcinomatous transformation. The anterior lobe contains littleglandular tissue, and the two lateral lobes on either side of the urethra form the major part of
the gland.
13. A 59-year-old man is diagnosed with prostate
cancer following a digital rectal examination.For the resection of prostate cancer, it isimportant to know that the prostatic ducts openinto or on which of the following structures:(A) Membranous part of the urethra (B) Seminal colliculus(C) Spongy urethra(D) Prostatic sinus(E) Prostatic utricle
13. The answer is D. Ducts from the prostate gland open into the prostatic sinus, which is a grooveon either side of the urethral crest. The prostate gland receives the ejaculatory duct, which
opens into the prostatic urethra on the seminal colliculus (a prominent elevation of the urethralcrest) just lateral to the prostatic utricle, which is a small blind pouch. The bulbourethral gland
lies on the lateral side of the membranous urethra within the deep perineal space, but its ductopens into the bulbous portion of the spongy (penile) urethra.
14. A 29-year-old woman with a ruptured ectopic
pregnancy is admitted to a hospital forculdocentesis. A long needle on the syringe is
most efficiently inserted through which of thefollowing structures?(A) Anterior fornix of the vagina(B) Posterior fornix of the vagina(C) Anterior wall of the rectum(D) Posterior wall of the uterine body (E) Posterior wall of the bladder
14. The answer is B. A needle should be inserted through the posterior fornix just below the posteriorlip of the cervix while the patient is in the supine position to aspirate abnormal fluid in
the cul-de-sac of Douglas (rectouterine pouch). Rectouterine excavation is not most efficientlyaspirated by puncture of other structures.
15. A 37-year-old man is suffering from carcinoma
of the skin of the penis. Cancer cells arelikely to metastasize directly to which of the following
lymph nodes?(A) External iliac nodes(B) Internal iliac nodes(C) Superficial inguinal nodes (D) Aortic (lumbar) nodes(E) Deep inguinal nodes
15. The answer is C. The superficial inguinal nodes receive lymph from the penis, scrotum, buttocks,labium majus, and the lower parts of the vagina and anal canal. These nodes have efferent
vessels that drain primarily into the external iliac and common iliac nodes and ultimatelyto the lumbar (aortic) nodes. The internal iliac nodes receive lymph from the upper part of the
rectum, vagina, uterus, and other pelvic organs, and they drain into the common iliac nodesand then into the lumbar (aortic) nodes. Lymph vessels from the glans penis drain initially into
the deep inguinal nodes and then into the external iliac nodes.
16. A 42-year-old woman who has had six
children develops a weakness of the urogenitaldiaphragm. Paralysis of which of the following
muscles would cause such a symptom?(A) Sphincter urethrae(B) Coccygeus
(C) Superficial transversus perinei (D) Levator ani(E) Obturator internus
16. The answer is A. The urogenital diaphragm consists of the sphincter urethrae and deep transverseperineal muscles. Weakness of the muscles, ligaments, and fasciae of the pelvic floor, such
as the pelvic diaphragm, urogenital diaphragm, and cardinal (transverse cervical) ligaments,occurs as a result of multiple child delivery, advancing age, and menopause. The pelvic diaphragm
is composed of the levator ani and coccygeus muscles. The superficial transversus perineiis one of the superficial perineal muscles, and the obturator internus forms the lateral wallof the ischiorectal fossa.
17. A 43-year-old man has a benign tumor
located near a gap between the arcuate pubicligament and the transverse perineal ligament.
Which of the following structures is most likelycompressed by this tumor?(A) Perineal nerve
(B) Deep dorsal vein of the penis (C) Superficial dorsal vein(D) Posterior scrotal nerve(E) Deep artery of the penis
17. The answer is B. The deep dorsal vein, dorsal artery, and dorsal nerve of the penis passthrough a gap between the arcuate pubic ligament and the transverse perineal ligament. The
perineal nerve divides into a deep branch, which supplies all of the perineal muscles, and superficialbranches as posterior scrotal nerves, which supply the scrotum. The superficial dorsal
vein of the penis empties into the greater saphenous vein. The deep artery of the penis runs inthe corpus cavernosum of the penis.
18. An obstetrician performs a median episiotomyon a woman before parturition to prevent
uncontrolled tearing. If the perineal body isdamaged, the function of which of the following
muscles might be impaired?(A) Ischiocavernosus and sphincter urethrae(B) Deep transverse perineal and obturatorinternus(C) Bulbospongiosus and superficial transverseperineal(D) External anal sphincter and sphincterurethrae(E) Bulbospongiosus and ischiocavernosus
18. The answer is C. The perineal body (central tendon of the perineum) is a fibromuscular nodeat the center of the perineum. It provides attachment for the bulbospongiosus, the superficial
and deep transverse perineal muscles, and the sphincter ani externus muscles. Other muscles(ischiocavernosus, sphincter urethrae, and obturator internus) are not attached to the perineal
body.
19. A 22-year-old man has a gonorrheal infectionthat has infiltrated the space between the
inferior fascia of the urogenital diaphragm andthe superficial perineal fascia. Which of the followingstructures might be inflamed?(A) Bulb of the penis(B) Bulbourethral gland(C) Membranous part of the male urethra(D) Deep transverse perineal muscle (E) Sphincter urethrae
19. The answer is A. The bulb of the penis is located in the superficial perineal space between theinferior fascia of the urogenital diaphragm and the membranous layer of the superficial perineal
fascia (Colles fascia). All of the other structures are found in the deep perineal pouch.
20. A 39-year-old man is unable to expel the
last drops of urine from the urethra at the endof micturition because of paralysis of the external
urethral sphincter and bulbospongiosusmuscles. This condition may occur as a resultof injury to which of the following nervousstructures?(A) Pelvic plexus(B) Prostatic plexus(C) Pudendal nerve(D) Pelvic splanchnic nerve(E) Sacral splanchnic nerve
20. The answer is C. The perineal branch of the pudendal nerve supplies the external urethralsphincter and bulbospongiosus muscles in the male. All other nervous structures do not supply
skeletal muscles but supply smooth muscles in the perineal and pelvic organs. The pelvicand prostatic plexuses contain both sympathetic and parasympathetic nerve fibers. The pelvic splanchnic nerve carries preganglionic parasympathetic fibers, whereas the sacral splanchnic
nerve transmits preganglionic sympathetic fibers
21. A 21-year-old marine biologist asks about
her first bimanual examination, and it is explainedto her that the normal position of the uterus is
(A) Anteflexed and anteverted (B) Retroflexed and anteverted (C) Anteflexed and retroverted (D) Retroverted and retroflexed (E) Anteverted and retroverted
21. The answer is A. The normal position of the uterus is anteverted (i.e., angle of 90 degrees at thejunction of the vagina and cervical canal) and anteflexed (i.e., angle of 160 to 170 degrees at the
junction of the cervix and body).
22. After his bath but before getting dressed,
a 4-year-old boy was playing with his puppy.The boy's penis was bitten by the puppy,
and the deep dorsal vein was injured. Thedamagedvein
(A) Lies superficial to Buck fascia (B) Drains into the prostatic venous plexus(C) Lies lateral to the dorsal artery of the penis(D) Is found in the corpus spongiosum(E) Is dilated during erection
22. The answer is B. The deep dorsal vein of the penis lies medial to the dorsal artery of the penison the dorsum of the penis and deep to Buck fascia, drains into the prostatic plexus of veins,
and is compressed against the underlying deep fascia of the penis during erection.
23. A 62-year-old man is incapable of penile
erection after rectal surgery with prostatectomy.The patient most likely has a lesion of which of
the following nerves?(A) Dorsal nerve of the penis (B) Perineal nerve(C) Hypogastric nerve(D) Sacral splanchnic nerve (E) Pelvic splanchnic nerve
23. The answer is E. The pelvic splanchnic nerve contains preganglionic parasympathetic fibers,whereas the sacral splanchnic nerve contains preganglionic sympathetic fibers. Parasympathetic
fibers are responsible for erection, whereas sympathetic fibers are involved with ejaculation. Theright and left hypogastric nerves contain primarily sympathetic fibers and visceral sensory fibers.The dorsal nerve of the penis and the perineal nerve provide sensory nerve fibers.
24. A 23-year-old massage therapist who specializes
in women's health attends a lecture atan annual conference on techniques of massage.
She asks, "What structure is drained bythe lumbar (aortic) lymph nodes?" Which of the
following structures is the correct answer to thisquestion?(A) Perineum
(B) Lower part of the vagina (C) External genitalia(D) Ovary(E) Lower part of the anterior abdominal wall
24. The answer is D. The lymphatic vessels from the ovary ascend with the ovarian vessels inthe suspensory ligament and terminate in the lumbar (aortic) nodes. Lymphatic vessels from
the perineum, external genitalia, and lower part of the anterior abdominal wall drain into thesuperficial inguinal nodes.
25. A sexually active adolescent presents with
an infection within the ischiorectal fossa.Which of the following structures is most likely
injured?(A) Vestibular bulb(B) Seminal vesicle(C) Greater vestibular gland (D) Inferior rectal nerve(E) Internal pudendal artery
5. The answer is D. The ischiorectal fossa contains the inferior rectal nerves and vessels and adiposetissue. The bulb of the vestibule and the great vestibular gland are located in the superficial
perineal space, whereas the bulbourethral gland is found in the deep perineal space. The internalpudendal artery runs in the pudendal canal, but its branches pass through the superficial
and deep perineal spaces
26. A first-year resident in the urology departmentreviews pelvic anatomy before seeing
patients. Which of the following statements iscorrect?(A) The dorsal artery of the penis supplies the
glans penis.(B) The seminal vesicles store spermatozoa.(C) The duct of the bulbourethral gland opensinto the membranous urethra.(D) The duct of the greater vestibular glandopens into the vagina.(E) The anterior lobe of the prostate gland isprone to carcinomatous transformation.
26. The answer is A. The dorsal artery of the penis supplies the glans penis. The seminal vesiclesstore no spermatozoa. The duct of the bulbourethral gland opens into the bulbous portion
of the spongy urethra, whereas the greater vestibular gland opens into the vestibule betweenthe labium minora and the hymen. The anterior lobe of the prostate is devoid of glandular
substance, the middle lobe is prone to benign hypertrophy, and the posterior lobe is prone tocarcinomatoustransformation.
27. A 43-year-old woman presents with a prolapsed
uterus. Repair of a prolapsed uterus requiresknowledge of the supporting structures
of the uterus. Which of the following structures plays the most important role in the support ofthe uterus?
(A) Levator ani(B) Sphincter urethrae(C) Uterosacral ligament (D) Ovarian ligament(E) Arcuate pubic ligament
27. The answer is A. The pelvic diaphragm, particularly the levator ani, provides the most importantsupport for the uterus, although the urogenital diaphragm and the uterosacral and ovarian
ligaments support the uterus. The arcuate pubic ligament arches across the inferior aspect ofthe pubic symphysis.
28. A 16-year-old boy presents to the emergency
department with rupture of the penile urethra. Extravasated urine from this injury canspread into which of the following structures?
(A) Scrotum(B) Ischiorectal fossa (C) Pelvic cavity(D) Testis(E) Thigh
28. The answer is A. Extravasated urine from the penile urethra below the perineal membranespreads into the superficial perineal space, scrotum, penis, and anterior abdominal wall. However,
it does not spread into the testis, ischiorectal fossa, pelvic cavity, and thigh because Scarpafascia ends by firm attachment to the fascia lata of the thigh.
29. A 23-year-old woman visits her obstetrician
for an annual checkup. During vaginal examination,which of the following structures may be palpated?(A) Apex of the urinary bladder(B) Fundus of the uterus(C) Terminal part of the round ligament of theuterus(D) Body of the clitoris(E) Uterine cervix
29. The answer is E. In addition to the uterine cervix, the uterus, uterine tubes, ovaries, and ureterscan be palpated. The apex of the urinary bladder is the anterior end of the bladder; thus, it cannot
be palpated. The fundus of the uterus is the anterosuperior part of the uterus. The terminalpart of the round ligament of the uterus emerges from the superficial inguinal ring and becomes
lost in the subcutaneous tissue of the labium majus.
30. A 53-year-old bank teller is admitted to a localhospital for surgical removal of a benign pelvic
tumor confined within the broad ligament.There is a risk of injuring which of the following
structures that lies in this ligament? (A) Ovary(B) Proximal part of the pelvic ureter (C) Terminal part of the round ligament of the
uterus(D) Uterine tube(E) Suspensory ligament of the ovary
30. The answer is D. The uterine tubes lie in the broad ligament. The anterior surface of the ovaryis attached to the posterior surface of the broad ligament of the uterus. The ureter descends
retroperitoneally on the lateral pelvic wall but is crossed by the uterine artery in the base (in theinferomedial part) of the broad ligament. The terminal part of the round ligament of the uterus
becomes lost in the subcutaneous tissue of the labium majus. The suspensory ligament of theovary is a band of peritoneum that extends superiorly from the ovary to the pelvic wall.
31. A 72-year-old man comes to his physician
for an annual checkup. Which of the followingstructures is most readily palpated during rectal
examination?(A) Prostate gland (B) Epididymis(C) Ejaculatory duct (D) Ureter(E) Testis
31. The answer is A. The prostate gland may be palpated on rectal examination. The ejaculatoryduct runs within the prostate gland and cannot be felt. In the male, the pelvic part of the ureter lies lateral to the ductus deferens and enters the posterosuperior angle of the bladder, where it is
situated anterior to the upper end of the seminal vesicle, and thus, it cannot be palpated duringrectal examination. However, in the female, the ureter can be palpated during vaginal examination
because it runs near the uterine cervix and the lateral fornix of the vagina to enter the posterosuperiorangle of the bladder. The testes are examined during a routine annual checkup but
obviously not during a rectal examination.
32. A 48-year-old college football coach undergoes
a radical prostatectomy for a malignanttumor in his prostate. Following surgery, he is
incapable of achieving an erection. Which of the following nerves is most likely damagedduring the surgery?
(A) Sacral splanchnic nerve (B) Pelvic splanchnic nerve (C) Pudendal nerve(D) Dorsal nerve of the penis (E) Posterior scrotal nerve
32. The answer is B. Parasympathetic preganglionic fibers in the pelvic splanchnic nerve are responsiblefor erection of the penis. Sympathetic preganglionic fibers in the sacral splanchnic
nerve are responsible for ejaculation. The pudendal nerve supplies the external anal sphincterand perineal muscles and supplies GSA fibers to the perineal region. The dorsal nerve of the
penis is a terminal branch of the pudendal nerve and supplies sensation of the penis. The posteriorscrotal nerves are superficial branches of the perineal nerve and supply sensory fibers to
the scrotum.
33. While performing a pelvic exenteration,
the surgical oncologist notices a fractured orruptured boundary of the pelvic inlet. Which of
the following structures is most likely damaged?(A) Promontory of the sacrum(B) Anterior-inferior iliac spine
(C) Inguinal ligament(D) Iliac crest(E) Arcuate pubic ligament
33. The answer is A. The pelvic inlet (pelvic brim) is bounded by the promontory and the anteriorborder of the ala of the sacrum, the arcuate line of the ilium, the pectineal line, the pubic crest,
and the superior margin of the pubic symphysis.
34. A 32-year-old patient with multiple fractures
of the pelvis has no cutaneous sensationin the urogenital triangle. The function of which
of the following nerves is most likely to bespared?(A) Ilioinguinal nerve
(B) Iliohypogastric nerve(C) Posterior cutaneous nerve of the thigh(D) Pudendal nerve(E) Genitofemoral nerve
34. The answer is B. The iliohypogastric nerve innervates the skin above the pubis. The skin ofthe urogenital triangle is innervated by the pudendal nerve, perineal branches of the posterior
femoral cutaneous nerve, anterior scrotal or labial branches of the ilioinguinal nerve, and thegenital branch of the genitofemoral nerve.
35. A 22-year-old victim of an automobile accidenthas received destructive damage to structuresthat form the boundary of the perineum.Which of the following structures is spared?(A) Pubic arcuate ligament(B) Tip of the coccyx(C) Ischial tuberosities(D) Sacrospinous ligament(E) Sacrotuberous ligament
35. The answer is D. The sacrospinous ligament forms a boundary of the lesser sciatic foramen.The pubic arcuate ligament, tip of the coccyx, ischial tuberosities, and sacrotuberous ligament
all form part of the boundary of the perineum.
36. A 32-year-old man undergoes vasectomy as
a means of permanent birth control. A physicianperforming the vasectomy by making an
incision on each side of the scrotum shouldremember which of the following statements
most applicable to the scrotum?(A) It is innervated by the ilioinguinal andgenitofemoral nerves.(B) It receives blood primarily from thetesticular artery.(C) Its venous blood drains primarily into therenal vein on the left.(D) Its lymphatic drainage is primarily intoupper lumbar nodes.(E) Its dartos tunic is continuous with theperineal membrane.
36. The answer is A. The scrotum is innervated by branches of the ilioinguinal, genitofemoral,pudendal, and posterior femoral cutaneous nerves. The scrotum receives blood from the posterior
scrotal branches of the internal pudendal arteries and the anterior scrotal branches of theexternal pudendal arteries, but it does not receive blood from the testicular artery. Similarly,
the scrotum is drained by the posterior scrotal veins into the internal pudendal vein. The lymphvessels from the scrotum drain into the superficial inguinal nodes, whereas the lymph vessels
from the testis drain into the upper lumbar nodes. The dartos tunic is continuous with themembranous layer of the superficial perineal fascia (Colles fascia).
37. A 37-year-old woman complains of a
bearing-down sensation in her womb and an increased frequency of and burning sensationon urination. On examination by her gynecologist,she is diagnosed with a uterine prolapse.Which of the following structures provides theprimary support for the cervix of the uterus?(A) External anal sphincter(B) Broad ligament of the uterus(C) Cardinal (transverse cervical) ligament(D) Round ligament of the uterus(E) Suspensory ligament of the ovary
37. The answer is C. The cardinal (transverse cervical) ligament provides the major ligamentoussupport for the uterus. The sphincter ani externus does not support the uterus. The broad and
round ligaments of the uterus provide minor supports for the uterus. The suspensory ligamentof the ovary does not support the uterus.
38. A woman is delivering a breech baby. The
obstetrician decides that it is best to perform amediolateral episiotomy. Which of the following
structures should the obstetrician avoidincising?(A) Vaginal wall
(B) Superficial transverse perineal muscle(C) Bulbospongiosus(D) Levator ani
(E) Perineal membrane
38. The answer is D. An obstetrician should avoid incising the levator ani and the external analsphincter. The levator ani is the major part of the pelvic diaphragm, which forms the pelvic floor
and supports all of the pelvic organs. None of the other choices applies here.
39. During pelvic surgery, a surgeon notices
severe bleeding from the artery that remainswithin the true pelvis. Which of the following
arteries is most likely to be injured? (A) Iliolumbar artery(B) Obturator artery(C) Uterine artery
(D) Internal pudendal artery (E) Inferior gluteal artery
39. The answer is C. Of all the arteries listed, the uterine artery remains within the pelvic cavity.
40. A neurosurgeon performs a surgical resection
of a rare meningeal tumor in the sacralregion. He tries to avoid an injury of the nerve
that arises from the lumbosacral plexus andremains within the abdominal or pelvic cavity.
To which of the following nerves should he payparticular attention?(A) Ilioinguinal nerve
(B) Genitofemoral nerve(C) Lumbosacral trunk(D) Femoral nerve(E) Lateral femoral cutaneous nerve
40. The answer is C. The lumbosacral trunk is formed by part of the ventral ramus of the fourthlumbar nerve and the ventral ramus of the fifth lumbar nerve. This trunk contributes to the formation
of the sacral plexus by joining the ventral ramus of the first sacral nerve in the pelvic cavityand does not leave the pelvic cavity. All other nerves leave the abdominal and pelvic cavities.
41. After repair of a ruptured diverticulum, a
31-year-old patient begins to spike with feverand complains of abdominal pain. An infection
in the deep perineal space would most likelydamage which of the following structures?
(A) Ischiocavernosus muscles(B) Superficial transverse perineal muscles(C) Levator ani(D) Sphincter urethrae(E) Bulbospongiosus
41. The answer is D. The sphincter urethrae are found in the deep perineal space, whereas theother structures are located in the superficial perineal space.
42. A radiologist interprets a lymphangiogram
for a 29-year-old patient with metastatic carcinoma.Upper lumbar nodes most likely receive
lymph from which of the following structures?(A) Lower part of the anal canal (B) Labium majus
(C) Clitoris (D) Testis (E) Scrotum
42. The answer is D. Lymphatic vessels from the testis and epididymis ascend along the testicularvessels in the spermatic cord through the inguinal canal and continue upward in the abdomen
to drain into the upper lumbar nodes. The lymph from the other structures drains into thesuperficial inguinal lymph nodes.
43. A 49-year-old woman has a large mass on
the pelvic brim. Which of the following structuresis most likely compressed by this masswhen crossing the pelvic brim? (A) Deep dorsal vein of the penis (B) Uterine tube(C) Ovarian ligament(D) Uterine artery(E) Lumbosacral trunk
43. The answer is E. All of the listed structures do not cross the pelvic brim except the lumbosacraltrunk, which arises from L4 and L5, enters the true pelvis by crossing the pelvic brim, and contributes
to the formation of the sacral plexus. The deep dorsal vein of the penis enters the pelvic cavityby passing under the symphysis pubis between the arcuate and transverse perineal ligaments.
44. A 26-year-old man comes to a hospital with
fever, nausea, pain, and itching in the perinealregion. On examination by a urologist, he is
diagnosed as having infected bulbourethral(Cowper) glands. Which of the following structures
is/are affected by this infection? (A) Superficial perineal space (B) Sphincter urethrae(C) Production of sperm
(D) Testis(E) Seminal vesicles
44. The answer is B. The bulbourethral glands lie on either side of the membranous urethra, embeddedin the sphincter urethrae. Their ducts open into the bulbous part of the penile urethra.
Semen—a thick, yellowish-white, viscous, spermatozoa-containing fluid—is a mixture of thesecretions of the testes, seminal vesicles, prostate, and bulbourethral glands. Sperm, or spermatozoa,
are produced in the seminiferous tubules of the testis and mature in the head of theepididymis. The seminal vesicles are lobulated glandular structures, produce the alkaline constituent
of the seminal fluid that contains fructose and choline, and lie inferior and lateral to theampullae of the ductus deferens against the fundus (base) of the bladder.
45. A 21-year-old man is involved in a highspeed
motor vehicle accident. As a result, hehas extensive damage to his sphincter urethra.
Which of the following best describes theinjured sphincter urethra?(A) Smooth muscle
(B) Innervated by the perineal nerve (C) Lying between the perineal membrane andColles fascia
(D) Enclosed in the pelvic fascia (E) Part of the pelvic diaphragm
45. The answer is B. The sphincter urethra is a striated muscle that lies in the deep perineal spaceand forms a part of the urogenital diaphragm but not the pelvic diaphragm. It is not enclosed in
the pelvic fascia. It is innervated by a deep (muscular) branch of the perineal nerve.
46. Child is taken to the children's hospital because he has no
testis in his scrotum. During physical examination,the pediatrician palpated the testis in the
inguinal canal. What is the diagnosis of thiscondition?(A) Male pseudohermaphroditism (B) Hypospadias
(C) Epispadias(D) Cryptorchid testis (E) Chordee
46. The answer is D. Cryptorchid testis is called an undescended testis, which is located in the inguinalregion. Male pseudohermaphroditism is a condition in which the affected individual is a
genetic and gonadal male with genital anomalies. Hypospadias occurs when the spongy urethraopens on the underside of the penis, frequently associated with the chordee, which is a ventral
curvature of the penis. Epispadias occurs when the urethra opens on the dorsal surface of thepenis.
47. An obstetrician is about to perform a pudendalblock so a woman can experience less
pain when she delivers her child. He recallswhat he learned in medical school about this
nerve. Which of the following statements iscorrect?(A) It passes superficial to the sacrotuberous
ligament(B) It innervates the testis and epididymisin a male(C) It provides motor fibers to the coccygeus(D) It can be blocked by injecting an anestheticnear the inferior margin of the ischial spine(E) It arises from the lumbar plexus
47. The answer is D. The pudendal nerve, which arises from the sacral plexus, provides sensoryinnervation to the labium majus (or scrotum in a male). It leaves the pelvis through the greater
sciatic foramen and enters the perineum through the lesser sciatic foramen near the inferiormargin of the ischial spine. Therefore, it can be blocked by injection of an anesthetic near the
inferior margin of the ischial spine
48. A trauma surgeon in the emergency departmentat a local center examines a 14-year-old
boy with extensive pelvic injuries after a hit andrun accident. The surgeon inspects the ischiorectal
fossa because it(A) Accumulates urine leaking from rupture ofthe bulb of the penis(B) Contains the inferior rectal vessels(C) Has a pudendal canal along its medial wall(D) Is bounded anteriorly by the sacrotuberousligament(E) Contains a perineal branch of the fifthlumbar nerve
48. The answer is B. The ischiorectal fossa is bounded posteriorly by the gluteus maximus andthe sacrotuberous ligament. It contains fat, the inferior rectal nerve and vessels, and perineal
branches of the posterior femoral cutaneous nerve. The pudendal canal runs along its lateralwall. Urine leaking from a ruptured bulb of the penis does not spread into the ischiorectal fossa
because Scarpa fascia ends by firm attachment to the fascia lata of the thigh.
49. An elderly man with prostatitis is seen at
an internal medicine clinic. The seminal colliculusof his prostate gland is infected, and itsfine openings are closed. Which of the followingstructures is/are most likely to be disturbed?(A) Ducts of the prostate gland(B) Prostatic utricle(C) Ducts of the bulbourethral glands (D) Ejaculatory ducts(E) Duct of the seminal vesicles
49. The answer is D. The ejaculatory ducts, which open onto the seminal colliculus, may beinjured.The prostate ducts open into the urethral sinus, the bulbourethral ducts open into
the bulbous part of the penile urethra, and the ducts of the seminal vesicle join the ampulla ofthe ductus deferens to form the ejaculatory duct. The prostatic utricle is a minute pouch on the
summit of the seminal colliculus.
50. A general surgeon is giving a lecture to a
team of surgery residents. She describes characteristicsof structures above the pectinate line of the anal canal, which include(A) Stratified squamous epithelium (B) Venous drainage into the caval system(C) Lymphatic drainage into the superficialinguinal nodes(D) Visceral sensory innervation(E) External hemorrhoids
50. The answer is D. The pectinate line is a point of demarcation between visceral and somaticportions of the anal canal. Characteristics above the pectinate line include columnar epithelium,
venous drainage into the portal system, lymphatic drainage into the internal iliac nodes,visceral sensory innervation, and internal hemorrhoids.
51. A 5-month-old boy is admitted to the children's
hospital because of urine being expelledfrom the dorsal aspect of the penis. Which of
the following embryologic structures failed tofuse in this patient?(A) Labioscrotal swellings or folds (B) Urogenital sinus
(C) Spongy urethra (D) Phallus(E) Urethral folds
51. The answer is C. A developmental defect in the spongy urethra results in epispadias, causingthe patient to pass urine through an opening on the dorsum of the penis. Labioscrotal swellings
form the scrotum in males and the labia majora in females. Urogenital sinus forms the urinarybladder, urethra, prostate, and bulbourethral glands in males, and the bladder, urethra, lower
vagina, and greater vestibular glands in females. The phallus (genital tubercle) forms the penisin males and the clitoris in females. Urethral (urogenital) folds form the spongy urethra and a
portion of the shaft of the penis in males and the labia minora in females.
52. A 78-year-old man has carcinoma of the
rectum. The cancer is likely to metastasize viathe veins into which of the following structures?(A) Spleen(B) Kidney(C) Liver(D) Duodenum(E) Suprarenal gland
52. The answer is C. Cancer cells from rectal cancer are likely to metastasize to the liver via thesuperiorrectal, inferior mesenteric, splenic, and portal veins. Cancer cells are not directly
spread to the other organs listed. The spleen and duodenum drain their venous blood to the portal venous system, and the kidney and suprarenal gland empty into the caval (inferior venacava) system.
53. During a partial hysterectomy leaving the
ovaries in tact, the surgeon detaches the ovaryfrom the uterus by transecting the ovarian ligament.
This ligament developed from which embryonic structure?(A) Mesonephric duct(B) Urogenital folds
(C) Gubernaculum(D) Processus vaginalis(E) Paramesonephric ducts
53. The answer is C. The ovarian ligament and the round ligament of the uterus are formed by thegubernaculum. The mesonephric duct gives rise only to the vestigial epoophoron in the female.
The urogenital folds form the labia minora. The processus vaginalis forms no adult femalestructures, while the paramesonephric ducts form the uterine tubes, uterus, cervix, and upper
vagina.
Questions 54 to 58: Choose the appropriate
letteredstructure in this magnetic resonance image (see Figure below) of the femaleperineum and pelvis.54. Which structure extends between the vestibuleand the cervix of the uterus and servesas the excretory channel for the products ofmenstruation?
54. The answer is D. The vagina is the genital canal in the female, extending from the vestibule tothe uterine cervix. The vagina transmits the products of menstruation and receives the penis incopulation.
55. Which structure in the female is much
shorter than the corresponding structure in themale?
55. The answer is A. In females, the urethra extends from the bladder, runs above the anteriorvaginal wall, and pierces the urogenital diaphragm to reach the urethral orifice in the vestibule
behind the clitoris. It is approximately 4 cm long. In males, the urethra is approximately 20 cmlong.
56. Into which structure does hemorrhage
occurafter injury to the inferior rectal vessels?
56. The answer is E. The ischiorectal fossa lies in the anal triangle and is bound laterally by the obturatorinternus with its fascia and superomedially by the levator ani and external anal sphincter.
It contains the inferior rectal vessels. Thus, hemorrhage occurs in the ischiorectal fossawhen it is ruptured.
57. Which structure has a Houston valve or
fold, with its venous blood drained by the portalvenous system?
57. The answer is C. The mucous membrane and the circular smooth-muscle layer of the rectumform three transverse folds; the middle one is called Houston valve. The venous blood returnsto the portal venous system via the superior rectal vein.
58. Which structure is innervated by the nerve
passing through both the greater and lessersciaticforamina?
58. The answer is B. The obturator internus muscle and its fascia form the lateral wall of the ischiorectalfossa. This muscle is innervated by the nerve to the obturator internus, which passes
through the greater and lesser sciatic foramen.
Questions 59 to 63: Choose the appropriate
letteredstructure in this computed tomographyscan (see Figure below) of the male perineumand pelvis.59. Which structure, when fractured, results inparalysis of the obturator internus muscles?
59. The answer is E. The greater trochanter provides an insertion site for the obturator internusmuscle.
60. Which structure secretes fluid containing
fructose, which allows for forensic determinationof rape?
60.The answer is B. The seminal vesicle is a lobulated glandular structure and produces the alkalineconstituent of the seminal fluid, which contains fructose and choline. Fructose, which is
nutritive to spermatozoa, also allows forensic determination of rape, whereas choline crystalsare the preferred basis for the determination of the presence of semen.
61. In which structure would ligation of the
externaliliac artery reduce blood pressure?
61. The answer is A. The external iliac artery becomes the femoral artery immediately after passingthe inguinal ligament. Therefore, ligation of the external iliac artery reduces blood pressure
in the femoral artery.
62. A knife wound to the obturator foramen
might injure which structure?
62. The answer is D. The obturator foramen transmits the obturator nerve and vessels. Therefore,the knife wound in this foramen injures the obturator nerve and vessels.
63. A stab wound immediately superior to
the pubic symphysis on the anterior pelvicwall would most likely injure which visceral
organ first?
63. The answer is C. The bladder is situated in the anterior part of the pelvic cavity. Thus, a stabwound superior to the pubic symphysis would injure the bladder.
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