Perineum and Pelvis

1.A 68-year-old woman with uterine carcinoma undergoes surgical resection. This cancer can spread directly to the labia majora in lymphatics that follow which of the following structures?

(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

2.A 17-year-old boy suffers a traumatic groin injury during a soccer match. The urologist notices tenderness and swelling of the boy's left testicle that may be produced by thrombosis in which 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

3.
On a busy Saturday night in Chicago, a 16-year-old boy presents to the emergency room with a stab wound from a knife that entered the pelvis above the piriformis muscle. Which of the following structures is most likely to be damaged?

(A) Sciatic nerve
(B) Internal pudendal artery
(C) Superior gluteal nerve
(D) Inferior gluteal artery
(E) Posterior femoral cutaneous nerve

4.A 22-year-old woman receives a deep cut in the inguinal canal 1 inch lateral to the pubic tubercle. 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

5.A 29-year-old carpenter sustains severe injuries of the pelvic splanchnic nerve by a deep puncture wound, which has become contaminated. The injured parasympathetic preganglionic fibers in the splanchnic nerve are most likely to synapse in which of the following ganglia?

(A) Ganglia in or near the viscera or pelvic plexus
(B) Sympathetic chain ganglia
(C) Collateral ganglia
(D) Dorsal root ganglia
(E) Ganglion impar

6.A 59-year-old woman comes to a local hospital for uterine cancer surgery. As the uterine artery passes from the internal iliac artery to the uterus, it crosses superior to which of the following structures 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

7.A 29-year-old woman is admitted to a hospital because the birth of her child is several days overdue. Tearing of the pelvic diaphragm during childbirth leads to paralysis of which of the following muscles?

(A) Piriformis
(B) Sphincter urethrae
(C) Obturator internus
(D) Levator ani
(E) Sphincter ani externus

8.A 37-year-old small business manager receives a gunshot wound in the pelvic cavity, resulting in a lesion of the sacral splanchnic nerves. Which of the following nerve fibers would primarily be damaged?

(A) Postganglionic parasympathetic fibers
(B) Postganglionic sympathetic fibers
(C) Preganglionic sympathetic fibers
(D) Preganglionic parasympathetic fibers
(E) Postganglionic sympathetic and parasympathetic fibers

9.A young couple is having difficulty conceiving a child. Their physician at a reproduction and 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 sympathetic response
(D) Ejaculation follows parasympathetic stimulation
(E) Fertilization occurs in the infundibulum or ampulla of the uterine tube

10.A 46-year-old woman has a history of infection in her perineal region. A comprehensive examination reveals a tear of the superior boundary of the superficial perineal space. Which of the following structures would most likely be injured?

(A) Pelvic diaphragm
(B) Colles' fascia
(C) Superficial perineal fascia
(D) Deep perineal fascia
(E) Perineal membrane

11.A 58-year-old man is diagnosed as having a slowly growing tumor in the deep perineal space. Which of the following structures would most likelybe injured?

(A) Bulbourethral glands
(B) Crus of penis
(C) Bulb of vestibule
(D) Spongy urethra
(E) Great vestibular gland

12.
An elderly man with benign enlargement of his prostate experiences difficulty in urination, urinary frequency, and urgency. Which of the following lobes of the prostate gland is commonly involved in benign hypertrophy that obstructs the prostatic urethra?

(A) Anterior lobe
(B) Middle lobe
(C) Right lateral lobe
(D) Left lateral lobe
(E) Posterior lobe

13.
A 59-year-old man is diagnosed with prostate cancer following a digital rectal examination. For the resection of prostate cancer, it is important to know that the prostatic ducts open into 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

14.A 29-year-old woman with a ruptured ectopic pregnancy is admitted to a hospital for culdocentesis. A long needle on the syringe is most efficiently inserted through which of the following 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

15.A 37-year-old man is suffering from carcinoma of the skin of the penis.Cancer cells are likely 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

16.A 42-year-old woman who has had six children develops a weakness of the urogenital diaphragm. 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

17.A 43-year-old man has a benign tumor located near a gap between the arcuate pubic ligament and the transverse perineal ligament. Which of the following structures is most likely compressed 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

18.An obstetrician performs a median epi-siotomy on a woman before parturition to prevent uncontrolled tearing. If the perineal body is damaged, the function of which of the following muscles might be impaired?

(A) Ischiocavernosus and sphincter urethrae
(B) Deep transverse perineal and obturator internus
(C) Bulbospongiosus and superficial transverse perineal
(D) External anal sphincter and sphincter urethrae
(E) Bulbospongiosus and ischiocavernosus

19. A 22-year-old man has a gonorrheal infection that has infiltrated the space between the inferior fascia of the urogenital diaphragm and the superficial perineal fascia. Which of the following structures 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

20.A 39-year-old man is unable to expel the last drops of urine from the urethra at the end of micturition because of paralysis of the external
urethral sphincter and bulbospongiosus muscles. This condition may occuras a result of injury to which of the following nervous structures?

(A) Pelvic plexus
(B) Prostatic plexus
(C) Pudendal nerve
(D) Pelvic splanchnic nerve
(E) Sacral splanchnic nerve

21.A 21-year-old marine biologist asks about her first bimanual examination, and it is explained to 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

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. The damaged vein:

(A) Lies superficial to Buck's 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

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

24.
A 23-year-old massage therapist who specializes in women's health attends a lecture at an annual conference on techniques of massage. She asks, “What structure is drained by the lumbar (aortic) lymph nodes?” Which of the following structures is the correct answer to this question?

(A) Perineum
(B) Lower part of the vagina
(C) External genitalia
(D) Ovary
(E) Lower part of the anterior abdominal wall

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

26.
A first-year resident in the urology department reviews pelvic anatomy before seeing patients. Which of the following statements is correct?

(A) The dorsal artery of the penis supplies the glans penis.
(B) The seminal vesicles store spermatozoa.
(C) The duct of the bulbourethral gland opens into the membranous urethra.
(D) The duct of the greater vestibular gland opens into the vagina.
(E) The anterior lobe of the prostate gland is prone to carcinomatous transformation.

27.
A 43-year-old woman presents with a prolapsed uterus. Repair of a prolapsed uterus requires knowledge of the supporting structures of the uterus. Which of the following structures plays the most important role in the support of the uterus?

(A) Levator ani
(B) Sphincter urethrae
(C) Uterosacral ligament
(D) Ovarian ligament
(E) Arcuate pubic ligament

28.A 16-year-old boy presents to the emergency department with rupture of the penile urethra. Extravasated urine from this injury can spread into
which of the following structures?

(A) Scrotum
(B) Ischiorectal fossa
(C) Pelvic cavity
(D) Testis
(E) 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 the uterus
(D) Body of the clitoris
(E) Uterine cervix

30.
A 53-year-old bank teller is admitted to a local hospital 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

31.A 72-year-old man comes to his physician for an annual checkup. Which of the following structures is most readily palpated during rectal examination?

(A) Prostate gland
(B) Epididymis
(C) Ejaculatory duct
(D) Ureter
(E) Testis

32. A 48-year-old college football coach undergoes a radical prostatectomy for a malignant tumor in his prostate. Following surgery, he is incapable of achieving an erection. Which of the following nerves is most likely damaged during the surgery?

(A) Sacral splanchnic nerve
(B) Pelvic splanchnic nerve
(C) Pudendal nerve
(D) Dorsal nerve of the penis
(E) Posterior scrotal nerve

33.
While performing a pelvic exenteration, the surgical oncologist noticesa fractured or ruptured 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

34.A 32-year-old patient with multiple fractures of the pelvis has no cutaneous sensation in the urogenital triangle. The function of which of the following nerves is most likely to be spared?

(A) Ilioinguinal nerve
(B) Iliohypogastric nerve
(C) Posterior cutaneous nerve of the thigh
(D) Pudendal nerve
(E) Genitofemoral nerve

35.A 22-year-old victim of an automobile accident has received destructive damage to structures that 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

36.
A 32-year-old man undergoes vasectomy as a means of permanent birth control. A physician performing the vasectomy by making an incision on each side of the scrotum should remember which of the following statements most applicable to the scrotum?

(A) It is innervated by the ilioinguinal and genitofemoral nerves.
(B) It receives blood primarily from the testicular artery.
(C) Its venous blood drains primarily into the renal vein on the left.
(D) Its lymphatic drainage is primarily into upper lumbar nodes.
(E) Its dartos tunic is continuous with the perineal membrane.

37.
A 37-year-old woman complains of a bearing-down sensation in her womb and an increased frequency of and burning sensation on urination. On examination by her gynecologist, she is diagnosed with a uterine prolapse. Which of the following structures provides the primary 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

38.A woman is delivering a breech baby. The obstetrician decides that it is best to perform a mediolateral episiotomy. Which of the following structures should the obstetrician avoid incising?

(A) Vaginal wall
(B) Superficial transverse perineal muscle
(C) Bulbospongiosus
(D) Levator ani
(E) Perineal membrane

39.During pelvic surgery, a surgeon notices severe bleeding from the artery that remains within 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

40.
A neurosurgeon performs surgical resection of a rare meningeal tumor in the sacral region. He tries to avoid an injury of the nerve that arises from the lumbosacral plexus and remains within the abdominal or pelvic cavity. To which of the following nerves should he pay particular attention?

(A) Ilioinguinal nerve
(B) Genitofemoral nerve
(C) Lumbosacral trunk
(D) Femoral nerve
(E) Lateral femoral cutaneous nerve

41. After repair of a ruptured diverticulum, a 31-year-old patient begins to spike with fever and complains of abdominal pain. An infection in the deep perineal space would most likely damage which of the following structures?

(A) Ischiocavernosus muscles
(B) Superficial transverse perineal muscles
(C) Levator ani
(D) Sphincter urethrae
(E) Bulbospongiosus

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

43.A 49-year-old woman has a large mass on the pelvic brim. Which of the following structures is most likely compressed by this mass when crossing the pelvic brim?

(A) Deep dorsal vein of the penis
(B) Uterine tube
(C) Ovarian ligament
(D) Uterine artery
(E) Lumbosacral trunk

44.A 26-year-old man comes to a hospital with fever, nausea, pain, and itching in the perineal region. On examination by a urologist, he is diagnosed as having infected bulbourethral (Cowper's) glandsWhich 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

45.
A 21-year-old man is involved in a highspeed motor vehicle accident. Asa result, he has extensive damage to his sphincter urethrae. Which of the following best describes the injured sphincter urethrae?

(A) Smooth muscle
(B) Innervated by the perineal nerve
(C) Lying between the perineal membrane and Colles' fascia
(D) Enclosed in the pelvic fascia
(E) Part of the pelvic diaphragm

46.
An obstetrician is about to perform a pudendal block so a woman can experience less pain when she delivers her child. He recalls what he learned in medical school about this nerve. Which of the following statements is correct?

(A) It passes superficial to the sacrotuberous ligament.
(B) It innervates the testis and epididymis in a male.
(C) It provides motor fibers to the coccygeus.
(D) It can be blocked by injecting an anesthetic near the inferior margin of the ischial spine.
(E) It arises from the lumbar plexus.

47. A trauma surgeon in the emergency room at a local center examines a 14-year-old boy with extensive pelvic injuries after a hit and run accident. The surgeon inspects the ischiorectal fossa because it:

(A) Accumulates urine leaking from rupture of the 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 sacrotuberous ligament
(E) Contains a perineal branch of the fifth lumbar nerve

48.
An elderly man with prostatitis is seen at an internal medicine clinic.The seminal colliculus of his prostate gland is infected, and its fine openings are closed. Which of the following structures 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. A general surgeon is giving a lecture to a team of surgery residents. She describes characteristics of 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 superficial inguinal nodes
(D) Visceral sensory innervation
(E) External hemorrhoids

50.
A 78-year-old man has carcinoma of the rectum. The cancer is likely to metastasize via the veins into which of the following structures?

(A) Spleen
(B) Kidney
(C) Liver
(D) Duodenum
(E) Suprarenal gland

51. Which structure extends between the
vestibule and the cervix of the uterus and serves as the excretory channel for the products of menstruation?

52. Which structure in the female is much shorter than the corresponding structure in the male?

53. Into which structure does hemorrhage occur after injury to the inferior rectal vessels?

54. Which structure has a Houston's valve or fold, with its venous blood drained by the portal venous system?

55. Which structure is innervated by the nerve passing through both the greater and lesser sciatic foramina?

56. Which structure, when fractured, results in paralysis of the obturator internus muscles?

57. Which structure secretes fluid containing fructose, which allows for forensic determination of rape?

58. In which structure would ligation of the external iliac artery reduce blood pressure?

59. A knife wound to the obturator foramen might injure which structure?

60. A stab wound immediately superior to the
pubic symphysis on the anterior pelvic wall would most likely injure which visceral organ first?