Block 7 Anatomy BRS Pretest Pelvis
(64).webp "Block 7 Anatomy BRS Pretest Pelvis - Quiz")
Questions and Answers
- 1.
Which of the following is a characteristic of the female (compared with the male) pelvis?
- A.
A heart-shaped (as opposed to an oval-shaped) pelvic inlet
- B.
A relatively deep (as opposed to shallow) false pelvis with ilia that are flared
- C.
A pelvic outlet of smaller diameter
- D.
A subpubic angle of about 85
Correct Answer
D. A subpubic angle of about 85Explanation
(Moore and Dalley, p 361.) The subpubic angle between inferior pubic rami is significantly greater (about 85) in the female than in the male (about 60) and this is perhaps the best identifying feature of the female pelvis. The female pelvis is generally lighter than the male pelvis. The male pelvis generally has more definitive muscle markings, which reflect the larger male musculature and generally heavier male build. In the female the false or greater pelvis tends to be shallower (answer b) with flared ilia. The female pelvic inlet tends to be more oval (answer a), rather than the heart-shaped inlet of most male pelves. The female pelvic outlet is generally larger (more suitable for child bearing)
than the male pelvis (answer c).Rate this question:
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- 2.
A young couple comes to your urology office because of inability to conceive a wanted child after 1 year of unprotected sex. The wife had already undergone a gynecological workup, including testing for 3 months showing a normal ovulation profile as confirmed by an ovulatory kit. The primary care physician describes the husband’s physical exam as normal and had already ordered a semen analysis and had forwarded the results to you. The semen volume was 0.5 mL, pH 6.8, and azospermic without any fructose. The husband has a brother, who has two children, one of whom has confirmed cystic fibrosis. You order a pelvic MRI of the husband to determine whether which of the following exist(s)?
- A.
Bilateral abdominal testicles
- B.
Hypospadias
- C.
Congenital absence of ejaculatory ducts and vas deferens
- D.
Congenital hydrocele
- E.
Congenital absence of the prostate gland
Correct Answer
C. Congenital absence of ejaculatory ducts and vas deferensExplanation
(Casals, pp 1476–1483.) If the brother has a child with cystic fibrosis, then he must be a carrier of the cystic fibrosis gene, meaning there is a 50% chance that the husband is a CF carrier. Congenital absence of the ejaculatory ducts is increased in carriers of CF. If the ejaculatory ducts are absent, then there should be no sperm from the vas deferens (normally 0.5 mL of the semen volume) and no products of the seminal vesicles (normally 2.0 mL of the semen volume). The seminal vesicle is responsible for fructose normally present in the ejaculate. Prostatic secretions are normally slightly acidic. The normal physical of the husband rules out hypospadias (answer b), bilateral cryptorchidism (answer a), and hydrocele (answer d). The congenital absence of the prostate gland is extremely rare (answer e).Rate this question:
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- 3.
The gubernaculum is a continuous mesenchymal condensation extending from the caudal pole of each gonad through the inguinal canal to the labioscrotal swelling, inferiorly. In the female the gubernaculum becomes which of the following?
- A.
Canal of Nuck
- B.
Ligament of the ovary or proper ligament of the ovary
- C.
Round ligament of the uterus
- D.
Round ligament of the uterus and the ligament of the ovary or proper ligament of the ovary
- E.
Suspensory ligament of the ovary
Correct Answer
D. Round ligament of the uterus and the ligament of the ovary or proper ligament of the ovaryExplanation
(Moore and Dalley, pp 218–219.) In the female, the gubernaculum becomes the round ligament of the uterus and the proper ligament of the ovary. The gubernaculum, which runs from the gonadal anlage to the sexually undifferentiated labioscrotal fold, guides the descent of the testes into the scrotum in the male and the descent of the ovary into the true pelvis in the female. In the female, the developing uterus grows into the gubernacular tract and divides it into the proper ligament of the ovary and the round ligament of the uterus. Thus, the proper ligament of the ovary runs within the broad ligament from the medial pole of each ovary to the uterus. It then continues within the broad ligament as the round ligament of the uterus into the deep inguinal ring. It thereby gains access to the canal of Nuck (the female homologue of the inguinal canal; (answer a) to insert into the major labial folds. The suspensory ligament of the ovary (answer e) contains the ovarian arteries and veins. Answers c
and d are thus incomplete.Rate this question:
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- 4.
Parts of some human skeletal remains are brought to you as coroner of a rural community. The pelvis is complete, yet the individual bones of the pelvis, the ilium, ischium, and pubis have just started to fuse together. The subpubic angle you estimate at 60° and the pelvic brim has a distinctive heartshaped appearance. On the basis of this information, you guess the remains are of which of the following?
- A.
3-year-old male
- B.
4-year-old female
- C.
14-year-old male
- D.
30-year-old female
- E.
80-year-old male
Correct Answer
C. 14-year-old maleExplanation
(Moore and Dalley, pp 358–359, 361.) The pelvis is most likely that of a 14-year-old male. Because the subpubic angle is about 60and the pelvic brim is heart shaped, you are looking at a male not a female (answers b and d). The bones of the pelvis arise from three different centers of ossification and generally fuse together between puberty and the twenty-third year. Therefore, you know you are looking at a 14-year-old male, not a 3-year-old (answer a; would have 3 separate pelvic bones) nor an 80-year-old (answer e; pelvic bones would be fused).Rate this question:
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- 5.
Following vaginal childbirth, a woman experienced urinary incontinence, particularly when coughing. This was most likely caused by tearing of which of the following?
- A.
Puborectalis muscle
- B.
Obturator internus muscle
- C.
Pubococcygeus muscle
- D.
Superficial transverse perineal muscle
- E.
Piriformis muscle
Correct Answer
C. Pubococcygeus muscleExplanation
. (Moore and Dalley, pp 373, 375, 467.) The pubococcygeus muscle is the most frequently torn muscle that results in femaleincontinence. The puborectalis, pubococcygeus, and iliococcygeus comprise the levator ani, the main muscular component of the pelvic floor. The
pubococcygeus is the part of the levator ani most frequently damaged during parturition. Because the pubococcygeus surrounds and supports the neck of the bladder and the proximal urethra, urinary leakage is a common result, particularly during increased abdominopelvic pressure, as occurs, during coughing. Damage to the puborectalis (answer a) results in fecal incontinence under similar situations. Both the obturator internus muscle (answer b) and the piriformis (answer e) are parts of the lateral wall of
the pelvis and assist in lateral rotation of the thigh. Generally damage to the superficial transverse perineal muscle (answer d) would be of little significance.Rate this question:
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- 6.
When one touches the upper medial thigh or scrotum of most young males, the testicles are pulled upwards towards the external inguinal ring. This is called the cremasteric reflex. The efferent limb of the cremasteric reflex is provided by which of the following?
- A.
Femoral branch of the genitofemoral nerve
- B.
Genital branch of the genitofemoral nerve
- C.
Ilioinguinal nerve
- D.
Pudendal nerve
- E.
Temperature differential between core body temperature and scrotal temperature
Correct Answer
B. Genital branch of the genitofemoral nerveExplanation
(Moore and Dalley, pp 220–221, 225.) The efferent portion of the cremasteric reflex is mediated by the genital branch of the genitofemoral nerve, which innervates the cremasteric muscle (skeletal). The femoral branch (answer a) supplies the afferent limb, and the genital branch supplies the efferent limb. The ilioinguinal nerve (answer c) provides sensory innervation to the medial aspects of the thigh and the anterior aspects of the mons or the base of the penis and can also provide afferent innervation to stimulate the cremasteric response, pulling the testicles upward. The pudendal nerve (answer d) provides sensation to most of the skin of the perineum as well as the motor supply to the perineal muscles. The involuntary scrotal reflex can also be based on temperature (answer e): warmth causes relaxation of the cremasteric (skeletal) and dartos (smooth) muscle, whereas cold causes contraction of both the cremasteric and dartos muscles.Rate this question:
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- 7.
A 36-year-old man complained to his primary care physician of occasional dull, throbbing pain associated with the right testis and scrotum. Examination indicated varicocele of the pampiniform plexus. The physician remarked that in all probability the patient had this condition since adolescence and should not be bothered by it. The patient was emphatic that the condition had arisen within the last few months and sought a second opinion from an urologist. The urologist ordered an abdominal and pelvic CT. Factors that the urologist considered include which of the following in regard to varicocele of the pampiniform plexus on the right side?
- A.
It is very uncommon
- B.
It occurs about as often as that on the left side
- C.
It may be the result of testicular torsion
- D.
It may be associated with a long, redundant mesorchium
Correct Answer
A. It is very uncommonExplanation
(Moore and Dalley, pp 228–229.) It is very uncommon. Varicocele usually occurs on the left side (~95%) and is rare on the right (answer b). Left varicocele results from local venous congestion caused by compression of the testicular vein as it passes beneath the usually full sigmoid colon. Testicular torsion (answer c), wherein a long mesorchium (answer d) is a contributing factor, strangulates the testicular artery, and produces testicular ischemia, not varicocele. Testicular torsion is a medical emergency which normally presents in adolescents as sudden testicular pain (Moore and Dalley, p 226).Rate this question:
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- 8.
A 19-year-old female college student presents to the emergency room at 10:30 PM on a Friday night with severe left side, back, and pelvic pain. While she has never had them before, she states that she thinks she has kidney stones. The pain started in her mid back about a week ago and then subsided and now the pain has decreased somewhat and also extends down into her labia majora. She is on birth control pills, but denies any sexual activity. She is having her period, but denies the pain is menstrual. You have her do a urine pregnancy test while she is waiting to get an abdominal and pelvic computer tomography (CT) to look for ureteric calculi. What specific location(s) will you look for in the CTs for obstructing calculi?
- A.
At the junction of the renal pelvis with the ureters
- B.
As the ureters cross the cranial edge of the greater pelvis
- C.
As the ureters cross the external iliac artery at the pelvic brim
- D.
As the ureters pass through the wall of the bladder
- E.
A, b, and c
- F.
A, c, and d
Correct Answer
F. A, c, and dExplanation
(Moore and Dalley, pp 319–320, 393.) A, c, and d. Renal and ureteric calculi (laymen’s kidney stones) generally are formed in the kidneys and then lodge at one of three locations: 1) at the junction of the renal pelvis with the ureter; 2) as the ureters cross the external iliac vessels at the pelvic brim; and 3) as the ureters pass through the wall of the bladder (see Fig. 3.14 A, p 393 Moore & Dalley). Stones generally do not lodge at the edge of the greater pelvis [answer b; all other answers (a, c, d, and e) are incomplete]. The referred pain from ureteric calculi is usually described as from “loin to groin” in that it often starts in back and side over the kidney and then extends in a band down towards the labia majora or scrotum (from T 11 to L2). Normally the pain is intermittent and comes and goes in waves and may change in location, generally moving inferiorly with time. Since the ureters undergo peristaltic movement, the calculi often move with time. Depending on the chemical composition and shape of the calculi they may either block urine flow or if spiky, stick into the wall of the ureter. Kidney stone pain is often described as being worse than labor pains. Treatments include pain relief and drinking lots of fluids, and either lithotripsy (use of ultrasound waves to break up the stone) or physical removal (surgical) of the stone in severe cases.Rate this question:
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- 9.
You deliver a full-term baby boy who is healthy and receives an Apgar score of 9 out of 10. You do note that his scrotum is rather large compared to his penis and when he cries and strains, the scrotum gets even bigger. You palpate for testes and epididymides and think both are present and don’t feel any abnormal structures. You tell the parents the newborn has which of the following?
- A.
Cryptorchidism
- B.
Direct inguinal hernia
- C.
Varicocele
- D.
Hydrocele
- E.
Klinefelter’s syndrome
Correct Answer
D. HydroceleExplanation
(Moore and Dalley, pp 225–226.) The newborn boy has congenital hydrocele. As the testicles migrate from the posterior abdominal wall to the anterior abdominal wall through the inguinal canal, they bring a process of the peritoneal lining, the processes vaginalis, which is filled with fluid and is connected to the peritoneal cavity. Normally, this process vaginalis disconnects from the abdominal cavity and forms the tunica vaginalis. Sometimes due to the late migration of the testis, the process vaginalis does not lose its connection with the peritoneal cavity, so that during straining and coughing or crying the scrotum swells. Normally this condition spontaneously corrects itself a few months after birth. Cryptorchidism (answer a) is the failure of the testis to migrate down into the scrotum, but the physical exam indicated the testes were in the scrotum. A direct inguinal hernia (answer b) is very rare in newborns. Congenital varicocele (answer c) would generally appear bluish and would feel like a bag of worms. Klinefelter’s newborn (answer e) would have normal-sized testicles and is not related to a hydrocele.Rate this question:
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- 10.
A 6-year-old boy badly bruised his perineum on the horizontal bar of his bicycle as he was learning to ride a bike. Blood extended into his scrotum, and onto the anterior abdominal wall from 3 in. below his umbilicus to just anterior to his anus, but did not pass into his thigh. Which anatomical layers most likely explain the distribution of extravasated blood?
- A.
Superficial membranous fascia and Camper’s fascia
- B.
Superficial membranous fascia and transversalis fascia
- C.
Dartos fascia and the perineal membrane
- D.
Superficial membranous fascia and the perineal membrane
- E.
Deep perineal fascia and inferior fascia of the pelvic diaphragm
Correct Answer
D. Superficial membranous fascia and the perineal membraneExplanation
(Moore and Dalley, pp 441–442.) The blood from straddle injuries is generally limited to the superficial perineal space which is bound by the superficial membranous fascia (superficially; including Scarpa’s fascia on the anterior abdominal wall, dartos fascia on penis and scrotum, and Colles’ fascia on the urogenital triangle) and the deep perineal membrane (deep). The superficial membranous fascia is attached to deep structures at the following locations: superiorly the superficial membranous fascia attaches to the deep fascia of the anterior abdominal muscles about half way between the pubic symphysis and the umbilicus; attaches to the inguinal ligament, and the fascia lata, laterally; and attaches to the posterior edge of the perineal membrane just anterior to the anus Camper’s fascia (answer a) is the fatty layer on the anterior abdominal wall, which extends beyond the umbilicus. Transversalis fascia (answer b) is the fascia just deep to the peritoneal lining in the abdomen. Dartos fascia (answer c) only covers the scrotum and penis. The inferior fascia of the pelvic diaphragm (answer e) is deep to the perineal membrane.Rate this question:
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- 11.
Fructose, a source of energy for spermatozoa, is found primarily in secretions from which of the following organs?
- A.
Bulbourethral glands
- B.
Epididymis
- C.
Prostate
- D.
Seminal vesicles
- E.
Testis
Correct Answer
D. Seminal vesiclesExplanation
(Kierszenbaum, pp 557–558.) The thick secretion from the seminal vesicles contributes substantially to the ejaculate volume that conveys the spermatozoa. The high fructose content of secretions of the seminal vesicles provides the primary metabolic energy source for sperm motility. The flavins that are contributed to the ejaculate by the seminal vesicles fluoresce strongly in ultraviolet light, a phenomenon that supplies a useful forensic test for the presence of semen. Bulbourethral glands (answer a) produce mucus that lubricates the urethra upon erotic stimulus. The epididymis (answer b) stores sperm. The prostate gland (answer c) produces proteins responsible for semen liquefaction. The testis (answer e) produces sperm.Rate this question:
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- 12.
In this CT of the pelvis, the muscle indicated by the yellow arrow is which of the following?
- A.
Sphincter urethrae/urogenital diaphragm
- B.
Levator ani/pelvic diaphragm
- C.
Obturator internus
- D.
Obturator externus
Correct Answer
B. Levator ani/pelvic diaphragmExplanation
(Moore and Dalley, pp 396–371, 436–438.) The muscle indicated is attached to the pubic bone and extends around the rectum. It is the puborectalis portion of the levator ani (pelvic diaphragm). The puborectalis is responsible for fecal continence. The urogenital diaphragm (answer a) is positioned inferior to the pelvic diaphragm and includes the deep transverse perineal muscle. The obturator internus (answer c) covers the lateral wall of the lesser pelvis. The obturator externus
(answer d) is found in the deep thigh.Rate this question:
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- 13.
Benign prostatic hypertrophy results in obstruction of the urinary tract. Patients present with weak urine flow, increased difficulty initiating urination, and increase frequency of urination since the bladder often is not fully emptied. Benign prostatic hypertrophy is associated with enlargement of which of the following?
- A.
Entire prostate gland
- B.
Lateral/posterior lobes
- C.
Mucosal and submucosal regions
- D.
Anterior region
Correct Answer
C. Mucosal and submucosal regionsExplanation
(Moore and Dalley, p 409. Kierszenbaum, p 559.) Benign prostatic hypertrophy is the result of enlargement of the mucosal and submucosal (median) region, which may compress the prostatic urethra leading to urinary retention [thus not (answer a)]. This hypertrophic tissue may also protrude into the urinary bladder to prevent complete emptying. The lateral/posterior lobes (answer b) are commonly associated with malignant transformation. The anterior region (answer d) tends to be
asymptomatic due to its mainly fibrous nature.Rate this question:
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- 14.
A rectal cancer that occurs within the anal canal penetrates the mucosa and basement membrane. Which nodes would you most likely harvest at the same time you removed the cancerous growth to send to pathology to determine if there has been metastasis?
- A.
Superficial inguinal nodes
- B.
Inguinal nodes and internal iliac nodes
- C.
Superficial inguinal, internal iliac and preaortic inferior mesenteric nodes
- D.
Internal iliac and external iliac nodes
- E.
External iliac, superficial inguinal, and preaortic nodes
Correct Answer
C. Superficial inguinal, internal iliac and preaortic inferior mesenteric nodesExplanation
(Moore and Dalley, p 431.) Lymph from the anal region is drained to three different regions because its blood supply comes from three different regions [thus (answers a and b) are incomplete]. Superior to the pectinate line the lymph drains into the internal iliac nodes and preaortic nodes (along the path of the superior rectal artery, a branch off the inferior mesenteric artery). Inferior to the pectinate line the lymph drains into the superficial inguinal nodes. Thus the external iliac nodes have nothing to do with the rectum [thus not (answers d and e)].Rate this question:
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- 15.
In the male, the homologue of the vaginal artery is which of the following?
- A.
Obturator artery
- B.
Internal pudendal artery
- C.
Middle rectal artery
- D.
Umbilical artery
- E.
Inferior vesical artery
Correct Answer
E. Inferior vesical arteryExplanation
(Moore and Dalley, pp 384–386.) All of the listed choices are branches of the internal iliac artery. The inferior vesical artery in the male supplies the seminal vesicle, prostate, fundus of the bladder, distal ureter, and the vas deferens. In the female, the vaginal artery supplies the vagina, urinary bladder, and pelvic portion of the urethra. The obturator artery (answer a) gives off muscular and nutrient branches within the pelvis and then leaves the pelvis via the obturator canal to supply the thigh. The internal pudendal artery (answer b) crosses the piriformis muscle, exits the pelvic cavity via the greater sciatic foramen, and enters the ischiorectal fossa via the lesser sciatic foramen. It supplies the external genitalia (penis and clitoris). The middle rectal artery (answer c) supplies the inferior rectum and forms important anastomoses with other rectal arteries. The umbilical artery (answer d) gives off the superior vesical artery in both sexes. Its distal portion degenerates to form the medial umbilical ligament.Rate this question:
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- 16.
A 24-year-old woman seeking assistance for apparent infertility has been unable to conceive despite repeated attempts in 5 years of marriage. She reveals that her husband fathered a child in a prior marriage. Although her menstrual periods are fairly regular, they are accompanied by extreme lower back pain. The lower back pain during menstruation experienced by this woman probably is referred from the pelvic region. The pathways that convey this pain sensation to the central nervous system involve which of the following?
- A.
Hypogastric nerve to L1–L2
- B.
Lumbosacral trunk to L4–L5
- C.
Pelvic splanchnic nerves to S2–S4
- D.
Pudendal nerve to S2–S4
Correct Answer
A. Hypogastric nerve to L1–L2Explanation
(Moore and Dalley, pp 423, 425.) The visceral afferent fibers that mediate sensation from the fundus and body of the uterus, as well as from the oviducts, tend to travel along the sympathetic nerve pathways (via the hypogastric nerve and lumbar splanchnics) to reach the upper lumbar levels (L1–L2) of the spinal cord. Thus, uterine pain will be referred to (appear as if originating from) the upper lumbar dermatomes and produce backache. The visceral afferent fibers that mediate sensation from the cervical neck of the uterus travel along the parasympathetic pathways [via the pelvic splanchnic nerves (nervi erigentes); (answer c)] to the midsacral levels (S2–S4) of the spinal cord. In this instance, pain originating from the cervix will be referred to the midsacral dermatomes and produce pain that appears to arise from the perineum, gluteal region, and legs. Neither the lumbosacral trunk to L4–L5 (answer b) nor the pudendal nerve (answer d) should be involved.Rate this question:
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- 17.
The body of the uterus tends to wander within the pelvic cavity. However the cervix of the uterus tends to remain fairly firmly in place most of the time. Which of the following would be found immediately inferior to the left cardinal (lateral cervical) ligament?
- A.
Ovarian neurovascular bundle
- B.
Uterine tube
- C.
Round ligament of the uterus
- D.
Ureter
- E.
Ovarian artery and vein
Correct Answer
D. UreterExplanation
(Moore and Dalley, pp 387, 414.) The ureter, lying just medial to the internal iliac artery in the deep pelvis, passes from posterior to anterior immediately inferior to the lateral cervical ligament. This ligament sits at the base of the broad ligament and contains the uterine artery and vein to which the ureters pass inferior approximately midway along their course between internal iliac artery and uterus. The ureter continues inferior to the anterior portion of the lateral cervical ligament (where it can sometimes be palpated through the walls of the vagina at the lateral fornices) to gain access to the base of the urinary bladder. The close association between uterine vessels and ureter is of major importance during surgical procedures in the female pelvis. At the top of the broad ligament would be the ovarian artery and vein (answers a and e), which continue on to supply blood to the fundus. The uterine tube (answer b) also runs along the top of the broad ligament. The round ligament of the uterus (answer c) runs anterior to the broad ligament.Rate this question:
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- 18.
A 50-year-old associate professor is scheduled for a routine physical exam for an increase in the level of coverage for his life insurance. He had never had a digital rectal exam or PSA level determined so you recommend both to him. As you have him hop off the examination table, turn away from you and face the table, then bend at the waist while you gently insert a lubricated gloved finger into his anus you can feel structures through the wall of the rectum. Typically what part of three reproductive organs can you palpate through the anterior wall of the rectum?
- A.
Main peripheral portion of the prostate gland
- B.
Ejaculatory ducts
- C.
Seminal vesicles
- D.
Epididymal ducts
- E.
Ampulla of the vas deferens
- F.
A, b, and c
- G.
A, b, and d
- H.
A, c, and e
- I.
B, c, and d
Correct Answer
H. A, c, and eExplanation
(Moore and Dalley, pp 404, 409, 433.) In most males, during a digital rectal exam, you can palpate the main peripheral portion of the prostate gland (answer a), then just a little more cranially, both the seminal vesicles (answer c) and ampulla of the vas (ductus) deferens (answer e). The main goal of the digital rectal exam is to palpate the backside of the prostate gland which is the main peripheral portion of the gland; the site of development of most growth of prostate cancer. An additional screening tool is the prostate specific antigen (PSA) level within blood. Generally the PSA level should be below 2.5 ng/mL. Elevated levels of PSA, however, can also indicate inflammation of the prostate in addition to cancerous growth. You can not palpate the ejaculatory ducts (answer b) as they are embedded within the substance of the prostate gland. You can not palpate the epididymis (answer d) during a digital rectal exam as it is within the scrotum next to the testicles. All other answers (f, g, and i) are wrong or incomplete.Rate this question:
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.JPG "In this CT of the pelvis, the muscle indicated by the yellow arrow is which of the following?")
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