Pelvis

Question 1

22204 – The pelvic inlet or brim
1: lies in an oblique plane at 30o to the horizontal
2: is bounded laterally by the iliac crest
3: is proportionately larger in the female than in the male
4: is bounded posteriorly by the sacral promontory

Answer 1

FFTT
Last 10th ed. PAGE:282
angle is 55 degreees with horizontal

Boundaries:
- Sacra+ala posterior
- Arcuate line laterally
- Anteriorly pubic crest/pecten/symphesis

Question 2

22904 – The pubic crest gives attachment to
1: part of the rectus abdominis
2: the interfoveolar ligament
3: external oblique aponeurosis
4: the lacunar ligament

Answer 2

TFTF
Last (8) PAGE: 217, 297 et. Seq.
Rectus abdominis arises pubic crest and symphysis and inserts 5,6,7 costal cartilages, inf costal margin and post aspect of xiphoid.

interfoveolar - lateral to the conjoint tendon and arises from the transversalis fascia to the superior ramus of the pubis

external oblique aponeurosis
external oblique arises anterior of lower eight ribs and inserts outer anterior half of iliac crest, inguinal ligament, pubic tubercle and crest, and aponeurosis of anterior rectus sheath, linea alba and xiphisternum

Lacunar ligament
- reflected fibres of external oblique aponeurosis, attached to pectineal line which is superior rami, and inguinal ligament

Question 3

8470 – The ilium
1: gives attachment to the rectus femoris muscle
2: gives attachment to the quadratus lumborum
3: gives attachment to the latissimus dorsi muscle
4: forms two-thirds of the acetabulum

Answer 3

TTTF
Last 10th ed, Ch 3

Rectus femoris
- Arises. straight head - anterior inferior iliac spine, reflected head - ilium above acetabulum
- extends leg at knee and flexes thigh at. hip
- n femoral L234

Quadratus lumborum
- arises inferior border of 12th rib and inserts on spices of transverse processes of L1-4, iliolumbar ligament and posterior third of iliac crest.
Action - fixes 12th rib during respiration and laterally flexes trunk
n - ant rami T12-L3

Latissimus dorsi
- Arises all thoracic spines and supraspinous ligaments from T7 downwards + lumbar and sacral spines via lumbar fascia, posterior third of iliac crest, last four ribs (interdigitating with ext oblique) and inferior angle of the scapula
- inserts floor of bicipital groove of humerus after spiralling around teres major

Acetabulum
- 2/5, 2/5, 3/5 of ischium, ilium, and pubis

Question 4

23629 – The greater sciatic foramen transmits
1: the piriformis muscle
2: the inferior gluteal vessels
3: the superior gluteal vessels
4: the posterior cutaneous nerve of the thigh

Answer 4

TTTT
Last PAGE: 147

Piriformis muscle exists and occupies most of the space. divides it.

Above the piriformis exits:
- superior gluteal vessels and nerve

Below the piriformis exists:
- inferior gluteal vessels and nerve
- internal pudendal vessels and pudendal nerve
- sciatic nerve
- nerve to obturator internus
- nerve to quadratus femoris
- posterior cutaneous femoral nerve

Question 5

19246 – A structure leaving the pelvis through the greater sciatic notch
above the piriformis muscle is
A. the inferior gluteal nerve
B. the nerve to the quadratus femoris muscle
C. the superior gluteal artery
D. the posterior femoral cutaneous nerve
E. the pudendal nerve

Answer 5

Answers: C
Last PAGE: 16

Question 6

22639 – Structures passing through the lesser sciatic foramen include
1: the pudendal nerve
2: the inferior gluteal vessels
3: the tendon of obturator internus muscle
4: the posterior cutaneous nerve of thigh

Answer 6

TFTF
Last 10th ed. PAGE: 161
Structures passing through lesser sciatic foramen:
- Tendon of obturator internus
- the internal pudendal vessels
- The pudendal nerve
- nerve to obturator internus

bounded by
- superior: spine of ischium and sacrospinous ligament,
- Posterior: sacrotuberous ligament
- Anterior: tuberosity of ischium

Question 7

22634 – Structures crossing the back of the ischial spine are
1: the nerve to obturator internus
2: the pudendal nerve
3: the inferior gluteal nerve
4: the nerve to quadratus femoris

Answer 7

TFFF
Last 10th ed. PAGE: 161.

Question 8

18970 – The ischial spine
A. gives rise to coccygeus
B. gives rise to piriformis
C. is crossed by the pudendal nerve
D. gives rise to gemellus inferior
E. gives rise to the falciform ligament

Answer 8

A
Last 10th ed. PAGE: 284; 282; 308; 122; 228; 374; 405; 313
The ischial spine attachments
- gemellus superior
- Coccygeus, levator ani, pelvic fascia,
- sacrospinout ligament

pudendal nerve lies close to it

piriformis muscle arises 2,3,4 transverse bars of anterior sacrum between sacral foramina and inserts on ant part of medial aspect of greater trochanter of femus, lateral rotaes and stabilises hip, anterior rami of S1,2, passes latearlly through greater sciatic foramen

Question 9

19563 – The inguinal canal
A. has the internal oblique muscle in the lateral part of its posterior wall
B. is situated inferior to the inguinal ligament
C. has the transversus abdominis in the medial part of its anterior wall
D. has the internal oblique muscle in the lateral part of its anterior wall
E. has an external ring directly lateral to the pubic tubercle

Answer 9

D
Last (6) PAGE: 259 et. seq.

Walls:
- inferior wall - inguinal ligament, reinforced medially by lacunar ligament,
- Superior wall/roof - musculoaponeurotic arches of internal oblique and TVA, and transversalis fascia, and medial crus of aponeurosis of external oblique.
- posterior wall - transversalis fascia, conjoint tendon, deep inguinal ring.
- Anterior wall - aponeurosis of external oblique muscle, reinforced laterally by the internal oblique muscle. superificial inguinal ring medial 1/3

Question 10

21503 – The inguinal canal
1: has an internal ring lying 1.5 cm lateral to the midpoint of the inguinal ligament
2: has the fascia transversalis as a posterior relation
3: is about 1.5cm long in the adult
4: has the lacunar ligament in the medial part of its floor

Answer 10

FTFT
Last (6) PAGE: 259

4cm long according to lasts, medial half of inguinal lig

Deep inguinal ring lies 1.25 cm above the midpoint of the inguinal ligament

superficial ring just above (?and medial) to pubic tubercle

femoral hernia below and lateral to pubic tubercle

Question 11

24234 – Structures forming the posterior wall of the inguinal canal include
1: the internal spermatic fascia
2: the fascia iliaca
3: the conjoint tendon
4: the fascia transversalis

Answer 11

FFTT
Last 10th Ed, Ch 5, page 220-221
Walls:
- inferior wall - inguinal ligament, reinforced medially by lacunar ligament,
- Superior wall/roof - musculoaponeurotic arches of internal oblique and TVA, and transversalis fascia, and medial crus of aponeurosis of external oblique.
- posterior wall - transversalis fascia, conjoint tendon, deep inguinal ring.
- Anterior wall - aponeurosis of external oblique muscle, reinforced laterally by the internal oblique muscle. superificial inguinal ring medial 1/3

Question 12

22304 – The lacunar ligament
1: in the erect position, has the spermatic cord on its superoanterior surface
2: forms part of the posterior wall of the inguinal canal
3: is attached to the pectineal line
4: is attached to the pubic bone in continuity with the adductor longus

Answer 12

TFTF
Last (8) PAGE: 297
Forms inferior wall of inguinal canal
Forms medial boundary of femoral ring

Question 13

22264 – The superficial inguinal nodes
1: consist of medial, lateral and vertical groups
2: receive lymph from subcutaneous tissues of the back below the waist
3: receive lymph from the gluteal region
4: receive lymph from the anal canal

Answer 13

TTTT
Last 8th ed. PAGE: 148

Question 14

23479 – The conjoint tendon (falx inguinalis)
1: has a free inferolateral border
2: attaches to the superior pubic ramus
3: attaches along the pectineal line
4: is formed partly from aponeurotic fibres of the transversus muscle

Answer 14

TTTT
Last (8) PAGE: 302
formed from lower part of common aponeurosis of internal oblique and TVA. forms posterior wall of inguinal canal.
inserts into pubic crest and pectineal line behind the superficial ring

Question 15

928 – Inguinal hernia is
1: More common in male than in female patients.
2: More common than femoral hernia in female patients.
3: Likely to be indirect if the swelling is inguinoscrotal.
4: Classically associated with Richter type hernia (strangulation of part of bowel wall).
5: More prone to recurrence after surgery than is femoral hernia.

Answer 15

Answers: TTTFT
Inguinal hernia is more common in males than females (1 true). The region of the male inguinal canal is more likely to have a congenital sac and also more prone under stress to herniate than the female inguinal canal, which only transmits the round ligament of the uterus in contrast to the male spermatic cord leading to the testis. Inguinal hernias are also more common than femoral hernias overall in both sexes (2 true).
When an inguinal hernia is found to be inguinoscrotal it is virtually certain to be indirect (3 true). Indirect hernias as they enlarge descend with the spermatic cord into the scrotum. Direct hernias do not; they remain in the groin above the scrotal neck. A Richter hernia describes a strangulated hernia with entrapment of portion of the circumference of
the bowel within a hernial sac with a small opening from the peritoneal cavity. This classically occurs with femoral (not inguinal) hernias (4 false). Overall recurrence after hernia repair is low; but inguinal hernias have in general a higher recurrence rate than do femoral hernias (5 true). A standard repair of an inguinal hernia defect in males must still leave a passageway for the spermatic cord through the inguinal canal. Repair of femoral hernias can obliterate or plug the femoral ring and femoral canal completely.

Question 16

940 – In direct inguinal hernia, the hernia sac
1: passes through the internal inguinal ring.
2: passes through the posterior wall of the inguinal canal.
3: passes through the external inguinal ring.
4: lies within the internal spermatic fascia.
5: may contain urinary bladder.

Answer 16

FTTFT
Both indirect and direct hernias pass through the superficial (external) ring (3 true). However a direct inguinal hernia (the sac of which is always acquired, and which thus occurs in an older age group) does not pass through the internal inguinal ring (1 false). A direct inguinal hernia passes through a defect in the posterior wall of the inguinal canal (2 true), usually through the fascia transversalis within the triangle of Hesselbach (bounded by the inferior epigastric vessels laterally, the lateral edge of rectus medially and the inguinal ligament below). A direct hernia as it emerges from the external inguinal ring, lies not within the internal spermatic fascia of the spermatic cord as does an indirect hernia (4 false), but behind the cord which it displaces forward. A portion of the urinary bladder, at the medial end of the inguinal canal, may occasionally protrude into the sac of a direct hernia. This needs to be recognised at operation to avoid bladder injury (5 true).

Question 17

916 – In indirect inguinal hernia, all of the following statements concerning
the hernial sac are true EXCEPT
A. Passes through the internal inguinal ring.
B. Passes through the external inguinal ring.
C. Runs within the spermatic cord
D. Requires total excision to prevent recurrence
E. Commences lateral to the inferior epigastric vessels

Answer 17

D
An indirect inguinal hernia sac may be congenital or acquired. Inguinal hernias in childhood occur mostly into preformed sacs due to incomplete closure of the processus vaginalis.
Hamilton Russell, a prominent Australian surgeon, was a strong proponent of the congenital basis of indirect inguinal hernias. In adult hernias the sac can be preformed but acquired sacs originating from the internal inguinal ring are also common. Whether of congenital or acquired origin, the sac of an INDIRECT inguinal hernia originates LATERAL to the inferior epigastric vessels and passes along the inguinal canal within the spermatic cord, passing successively through the internal (deep) and external (superficial) inguinal rings before giving a palpable groin swelling. (responses A, B, C, E all true). Herniotomy (exploration followed by excision of the sac) is usual in open repair of an indirect inguinal hernia. Total sac excision (provided a sound repair of the orificial defect is performed) is not obligatory; and is contradicted in at least two clinical circumstances (D is false and thus is the correct answer).

KEY ISSUE
Left sided indirect inguinal hernias containing sigmoid colon are quite common in elderly patients and are associated with a large indirect inguinal hernial sac. The serosa of sigmoid colon in this instance progressively descends as part of the wall of the sac. The bowel does not lie within the sac lumen, but forms part of its posterior wall. These are known as sliding hernias (“hernia en glissade”). They usually present clinically as large reducible inguinoscrotal hernias containing bowel. When diagnosed the sac is simply closed and the defect of the inguinal ring repaired by any of the appropriate techniques.
Occasionally the patent processus vaginalis forming a congenital sac remains in its embryonic form. This leads to a large inguinoscrotal hernia, and on exploration the lower part of the sac is found to be continuous with the coverings of the testis. The sac must be transected and its lower portion left in situ on the testis and cord (aka not total excision)

Question 18

21273 – Branches of the lumbar plexus which appear at the medial border
of the psoas major are
1: obturator nerve
2: ilio-hypogastric
3: lumbo-sacral trunk
4: femoral nerve

Answer 18

TFTF
Last (8) PAGE: 356.
Medial: obturator, lumbosacral
Lateral: femoral, iliohypogastric

Question 19

19587 – The branch of the lumbar plexus which appears at the medial border of the psoas major muscle is
A. iliohypogastric nerve
B. sciatic nerve
C. femoral nerve
D. obturator nerve
E. genitofemoral nerve

Answer 19

D
Last (8) PAGE: 416

Question 20

20037 – The ilioinguinal nerve
A. supplies the rectus abdominus muscle
B. enters the deep inguinal ring
C. supplies the cremaster muscle
D. supplies the urethra
E. supplies skin over the root of the penis

Answer 20

E
Last (9) PAGE: 145; 304; 362
Supplies skin of the root of the penis and the anterior one-third of the scrotum, but it supplies also a small area of thigh below the medial end of the inguinal ligament

Question 21

19887 – The ilio-inguinal nerve
A. supplies the rectus abdominis
B. enters the deep inguinal ring
C. supplies the cremaster muscle
D. supplies the urethra
E. does none of the above

Answer 21

E
Last p145
In the anterior abdominal wall it lies in the neurovascular plane between the internal oblique and transversus abdominis muscles, pierces internal oblique and supplies its lower fibres, and passes down beneath the external oblique to emerge on the front of the cord through the SUPERFICIAL inguinal ring. Piercing the external spermatic fascia its chief distribution is to the skin of the root of the penis and the anterior one-third of the scrotum.

Question 22

23504 – The lumbosacral trunk
1: contributes to the sacral plexus
2: first appears medial to the psoas major muscle
3: gives off the presacral nerve
4: does not contribute fibres to any cutaneous nerves

Answer 22

TTFF
Last 8th ed. PAGE: 310, 362, 398
presacral nerve or superior hypogastric plexus - lie anterior to aorta bifurcation and then medial to iliac arteries, sends sympathetic fibres to ovary and uterus mixes with lumbar and pelvic splanchnic to form interior hypogastric plexus

Question 23

15002 – With regard to the obturator internus
1: the pudendal nerve lies adjacent to it
2: the internal pudendal artery lies adjacent to it
3: the levator ani arises adjacent to its medial aspect
4: it forms a wall of the ischiorectal fossa

Answer 23

TTTT
Refer to Last, 10th Ed, page 282-283
Obturator internus
Arises from inner surface of obturator membrane, rim of pubis and ischium bordering membrane. Inserts on middle part of medial aspect of greater trochanter of femur
laterally rotates and stabilises hip.
Nerve to obturator internus: (sciatic) L5, S1, S2

Question 24

22789 – The obturator internus muscle forms
1: part of the lateral pelvic wall
2: a wall of the ischioanal fossa
3: a boundary of the lesser sciatic foramen
4: part of the pelvic floor

Answer 24

TTFF
Last 10th ed. PAGE: 283
Pelvic floor is comprised of levator ani: pubococcygeus, puborectalis, and iliococcygeus. and coccygeus

Question 25

19785 – The obturator nerve often
A. supplies the skin of the labium majus
B. divides into an anterior division which innervates pectineus
C. may leave the pelvis through the greater sciatic foramen
D. arises from anterior divisions of anterior rami of L2, L3 and L4
E. emerges onto the sacrum to lie medial to the lumbosacral trunk

Answer 25

D
Last 8th ed. PAGE: 398

Question 26

7839 – The obturator nerve
1: arises from the anterior divisions of the posterior rami of L2, L3 and L4
2: lies above the obturator vessels on the lateral wall of the pelvis
3: supplies the gracilis muscle
4: has no sensory branches

Answer 26

FTTF
Last 10th ed, Ch 3 and Ch 5

1- ant division of ant rami of L2, L3, L4

obt n - It divides into anterior and posterior divisions which straddle adductor brevis. The posterior division pierces a few fibres of obturator externus and runs deep to adductor brevis on adductor magnus. The anterior division runs on the anterior aspect of adductor brevis deep to pectineus and then deep to adductor longus to end by contributing, together with the saphenous and medial femoral cutaneous n., to the subsartorial plexus which supplies the skin over the medial thigh.

Question 27

23494 – The obturator nerve
1: has an anterior branch which is anterior to the adductor longus muscle
2: is lateral to the ureter in the pelvis
3: has a posterior branch which supplies the obturator externus muscle
4: supplies both the knee and hip joints

Answer 27

FTTT
Last (6) PAGE: 341, 357, 144

1 - deep to adductor longus

This nerve is formed within psoas major and emerges from the medial aspect of the muscle on the ala of the sacrum to pass behind the common iliac vessels. It runs over the pelvic brim on the lateral wall
of the pelvis and over the upper fibres of obturator internus to pass through the upper anterior aspect of the obturator
foramen. It divides into anterior and posterior divisions which straddle adductor brevis. The posterior division pierces a few fibres of obturator externus and runs deep to adductor brevis on adductor magnus. The anterior division runs on the anterior aspect of adductor brevis deep to pectineus and then deep to adductor longus to end by contributing, together with the saphenous and medial femoral cutaneous n, to the subsartorial plexus which supplies the skin over the medial thigh.

Question 28

8465 – The obturator nerve
1: pierces the medial border of the psoas muscle
2: supplies the obturator internus muscle
3: arises from anterior divisions of ventral rami of L2, L3, L4
4: passes lateral to the sacroiliac joint

Answer 28

TFTF
Last 10th ed, Ch 5
Obturator internus = S2,3,4

Question 29

20505 – S. Pain associated with an obstructed obturator hernia is referred along the medial thigh BECAUSE R. the obturator nerve straddles adductor brevis and supplies medial thigh sensation

Answer 29

S is true, R is true and a valid explanation of S
Last 10th Ed, Ch 3, page 118-119

Question 30

15375 – The levator ani receives its motor nerve supply from
1: the inferior hypogastric plexus on its pelvic surface
2: the pudendal nerve on its perineal surface
3: the coccygeal plexus
4: the perineal branches of S3 and S4 on its pelvic surface

Answer 30

FTFT
Refer to Last, 10th Ed, Ch 5, page 283-284.

inferior hypogastric plexus supplies the viscera of the pelvic cavity.

coccygeal plexus - ventral rami of s4,5, coc1, innervate the skin over the coccyx (tailbone) and around the anus. supplies the anococcygeal nerve. supplies sacrotuberus ligament.

Question 31

22934 – The nervi erigentes carry
1: motor fibres to the descending colon
2: sensory fibres from the trigone of the bladder
3: postganglionic parasympathetic fibres
4: branches of the sympathetic trunks

Answer 31

TTFF
Last (8) PAGE: 398

Pelvic Splanchnic nerves

Parasympathetic innervation to the organs of the pelvic cavity. They regulate emtyping of the urinary bladder, control opening and closing of internal urethral sphincter. influence motility in the rectum and sexual functions like erection.

They do not carry sympathetic efferents like other splanchnic nerves.

Arise from anterior rami sacral spinal nerves S2,3,4,
travel to inferior hypogastric plexus on the walls of the rectum.

contains preganglionic (not postganglionic) parasympathetic and visceral sensory afferent fibres.

also contain autonomic visceral efferent efferent

Question 32

14576 – The urogenital diaphragm
1: contains the external urethral sphincter
2: lies above the perineal membrane
3: contains the deep transverse perineal muscle
4: is contained by the deep perineal pouch

Answer 32

TTTT
Refer to Last, 10th Ed, page 285
urogenital diaphragm
- muscular membrane that occupies area between symphysis pubic and ischial tuberosities. across triangular. anterior portion of pelvic outlet

Question 33

22649 – The urinary bladder
1: is related to the cervix uteri and anterior wall of the vagina
2: has pain sensation through the superior hypogastric plexus only
3: contains mucus glands in the submucosa
4: has a base which is covered by peritoneum

Answer 33

TFFF
Last (8) PAGE: 384; 365

Question 34

7652 – The urinary bladder has
A. a base posteriorly which is completely covered by peritoneum
B. an internal urethral sphincter in both sexes
C. a parasympathetic nerve supply from the vagus nerve
D. a sensory nerve supply via the parasympathetic pathway
E. mucous glands in the submucosa

Answer 34

D
Last 10th ed, Ch 5

Question 35

8555 – The trigone of the bladder is
1: smoother than the rest of the lining of the bladder
2: immediately adjacent to the apex of the prostate
3: the least mobile part of the bladder
4: attached to the side wall of the pelvis by way of the lateral ligament of the bladder

Answer 35

TFTF
Last 10th ed, Ch 5

Question 36

27663 – During radical prostatectomy the common sources of major bleeding include
1: dorsal vein complex of the penis
2: bladder neck vessels
3: external iliac vessels
4: neurovascular bundles to the penis, containing cavernosal arteries and veins
5: internal iliac vessels

Answer 36

TFFTF
The common sites of bleeding during a radical prostatectomy include the dorsal vein complex of the penis, a large venous complex anterior to the urethra (1 True). This dorsal vein complex needs to be controlled and divided in order to expose the apex of the prostate during the dissection. The neurovascular bundles to the penis to assist in erectile ability run posterior to the lateral prostatic fascia immediately in the groove between the prostate and the lateral surface of the rectum. As the prostate is being dissected off the rectal surface, disruption of these neurovascular bundles are common leading not only to intra-operative bleeding but also to post-operative potency difficulties (4 True). Although minor bleeding can be identified at the bladder neck from vessels originating from the inferior vesical pedicles, this is usually negligible; and both iliac vessels should be well outside the field of dissection and would be uninjured during a routine radical prostatectomy (2, 3 & 5 False)

Question 37

19264 – The seminal vesicles
A. lie medial to the termination of each ductus deferens
B. are posterior relations of the prostate gland
C. are posterior relations of the bladder
D. empty directly into the prostatic urethra
E. can normally be felt through the posterior wall of the rectum

Answer 37

C
Last 9th ed. PAGE: 386

reltaions
- anterior aspect of each seminal vesicle is in contact with posterior wall of the bladder, posterior aspect of each vesicle separated from rectum by rectoprostatic fascia,
inferior to SV is the prostate with ureters anterior to them
medial to SV are ampulla of ductus deferens,
veins of prostatic venous plexus lateral to them

Question 38

22654 – The seminal vesicles
1: are partly invested by the peritoneum of the rectovesical pouch
2: are lined by ciliated simple columnar epithelium
3: terminate in ejaculatory ducts which enter the apex of the prostate
4: separate the terminal parts of the ureters from the bladder wall

Answer 38

TFFF
Last (8) PAGE: 387

Question 39

15355 – The ductus deferens
1: lies lateral to the external iliac artery
2: crosses the ureter
3: is crossed anteriorly by the obturator nerve
4: passes lateral to the inferior epigastric artery

Answer 39

FTFT
Refer to Last, 10th Ed, Ch 5, page 225-226.
anterior to ext iliac artery
crosses over ureter

Question 40

22554 – The ductus deferens
1: is ampullated posterior to the prostate
2: lies lateral to the epididymis at its commencement
3: lies medial to the seminal vesicles at its termination
4: is lined by stereo-ciliated columnar epithelium

Answer 40

FFTT
Last 8th ed. PAGE: 386

Question 41

15224 – The terminal part of the ductus deferens
A. lies lateral to the seminal vesicles
B. is a storehouse for spermatozoa
C. is lined by transitional epithelium
D. is crossed superiorly by the ureter
E. opens onto the urethral crest of the prostate, separate from the ejaculatory duct

Answer 41

B
Refer to Last, 10th Ed, Ch 5, page 292

Question 42

22514 – The ejaculatory ducts
1: are formed by the union of the prostatic ducts and the ducts of the seminal vesicles
2: lie on the posterior surface of the bladder
3: open into the membranous urethra
4: open on the sides of the urethral crest

Answer 42

FFFT
Last (8) PAGE: 386.

Question 43

23729 – The mesonephric (Wolffian) ducts
1: form the prostatic utricle
2: form part of the epoophoron
3: form part of the paroophoron
4: form part of the bladder wall

Answer 43

FTFT
Last 8th ed. Page: 384, 394

Question 44

8480 – In the male
1: the deep dorsal vein of the penis remains closed during erection of the penis
2: the corpus spongiosum is continuous distally with the glans penis
3: the openings of the ejaculatory ducts lie lateral to the prostatic utricle
4: the prostatic utricle is the homologue of the uterus

Answer 44

FTTT
Last 10th ed, Ch 5

Question 45

2674 – The corpus cavernosum
1: is firmly anchored posteriorly to the perineal membrane
2: is enclosed in the tunica albuginea
3: has venous drainage into the prostatic venous plexus
4: is supplied by the deep artery to the penis

Answer 45

TTTT
Last 8th ed. Page: 408 & 409

Question 46

19881 – The testis
A. has lymph drainage to common iliac nodes
B. receives an arterial supply from the deep external pudendal artery
C. receives parasympathetic innervation via the nervi erigentes
D. has venous drainage on both sides to the renal veins
E. descends to the deep inguinal ring by the seventh month in the male foetus

Answer 46

E
Last (9) PAGE: 305, 308
- Blood supply:
a - testicular a from aorta
v - pampiiniform plexus –> testicular vein –> left to left renal vein, right directly to IVC
- Lymph drainage: along testicular a to para-aortic nodes at L2. (scrotal skin drains to inguinal nodes)
- Nerve supply: sympathetic supply via splanchnic nerve T10

Question 47

19569 – The testis
A. has a venous drainage ending on both sides in the renal veins
B. has the sinus epididymis on its posteromedial aspect
C. has a lymph drainage to the superficial inguinal nodes
D. is continuous with the lobules of the epididymis via the efferent ductules
E. has a sensory innervation from the pelvic parasympathetics

Answer 47

D
Last p305
B - posteriolateral

Question 48

23099 – The testis
1: has a rete testis composed of straight tubules
2: has Sertoli cells adjacent to the basal lamina of the seminiferous tubules
3: has primary spermatocytes adjacent to the basal lamina of the seminiferous tubules
4: drains lymph to the para-aortic nodes

Answer 48

FTFT
Last (6) , Leeson & Leeson PAGE: 263 (Last), 510 et. seq. (L & L)
3 - secondary spermatocytes?

Question 49

27707 – Concerning varicocele
1: the most common presentation of varicocele is infertility
2: accidental ligation of the gonadal vein at laparotomy results in varicocele
3: a varicocele is a dilatation of the pampiniform plexus of testicular veins (above the testes) associated with venous failure/incompetence in the gonadal vein
4: varicocele is usually bilateral

Answer 49

FFTF
Varicocele is fairly common and is seen in approximately 15% of young men. The majority of such men are asymptomatic. Patients may present with dragging discomfort, particularly following prolonged standing or lifting. Varicocele may occasionally be associated with infertility and testicular atrophy, but this is not the most common presentation (1 False). Symptomatic varicocele is usually treated with a high ligation of the gonadal vein above the pampiniform plexus (2 False). Ligation may be at the level of inguinal canal or in the retroperitoneum.
Division of the gonadal vein during other abdominal surgery has no apparent effect. Ligation presumably relieves the pressure effect of the column of blood exerted down the gonadal vein in the standing position. Venous infarction does not occur as alternative venous return channels develop and open up. The pampiniform plexus drains into the gonadal vein which drains into the left renal vein (or IVC on right) (3 True). Primary varicocele is usually unilateral and is most frequently found on the left side (4 False).

Question 50

27712 – Concerning varicocele
1: a renal ultrasound should be obtained at the time of diagnosis of varicocele
2: if unilateral, varicoceles are commoner on the right side
3: injection of sclerosants is the preferred method of treatment
4: varicoceles are more easily diagnosed with the patient recumbent

Answer 50

TFFF
Varicocele is usually primary but may result from obstruction of the renal vein, particularly the left, by renal cell carcinoma (1 True).
Primary varicoceles in young males are more frequent on the left (2 False) - perhaps related to the differing anatomy of the left-sided gonadal vein compared to the right, or to the fact that males more commonly ‘dress on the left’! More importantly, any recently appearing varicocele on either side in older males should raise the suspicion of a renal tumour, so check clinically and by imaging. The preferred treatment is high gonadal vein ligation (3 False). Sclerosant injection and local surgery are each hazardous and ineffective. Varicoceles are best diagnosed with the patient standing, and give the characteristic ‘bag of worms’ sign. They collapse on recumbency (4 False).

Question 51

27701 – Concerning vasectomy
1: the operation is best performed through an inguinal approach to minimise damage to the pampiniform plexus
2: there is a 1:5000 risk of spontaneous recanalisation of the vas
3: the patient must wait 2 weeks before having intercourse without contraception
4: vasectomy can be performed adequately under either local or general anaesthesia
5: there appears to be a strong relationship between vasectomy and prostate cancer

Answer 51

Answers: FTFTF
Response 1 is False
Response 2 is True - Patients must be warned of this pre-operatively.
Patients require 25 ejaculations or 10 weeks before a semen analysis is made (3 False). Only when this semen analysis is clear can other forms of contraception be withdrawn.
Either general or local anaesthesia may be used (4 True).
Several years ago a large study suggested a relationship between vasectomy and prostate cancer but this has been since refuted (5 False). On this happier note we conclude this commentary

Question 52

19228 – The nerve supply of the testis is
A. ilio-inguinal nerve
B. genital branch of genito-femoral nerve
C. sympathetic nerves
D. parasympathetic nerves
E. all of the above

Answer 52

C
Last 8th ed. PAGE: 306

Question 53

20109 – S. Ligation of the testicular artery carries a risk of atrophy of the testis BECAUSE R. the artery of the vas, which anastomoses with the testicular artery, is small

Answer 53

Answer: S is true, R is true and a valid explanation of S
Last 8th ed. PAGE: 308

Question 54

24099 – The internal spermatic fascia is derived from
1: transversalis fascia
2: tansversus abdominis muscle
3: internal oblique muscle
4: external oblique muscle

Answer 54

TFFF
Last (6) PAGE: 263

Question 55

22309 – The contents of the spermatic cord in the inguinal canal include
1: the ductus deferens
2: the cremaster muscle
3: the obliterated processus vaginalis
4: the ilio-hypogastric nerve

Answer 55

TFTF
Last 8th ed. PAGE: 304-305.

Question 56

19575 – A structure never included amongst the components of the
spermatic cord is
A. the genital branch of the genitofemoral nerve
B. the processus vaginalis
C. the testicular artery
D. the ilioinguinal nerve
E. sympathetic fibres from T10

Answer 56

D
Last (8) PAGE: 304

Question 57

20355 – S. The scrotum is not anaesthetized by a low spinal anaesthetic BECAUSE R. the skin of the anterior third of the scrotum is innervated by the first lumbar segment of the spinal cord

Answer 57

Answers: S is true, R is true and a valid explanation of S Last 8th ed. PAGE: 25

Question 58

21523 – The cutaneous nerves of the scrotum include
1: scrotal branches of the perineal nerve
2: twigs from the anterior branch of the obturator nerve
3: anterior scrotal branches of the ilio-hypogastric nerve
4: the ilio-inguinal nerve

Answer 58

TFFT
Last (6) PAGE: 351

Question 59

7102 – The most constricted part of the male urethra is
A. at the external meatus
B. where it pierces the perineal membrane (inferior fascia of the pelvic diaphragm)
C. at the apex of the prostate
D. at the level of the urethral crest
E. at the internal meatus

Answer 59

A
The external meatus is the narrowest portion of the male urethra; the constriction focusses and
spirals the urinary stream.

Question 60

7694 – S: Continence of urinary function is ensured by the integrity of the sphincter urethrae externus because R: the sphincter urethrae externus can maintain urinary continence even if the internal sphincter is weak or incompetent

Answer 60

S is true, R is true and a valid explanation of S
Last 10th ed, Ch 5

Question 61

22219 – The perineal membrane
1: is attached to the ischio-pubic rami
2: in the male is pierced by the deep dorsal vein of the penis
3: in the male is pierced by the ducts of the bulbo-urethral glands
4: lies above the dorsal nerve of the penis

Answer 61

TFTF
Last 9th ed. PAGE: 406
- pierced by urethra, ducts of the bulbourethral glands, and by foramina for nerves and vessles

Question 62

15007 – The superficial perineal pouch
1: contains the ischio-cavernosus muscle
2: is enclosed by the superficial perineal fascia of Colles
3: contains the vestibular glands
4: extends in front of the symphysis pubis

Answer 62

TTTT
Refer to Last, 10th Ed, page 310
- Superficial perineal pouch contains structures that lie below (superficial to) the perineal membrane and within the region bounded by the superficial perineal fascia: root of penis, superficial perineal muscles, asso vessels and nerves
- attached to the front of pubic bone, pubic ramus, posterior margin of perineal membrane

Question 63

22669 – The superficial perineal pouch
1: is traversed by only the urethra in the male
2: has a membranous covering which provides a fascial sheath around the penis
3: contains the testes
4: is limited inferiorly by the perineal membrane

Answer 63

TTTF
Last (8) PAGE: 408
4 - perineal membrane forms the lower boundary of the deep perineal pouch

Question 64

20751 – S. Urine extravasated from a ruptured bulbous urethra can pass into the scrotum BECAUSE R. the membranous layer of the superficial fascia of the abdominal wall attaches to the external oblique aponeurosis

Answer 64

Answer: S is true and R is false.
Last 9th ed. Page: 149, 408

Question 65

15388 – The contents of the deep perineal pouch in the male include the
1: bulbo-urethral glands
2: internal pudendal artery
3: membranous urethra
4: sphincter urethrae muscle

Answer 65

TTTT
Refer to Last, 10th Ed, Ch 5, page 309

Question 66

27502 – The broad ligament
1: has the ovarian artery in its lower attached border
2: has the ureter passing forward in its lower attached border
3: is the main support of the uterus
4: has the uterine artery cross anterior to the ureter within its lower attached border

Answer 66

FTFT
- contains the blood vessels to the ovaries, fallopian tubes, and uterus.
The broad ligament is a loose double fold of peritoneum rather than a ligament; as a result it offers little support to the uterus (3 False). The uterus is supported by the transverse cervical ligaments which extend laterally to the side wall of the pelvis from the cervix and vaginal fornix on the pelvic floor, within the lower attached border of broad ligament; by the uterosacral ligaments which extend backwards from the cervix to the front of the sacrum, running lateral to the recto-uterine pouch; and by (most importantly) the levator ani muscle.
The ureter, uterine artery and inferior hypogastric plexus all traverse the connective tissue of the transverse cervical ligament which is at the base of the broad ligament (2 True). The ovarian vessels (artery, vein and lymphatics) are contained in the upper lateral part of the broad ligament (1 False).
The relationship of the ureter and uterine artery, which cross each other within the transverse cervical ligament (4 True), is critical in hysterectomy as both the ligament and the uterine artery (but not the ureter!) need to be divided.
Key Issue: The uterine artery, along with other anteriorly-running branches of the internal iliac artery, runs initially on the side wall of the pelvis and as it runs forwards is crossed on its medial aspect by the ureter running down the lateral pelvic wall. The uterine artery then curves inwards to enter the transverse cervical ligament and runs to the cervix and uterus. As it runs medially it lies anterior to the ureter and again crosses the ureter as the latter inclines forwards to the bladder.

Question 67

20943 – S. The broad ligament forms the most important ligamentous support of the uterus BECAUSE R. the broad ligament attaches the whole body of the uterus to the lateral wall of the pelvis

Answer 67

S is false and R is true
Last 10th ed. PAGE: 293; 294

Question 68

27523 – The right ovary
1 : is covered by peritoneum in the adult
2: has its lymphatic drainage to internal iliac nodes
3: has a mesovarium attached equatorially around the ovary
4: is attached to the anterior (inferior) layer of the broad ligament

Answer 68

FFTF
The ovary is covered with cubical cells rather than the flattened mesothelium of the peritoneum (1 False). The junction is usually marked by a fine white line around the anterior (mesovarian) border of the ovary. The mesovarian border runs equatorially along the anterior border of the ovary attaching to the posterior (superior) leaf of the broad ligament (3 True, 4 False). The lymph drainage follows the ovarian artery to its origin at the L2 level of the aorta, thus involving para-aortic nodes at this level (2 False).

Question 69

20151 – S. Pain from the ovary may be referred to the skin on the medial side of the thigh BECAUSE R. the obturator nerve supplies the parietal peritoneum adjacent to the ovary

Answer 69

S is true, R is true and a valid explanation of S
Last 9th ed. PAGE: 214

Question 70

19096 – The uterus
A. has a supravaginal cervix separated from the bladder by peritoneum
B. sometimes sends lymph vessels to the superficial inguinal lymph nodes
C. depends for its support mainly on the round ligaments
D. is in extraperitoneal contact with the rectum
E. has a cervix lined throughout with stratified squamous epithelium

Answer 70

B
Last 8th ed. PAGE: 389

Question 71

27528 – The uterus
1: has a direct extra-peritoneal relation to the rectum in its cervical portion
2: has a direct extra-peritoneal relation to the bladder in its cervical portion
3: forms an angle of 90o or more with the vagina
4: is supported by levator ani muscle

Answer 71

Answers: FTTT
there is a direct extra-peritoneal relationship of the uterus, via its cervical part, to the bladder
anteriorly; but not to the rectum posteriorly (1 False, 2 True). The word “direct” is used as “indirect” is redundant - The distinction is direct OR otherwise. In addition observe the angulation of the uterus and vagina of 90 degrees or more (3 True). The pubovaginalis part of the levator ani, and the perineal body,
support the vagina and cervix of the uterus (4 True). Uterine prolapse or retroversion may follow damage to these structures during childbirth.

Question 72

27508 – The uterus
1: derives its entire blood supply from the uterine arteries
2: has no sympathetic autonomic nerve supply
3: is posteriorly covered by peritoneum to a greater extent than anteriorly
4: has in the wall of its body as much fibrous tissue as muscular tissue

Answer 72

Answers: FFTF
The blood supply of the uterus is derived primarily from the uterine artery with significant anastomoses with the vaginal arteries below and ovarian arteries above (1 False).
The uterus receives branches from the inferior hypogastric plexus with the sympathetic elements being vasoconstrictor (2 False). Parasympathetics convey pain from the cervix but not from the body of the uterus. Abolition of uterine sensation requires division of all nerves, or transection of the cord, above T10 level.
The peritoneal covering can be seen to be more extensive posteriorly (3 True), coming to a level below the cervix. This gives potential access to the peritoneal cavity through the posterior fornix of the vagina.
The uterus is composed of three ill-defined layers of smooth muscle. It is only in the vaginal portion of the cervix that the muscle is almost completely replaced by elastic and fibrous tissue (4 False).

Question 73

7799 – The cervix of the uterus
1: is related laterally to the ureters and uterine arteries
2: is attached to the base of the bladder anteriorly
3: is separated from the rectum by the recto-uterine pouch
4: is the most freely moveable part of the uterus

Answer 73

TTTF
Last 10th ed, Ch 5.

Question 74

8560 – The uterine artery
1: arises from the anterior division of the internal iliac artery
2: supplies the vaginal vault
3: supplies the medial part of the uterine tube
4: crosses above the ureter in the broad ligament

Answer 74

TTTT
Last 10th ed, Ch 5

Question 75

27497 – The uterine (Fallopian) tube
1: is lined by non-ciliated columnar epithelium
2: undergoes cyclical change during the menstrual cycle
3: is developed from the paramesonephric duct
4: is narrower at its lateral than its medial end

Answer 75

FTTF
The uterine tube is lined by a mixture of ciliated and non-ciliated columnar cells (1 False). The cilia are most abundant at the fimbriated end of the tube and beat towards the uterus. The tube is composed of two layers of muscle (inner circular and outer longitudinal). The tube widens laterally at the ampulla and infundibulum (4 False).
The uterine tube is influenced by both ovarian hormones (2 True). Oestrogens cause the glandular tissues to proliferate, as well as an increase in both the number and activity of ciliated cells. Progesterone promotes secretory changes to enhance nourishment of the fertilised, dividing ovum as it traverses the tube.
The paramesonephric (Mullerian) ducts begin to develop in the sixth week as a groove-like
invagination of the coelomic epithelium on the lateral aspect of the mesonephric ridge. The upper (cranial) vertical part forms the uterine tube whilst the lower (caudal) parts of right and left paramesonephric ducts ultimately fuse to form the uterus (3 True).

Question 76

27518 – The following open into the vestibule of the vagina
1: urethra
2: para-urethral glands
3: greater vestibular glands (Bartholin’s glands)
4: bulbo-urethral glands (Cowper’s glands)

Answer 76

TTTF
The vestibule of the vagina is the cleft between the labia minora. In it are the orifices of both the vagina and external urethra. In addition there are the mucous glands (para-urethral glands) which open just inside the external meatus whilst the ducts of the greater vestibular (Bartholin’s) glands open on each side just below the hymen in the postero-lateral wall (1, 2 and 3 True). Cowper’s glands (bulbo-urethral) are found in the male lying above the bulb of the penis with a 3 cm excretory duct entering the spongy portion of the urethra 2.5 cm below the inferior fascia of the urogenital diaphragm (4 False).

Question 77

22509 – The rectum has peritoneum
1: on its lateral surface for its upper 2/3
2: on its anterior surface for the upper 2/3
3: surrounding its upper 2/3
4: on its lateral surface for its upper 1/3

Answer 77

FTFT
Last (9) PAGE: 378
- Upper 1/3 of rectum is covered by peritoneum on anterior and lateral surfaces.
- middle 1/3 is covered by peritoneum only on anterior surface
- Lower 1/3 of rectum below the level of the peritoneal reflexion (level at which peritoneum leaves anterior rectal wall) and consequently has no peritoneum covering any of its surfaces.
The middle rectal shelf conveniently indicates the level of peritoneal reflexion.

Question 78

22794 – The rectum
1: is covered laterally by peritoneum in its upper two-thirds
2: has no taeniae coli
3: has an ampulla which is concave to the left
4: has permanent folds running transversely, consisting of mucous membrane and circular smooth muscle

Answer 78

FTTT
Last’s 9th Ed., p378.
Teo anteroposterior curves, upper flexure (sacral flexure)
It has three lateral flexures/curves
- Convex to right
- Convex to left
- Convex to right

Question 79

22209 – With respect to the rectum
1: there is an incomplete outer layer of longitudinal muscle
2: the fascia of Denonvilliers separates the anterior wall of the rectum from the prostate and seminal vesicles
3: the lateral ligament of the rectum contains the middle rectal artery
4: the fascia of Waldeyer suspends the rectum in the hollow of the sacrum

Answer 79

FTTT
Last (8)

Question 80

15380 – The following structures separate the distended rectum from the sacrum and coccyx
1: the ganglion impar
2: the sacral part of the sympathetic trunk
3: the piriformis muscle
4: the inferior hypogastric plexuses

Answer 80

TTTF
Refer to Last, 10th Ed, Ch 5, page 285-286

Question 81

3361, 20641 – S: Abdomino-perineal resection in the male can result in failure of erection because R: damage to the sympathetic fibres may occur during the operation of abdomino-perineal resection

Answer 81

Answer: S is true, R is true but not a valid explanation of S
Last 8th ed. PAGE: 386. The mechanism of erection, though incompletely understood, involves vasodilatation of arteries of the erectile tissue of the corpora. This vasodilatation is mediated by pelvic parasympathetic nerves. These may be injured during excision of the rectum (S true). Sympathetic fibres derived from T11 and T12 mediate ejaculation by stimulating contraction of smooth muscle in the epididymis, ductus deferens, seminal vesicle, ejaculatory duct and prostate. These may be damaged during abdomino-perineal resection (R true). Injury to the sympathetic fibres controlling the internal urethral opening of the bladder neck may allow retrograde ejaculation into the bladder. Failure of erection is not due to injury to sympathetic fibres.

Question 82

13355 – S: The anterior surface of the ampulla of the rectum can be separated from the posterior surface of the prostate at operation without bleeding because R: peritoneum descends to the apex of the prostate
between it and the rectum

Answer 82

Answer: S is true and R is false
Sharp dissection is necessary to separate the ampulla of the rectum from the posterior surface of the prostate at operation. The rectovesical pouch does not extend behind the prostate in the adult (R false). In the fetus the rectovesical pouch extends down to the pelvic floor to the apex of the prostate between prostate and rectum. Fusion of anterior and posterior layers of the pouch makes it more shallow, and the fused layers persist in the adult as a membrane between the rectovesical pouch and the pelvic floor. The membrane covers the seminal vesicles and posterior surface of the prostate and is called the rectovesical fascia (of Denovilliers). The anterior wall of the rectum is freely mobile over the fascia and once the space is entered between the two layers by incising the peritoneum in the floor of the rectovesical pouch an avascular plane is found between rectum and prostate right down to the apex of the prostate (S true).

Question 83

22684 – The superior rectal artery
1: crosses the bifurcation of the left common iliac artery
2: freely anastomoses with the inferior rectal artery in the submucosa
3: is a direct continuation of the inferior mesenteric artery
4: crosses the ureter at the level of the sacroiliac joint

Answer 83

TTTF
Last 8th ed. PAGE: 329; 381; 403

Question 84

22214 – The anal valves
1: are felt on rectal examination
2: lie above a smooth surfaced area of the anal canal
3: lie inferior to the pectinate line
4: are at the lower end of the anal columns

Answer 84

FTFT
Last (8) PAGE: 403.

Question 85

19324 – The internal sphincter of the anal canal
A. is a striated muscle
B. is supplied by the perineal nerve
C. is without bony attachments
D. is a continuation of the longitudinal muscle coat of the rectum
E. surrounds the lower 2/3 of the anal canal

Answer 85

C
Last (8) PAGE: 403

Question 86

20439 – S. The ischio-rectal fossa extends anteriorly above the urogenital diaphragm BECAUSE R. the ischio-rectal fossa extends forwards below the levator ani muscles which are attached to the body of the pubic bone above the level of the urogenital diaphragm

Answer 86

S is true, R is true and a valid explanation of S
Last 9th ed. PAGE: 404