Pelvis & Perineum 1

Question 1

Male patient had painful urination and urination during the night. Examination revealed enlargemetn of the uvula of the urethra. Which lobe of the prostate gland is hypertrophied?

Answer 1

When the internal uretrhal orifice is obstructed, it is most likely due to an enlargement of the median (or middle) lobe of the prostate.

Question 2

A woman complains of fecal incontinence. The most likely contributing factor to such a problem is atrophy, paralysis, or dysfunction of which structure?

Answer 2

The pubococcygeus muscle (especially its most medial portion, the puborectalis) is of prime importance in fecal continence.

The levator ani has 2 major portions: pubococcygeus + iliococcygeus.

Question 3

A woman is complaining of urinary incontinence. Examination reveals one of the skeletal muscles of the pelvis has a tear. Which muscle is most significant in maintaining continence?

Answer 3

The pubococcygeus is the muscle that is most directly associated with the vagina and the support of the bladder.

Question 4

An older man complains of pain upon urination. Examination reveals an enlarged, cancerous prostate. Postoperatively, he suffers from urinary incontinence because of paralysis of the external urethral sphincter. Which nerve was injured?

Answer 4

The perineal branch of the pudendal nerve is responsible for the innervation of the external urethral sphincter and injury to this nerve can result in paralysis of the sphincter and urinary incontinence.

Question 5

Cancer of the testis metastasize first to which lymph nodes?

Answer 5

Lymph from the testicles drains into the lumbar nodes.

The deep inguinal nodes drain the glans of the penis and spongy urethra.

Question 6

Colpocentesis is performed to ascertain the presence of blood in the pelvis from a ruptured ectopic pregnancy. Through which structures does the needle need to be inserted to perform colpocentesis?

Answer 6

It is likely that the ectopic pregnancy ruptured into the rectouterine pouch (of Douglas). The most direct route to the rectouterine pouch is through the posterior vaginal fornix.

Question 7

A woman has a noticeable bulge through her vaginal opening. A rectocele is identified. What is responsible for this condition?

Answer 7

A break of tear in the rectovaginal septum can allow small intestine (enterocele) or rectum (rectocele) to herniate through the posterior vaginal wall.

Question 8

What is the most common position of the uterus?

Answer 8

The uterus is anteflexed at the junction of the cervix and the uterine body

and

anteverted at the junction of the vagina and cervix

Question 9

A female patient has a complete uterine prolapse. Which ligaments provide direct support to the uterus?

Answer 9

The cardinal ligament/transverse cervical ligament, is composed fascia that provide direct support to the uterus.

Question 10

Which lymph nodes are the first to receive lymph from the diseased ovaries?

Answer 10

Ovarian lymph first drains into the para-aortic/lumbar nodes.

Question 11

Examination reveals a prolapsing of abdominal viscera, probably due to a tear of the rectovaginal septum. Which condition will most likely result from a defect in the rectovaginal septum?

Answer 11

An enterocele (hernation of small intestine into the post. wall of the vagina) is caused by a tear of the rectovaginal septum.

An uretrhocele is characterized by prolapse of the urethra into the vagina. It is usually associated with a cystocele (prolapse of the bladder into the urethra).

Question 12

What can be done to reduce pain from an ovarian carcinoma?

Answer 12

The ovarian vessels and nerves lie within the suspensory ligament/infundibulopelvic ligament. Therefore, cutting this ligament interrupts pain fibers from the ovary.

Question 13

Examination reveals the presence of ascites in the peritoneal cavity. A needle is placed through the post. vaginal fornix to drain the fluid. Which space must the needle enter to drain the fluid?

Answer 13

The rectouterine pouch (of Douglas) is the lowest point of the woman’s peritoneal cavity. Fluid collection within the peritoneal cavity accumulates here when the patient is standing or sitting.

Question 14

A patient has a cystocele. Loss of which structure to the anterior part of the vagina is responsible for this problem?

Answer 14

The uterus is stabilized/anchored to the bladder by the pubovesical ligament on its anterior surface.

Question 15

Which ligaments provide direct support to the uterus and thereby resists prolapse?

Answer 15

Question 16

A male patient underwent a radical prostatectomy. He complains of being incapable of penile erection. Which nerve was damaged during the operation?

Answer 16

Penile erection is a parasympathetic mediated response that is delivered via the pelvic splanchnics.

The pudendal nerve and its terminal branch, the dorsal nerve of the penis, carry the primary skeletal motor and snesory innervation to the external genitalia and also symp. fibers.

Sacral splanchnic nerves contain symp. fibers.

Question 17

Which nerves convey sensory fibers from the cervix?

Answer 17

Pain from the cervix is transmitted via the pelvic splanchnic nerves because the cervix is below the PPP.

Question 18

Examination reveals a large hematoma adjacent to the external iliac artery. Which vessels are most likely injured?

Answer 18

The ovarian arteries arise from the abdominal aorta, descend retroperitoneally along the post. abdominal wall and cross just anterior the external iliac vessels.

Question 20

A physician was too forceful when inserting a catheter and accidentally damaged the wall of the membranous portion of the urethra in the deep perineal compartment. Which structure is injured?

Answer 20

If the membranous portion of the urethra is injured, urine and blood can leak upward into the retropubic space (of Retzius), limited inferiorly by the urogenital diaphragm and the muscle within, which is the compressor urethra/external urethral sphincter.

Question 21

During labor, a physician performs a median episiotomy. She later complains of fecal incontinence. Which structure was also most likely damaged during the episiotomy?

Answer 21

The external anal sphincter is located immediately posterior to the perineal body and would be susceptible to damage during a median episiotomy.

Question 22

Which lymph nodes should be removed during prostatectomy?

Answer 22

The internal iliac lymph nodes

Question 23

Examination reveals rupture of the penile urethra and deep (Buck’s) fascia. Where is the most likely place to which extravasated urine will flow?

Answer 23

Rupture of the penile urethra leads to extravasation and collection of urine in the superifical perineal pouch.

Question 24

The cavernous nerves provide efferent fibers to which structures?

Answer 24

Cavernous nerves are postgang. PS fibers that mediate penile erection, and therefore supply the erectile bodies of the penis

Question 25

(4.18) A woman has a malignancy involving the clitoris. What are the first lymph nodes to filter the lymphatic drainage of this area?

Answer 25

The deep inguinal lymph nodes drain the glans clitoris.

Question 26

(4.28) Pathology report revealed positive cancerous cells only at the inguinal lymph nodes. Which parts of the GI tract were affected?

Answer 26

Lymph from the cutaneous portion of the anal canal (below the pectinate line) drains into the inguinal nodes.

Lymph from above the pectinate line drains into the internal iliac nodes.

Question 27

(4.29) A urologist orders drainange of the urinary bladder. Which space needs to be traversed by the needle to reach the bladder?

Answer 27

The retropubic space (of Retzius) is the extraperitoneal space between the pubic symphysis and the bladder.

Question 28

(4.39) A man complains of erectile dysfunction. Compromise of which arteries would cause this condition?

Answer 28

The internal pudendal artery gives rise to both, the dorsal artery and the deep artery of the penis.

The deep artery is the main supply for erectile tissue; therefore, significant atherosclerosis of the internal pudendal a. may result in erectile dysfunction.

Question 29

(4.42) A woman has a malignancy involving the vestibule of her vagina. Which lymph nodes filter the lymph drainage from this area first?

Answer 29

The superficial inguinal nodes drain superficial perineal structures.

The internal iliac nodes drain the middle and upper vagina, cervix and body of the uterus.

The lumbar/aortic lymph nodes drain the ovaries.

Question 30

(4.49) A man has a hematoma of the perineum spreading to his abdominal wall beneath the superficial fascia. Where is the initial extravasation located?

Answer 30

This is a classic example of extravasation of blood and urine from the superficial perineal pouch. This usually is a result of rupture of the spongy urethra. The extravasation of the fluid will begin to invade the layer between Buck’s fascia and the dartos layer.