1. During a practice match, a heavyweight prizefighter endured an illegal hit to the left flank. Following the match, a focused assessment with sonography for trauma (FAST) exam revealed that blood from a renal laceration had tracked inferiorly and accumulated in the groove between the psoas major and iliacus muscles. What nerve would you expect to be irritated by blood in this location?
A. Sciatic
B. Femoral
C. Obturator
D. Superior gluteal
E. Lateral femoral cutaneous
2. Which one of the following statements best describes the muscles of the pelvis?
A. The obturator internus muscle leaves the pelvis through the greater sciatic foramen.
B. The levator ani muscle is composed of the pubococcygeus, puborectalis, and iliococcygeus.
C. The pelvic diaphragm is a sling of muscle that separates the true pelvis from the false pelvis.
D. The piriformis muscle forms the lateral wall of the pelvis.
E. The coccygeus muscle attaches to the sacrotuberous ligament.
3. Typically, the posterior division of the internal iliac artery supplies
A. structures of the perineum
B. muscles of the medial thigh
C. meninges of the sacral spinal roots
D. uterus and uterine tubes
E. prostate
4. The components of the pelvic splanchnic nerves are most similar to the components of the
A. lumbar splanchnic nerves
B. sacral splanchnic nerves
C. pudendal nerve
D. vagus nerve
E. hypogastric nerves
5. Carcinoma of the prostate can metastasize to bone and the brain through its connections with the vertebral venous plexus. Which other structures communicate with this venous plexus?
A. Breast
B. Spinal cord
C. Intercostal muscles
D. Esophagus
E. All of the above
6. Although branches of the uterine artery anastomose extensively throughout the pelvis, the main stem of the vessel travels within the
A. proper ovarian ligament
B. cardinal ligament
C. uterosacral ligament
D. ovarian suspensory ligament
E. round ligament
7. Which of the following statements accurately describes the relations of the ureter?
A. It is crossed anteriorly by the gonadal vessels on the posterior abdominal wall.
B. It crosses the brim of the pelvis at the bifurcation of the common iliac artery.
C. In females it passes under the uterine artery ~2 cm lateral to the cervix.
D. It enters the bladder at the posterolateral aspect of the trigone.
E. All of the above
8. During a routine physical exam on a male patient, you test the integrity of the external anal sphincter. What spinal cord segments are involved in this?
A. T12–L1
B. L2–L4
C. L4–L5
D. S1–S2
E. S2–S4
9. The superficial perineal fascia is continuous with the
A. perineal membrane
B. dartos fascia
C. deep penile fascia
D. tunica albuginea of the penis
E. endopelvic fascia
10. The boundary of the pelvic inlet
A. provides the attachment site for the pelvic diaphragm
B. includes the iliac crests
C. includes the ramus of the ischium
D. is crossed by the ovarian and testicular arteries
E. separates the cavity of the true pelvis from the abdominal cavity
11. Several years after delivering her twin boys, Laura experienced mild uterine prolapse and urinary incontinence. Her gynecologist was able to confirm that the angle of her anococcygeal ligament had changed, suggesting a laxity in her pelvic floor muscles. Which muscles insert on the anococcygeal ligament?
A. Coccygeus
B. Iliococcygeus
C. Piriformis
D. Deep transverse perineal
E. Obturator internus
12. Tumors that metastasize via the bloodstream often form metastases in the first capillary bed that the cells reach after they enter the bloodstream. Based on their venous drainage, tumors in which of the following locations are likely to reach the lung before they reach the liver?
A. Ascending colon
B. Sigmoid colon
C. Pancreas
D. Superior (proximal) rectum
E. Inferior (distal) rectum
13. Which one of the following structures passes through the genital hiatus?
A. Ductus deferens
B. Cavernous nerves
C. Round ligament
D. Obturator nerve
E. External iliac artery
14. A 44-year-old woman undergoes a total hysterectomy for painful fibroids. The ovaries will not be removed during the procedure. Which of the following ligaments must be preserved?
A. Suspensory ligament
B. Ovarian ligament
C. Uterosacral ligament
D. Transverse cervical ligament
E. Round ligament
15. Which of the following statements best describes the uterine cervix?
A. In a normally anteflexed uterus, the cervix is tilted posteriorly.
B. Vaginal fornices surround its supravaginal part.
C. It is the attachment site for the round ligament.
D. It makes up the inferior third of the uterus.
E. It communicates with the uterine cavity through the external os.
16. A 53-year-old man had an aortic aneurysm that extended through his aortic bifurcation into his common iliac arteries. During the open repair, the surgeon opened the vessels longitudinally and fixed a synthetic graft to the walls of the vessels above and below the aneurysm. Following surgery, the man experienced retrograde ejaculation because of damage to nerves that innervated his internal urethral sphincter. Which nerves were damaged?
A. Sympathetic nerves of the superior hypogastric plexus
B. Parasympathetic nerves of the superior hypogastric plexus
C. Somatic nerves of the sacral plexus
D. Pelvic splanchnic nerves
E. Sympathetic trunk
17. You are treating a 34-year-old woman for hemorrhoids. Although she does not complain of pain, the hemorrhoids protrude into her anal canal and are becoming ulcerated. There is no evidence of portal hypertension, but blood from the ulcers is bright red. Based on her brief history, what can you surmise about her condition?
A. The prolapsed tissue contains the dilated veins of the external rectal plexus.
B. The hemorrhoids originate from below the dentate line.
C. The dilated veins in the hemorrhoids drain to the inferior rectal veins.
D. The dilated veins communicate with the rectal arteries to form an arteriovenous hemorrhoidal plexus.
E. All of the above
18. During a robotic prostatectomy on a 41-year-old man, the cavernous nerves were inadvertently damaged. What symptoms would you expect in this patient?
A. Loss of tone in his external anal sphincter
B. Urinary incontinence
C. Inability to ejaculate
D. Inability to form an erection
E. Loss of sensation at the tip of the penis
19. Structures that pass through the greater sciatic foramen include the
A. obturator internus
B. coccygeus
C. iliopsoas
D. piriformis
E. obturator nerve
20. The tendinous arch of the pelvic fascia
A. is a condensation of endopelvic fascia
B. includes the lateral rectal ligament
C. supports the pelvic viscera
D. provides an attachment site for the pelvic diaphragm
E. All of the above
21. Structures that drain (directly or indirectly) into the deep inguinal lymph nodes include the
A. glans of the penis
B. perianal skin
C. supralateral part of the uterus via the round ligament
D. scrotum
E. all of the above
22. During the national championships an Olympic gymnast fell backward off the balance beam, fracturing the tip of her coccyx and subluxing (dislocating) her sacroiliac joint. The team physician was concerned about damage to her sacral plexus and its branches that exit the pelvis. Nerves of the sacral plexus pass through the
A. posterior sacral foramina
B. obturator canal
C. lesser sciatic foramen
D. superficial inguinal ring
E. deep inguinal ring
23. A young, pregnant woman in her third trimester was alarmed when she experienced a sharp pain in the anterior part of her labia majora when she stood up. Her obstetrician assured her that this was a common problem in late pregnancy and was most likely caused by
A. stretching of the round ligament
B. tightening of the inguinal ligament
C. pressure on the obturator nerve
D. irritation of the perineal branch of the pudendal nerve
E. stretching of the iliohypogastric nerve
24. A vascular surgeon is repairing an aneurysm of the aortic bifurcation that extends along the right common iliac artery to its division into internal iliac and external iliac branches. What structure does the surgeon encounter that is at risk as it crosses over the pelvic brim at this distal end of the aneurysm?
A. Ureter
B. Testicular artery
C. Lumbosacral trunk
D. Sciatic nerve
E. Ductus deferens
25. Similar to other sections of the large intestine, the rectum is characterized by
A. teniae coli
B. haustra
C. a mesentery
D. epiploic appendices
E. None of the above
26. Which of the following are found within the superficial perineal space?
A. Bulbourethral glands
B. External urethral sphincter
C. Bulbospongiosus muscle
D. Anterior extension of ischioanal fat pad
E. Inferior rectal nerve
Answers and Explanations
1. B The femoral nerve runs in the groove between the psoas and iliacus muscles (Sections 10.1 and 15.4d).
A The blood accumulated above the pelvic brim in a muscular pocket of the false pelvis. The sciatic nerve does not pass through the false pelvis.
C The obturator nerve passes medial to the psoas muscle and not in the groove between the psoas and iliacus muscles.
D The superior gluteal nerve is a branch of the sacral plexus and does not pass through the false pelvis where the blood accumulated.
E The lateral femoral cutaneous nerve crosses the iliacus muscle in the iliac fossa and passes under the inguinal ligament close to the anterior superior iliac spine to innervate the skin of the lateral thigh.
2. B The levator ani muscle is composed of the pubococcygeus, puborectalis, and iliococcygeus muscles (Section 10.3).
A The obturator internus muscle covers the sidewall of the pelvis and perineum. Its tendon passes from the perineum to the gluteal region through the lesser sciatic foramen.
C The pelvic diaphragm separates the true pelvis from the perineum, which lies below it.
D The piriformis muscle forms the posterior muscular wall of the pelvis.
E The coccygeus muscle attaches to the sacrospinous ligament along its entire length.
3. C The posterior division supplies parietal branches to the posterior abdominal wall, some gluteal muscles, and the meninges of the sacral spinal roots (Section 10.6a).
A The internal pudendal artery, a branch of the anterior division of the internal iliac artery, supplies most structures of the perineum.
B The obturator artery, a branch of the anterior division of the internal iliac artery, supplies muscles of the medial thigh.
D The uterine artery, a branch of the anterior division of the internal iliac artery, supplies the uterus and uterine tubes.
E The prostatic arteries, usually branches of the inferior vesical arteries, are derived from the anterior division of the internal iliac artery.
4. D The pelvic splanchnic nerves represent the sacral component of the parasympathetic system; the vagus nerve represents the cranial component of the parasympathetic system (Section 10.6d).
A Lumbar splanchnic nerves arise from the lumbar sympathetic trunk and carry postganglionic sympathetic fibers.
B Sacral splanchnic nerves arise from the sacral sympathetic trunk and carry postganglionic sympathetic fibers.
C The pudendal nerve arises from the sacral plexus and carries somatic sensory and motor fibers.
E Hypogastric nerves derive from the superior hypogastric plexus carrying postganglionic sympathetic fibers to the pelvic plexus.
5. E The vertebral venous system is a tributary of the azygos system. The breast, intercostal muscles, and esophagus drain via intercostal veins to the azygos system, and the spinal cord drains directly into the vertebral venous plexus (Section 11.1b and Thorax unit).
A Blood from the breast drains to intercostal veins and the azygos system, which communicates with the vertebral venous plexus. B through D are also correct (E).
B The veins of the spinal cord drain to the vertebral venous plexus. A, C, and D are also correct (E).
C The intercostal veins that drain intercostal muscles terminate in the azygos system, which also receives the vertebral venous plexus. A, B, and D are also correct (E).
D Veins of the lower esophagus drain to the portal system, but in the thorax esophageal veins drain to the azygos system, which also receives the vertebral venous plexus. A through C are also correct (E).
6. B The uterine artery and vein travel within the cardinal ligament at the base of the broad ligament (Section 11.2c).
A The proper ovarian ligament connects the ovary to the uterus and does not contain any major vessels.
C The uterosacral ligament is a thickening of endopelvic fascia that connects the cervix of the uterus to the sacrum. It does not contain any major vessels.
D The ovarian suspensory ligament is a fold of peritoneum that contains the ovarian vessels as they cross over the pelvic brim.
E The round ligament extends from the uterus through the inguinal canal to the labia majora. Although it is accompanied by small vessels, it does not contain any major arteries.
7. E All are correct (Section 11.3a).
A The gonadal vessels cross anterior to the ureter as it descends along the posterior abdominal wall. B through D are also correct (E).
B The bifurcation of the common iliac artery is a useful landmark for locating the ureter as it crosses the pelvic brim. A, C, and D are also correct (E).
C The ureter passes under the uterine artery lateral to the uterine cervix and therefore is at risk of injury during a hysterectomy. A, B, and D are also correct (E).
D The ureteral openings posterolaterally and the urethral opening in the anterior midline define the apexes of the trigone. A through C are also correct (E).
8. E The pudendal nerve (S2–S4) provides motor innervation to the external sphincter (Sections 11.4 and 10.6d).
A T12–L1 nerve roots contribute to the subcostal, iliohypogastric, and ilioinguinal nerves, which innervate muscles of the anterior abdominal wall.
B The L2–L4 nerve roots form the femoral and obturator nerves, which innervate muscles of the anterior and medial thigh.
C Nerves from L4–L5 spinal cord segments form the lumbosacral trunk, which joins the sacral plexus to innervate muscles of the lower limb.
D S1–S2 nerve roots contribute to the sacral plexus, which innervates muscles of the lower limb.
9. B The superficial perineal fascia is continuous with the dartos fascia that lines the scrotum and with the membranous layer (Scarpa’s fascia) of the superficial fascia of the abdominal wall (Section 12.1).
A The perineal membrane is a fibrous sheet that forms the roof of the superficial perineal space.
C Deep penile fascia is a fibrous layer that binds the three erectile bodies of the penis.
D Each of the three erectile bodies of the penis is surrounded by the dense, fibrous tunica albuginea.
E Endopelvic fascia is the loose connective tissue matrix that fills the subperitoneal spaces of the pelvis.
10. E The pelvic inlet separates the true pelvis from the false pelvis. The cavity of the false pelvis is the lower part of the abdominal cavity and contains abdominal viscera (Section 10.1).
A The pelvic diaphragm attaches to the superior pubic ramus, tendinous arch of the levator ani, and sacrospinous ligament.
B The iliac crests form the upper boundary of the false pelvis. The pelvic inlet forms its lower boundary.
C The ramus of the ischium forms part of the pelvic outlet but not the pelvic inlet.
D The ovarian arteries cross the pelvic inlet, but the testicular arteries pass along the brim of the pelvis (pelvic inlet) to the deep inguinal ring, where they enter the inguinal canal as part of the spermatic cord.
11. B The anococcygeal ligament (also known as the levator plate) is a midline raphe between the anus and coccyx that serves as the insertion for the pubococcygeus and iliococcygeus muscles (Section 10.3).
A The coccygeus inserts on the ischial spine.
C The piriformis inserts on the greater trochanter of the femur.
D Deep transverse perineal muscles insert on the vagina (or prostate) and perineal body.
E The obturator internus inserts on the greater trochanter of the femur.
12. E The inferior rectal veins drain through the caval system (via the internal iliac vein and inferior vena cava) back to the heart and pulmonary circulation. All other choices are tributaries of the portal system, which drains through the liver before returning to the heart (Sections 8.2b and 11.4).
A Veins of the ascending colon are tributaries of the portal system. Therefore, blood passes through the liver before returning to the heart and pulmonary circulation.
B Veins of the sigmoid colon, and all parts of the gastrointestinal tract, are tributaries of the portal system. Therefore, blood passes through the liver before returning to the heart and pulmonary circulation.
C Veins of the pancreas are tributaries of the portal system. Therefore, blood from the pancreas drains through the liver before returning to the heart and pulmonary circulation.
D The superior rectal vein that drains the superior rectum is a tributary of the portal system. Therefore, this blood passes through the liver before returning to the heart and pulmonary circulation.
13. B The cavernous nerves carry parasympathetic innervation from the pelvic plexus to the perineum by passing through the genital hiatus (Section 10.6d).
A The ductus deferens passes through the deep inguinal ring and inguinal canal of the male.
C The round ligament traverses the female inguinal canal and terminates in the labia majora.
D The obturator nerve passes through the obturator canal into the medial thigh.
E The external iliac artery passes below the inguinal ligament into the anterior thigh.
14. A The suspensory ligament contains the ovarian vessels and is removed only during the removal of the ovary (Section 11.2a).
B The ovarian ligament attaches the ovary to the uterus and must be ligated to extract the uterus.
C The uterosacral ligament connects the cervix to the sacrum.
D The transverse cervical ligament contains the uterine arteries, which are ligated during a hysterectomy.
E The round ligament passes through the inguinal canal and connects the uterus to the labia majora.
15. D The uterus comprises a body that forms the superior two thirds and a cervix that forms the inferior one third (Section 11.2c).
A In an anteflexed uterus, the cervix is tilted anteriorly.
B The vaginal part of the cervix is surrounded by the vaginal fornices.
C The round ligaments arise from the upper part of the uterus.
E The cervix communicates with the body of the uterus through the internal os.
16. A The superior hypogastric plexus, a sympathetic nerve plexus, drapes over the aortic bifurcation as it enters the pelvis. It is frequently cut during surgery for the repair of an aneurysm at the location. The sympathetic nerves stimulate closure of the internal urethral sphincter during ejaculation, preventing the retrograde flow of seminal fluid into the bladder. Damage to these nerves can result in retrograde ejaculation (Sections 10.6d and 12.3d).
B The superior hypogastric plexus is a sympathetic nerve plexus derived from the intermesenteric plexus and lumbar splanchnic nerves.
C Somatic nerves do not stimulate visceral responses such as closure of the sphincter.
D Pelvic splanchnic nerves do not innervate the internal urethral sphincter.
E The paired sympathetic trunks run along the vertebral bodies on either side and would not be damaged in this procedure.
17. D The submucosal venous plexus of the anorectal region communicates with branches of the rectal arteries in an arteriovenous anastomosis, creating a thickened vascular tissue known as the hemorrhoidal plexus. As a result of these anastomoses, bleeding from the internal rectal plexus appears bright red (Section 11.4). A Prolapsed internal hemorrhoids contain the dilated veins of the internal rectal plexus and are painless. External hemorrhoids, containing the external rectal plexus, are covered by skin and sensitive to pain.
B External hemorrhoids that occur below the dentate line are somatically innervated and therefore very painful, but internal hemorrhoids are viscerally innervated and painless.
C Veins of painless internal hemorrhoids lie above the dentate line and therefore drain to the superior rectal vein, a tributary of the portal system.
E A, B, and C are incorrect.
18. D The cavernous nerves carry parasympathetic nerves that are responsible for engorgement of the erectile tissue of the penis (Sections 10.6d and 12.3b).
A The external anal sphincter is innervated by the pudendal nerve, a branch of the sacral plexus.
B The external urethral sphincter that regulates urinary continence is innervated by the pudendal nerve, a branch of the sacral plexus.
C Ejaculation is a sympathetically mediated response. The cavernous nerves carry parasympathetic nerves from the inferior hypogastric plexus.
E The pudendal nerve carries sensation from perineal structures such as the tip of the penis.
19. D The piriformis passes through the greater sciatic foramen to insert on the trochanter of the femur (Section 10.3).
A The tendon of the obturator internus muscle passes through the lesser sciatic foramen from the perineum to the gluteal region.
B The coccygeus muscle lies along the sacrospinous ligament and forms the lower border of the greater sciatic foramen.
C The iliopsoas muscle passes under the inguinal ligament into the thigh.
E The obturator nerve passes along the sidewall of the pelvis and through the obturator canal into the thigh.
20. C The tendinous arch of the pelvic fascia is a thickening of the membranous fascia on the floor of the pelvis where visceral and parietal fascial layers meet. It provides support for pelvic viscera (Section 10.4).
A The tendinous arch of the pelvic fascia is a thickening of the membranous fascia, which lines the pelvic walls and viscera. Endopelvic fascia is a loose connective tissue layer that fills the subperitoneal spaces.
B The lateral rectal ligaments, like the lateral vesicular ligaments, are supporting columns of endopelvic fascia that connect the viscera to the pelvic walls.
D The tendinous arch of the levator ani, a condensation of the fascia over the obturator internus muscle, is the attachment site for the levator ani part of the pelvic diaphragm.
E A, B, and D are incorrect.
21. E The superficial and deep inguinal nodes drain most structures of the perineum, including the glans of the penis, perianal skin, and scrotum. The supralateral parts of the uterus drain along the round ligaments (which terminate in the labia majora) to superficial inguinal nodes. These nodes drain to the deep inguinal nodes (Section 10.6c).
A Lymph from the glans of the penis drains to deep inguinal nodes. B through D are also correct (E).
B Lymph from perianal skin, like all skin of the perineum, drains to superficial inguinal nodes, which drain to deep inguinal nodes. A, C, and D are also correct (E).
C Lymph from the supralateral parts of the uterus drain along the round ligaments (which terminate in the labia majora) to superficial inguinal nodes. These nodes drain to the deep inguinal nodes. A, B, and D are also correct (E).
D Lymph from the scrotum drains to superficial inguinal nodes, which drain to deep inguinal nodes. A through C are also correct (E).
22. C The pudendal nerve is a branch of the sacral plexus that passes through the lesser sciatic foramen (Section 10.6d).
A Only posterior rami of sacral spinal nerves pass through the posterior sacral foramina. The sacral plexus is formed by anterior rami of sacral spinal nerves.
B The obturator nerve, which passes through the obturator canal, is a branch of the lumbar plexus.
D The ilioinguinal and genitofemoral nerves, which pass through the superficial inguinal ring, are branches of the lumbar plexus.
E The genitofemoral nerve, a branch of the lumbar plexus, passes through the deep inguinal ring.
23. A The round ligament originates on the superior aspect of the anterolateral uterus and inserts in the labia majora. As the uterus enlarges and stretches the ligament, pain is felt in the labia (Section 11.2c).
B During late pregnancy pelvic ligaments are more relaxed in preparation for the passage of the child through the birth canal.
C Pressure on the obturator nerve would be felt on the medial thigh.
D The anterior part of the labia majora is innervated by the labial branches of the genitofemoral nerve, not the pudendal nerve.
E The iliohypogastric nerve innervates the skin above the pubic crest and does not extend inferiorly to the labia.
24. A The ureter crosses the pelvic brim at the bifurcation of the common iliac artery into its internal iliac and external iliac branches (Section 11.3a).
B The testicular artery does not cross the pelvic brim but enters the deep inguinal ring.
C The lumbosacral trunk crosses the pelvic brim posterior to the common iliac vessels and anterior to the sacroiliac joint. It enters the pelvis to join the sacral plexus.
D The sciatic nerve passes through the greater sciatic foramen and does not cross the pelvic brim.
E The ductus deferens courses around the inferior epigastric vessels and over the distal end of the external iliac vessels to descend into the pelvis.
25. E The rectum is devoid of ta eniae coli, haustra, a mesentery, and epiploic appendices (Section 11.4).
A The taeniae coli of the large intestine converge to form a uniform layer surrounding the rectum.
B The haustra of the large intestine disappear at the rectosigmoid junction.
C The rectum has no mesentery. The upper rectum is covered anteriorly by peritoneum, but the lower rectum lies in the subperitoneal space.
D Epiploic appendices are not present in the rectum.
26. C The bulbospongiosus muscle is found within the superficial perineal space (Section 12.1).
A The bulbourethral glands are found in the deep perineal space.
B The external urethral sphincter is located in the deep perineal space.
D The anterior extensions of the ischioanal fat pads are found in the deep perineal space.
E The inferior rectal nerve is found in the anal triangle, not the deep perineal or the superficial perineal spaces of the urogenital triangle.