1 A. Perineal hypospadias is due to a failure of fu-
sion of labioscrotal folds so that the external urethral orifi ce is between the unfused halves of the scrotum.
The cloacal membrane is formed from endoderm of the cloaca and ectoderm of the procotodeum and forms the future anus. The urogenital folds normally fuse along the ventral side of the penis to form the spongy urethra. Epispadias is a condition in which the urethra opens on the dorsal surface of the penis resulting from the genital tubercle developing more dorsally during development. The urogenital mem- brane is bounded by the urogenital folds and ruptures to form the urogenital orifi ce.
GAS 444-446; GA 224-225
2 B. Most anorectal anomalies result from abnor-
mal development of the urorectal septum, ultimately resulting in nondivision of the cloaca into urogenital and anorectal parts. The common outlet of the intes- tinal, urinary, and reproductive tracts is specifi cally associated with a persistent cloaca. The labioscrotal folds are involved in forming the external urethral orifi ce only. The urogenital folds normally fuse along the ventral side of the penis to form the spongy ure- thra. Epispadias is an anomaly in the development of the genital tubercle and involves the urethral orifi ce.
The urogenital membrane is bounded by the urogeni- tal folds and ruptures to form the urogenital orifi ce.
GAS 312, 406, 438-440; GA 213-215
3 A. The gubernaculum arises in the upper abdo-
men from the lower end of the gonadal ridge and helps guide the testis in its descent to the inguinal region and then through the abdominal wall. Ectopic testes occur when a portion of the gubernaculum passes to an abnormal position or otherwise fails to descend or become fi xed to the skin of the scrotum.
The processus vaginalis is a tube of peritoneum that follows the same oblique course through the body
wall as the testis, ventral to the gubernaculum. The distal part of the processus is retained as the tunica vaginalis. If part of the remainder of the processus remains patent, it can fi ll with fl uid as a hydrocele of the testis or spermatic cord. The genital tubercle forms the primordial phallus and is associated with epispadias. The seminiferous cords form the primor- dia of the seminiferous tubules. The labioscrotal swellings approach each other and fuse to form the scrotum.
GAS 260, 263, 287, 453; GA 225
4 A. When the urinary bladder mucosa is open to
the outside in the fetus or newborn, the condition is referred to as extrophy of the bladder. The extrophy results from failure of the primitive streak mesoderm to migrate around the cloacal membrane, and it oc- curs often in combination with epispadias. Penile hypospadias is characterized by a failure of fusion of the labioscrotal folds, with the external urethral ori- fi ce located between the two unfused halves of the scrotum. Androgens are responsible for development of the testes. Klinefelter syndrome is a condition in which the male has 47 XXY chromosomes. A persis- tent allantois is associated with a patent urachus and an allantoic cyst.
GAS 441, 453-455; GA 208, 210, 216, 218
5 A. The ureteric bud, or metanephric diverticu-
lum, is an outgrowth from the mesonephric duct. It is the primordium of the ureter, renal pelvis, the calyces, and the collecting tubules. Incomplete division results in a divided kidney with a bifi d ureter. Complete divi- sion results in a double kidney with a bifi d ureter, or separate ureters.
GAS 441, 453; GA 210, 218-219
6 A. Failure of fusion of the inferior parts of the
paramesonephric ducts results in a double uterus. A bicornuate uterus is the result of failure of fusion of the superior parts of the paramesonephric (Mülle-
123 rian) ducts. A failure of the sinovaginal bulbs to
form the vaginal plate causes agenesis of the vagina.
The mesonephric ducts are important embryologic structures involved in the development of male uro- genital structures.
GAS 441, 453; GA 137, 210, 227-229
7 E. The persistence of the epithelial lining of the
urachus can give rise to a urachal cyst. This swelling is found in the midline in the umbilical region. Hydro- cele is fl uid accumulation between the visceral and parietal layers of the tunica vaginalis of the testis. A Meckel diverticulum is located in the ileum of the small intestine. When it becomes infl amed, it can cause symptoms of appendicitis. A diverticulum can form a cyst (Meckel cyst). An omphalocele is the per- sistence of the herniation of the abdominal contents into the umbilical cord.
GAS 441, 453; GA 208, 210, 216, 218
8 B. A double uterus is caused by failure of inferior
parts of the paramesonephric ducts. A complete fu- sion results in abnormal development of the uterine tubes because the uterine tubes form from the un- fused portions of the cranial parts of the parameso- nephric ducts. Hydronephros, swelling of the renal pelvis and calyces with urine, can result from the obstruction of the ureter by a renal stone. Cryptorchi- dism is a condition characterized by an undescended testis, in which the testis can be localized in the ab- dominal cavity or in any place along the path of tes- ticular descent. The pronephros is part of the primor- dial urinary system and generally degenerates in the fi rst four weeks of development.
GAS 455-457; GA 137, 210, 227-229
9 A. The ureters cross the pelvic brim anterior to
the bifurcation of the common iliac artery bilaterally.
Because of the proximity of this artery to the ureter, it is in danger of being damaged during surgery.
GAS 359-364; GA 218-219, 223
10 C. Hypospadias is a developmental defect in the
urethra resulting in urine being expelled from the ventral side of the penis. This ectopic malformation may present when the urethral folds fail to completely fuse. Failure of fusion of the spongy urethra would result in epispadias. A failure of the labioscrotal folds to fuse will cause the external urethral orifi ce to be situated between the two scrotal halves. This is re- ferred to as penile hypospadias. Failure of the uro- genital folds to fuse would lead to agenesis of the external urethral folds.
GAS 444-453; GA 219, 222
11 A. Epispadias is a developmental defect in the
spongy urethra resulting in urine being expelled from the dorsal aspect of the penis. A failure of the labioscrotal folds to fuse will cause the external ure- thral orifi ce to be situated between the two scrotal halves. This is referred to as penile hypospadias.
Failure of the urogenital folds to fuse would lead to agenesis of the external urethral folds. The genital tubercle would not directly cause epispadias, as the tubercle still continues to develop, but it is located more dorsally.
GAS 444-453; GA 219, 222
12 D. Hydrocele results from an excess amount of
fl uid within a persistent processus vaginalis. Hydro- cele can result from injury to the testis or by retention of a processus that fi lls with fl uid in infants. The tu- nica vaginalis consists of parietal and visceral layers, the latter of which is closely attached to the testis and epididymis. The fl uid buildup occurs within the cav- ity between these layers. A varicocele consists of varicosed veins of the pampiniform plexus and is as- sociated with increased venous pressure in the tes- ticular vein, followed by the accumulation and coagu- lation of venous blood.
GAS 504; GA 139, 224-225
13 A. Varicose veins occur with loss of elasticity
within the walls of the vessels. As the veins weaken, they simultaneously dilate under pressure. A varico- cele often occurs with a varicosity of the veins of the pampiniform venous plexus, resulting in a swelling of the veins. This condition can arise from a tumor in the left kidney, which occludes the testicular vein due to an anatomic constriction. A hydrocele is an accu- mulation of fl uid within the cavity of the tunica vagi- nalis. Hypospadias occurs from failure of fusion of the urethral and labioscrotal folds, resulting in an exter- nal urethral opening on the ventral surface of the pe- nis or in the perineum.
GAS 339-340, 504, 638-639; GA 139, 224-225
14 A. When veins lose their elasticity, they can be-
come weak and often dilate. This causes the veins to become swollen and oftentimes tortuous, as a result of incompetent valves. The appearance of a “bag of worms” on the radiograph is characteristic of a vari- cosity of the pampiniform venous plexus. A hydrocele is an accumulation of fl uid within the tunica vaginalis cavity. Hypospadias occurs from failure of fusion of the urethral and labioscrotal folds, resulting in an external urethral opening on the ventral surface of the penis or in the perineum.
GAS 339-340, 504; GA 139, 224-225
124
15 B. It is very likely that the ectopic pregnancy
ruptured into the rectouterine pouch, also known as the pouch of Douglas. The most direct route to the rectouterine pouch is through the vaginal wall at the posterior vaginal fornix. It is unlikely that the preg- nancy would have occurred in the vesicouterine space because the transfer of ova from the ovary to the fi m- briae occurs on the posterior side of the broad liga- ment. Therefore, it would not be advisable to attempt initially to insert a needle into the vesicouterine space. Inserting a needle through the anterior fornix into the endocervical canal would lead one into the uterine cavity, with the probability of other undesir- able consequences. The urogenital diaphragm is a closed space in the perineum. Entering a vestibular gland with a needle would not be near the location of ectopic pregnancy.
GAS 508; GA 208, 210, 231
16 A. A break or tear in the rectovaginal septum
(fascia of Denonvilliers) can allow small intestine (in an enterocele) or rectum (in a rectocele) to herniate into the posterior vaginal wall, even to the point of protrusion through the vaginal introitus. The muscles listed are all in the anterior region of the perineum and have no association with an enterocele or recto- cele. The sacrospinous ligament is unrelated to this condition.
GAS 454, 459; GA 208, 231
17 B. When the internal urethral orifi ce is ob-
structed, it is most likely due to an enlargement of the median (or middle) lobe of the prostate gland. The prostate gland is located at the base of the urinary bladder and is often described as possessing fi ve ill- defi ned lobes, although this is not accepted by most urologists. The middle lobe consists of glandular tis- sue dorsal to the uvula of the urethral meatus of the urinary bladder, adjacent to the beginning of the ure- thra. This glandular tissue is most frequently involved in benign hypertrophy.
GAS 447, 451-452; GA 216, 218-223
18 A. The deep inguinal lymph nodes drain the
glans clitoris and receive lymph also from superfi cial nodes. The internal iliac nodes drain the inferior pel- vic structures, deep perineal structures, and sacral nodes. The paraaortic lymph nodes, or lumbar nodes, receive lymph from the common iliac nodes. The drainage of presacral lymph nodes can pass to the common or internal iliac nodes. Axillary nodes drain body wall structures above the T10 dermatome (or the umbilicus).
GAS 477; GA 254-256
19 B. 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 (com- pressor urethra), which would be injured. The bulbo- spongiosus muscle and other perineal muscles, the corpus cavernosa penis, and the openings of the bul- bourethral ducts are inferior and anterior to the region of injury.
GAS 444-447; GA 210, 220, 227
20 A. Conscious pain due to bladder fullness re-
sults from the excitation of stretch receptors in the bladder wall. These pain fi bers are carried through the pelvic nerve plexuses and into the pelvic splanch- nic nerves. The sensory fi bers enter the dorsal root ganglia of spinal nerves S2, S3, and S4. Sensory fi bers enter the spinal cord via these ganglia. The interme- diomedial cell column of spinal cord levels S2, S3, and S4 contains parasympathetic soma. The levels T5 to T9, T10 to L2, and preaortic ganglia are well above where sensory fi bers from the bladder are located.
GAS 441-444, 462-471; GA 238-240, 250-253
21 A. The pubococcygeus muscle, especially its
most medial portion, the puborectalis, is of most im- portance in fecal continence. The levator ani consists of two major portions, the pubococcygeus and ilio- coccygeus, which help support pelvic viscera and re- sist increases in intraabdominal pressure. The pu- borectalis muscle is the most medial and inferior portion of the pubococcygeus. The puborectalis forms a loop around the rectoanal junction, and the integrity of this muscle is critical in maintenance of fecal con- tinence. The coccygeus and pubovesicocervical fascia are not in direct contact with the rectum. Damage to the urogenital diaphragm can contribute to urinary incontinence but not fecal incontinence.
GAS 432-436; GA 214-215, 220
22 E. The lateral femoral cutaneous nerve (L2, L3)
emerges from the lateral side of the psoas muscle and runs in front of the iliacus and through, or behind, the inguinal ligament and innervates the skin of the lat- eral aspect of the thigh to the level of the knee. This nerve has been constricted in this case of “Calvin Klein syndrome” (in this case from the patient’s obe- sity, not too-tight jeans) causing pain, tingling, or burning sensations in the lateral thigh. The femoral branch of the genitofemoral nerve (L1, L2) supplies a small area of skin (over the femoral triangle), just inferior to the midpoint of the inguinal ligament. The femoral nerve (L2 to L4) is motor to the quadriceps and sartorius muscles and sensory to the anterior
125 thigh and the medial thigh and leg. The ilioinguinal
supplies the suprapubic region; part of the genitalia and anterior perineum; and the upper, medial thigh.
Cutaneous branches of the iliohypogastric nerve in- nervate skin of the anterolateral gluteal area and su- prapubic region.
GAS 462-471; GA 238-240, 250-253
23 C. Normally the uterus is antefl exed at the junc-
tion of the cervix and the body and anteverted at the junction of the vagina and the cervical canal.
GAS 455-458; GA 227
24 D. The cardinal ligament, also known as Mack-
enrodt’s ligament or transverse cervical ligament, is composed of condensations of fi bromuscular tissues that accompany the uterine vessels. These bands of pelvic fascia provide direct support to the uterus. The other ligaments listed do not play a direct role in uter- ine stability.
GAS 455-458; GA 228-229
25 C. Ovarian lymph fi rst drains into the paraaortic
nodes at the level of the renal vessels. The superfi cial and deep inguinal nodes drain the body wall below the umbilicus, the lower limbs, and the cutaneous portion of the anal canal and parts of the perineum. The exter- nal iliac nodes receive the lymph from the inguinal nodes. The node of Cloquet is located in the femoral ring, adjacent to the external iliac vein and beneath the inguinal ligament. The node of Cloquet drains into the common iliac nodes. The internal iliac nodes accom- pany the uterine artery and vein, receiving lymph from much of the uterus but not the ovaries.
GAS 477; GA 254-256
26 B. The external anal sphincter is important for
maintaining fecal continence. The external anal sphincter is located immediately posterior to the perineal body (central tendon) and would be suscep- tible to damage during a median episiotomy. The other structures listed play no role in maintaining fecal continence.
GAS 413, 436-438; GA 208, 210, 216-217
27 C. The tendinous arch of fascia pelvis is a dense
band of connective tissue that joins the fascia of the levator ani to the feltlike pubocervical fascia that cov- ers the anterior wall of the vagina. If this fascial band is torn, the ipsilateral side of the vagina falls, carrying with it the bladder and urethra, often leading to uri- nary incontinence. The tendinous arch of the levator ani is a thickened portion of the fascia of the obtura- tor internus and provides part of the origin of the le-
vator ani muscle, but it plays no direct role in incon- tinence. The coccygeus muscle supports and raises the pelvic fl oor but is not directly associated with urinary incontinence. The obturator internus is in- volved with lateral rotation of the thigh. If the recto- vaginal septum is torn, the patient can be subject to the occurrence of rectocele or enterocele, as the lower portion of the GI tract prolapses into the posterior wall of the vagina.
GAS 413, 436-438, 454, 459; GA 213
28 A. Lymph from the cutaneous portion of the
anal canal (below the pectinate line) drains into the inguinal nodes. Lymph from most parts of the rectum and from the mucosal zone of the anal canal (above the pectinate line) drains into the internal iliac nodes.
Lymph from some parts of the rectum also drains into the sacral nodes.
GAS 477; GA 254-256
29 C. The retropubic space (of Retzius) is the extra-
peritoneal space between the pubic symphysis and the bladder. A needle placed over the pubic bone, through the body wall, and into the space of Retzius will enter the full bladder but avoids entry into the peritoneum and there is little risk of damaging major organs or vessels. Entry through the ischioanal fossa would not provide a direct route to the bladder. With entry through the superfi cial perineal cleft, perineal body, and deep perineal pouch there is a high risk of damaging important structures.
GAS 438-447; GA 210, 220, 227
30 C. Hematocolpos is characterized by fi lling of the
vagina with menstrual blood. This commonly occurs due to the presence of an imperforate hymen. Bartholin gland ducts open into the vestibule of the vagina;
therefore, a cyst in Bartholin gland would not cause hematocolpos. Blood from a ruptured ectopic preg- nancy most often drains into the rectouterine pouch (of Douglas). Females often have a diminutive cremaster muscle and cremasteric artery and vein, but none of these is associated with hematocolpos. The cremasteric artery provides a small branch to the round ligament of the uterus (sometimes called “Samson’s artery”), which must be kept in mind during a hysterectomy, with division of the round ligament. Bleeding from the uterine veins would not fl ow into the vagina.
GAS 508; GA 227, 231
31 C. An enterocele (herniation of small intestine
into the posterior wall of the vagina) is caused by a tear of the rectovaginal septum, which weakens the pelvic fl oor. A urethrocele is characterized by prolapse of the
126
urethra into the vagina. It is usually associated with a cystocele (prolapse of the bladder into the urethra).
Cystocele or urethrocele are associated with defects in the pubocervical fascia that covers the anterior wall of the vagina and assists in supporting the bladder. Uri- nary incontinence can result from weakening of the muscles that surround the urethra but would not be caused by a tear of the rectovaginal septum. Prolapse of the uterus is caused by weakening or tearing of the ligaments that support the uterus (especially the cardi- nal and/or uterosacral ligaments).
GAS 454, 459; GA 227, 231
32 A. Of the answer choices listed, the pubococ-
cygeus is the muscle that is most directly associated with the arcus tendineus fascia pelvis and connective tissues of the vagina and the support of the bladder.
The obturator internus, piriformis, and coccygeus do not form parts of the levator ani and provide no direct support to the urogenital organs, nor do they have any role in urinary incontinence. The iliococcygeus does form part of the levator ani, but it is located lateral to the pubococcygeus and therefore does not play a direct role in maintaining urinary continence.
GAS 432-436; GA 212-217
33 A. The ovarian vessels and nerves lie within the
infundibulopelvic ligament (suspensory ligament of the ovary); therefore, cutting this ligament interrupts pain fi bers from the ovary. Cutting the sympathetic chain might help to reduce some of the pain from the ovary, but the results of such a procedure are rather unpredictable, plus locating the lumbar sympathetic chain is more of a surgical challenge. The cluneal nerves are cutaneous nerves that innervate parts of the buttocks. They are not associated with the ova- ries. The pudendal nerve innervates the perineum and does not carry afferent pain fi bers from the ovary.
The broad ligament contains only the uterovaginal vessels and nerve plexus and does not carry any nerve fi bers from the ovary.
GAS 471-477; GA 228-229, 235
34 C. The superfi cial perineal space or cleft lies be-
tween the external perineal fascia of Gallaudet (fascia of inferior perineal muscles in the superfi cial perineal compartment) and the membranous layer of Colles’
fascia. Camper’s fascia is the superfi cial fatty layer of the anterior abdominal wall and the perineum; Scar- pa’s fascia is the deep membranous layer of the ab- dominal wall. The perineal membrane is the inferior fascia of the urogenital diaphragm that forms the infe- rior boundary of the deep perineal compartment. The superior fascia of the urogenital diaphragm bounds the
inferior border of the anterior recess of the ischioanal fossa. There is no space between the urogenital dia- phragm and the apex of the prostate gland.
GAS 478-482; GA 246, 248
35 B. The urinary bladder wall is formed by the
detrusor muscle, and it receives both its motor and sensory innervation from parasympathetic nerve fi - bers transmitted by way of the pelvic splanchnic nerves from S2 to S4.
GAS 462-471; GA 258, 260
36 A. The rectouterine pouch (of Douglas) is the
lowest point of the female peritoneal cavity. There- fore, fl uid buildup within the peritoneal cavity accu- mulates here when the patient is standing or sitting.
It is accessible transvaginally through the posterior fornix, with the patient positioned appropriately.
GAS 460-462; GA 210, 227
37 E. Because the penile urethra and deep (Bucks)
fascia are both located in the superfi cial perineal pouch, rupture will occur here, with extravasation of fl uids into the superfi cial perineal cleft. The ischio- anal fossa is located posterior to the urogenital trian- gle, behind the area of injury. The other listed spaces are deep to the superfi cial compartment or within the pelvis and are not associated with the area of injury.
GAS 444-448, 478-481; GA 224-226
38 C. The perineal branch of the pudendal nerve is
responsible for the innervation of the external ure- thral sphincter, and injury to this nerve can result in paralysis of the sphincter and urinary incontinence.
Pelvic splanchnic and sacral splanchnic nerves are autonomic nerves that do not supply skeletal muscles in the urogenital region. The gluteal nerves innervate gluteal muscles.
GAS 462-471; GA 238-240, 250-253
39 D. The internal pudendal artery gives rise to both
the dorsal artery and deep artery of the penis. The deep artery is the main supply for erectile tissue; therefore, signifi cant atherosclerosis of the internal pudendal ar- tery may result in impotence (erectile dysfunction).
GAS 471-476; GA 231-232, 236-237, 250, 252
40 A. Cancer present in the inguinal nodes can be
indicative of cancer of the uterus at the level of the round ligaments, by which the cancer passes to the inguinal region. Uterine cancer must be especially sus- pected if the tissues of the lower limb, vulva, and anal canal appear normal. The pectinate line marks the end of the mucosal lining of the anal canal, below which