112
6 A 16-year-old woman is visiting her gynecologist
for her fi rst checkup. On ultrasound examination it is noted that the woman has a double uterus. Failure of which of the following processes is responsible for the double uterus?
⃣ A. Fusion of the inferior parts of the parameso- nephric ducts
⃣ B. Fusion of the superior parts of the mesoneph- ric ducts
⃣ C. Development of the hymen
⃣ D. Development of the sinovaginal bulbs
⃣ E. Fusion of the inferior parts of the mesoneph- ric ducts
7 A 6-year-old boy has a large intraabdominal mass
in the midline just above the pubic symphysis. During surgery a cystic mass is found attached to the umbili- cus and to the apex of the bladder. Which of the follow- ing is the most likely diagnosis?
⃣ A. Hydrocele
⃣ B. Meckel cyst
⃣ C. Meckel diverticulum
⃣ D. Omphalocele
⃣ E. Urachal cyst
8 A 26-year-old pregnant woman visits her gyne-
cologist for a routine checkup. Ultrasound examination reveals that the patient has a normal pregnancy but that she also has two uteri. What is the most likely embryologic explanation of this condition?
⃣ A. A complete fusion of the paramesonephric ducts
⃣ B. An incomplete fusion of the paramesonephric ducts
⃣ C. Hydronephros
⃣ D. Cryptorchidism
⃣ E. Regression of the pronephros
9 A 35-year-old woman is admitted to the emer-
gency department with severe left abdominal and back pain. Radiographic evaluation reveals that the left ureter is blocked with a kidney stone. Because the ureter is completely obstructed, an emergency surgi- cal procedure must be performed. Which of the fol- lowing landmarks is most reliable for the identifi ca- tion of the ureter?
⃣ A. The left ureter is located anterior to the left common iliac artery.
⃣ B. The left ureter is located medial to the left in- ferior epigastric artery.
⃣ C. The left ureter is located anterior to the left gonadal artery.
⃣ D. The left ureter is located anterior to the left renal vein.
⃣ E. The left ureter is located anterior to the left inferior epigastric artery.
10 A 1-year-old infant is admitted to the pediatric
clinic because he is passing urine on the underside of the penis as shown in Fig. 4-1 . Which embryologic structure failed to fuse?
⃣ A. Spongy urethra
⃣ B. Labioscrotal folds
⃣ C. Urethral folds
⃣ D. Urogenital folds
⃣ E. Genital tubercle
11 A 4-month-old infant is admitted to the pediatric
clinic because urine can be observed passing through an opening on the dorsum of the penis. Which of the following embryologic structures failed to fuse?
⃣ A. Spongy urethra
⃣ B. Labioscrotal folds
⃣ C. Cloacal membrane
⃣ D. Urogenital folds
⃣ E. Genital tubercle
12 A 25-year-old male is admitted to the hospital
with testicular pain. Physical examination reveals a swollen and infl amed right testis. CT scan examination
Fig. 4-1
113 reveals abnormal accumulation of fl uid in the cavity of
the tunica vaginalis ( Fig. 4-2 ). Which of the following conditions will most accurately describe the signs ob- served in the patient?
⃣ A. Varicocele
⃣ B. Rectocele
⃣ C. Cystocele
⃣ D. Hydrocele
⃣ E. Hypospadias
13 A 54-year-old male is admitted to the hospital
with severe back pain. Radiographic examination re- veals carcinoma of the left kidney blocking the drain- age of the testicular vein. Which of the following condi- tions will be most likely associated with these signs?
⃣ A. Varicocele
⃣ B. Rectocele
⃣ C. Cystocele
⃣ D. Hydrocele
⃣ E. Hypospadias
14 A 54-year-old male is admitted to the hospital
with severe back pain. Upon radiographic examination ( Fig. 4-3 ) the scrotum resembles a “bag of worms.”
Which of the following conditions will be most likely associated with this radiographic picture?
⃣ A. Varicocele
⃣ B. Rectocele
⃣ C. Cystocele
⃣ D. Hydrocele
⃣ E. Hypospadias
15 A 16-year-old female is brought to the emergency
department with severe abdominal pain and fever.
Laboratory examination is remarkable for an elevated white blood cell count and a positive test for preg- nancy. Colpocentesis is performed to ascertain the presence of blood in the pelvis from the ruptured ec- topic pregnancy. Through which of the following struc- tures does the needle need to be inserted?
⃣ A. Through the perineal body into the vesico- uterine space
⃣ B. Through the posterior fornix into the recto- uterine pouch
⃣ C. Through the anterior fornix into the endocer- vical canal
⃣ D. Through the introitus into the vestibular gland
⃣ E. Though the perineal membrane into the uro- genital diaphragm
Fig. 4-2
Fig. 4-3
114
16 A 46-year-old woman is admitted to the hospital
with a noticeable bulge of tissue through her vaginal opening. During physical examination a rectocele is identifi ed. Which of the following is most likely respon- sible for this condition?
⃣ A. Compromised rectovaginal septum
⃣ B. Weakened superfi cial and deep transverse perineal muscles
⃣ C. Paralyzed ischiocavernosus muscle
⃣ D. Loose sacrospinous ligament
⃣ E. Ruptured sphincter urethra
17 A 68-year-old male is admitted to the hospital
with painful urination and nocturia (urination during the night). MRI examination reveals enlargement and irregularity of the uvula of the urethra. This enlarge- ment resulted in diffi culty with urinary voiding and inadequate emptying of the bladder. Which of the fol- lowing lobes of the prostate gland will most likely be hypertrophied?
⃣ A. Anterior
⃣ B. Median
⃣ C. Lateral
⃣ D. Posterior
⃣ E. Lateral and Posterior
18 Radiographic studies of a 42-year-old woman re-
veal that she has a vulvar malignancy involving the clitoris. Removal of all affected lymph nodes would be indicated to avoid spread of this cancer. Which are the fi rst lymph nodes to fi lter the lymphatic drainage of the involved area?
⃣ A. Superfi cial and deep inguinal lymph nodes
⃣ B. Internal iliac nodes
⃣ C. Paraaortic lymph nodes
⃣ D. Presacral lymph nodes
⃣ E. Axillary lymph nodes
19 While performing a voiding cystourethrogram on
a 45-year-old male, the urologist was too forceful when he inserted the catheter and accidentally damaged the wall of the membranous portion of the urethra in the deep perineal compartment (urogenital diaphragm).
Which of the following structures would most likely be traumatized at this location?
⃣ A. Bulbospongiosus muscle
⃣ B. Sphincter urethra (compressor urethra)
⃣ C. Corpus cavernosus penis (crus)
⃣ D. Ischiocavernosus muscle
⃣ E. Opening of the bulbourethral duct
20 A 22-year-old male complained to the urologist of
pain that he experiences from bladder fullness after drinking large quantities of fl uid. What is the location of the neural cell bodies responsible for pain sensation from the urinary bladder?
⃣ A. Dorsal root ganglia of spinal cord levels S2, S3, and S4
⃣ B. The intermediolateral cell column of spinal cord levels S2, S3, and S4
⃣ C. The sensory ganglia of spinal nerves T5 to T9
⃣ D. The preaortic ganglia at the site of origin of the testicular arteries
⃣ E. Dorsal root ganglia of spinal levels T10 to L2
21 A 55-year-old woman complains of fecal inconti-
nence. The most likely contributing factor to such a problem is atrophy, paralysis, or dysfunction of which of the following structures?
⃣ A. Pubococcygeus muscle
⃣ B. Iliococcygeus muscle
⃣ C. Coccygeus muscle
⃣ D. Pubovesicocervical fascia
⃣ E. Urogenital diaphragm
22 A 45-year-old obese woman was admitted to the
hospital because of “pains in her leg.” Physical exami- nation led to a diagnosis of “meralgia paresthetica.” In her condition, excessive adipose tissue bulging over the inguinal ligament exerted traction upon it, compressing a nerve that passed through, or beneath, the ligament, just medial to the anterior superior iliac spine. Which of the following nerves was most likely affected in this patient?
⃣ A. Femoral branch of the genitofemoral nerve
⃣ B. Femoral nerve
⃣ C. Iliohypogastric nerve
⃣ D. Ilioinguinal nerve
⃣ E. Lateral femoral cutaneous nerve
23 On digital examination of the vagina, the portion
of the uterus that one anticipates palpating with the examining fi nger is the cervix and its external os.
Which of the following is the most common position of the uterus?
⃣ A. Antefl exed and retroverted
⃣ B. Retrofl exed and anteverted
⃣ C. Antefl exed and anteverted
⃣ D. Retrofl exed and retroverted
115
24 A 42-year-old woman is admitted to the emer-
gency department because of pelvic discomfort. During physical examination the gynecologist discovers that the patient has suffered complete uterine prolapse.
Which of the following ligaments provides direct sup- port to the uterus?
⃣ A. Mesosalpinx and mesometrium
⃣ B. Infundibulopelvic ligament
⃣ C. Round ligament of the uterus
⃣ D. Lateral cervical (cardinal) ligament
⃣ E. Broad ligament of the uterus
25 A 34-year-old woman is admitted to the hospital
due to severe lower abdominal pain. Radiographic ex- amination reveals tumors in both of her ovaries. A bi- opsy is ordered and confi rms the initial diagnosis of ovarian cancer. Which of the following lymph nodes are the fi rst to receive lymph from the diseased ovaries?
⃣ A. Superfi cial and deep inguinal lymph nodes
⃣ B. External iliac nodes
⃣ C. Paraartotic nodes at the level of the renal vessels
⃣ D. Node of Cloquet
⃣ E. Internal iliac nodes accompanying the uterine artery and vein
26 A 29-year-old pregnant woman is admitted to the
hospital for her delivery. During a vaginal delivery the obstetrician performs a median episiotomy in which the area of the perineal body is cut deeply. Two weeks after the delivery the woman complains that she has had fecal incontinence since the delivery. Which of the following structures was also most likely damaged dur- ing the episiotomy?
⃣ A. Superfi cial and deep transverse perineal muscles
⃣ B. External anal sphincter
⃣ C. Ischiocavernosus muscle
⃣ D. Sacrospinous ligament
⃣ E. Sphincter urethra
27 After having given birth to fi ve children, a 41-
year-old woman seeks correction of chronic urinary incontinence. While relating her history the patient re- veals that she has leakage of urine with increased in- traabdominal pressure. An MRI examination reveals injury to the pelvic fl oor that has altered the position of the neck of the bladder and the urethra. Which of the following structures has most probably been injured during the multiple deliveries?
⃣ A. Tendinous arch of levator ani
⃣ B. Coccygeus
⃣ C. Tendinous arch of fascia pelvis
⃣ D. Obturator internus
⃣ E. Rectovaginal septum
28 A 58-year-old postmenopausal woman is diag-
nosed with carcinoma of the distal gastrointestinal tract.
During surgery lymph nodes from the sacral, internal iliac, and inguinal lymph node groups were removed and sent for histopathologic examination. The pathology report revealed positive cancerous cells only at the ingui- nal lymph nodes. Which of the following parts of the gastrointestinal tract were most likely affected?
⃣ A. Cutaneous portion of anal canal
⃣ B. Distal rectum
⃣ C. Mucosal zone of anal canal
⃣ D. Pectinate line of anal canal
⃣ E. Proximal rectum at the inferior valve (of Houston)
29 A 62-year-old man is admitted to the emergency
department due to increasing diffi culty in urinating over a period of several months. Physical examination reveals prostatic hypertrophy. After several unsuccess- ful attempts to catheterize the penile urethra, the urologist orders drainage of the urinary bladder by the least invasive procedure, avoiding entry into the perito- neal cavity or the injury of any major vessels or organs.
Which of the following spaces needs to be traversed by the needle to reach the bladder?
⃣ A. Ischioanal fossa
⃣ B. Perineal body
⃣ C. Retropubic space (of Retzius)
⃣ D. Superfi cial perineal cleft
⃣ E. Deep perineal pouch
30 A 13-year-old female is brought to the emergency
department with a complaint of severe, deep pelvic discomfort. Physical examination reveals that the pa- tient has an intact hymen. Incision of the hymen re- veals hematocolpos. Which of the following conditions is associated with hematocolpos?
⃣ A. Cyst of Bartholin gland
⃣ B. Bleeding from an ectopic pregnancy
⃣ C. Imperforate hymen
⃣ D. Indirect inguinal hernia with cremasteric arte- rial bleeding
⃣ E. Iatrogenic bleeding from the uterine veins
31 A 42-year-old woman is admitted to the emer-
gency department with a complaint of dull, poorly lo- calized pain in the deep pelvis. An MRI examination
116
reveals a prolapsing of abdominal viscera, probably due to a tear of the rectovaginal septum. Which of the following conditions will most likely result from a de- fect in the rectovaginal septum?
⃣ A. Cystocele
⃣ B. Urethrocele
⃣ C. Enterocele
⃣ D. Urinary incontinence
⃣ E. Prolapsed uterus
32 A 34-year-old woman is admitted to the hospital
complaining of urinary incontinence. MRI examination reveals that one of the skeletal muscles of the pelvis has a signifi cant tear. Which of the following muscles is the most signifi cant in terms of maintaining continence?
⃣ A. Pubococcygeus
⃣ B. Obturator internus
⃣ C. Piriformis
⃣ D. Coccygeus
⃣ E. Iliococcygeus
33 A 42-year-old woman is admitted to the emer-
gency department with severe abdominal pain. MRI examination reveals a tumor at her left ovary. A fro- zen biopsy during the time of surgery reveals an ovar- ian carcinoma. Which of the following actions can be performed to reduce the pain from the ovarian carcinoma?
⃣ A. Cut the infundibulopelvic ligament.
⃣ B. Cut the pelvic sympathetic chain.
⃣ C. Cut the cluneal nerves.
⃣ D. Cut the pudendal nerve.
⃣ E. Cut the broad ligament.
34 A 45-year-old man is admitted to the emergency
department after a violent car crash. Physical examina- tion reveals that the patient suffers from a “straddle”
injury to the perineum. An MRI examination reveals that extravasating urine and blood from a torn bulbar urethra are present in the superfi cial perineal cleft.
Which of the following fasciae provide boundaries for this space?
⃣ A. Camper’s fascia and Scarpa’s fascia
⃣ B. Perineal membrane and external perineal fas- cia of Gallaudet
⃣ C. Colles’ fascia and external perineal fascia of Gallaudet
⃣ D. Perineal membrane and the superior fascia of the urogenital diaphragm
⃣ E. The urogenital diaphragm and the apex of the prostate gland
35 Several days after a 34-year-old woman was ad-
mitted to the hospital after her automobile collided with a lamppost, her urinary bladder gives evidence of paralysis. A CT scan reveals multiple fractures of her pelvis with a signifi cant pelvic hematoma, either of which could have interrupted or injured the nerve sup- ply of the organ. Which of the following nerves was most likely traumatized?
⃣ A. Superior hypogastric
⃣ B. Pelvic splanchnic
⃣ C. Sacral splanchnic
⃣ D. Lumbar splanchnic
⃣ E. Pudendal
36 A 34-year-old woman is hospitalized because of
an enlarged, painful abdomen. An ultrasound examina- tion is performed and the presence of ascites (fl uid) in the peritoneal cavity is confi rmed. A needle is placed through the posterior vaginal fornix to drain the fl uid.
Which space must the needle enter to drain the fl uid?
⃣ A. Rectouterine pouch
⃣ B. Pararectal fossa
⃣ C. Paravesical space
⃣ D. Uterovesical pouch
⃣ E. Superfi cial perineal pouch
37 A 36-year-old male rodeo rider is admitted to the
hospital after being thrown violently from a Brahma bull. An MRI scan reveals rupture of the penile urethra and deep (Bucks) fascia. Where is the most likely place that extravasated urine will fl ow?
⃣ A. Ischioanal fossa
⃣ B. Rectovesical pouch
⃣ C. Deep perineal pouch
⃣ D. Retropubic space
⃣ E. Superfi cial perineal cleft
38 A 68-year-old man complains of pain upon urina-
tion. A CT scan and a biopsy provide evidence of an enlarged, cancerous prostate gland. Subsequently, he undergoes a radical prostatectomy. Postoperatively, he suffers from urinary incontinence because of paralysis of the external urethral sphincter. Which of the follow- ing nerves was injured during the operation?
⃣ A. Pelvic splanchnic
⃣ B. Sacral splanchnic
⃣ C. Pudendal
⃣ D. Superior gluteal
⃣ E. Inferior gluteal
117
39 A 65-year-old male with a history of heavy smok-
ing and hypercholesterolemia is diagnosed with severe atherosclerosis, affecting most of the arteries of his body. During the taking of the patient’s history he com- plains also of impotence. Occlusion of which of the following arteries would most likely be the cause of this condition?
⃣ A. External iliac
⃣ B. Inferior epigastric
⃣ C. Umbilical
⃣ D. Internal pudendal
⃣ E. Superfi cial and deep circumfl ex
40 A 58-year-old postmenopausal woman complains
of pelvic discomfort and dull pain. Lymph nodes from the sacral, internal iliac, and inguinal lymph node groups are surgically removed for histopathologic ex- amination. The pathology report reveals positive cancer- ous cells only in the inguinal lymph nodes. Which pelvic organ would most likely be involved in the cancer?
⃣ A. The body of the uterus
⃣ B. Distal rectum
⃣ C. One or both of her ovaries
⃣ D. Proximal rectum
⃣ E. Anal canal superior to the pectinate line
41 A 34-year-old woman is admitted to the hospital
due to severe lower abdominal pain. Radiographic ex- amination reveals an ovarian tumor. Which of the fol- lowing lymph nodes will most likely become invaded by cancerous cells?
⃣ A. Superfi cial inguinal
⃣ B. External iliac
⃣ C. Lumbar/lateral aortic
⃣ D. Deep inguinal
⃣ E. Internal iliac
42 A 42-year-old female patient has a malignancy
involving the vestibule of her vagina. Which are the fi rst lymph nodes to fi lter the lymph drainage from this area and therefore the most likely to become involved in tumor spread?
⃣ A. Superfi cial inguinal
⃣ B. Internal iliac
⃣ C. Lumbar/lateral aortic
⃣ D. Presacral lymph
⃣ E. Axillary lymph
43 A 34-year-old pregnant woman is prepared in the
hospital for delivery. The gynecologist decides to per- form a pudendal nerve block using a transvaginal ap-
proach. Which bony structure would be the most reli- able as a landmark to block the pudendal nerve?
⃣ A. Ischial spine
⃣ B. Posterior inferior iliac spine
⃣ C. Ischial tuberosity
⃣ D. Posterior superior iliac spine
⃣ E. Coccyx
44 A 55-year-old man complains of pain at his
anus. Examination reveals external hemorrhoids.
Which of the following nerves carries pain sensation from the anus?
⃣ A. Sacral splanchnic
⃣ B. Superior hypogastric
⃣ C. Pelvic splanchnic
⃣ D. Pudendal
⃣ E. Ilioinguinal
45 A 42-year-old woman visits the outpatient clinic
due to painful urination. A dipstick test reveals leukocytosis, which confi rms the diagnosis of urinary tract infection. Which of the following is the best anatomic explanation for the fact that women are more susceptible to urinary tract infections than men?
⃣ A. The vagina contains less bacterial fl ora than the penis.
⃣ B. The prostate gland produces antibacterial prostatic fl uids.
⃣ C. The urethra is much shorter in females.
⃣ D. The urethra is located within the vagina.
⃣ E. The seminal vesicles produce fl uids resistant to bacteria.
46 A 52-year-old woman visits the outpatient clinic
due to a mass of tissue prolapsing through the vaginal introitus. Physical examination reveals that the patient has a cystocele. Loss of which of the following struc- tures to the anterior part of the vagina is responsible for this problem?
⃣ A. Pubovesical and vesicocervical fasciae
⃣ B. Cardinal ligament
⃣ C. Uterosacral ligament
⃣ D. Levator ani muscle
⃣ E. Median umbilical ligament
47 A 47-year-old woman with a family history
of breast cancer mutations in the BRCA1 and BRCA2 genes has made a decision to have an elective hysterectomy as a prophylactic treatment. During ligation of the uterine artery which of the following
118
adjacent structures must the surgeon be careful not to injure?
⃣ A. Ureter
⃣ B. Internal iliac artery
⃣ C. Internal iliac lymph nodes
⃣ D. Obturator nerve
⃣ E. Lumbosacral trunk
48 A 32-year-old woman is admitted to the hospital
with a complaint of painful spasms of her vagina. Phys- ical examination reveals several involuntary contractions of the vaginal musculature. The patient also complains of painful intercourse. Which of the following conditions will most likely describe the signs of this patient?
⃣ A. Vaginismus
⃣ B. Pudendal nerve compression in the pudendal (Alcock) canal
⃣ C. Disruption of the perineal body
⃣ D. Endometriosis
⃣ E. Fibroma of the uterus
49 A 46-year-old male is admitted to the emergency
department after a car crash. An MRI examination re- veals a hematoma of the perineum spreading to his abdominal wall beneath the superfi cial fascia. Where should the initial extravasation be located?
⃣ A. Between the superior aspect of the urogenital diaphragm and the pelvic diaphragm
⃣ B. Between the perineal membrane and the fas- cia of Gallaudet
⃣ C. Between Camper’s fascia and Scarpa’s fascia
⃣ D. Between Colles’ fascia and Gallaudet’s fascia
⃣ E. Between Buck’s fascia and the tunica albuginea
50 A 45-year-old woman is admitted to the hospital
with lower abdominal and pelvic discomfort. Combined laparoscopic and MRI examinations reveal tears of the ligaments supporting the uterus with moderate uterine prolapse. Which of the following ligaments provides di- rect support to the uterus and thereby resists prolapse?
⃣ A. Uterosacral
⃣ B. Round ligament of the uterus
⃣ C. Broad ligament
⃣ D. Arcus tendineus fascia pelvis
⃣ E. Levator ani muscle
51 A 68-year-old male is admitted to the hospital with
dysuria, nocturia, urgency, and painful urination. MRI examination reveals enlargement and irregularity of the uvula of the urethra due to prostatic hypertrophy. Labo-
ratory investigation reveals high levels of PSA (prostate- specifi c antigen) suggesting prostatic carcinoma, and a prostatectomy is performed. Which of the following lymph nodes should be removed during prostatectomy?
⃣ A. Internal iliac and sacral
⃣ B. External iliac
⃣ C. Superfi cial inguinal
⃣ D. Deep inguinal
⃣ E. Gluteal
52 A 22-year-old male is admitted to the hospital
with groin pain and blood in the semen. An MRI ex- amination and biopsy reveal testicular cancer. Which of the following lymph nodes will be fi rst involved in case of metastasis?
⃣ A. Internal iliac
⃣ B. External iliac
⃣ C. Superfi cial inguinal
⃣ D. Deep inguinal
⃣ E. Paraaortic and lumbar
53 A 68-year-old male underwent a radical prostatec-
tomy. Six months postoperatively the patient complains of being incapable of penile erection without the use of sildenafi l (Viagra). Which of the following nerves was most probably damaged during the operation?
⃣ A. Pudendal
⃣ B. Perineal
⃣ C. Pelvic splanchnic
⃣ D. Sacral splanchnic
⃣ E. Dorsal nerve to the penis
54 A 15-year-old is admitted to the emergency de-
partment 2 days after crashing his bicycle. MRI exami- nation reveals severe edema of the boy’s scrotum and abdominal wall and extravasated urine. Which of the following structures is most likely ruptured?
⃣ A. Spongy urethra
⃣ B. Preprostatic urethra
⃣ C. Prostatic urethra
⃣ D. Urinary bladder
⃣ E. Ureter
55 A 35-year-old man is admitted to the surgery ward
for correction of an inguinal hernia. During physical ex- amination an indirect hernia is noted, together with an absent cremasteric refl ex. Which of the following nerves carries the efferent component of the cremasteric refl ex?
⃣ A. Ilioinguinal nerve
⃣ B. Genital branch of genitofemoral