Pelvis, perineum and pelvic organs

22 NEET-PG practice questions on Pelvis, perineum and pelvic organs, part of Anatomy. The first 22 are below; the first 5 with answers and explanations (tap Show answer after you have chosen), the rest in Learn with a free account.

1. Question 1 · Hard

   A 64-year-old man in the urology OPD asks why his doctor checks his prostate with a finger when he has had TURP for an enlarged gland five years ago. Consider these statements on the zones of the prostate: 1. The central zone forms most of the glandular tissue. 2. Benign hyperplasia arises mainly in the transition zone. 3. The central zone surrounds the ejaculatory ducts. 4. Most carcinomas arise in the peripheral zone, which can be felt per rectum. Which statements are correct?

   1. A3 and 4 only
   2. B2, 3 and 4 only
   3. C2 and 4 only
   4. D1, 3 and 4 only

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   Answer: B · 2, 3 and 4 only

   Statements 2, 3 and 4 are correct. In McNeal's zonal anatomy the peripheral zone, not the central zone, forms about 70% of the glandular prostate, the central zone (about a quarter) is a cone around the ejaculatory ducts, and the transition zone is a small area around the proximal urethra where hyperplasia begins. TURP removes transition-zone adenoma but leaves the peripheral zone, so cancer can still develop there and rectal examination and PSA remain useful. This is the counselling point for the patient.

   • A: Leaves out statement 2: hyperplasia does begin in the transition zone.
   • C: Leaves out statement 3: the central zone does surround the ejaculatory ducts.
   • D: Includes statement 1, which is false: the peripheral zone is the largest, and leaves out statement 2.

2. Question 2 · Hard

   A 32-year-old man is brought to casualty after a motorcycle crash. BP is 108/70 mmHg after 2 L of crystalloid. Pelvic X-ray shows bilateral pubic rami fractures. He has blood at the external meatus and a palpable bladder, and the prostate feels high on rectal examination. What is the next best step regarding his urinary tract?

   1. AIntravenous urogram
   2. BGentle urethral catheterisation
   3. CRetrograde urethrogram
   4. DMicturating cystourethrogram

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   Answer: C · Retrograde urethrogram

   Blood at the meatus, a full bladder and a high-riding prostate after a pelvic fracture indicate a posterior urethral injury above the perineal membrane. A retrograde urethrogram is done first to show the site and extent of contrast extravasation; blind catheterisation is avoided because it can turn a partial tear into a complete one and introduce infection. If the urethra is disrupted, the bladder is drained by suprapubic cystostomy, with delayed or endoscopic urethral repair later. A CT cystogram is added if a bladder injury is also suspected.

   • A: An intravenous urogram images the kidneys and ureters, not the urethra.
   • B: Blind catheterisation can complete a partial tear and is avoided until the urethra is imaged.
   • D: A micturating study needs the patient to void, which he cannot, and does not show the tear first.

3. Question 3 · Medium

   A 40-year-old truck driver is brought to casualty after a road accident with an unstable pelvic fracture. He has blood at the meatus and a distended bladder, and on rectal examination the prostate cannot be felt in its usual place. Where does the extravasated urine collect in this injury?

   1. APenile shaft deep to Buck's fascia
   2. BExtraperitoneal space around the bladder
   3. CSuperficial perineal pouch and scrotum
   4. DPeritoneal cavity

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   Answer: B · Extraperitoneal space around the bladder

   Pelvic fractures shear the posterior urethra at the junction of the membranous and prostatic parts, above the perineal membrane, as the puboprostatic ligaments pull the prostate away. Urine and blood then collect in the extraperitoneal pelvic tissue around the bladder and prostate (including the retropubic space), and the haematoma lifts the prostate so that it is 'high-riding' or impalpable. The perineum and scrotum are spared while the perineal membrane is intact. Intraperitoneal leak needs a dome rupture of the bladder, a different injury.

   • A: Fluid confined deep to Buck's fascia follows a penile urethral tear with the fascia intact.
   • C: Perineal and scrotal spread follows a bulbar (straddle) injury below the perineal membrane.
   • D: Urine enters the peritoneal cavity only when the bladder dome ruptures.

4. Question 4 · Medium

   A 26-year-old construction worker slipped and fell astride a steel beam. He cannot pass urine, there is blood at the external meatus, and over the next hours a butterfly-shaped swelling appears in the perineum and spreads to the scrotum and penis. Into which of the following regions can the extravasated urine also spread?

   1. ARetropubic space
   2. BLower anterior abdominal wall
   3. CIschioanal fossa
   4. DUpper medial thigh

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   Answer: B · Lower anterior abdominal wall

   A straddle injury ruptures the bulbar urethra below the perineal membrane, and when Buck's fascia is torn, urine and blood enter the superficial perineal pouch. This space is bounded by the membranous layer of superficial fascia (Colles' fascia), which is continuous with the dartos of the scrotum and penis and with Scarpa's fascia of the anterior abdominal wall. The fluid cannot pass into the thigh because the membranous layer fuses with the fascia lata just below the inguinal ligament, and it cannot pass backwards because Colles' fascia is fixed to the posterior border of the perineal membrane. A retrograde urethrogram defines the injury.

   • A: The retropubic space fills when the urethra tears above the perineal membrane, as in pelvic fractures.
   • C: The ischioanal fossa is behind the line where Colles' fascia fuses with the perineal membrane.
   • D: Spread into the thigh is blocked where the membranous layer attaches to the fascia lata.

5. Question 5 · Medium

   A 23-year-old woman is having a perineal tear repaired after a vaginal delivery under a bilateral pudendal block that has worked well over the posterior perineum. She still feels the needle when a small tear on the front of the left labium majus is sutured. Which nerve most likely supplies this area?

   1. AInferior rectal nerve
   2. BPerineal branch of the pudendal nerve
   3. CDorsal nerve of the clitoris
   4. DIlioinguinal nerve

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   Answer: D · Ilioinguinal nerve

   The anterior part of the labium majus and the mons are supplied by the ilioinguinal nerve and the genital branch of the genitofemoral nerve, both from the lumbar plexus, so a pudendal block does not cover them. The posterior labia and most of the perineum are supplied by the pudendal nerve's perineal branch, and the lateral perineum partly by the posterior femoral cutaneous nerve. In practice local infiltration is added for anterior tears. Knowing these gaps avoids blaming a failed block.

   • A: The inferior rectal nerve supplies the anal canal and perianal skin, not the labium.
   • B: The perineal branch of the pudendal nerve is blocked and supplies the posterior labia.
   • C: The dorsal nerve of the clitoris is a pudendal branch and would be blocked too.

6. Question 6 · Medium

   A 35-year-old long-distance cyclist has burning pain and numbness of the perineum that worsen on sitting, with reduced penile sensation. MRI shows compression of the pudendal nerve where it runs in the lateral wall of the ischioanal fossa. The canal enclosing the nerve at this site is formed by a split in the fascia of which muscle?

   1. AObturator internus
   2. BLevator ani
   3. CCoccygeus
   4. DPiriformis

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7. Question 7 · Easy

   A 67-year-old man has a PSA of 14 ng/mL. On digital rectal examination the urologist feels a hard, irregular nodule in the posterolateral part of the gland. In which zone of the prostate does this tumour most likely lie?

   1. ACentral zone
   2. BTransition zone
   3. CPeriurethral gland region
   4. DPeripheral zone

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8. Question 8 · Medium

   A 71-year-old man from Kanpur has low back pain for two months. X-rays show sclerotic deposits in the lumbar vertebrae and pelvis, and his PSA is 96 ng/mL. His chest X-ray and liver are normal. Which route best explains how the tumour reached his spine without lung deposits?

   1. AProstatic venous plexus to vertebral venous plexus
   2. BLymphatics along the internal iliac nodes
   3. CDirect extension along the presacral fascia
   4. DSystemic arterial spread after lung seeding

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9. Question 9 · Easy

   A 24-year-old primigravida in the labour room of a district hospital needs an outlet forceps delivery. The obstetrician gives a transvaginal pudendal nerve block. Which bony landmark does she palpate to guide the needle?

   1. ASacral promontory
   2. BPubic tubercle
   3. CIschial spine
   4. DIschial tuberosity

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10. Question 10 · Medium

    On the second day after an abdominal hysterectomy for fibroids, a 46-year-old woman has right loin pain and fever, and ultrasound shows right hydroureteronephrosis. The surgeon recalls a difficult clamp placed on the right uterine vessels close to the cervix. Which structure lying just below the uterine artery at that point was most likely caught?

    1. AInternal iliac vein
    2. BUreter
    3. CObturator nerve
    4. DSuperior vesical artery

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11. Question 11 · Medium

    A 38-year-old woman with four vaginal deliveries wants to keep her uterus. She has second-degree uterine descent with an elongated cervix and a cystocele, and the gynaecologist plans a Manchester (Fothergill) repair. Which supporting structures are shortened and sutured in front of the cervix in this operation?

    1. ARound ligaments of the uterus
    2. BBroad ligaments
    3. CCardinal (Mackenrodt's) ligaments
    4. DUterosacral ligaments

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12. Question 12 · Medium

    A 72-year-old retired clerk has a weak stream, nocturia four times a night and a sense of incomplete emptying. The prostate is smooth, rubbery and enlarged on rectal examination, and PSA is 2.8 ng/mL. He is listed for transurethral resection. From which zone does the tissue that the surgeon resects mainly arise?

    1. ATransition zone
    2. BCentral zone
    3. CPeriurethral stroma of the bladder neck only
    4. DPeripheral zone

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13. Question 13 · Medium

    During vigorous intercourse, a newly married man hears a cracking sound, loses his erection at once and develops a swollen, purple penis bent to one side. In the casualty the bruising is confined to the shaft of the penis and has not spread into the scrotum, perineum or lower abdominal wall. Which intact layer is holding the haematoma within the shaft?

    1. ABuck's fascia
    2. BTunica albuginea
    3. CColles' fascia
    4. DScarpa's fascia

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14. Question 14 · Medium

    A diabetic man has a throbbing, tender swelling on the right side of the anus with fever. It is drained at a CHC. Two days later he returns with a tender, indurated swelling on the left side of the anus as well, and probing suggests the two cavities connect behind the anal canal. Through which space has the infection most likely crossed the midline?

    1. ADeep postanal space
    2. BSuperficial perineal pouch
    3. CPelvirectal (supralevator) space
    4. DRectovesical pouch

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15. Question 15 · Medium

    Three months after a prolonged second stage of labour and a difficult forceps delivery, a primipara reports that she cannot control flatus and sometimes soils herself. Endoanal ultrasound shows an intact sphincter ring, but electrophysiology shows prolonged nerve conduction to the external anal sphincter. Which nerve has most likely been stretched?

    1. APerineal branch of posterior femoral cutaneous
    2. BHypogastric nerves
    3. CPelvic splanchnic nerves
    4. DInferior rectal branch of the pudendal nerve

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16. Question 16 · Medium

    Which zone of the prostate surrounds the ejaculatory ducts and gives rise to only a small proportion of cancers?

    1. ACentral zone
    2. BAnterior fibromuscular stroma
    3. CPeripheral zone
    4. DTransition zone

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17. Question 17 · Hard

    Consider these statements about the perineal pouches: 1. The sphincter urethrae lies in the deep perineal pouch. 2. The greater vestibular (Bartholin) glands lie in the superficial perineal pouch. 3. The ducts of the bulbourethral glands open into the membranous urethra. 4. Bulbospongiosus is attached to the perineal body. Which statements are correct?

    1. A1, 2 and 4 only
    2. B1, 2, 3 and 4
    3. C1 and 2 only
    4. D2, 3 and 4 only

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18. Question 18 · Easy

    The pudendal nerve, blocked before an episiotomy repair, arises from which ventral rami of the sacral plexus?

    1. AL4, L5 and S1
    2. BS2, S3 and S4
    3. CL1 and L2
    4. DS4, S5 and Co1

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19. Question 19 · Medium

    At laparoscopy for a twisted, gangrenous right ovarian cyst, the gynaecologist decides on oophorectomy. She must ligate the ovarian vessels in the peritoneal fold that runs from the ovary over the pelvic brim to the lateral pelvic wall, keeping the ureter, which crosses the brim nearby, in view. What is this fold called?

    1. AUterosacral ligament
    2. BOvarian ligament proper
    3. CSuspensory ligament of the ovary
    4. DRound ligament of the uterus

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20. Question 20 · Medium

    A squamous cell carcinoma 1 cm below the pectinate line of the anal canal is found in a man living with HIV. Biopsy confirms the diagnosis and staging is planned. On examination, which group of lymph nodes should the surgeon palpate first for spread?

    1. ASuperficial inguinal nodes
    2. BInternal iliac nodes
    3. CInferior mesenteric nodes
    4. DPara-aortic nodes

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21. Question 21 · Hard

    At follow-up three months after radical retropubic prostatectomy for localised adenocarcinoma, a schoolteacher is fully continent but has lost erections completely, though penile skin sensation is normal and the bulbocavernosus reflex is present. The operation note records that the neurovascular bundles lying posterolateral to the prostate were excised on both sides because tumour reached the capsule. His PSA is now undetectable, and he wants to discuss treatment options with his wife. The nerves damaged carry fibres that arise from which source, and what is their function in erection?

    1. AGenitofemoral nerve (L1-L2); cremasteric reflex
    2. BPelvic splanchnic nerves (S2-S4); parasympathetic vasodilation
    3. CPudendal nerve (S2-S4); somatic sensation
    4. DLumbar splanchnic nerves (L1-L2); sympathetic emission

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22. Question 22 · Easy

    At the gynaecology OPD, a multiparous woman complains of a bulge in the vagina that worsens on coughing and straining. Her gynaecologist explains that the muscular floor supporting the uterus, vagina and rectum was stretched and partly torn during her deliveries. Which muscle forms most of this floor?

    1. ALevator ani
    2. BBulbospongiosus
    3. CPiriformis
    4. DObturator internus

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