Pelvic Walls and Floor — MCQs
Injury to which of the following muscles that forms the deep support of the perineal body causes cystocele, enterocele and urethral descent?
Howship-Romberg sign is seen in
All are true regarding course of ureter in pelvis except
Which of the following statements about the Levator Ani is false?
All of the following muscles are supplied by the accessory nerve except:
Subpubic angle in females is
Which of the following is least important in the maintenance of normal fecal continence?
Which of the following statements is false regarding postpartum hemorrhage and pelvic hematomas?
The most important structure preventing uterine prolapse is:
Which of the following set of muscles collectively form the muscle 'Levator Ani' that forms the pelvic floor ? 1. Puborectalis 2. Pubococcygeus 3. Sacrococcygeus 4. Iliococcygeus Select the correct answer using the code given below :
Pelvic Walls and Floor Indian Medical PG Practice Questions and MCQs
Question 1: Injury to which of the following muscles that forms the deep support of the perineal body causes cystocele, enterocele and urethral descent?
- A. Sphincter of urethra and anus
- B. Pubococcygeus (Correct Answer)
- C. Bulbospongiosus
- D. Ischiocavernosus
Explanation: ***Pubococcygeus*** - The **pubococcygeus muscle** is a major component of the **levator ani muscle** group, forming the primary support structure of the pelvic floor [1]. Damage to this muscle impairs the support for the bladder, rectum, and uterus, leading to prolapse conditions like **cystocele**, **enterocele**, and **urethral descent**. - Its integrity is crucial for maintaining the position of pelvic organs and proper function of the urinary and defecatory systems, as it directly supports the vagina, rectum, and bladder neck [3]. *Sphincter of urethra and anus* - The **external urethral sphincter** primarily controls voluntary urination, and its injury mainly leads to **stress urinary incontinence**, not necessarily prolapse [2]. - The **external anal sphincter** controls defecation, and its injury would primarily lead to **fecal incontinence**, not cystocele, enterocele, or urethral descent [2]. *Bulbospongiosus* - The **bulbospongiosus muscle** is superficial, supporting the clitoris and compressing erectile tissue in females, and expelling semen/urine in males. - Its injury would primarily affect sexual function and perineal body integrity but is **not a primary cause of pelvic organ prolapse** like cystocele or enterocele [3]. *Ischiocavernosus* - The **ischiocavernosus muscle** is also superficial, maintaining erection of the clitoris/penis by compressing the crura. - Injury to this muscle would mainly disrupt **erectile function** and contribute minimally to pelvic organ support or prolapse.
Question 2: Howship-Romberg sign is seen in
- A. Spigelian hernia
- B. Femoral hernia
- C. Inguinal hernia
- D. Obturator hernia (Correct Answer)
Explanation: ***Obturator hernia*** - The **Howship-Romberg sign** is characterized by **medial thigh pain** on hip extension, adduction, and internal rotation, which is indicative of an obturator hernia. - This symptom arises from compression of the **obturator nerve** as it passes through the obturator canal alongside the hernia sac. *Spigelian hernia* - A Spigelian hernia presents as a **ventrolateral abdominal wall defect**, typically between the rectus abdominis muscle and linea semilunaris. - It usually causes localized pain and a palpable lump but does not involve **obturator nerve compression**. *Femoral hernia* - A femoral hernia manifests as a bulge in the **groin region** below the inguinal ligament, often presenting as an emergent strangulated hernia. - While it can cause groin pain, it does not typically involve the **obturator nerve** or present with the **Howship-Romberg sign**. *Inguinal hernia* - Inguinal hernias are common, presenting as a bulge in the groin, either **direct or indirect**, above the inguinal ligament. - Symptoms include a palpable mass and discomfort, but not the specific **medial thigh pain** associated with obturator nerve compression.
Question 3: All are true regarding course of ureter in pelvis except
- A. It is crossed by ovarian vessels where it enters true pelvis
- B. Ureter pierces lateral ligament where ureteric canal is developed.
- C. Ureter passes over bifurcation of common iliac artery
- D. Obturator vessels and nerve lie medially in relation to ureter at pelvic brim (Correct Answer)
Explanation: ***Obturator vessels and nerve lie medially in relation to ureter at pelvic brim*** - This statement is **FALSE** and is the correct answer to this "except" question. - The obturator nerve and vessels actually lie **laterally** (not medially) in relation to the ureter at the pelvic brim. - As the ureter descends into the pelvis, it crosses **anterior and medial** to the obturator nerve and vessels. - The obturator structures run along the **lateral pelvic wall** toward the obturator foramen. *It is crossed by ovarian vessels where it enters true pelvis* - This is **TRUE**. - The ovarian vessels cross anterior to the ureter at the pelvic brim as it enters the true pelvis [1]. - This is an important surgical landmark, particularly during **oophorectomy** and pelvic surgery to avoid ureteral injury [1]. - The relationship is remembered as "water (ureter) under the bridge (ovarian vessels)." *Ureter pierces lateral ligament where ureteric canal is developed* - This statement is **questionable** but may refer to the ureter's passage through the **parametrium** (base of broad ligament). - The ureter runs in the lateral parametrial tissue before passing beneath the uterine artery. - While not standard terminology, "ureteric canal" may refer to this passage through parametrial tissue. *Ureter passes over bifurcation of common iliac artery* - This is **TRUE**. - The ureter crosses **anterior** to the bifurcation of the common iliac artery at the pelvic brim. - This occurs at approximately the level of the **sacroiliac joint**. - This is a consistent and important anatomical landmark during pelvic and retroperitoneal surgery.
Question 4: Which of the following statements about the Levator Ani is false?
- A. Converges downwards & medially
- B. Attached to the pelvic brim. (Correct Answer)
- C. Made up of iliococcygeus, pubococcygeus, and puborectalis.
- D. Supports pelvic viscera.
Explanation: Attached to the pelvic brim - This statement is **false** because the levator ani does not attach to the pelvic brim (the inlet of the true pelvis). - The levator ani originates from: the **posterior surface of the body of pubis**, the **tendinous arch of obturator fascia** (thickening of obturator fascia on lateral pelvic wall), and the **ischial spine**. - All these attachments are on the **lateral pelvic wall below the pelvic brim**, not at the pelvic brim itself. - The muscles insert into the **perineal body**, **anococcygeal ligament**, and walls of pelvic viscera. *Converges downwards & medially* - This statement is **true** - the levator ani muscles arise from lateral attachments on the pelvic sidewalls and converge **medially and downward** toward the midline. - This creates the characteristic **funnel-shaped pelvic diaphragm** that narrows inferiorly. - The fibers run inferomedially to form a muscular sling supporting pelvic structures. *Supports pelvic viscera* - This is the **primary function** of the levator ani muscle group [1]. - It forms a muscular floor that supports the **bladder, uterus/prostate, and rectum**, preventing prolapse. - The muscle maintains the position of pelvic organs against intra-abdominal pressure. *Made up of iliococcygeus, pubococcygeus, and puborectalis* - This statement is **correct** - the levator ani consists of three main components [1]: - **Puborectalis** - forms a sling around the anorectal junction, important for fecal continence [1]. - **Pubococcygeus** - middle portion, supports pelvic viscera [1]. - **Iliococcygeus** - most posterior portion, extends from ischial spine to coccyx [1].
Question 5: All of the following muscles are supplied by the accessory nerve except:
- A. Palatopharyngeus
- B. Musculus uvulae
- C. Palatoglossus
- D. Stylopharyngeus (Correct Answer)
Explanation: ***Stylopharyngeus*** - The stylopharyngeus muscle is supplied by the **glossopharyngeal nerve (CN IX)**, making it the exception. - This muscle is responsible for **elevating the pharynx and larynx** during swallowing. - **All other options are pharyngeal muscles supplied by the vagus nerve (CN X) via the pharyngeal plexus, NOT by the accessory nerve.** *Palatopharyngeus* - The palatopharyngeus muscle is supplied by the **vagus nerve (CN X)** via the **pharyngeal plexus**. - It depresses the **soft palate** and elevates the **pharynx and larynx**. - **Note:** The accessory nerve does NOT supply pharyngeal muscles. *Palatoglossus* - The palatoglossus muscle is supplied by the **vagus nerve (CN X)** via the **pharyngeal plexus**. - It elevates the **posterior part of the tongue** and depresses the **soft palate**. - **Note:** The accessory nerve does NOT supply pharyngeal muscles. *Musculus uvulae* - The musculus uvulae is supplied by the **vagus nerve (CN X)** via the **pharyngeal plexus**. - This muscle **shortens and elevates the uvula**. - **Note:** The accessory nerve does NOT supply pharyngeal muscles. **Clinical Pearl:** The accessory nerve (CN XI) actually supplies the **sternocleidomastoid** and **trapezius** muscles, not pharyngeal muscles. The cranial part of CN XI joins the vagus but does not independently innervate pharyngeal musculature.
Question 6: Subpubic angle in females is
- A. 120 degrees
- B. 180 degrees
- C. 70 degrees
- D. 90 degrees (Correct Answer)
Explanation: ***90 degrees*** - The **subpubic angle** in females typically ranges from **80-90 degrees**, making **90 degrees** the most accurate answer among the given options. - This wider angle is a distinguishing feature of the **female pelvis**, reflecting adaptations for childbirth and is significantly wider than the male angle (50-60 degrees). - Standard anatomy references cite the female subpubic angle as approximately **90 degrees** at the upper limit of normal. *120 degrees* - While the female pelvis has a wider angle than males, **120 degrees** exceeds the normal anatomical range. - This value is an overestimation and not representative of the typical female subpubic angle. *180 degrees* - A subpubic angle of **180 degrees** would imply a completely flat, straight line between the pubic rami, which is anatomically impossible. - This value does not represent any normal anatomical configuration in the human pelvis. *70 degrees* - An angle of **70 degrees** is characteristic of the **male subpubic angle**, which is narrower (typically 50-60 degrees, but can be up to 70 degrees). - This narrower angle is not conducive to childbirth and distinguishes the male from the female pelvis.
Question 7: Which of the following is least important in the maintenance of normal fecal continence?
- A. Anorectal angulation
- B. Rectal innervation
- C. Internal sphincter
- D. Haustral valve (Correct Answer)
Explanation: **Haustral valve** - The **haustral valve** (or redundant mucosal folds within the haustra) primarily functions to *increase surface area* for water absorption and slow the passage of contents through the colon. - While critical for digestive function, it plays a *negligible direct role* in the mechanisms preventing involuntary stool leakage. *Anorectal angulation* - The **anorectal angle**, formed by the pull of the **puborectalis muscle**, creates a sharp bend that acts as a flap valve, significantly contributing to continence. - Loss of this angle (e.g., due to injury or structural changes) substantially impairs continence. *Rectal innervation* - **Intact innervation** of the rectum provides crucial sensory feedback regarding rectal distension and stool consistency, allowing for conscious control of defecation. - It also mediates the **rectoanal inhibitory reflex** and the ability to voluntarily contract external anal sphincters, both vital for continence. *Internal sphincter* - The **internal anal sphincter** is an *involuntary smooth muscle* responsible for approximately 70-80% of the resting anal tone, providing continuous passive continence. - Damage to this sphincter leads to substantial impairment in continence, particularly against flatus and liquid stool.
Question 8: Which of the following statements is false regarding postpartum hemorrhage and pelvic hematomas?
- A. The vulva is the most common site for pelvic hematoma. (Correct Answer)
- B. Hematomas less than 5 cm can often be managed conservatively.
- C. Uterine atony is the most common cause of postpartum hemorrhage.
- D. The most common artery to form a vulvar hematoma is the pudendal artery.
Explanation: ***The vulva is the most common site for pelvic hematoma.*** - While vulvar hematomas are common, the **vagina is actually the most common site** for puerperal hematomas. - **Retroperitoneal hematomas** are the least common but most dangerous type, often associated with a higher mortality rate due to delayed diagnosis. *Hematomas less than 5 cm can often be managed conservatively.* - **Small, stable hematomas** (typically less than 2-5 cm) that are not expanding can often be managed with observation, pain control, and ice packs. - Close monitoring for continued bleeding, signs of infection, or hemodynamic instability is crucial even with conservative management. *Uterine atony is the most common cause of postpartum hemorrhage.* - **Uterine atony** (failure of the uterus to contract after birth) accounts for approximately 70-80% of all cases of postpartum hemorrhage. - This condition leads to excessive bleeding from the placental site due to the inability of uterine muscle fibers to compress blood vessels effectively. *The most common artery to form a vulvar hematoma is the pudendal artery.* - Vulvar hematomas primarily arise from injury to branches of the **pudendal artery**, particularly during lacerations or episiotomies. - Trauma to the **perineum** during childbirth can cause these arteries or their venous counterparts to bleed into the surrounding loose connective tissue.
Question 9: The most important structure preventing uterine prolapse is:
- A. Uterosacral ligament
- B. Broad ligament
- C. Cardinal ligament (Correct Answer)
- D. Round ligament
Explanation: ***Cardinal ligament*** - The **cardinal ligaments** (also known as transverse cervical ligaments) are crucial for supporting the uterus and preventing **uterine prolapse** by anchoring the cervix and upper vagina laterally to the pelvic sidewalls [1]. - They provide significant **suspension and stability** to the uterus due to their strong fibrous and muscular composition [1]. *Uterosacral ligament* - These ligaments attach the posterior cervix to the sacrum, primarily preventing **retroversion** of the uterus and providing posterior support [1]. - While they contribute to uterine support, their role in preventing descent is secondary to the cardinal ligaments [1]. *Broad ligament* - The **broad ligament** is a wide fold of peritoneum that drapes over the uterus, fallopian tubes, and ovaries, providing a suspensory role rather than strong structural support [1]. - It contains blood vessels and nerves but offers minimal support against **uterine prolapse** itself. *Round ligament* - The **round ligaments** extend from the uterine horns, through the inguinal canal, and insert into the labia majora, primarily helping to maintain the **anteverted and antiflexed position** of the uterus [2]. - They do not play a significant role in preventing the downward descent or **prolapse** of the uterus.
Question 10: Which of the following set of muscles collectively form the muscle 'Levator Ani' that forms the pelvic floor ? 1. Puborectalis 2. Pubococcygeus 3. Sacrococcygeus 4. Iliococcygeus Select the correct answer using the code given below :
- A. 2, 3 and 4
- B. 1, 3 and 4
- C. 1, 2 and 3
- D. 1, 2 and 4 (Correct Answer)
Explanation: ***1, 2 and 4*** - The **levator ani** muscle group is comprised of three distinct muscles: **puborectalis**, **pubococcygeus**, and **iliococcygeus** [1]. - These muscles collectively form the main component of the **pelvic floor**, supporting pelvic organs and controlling continence [1]. - The levator ani, together with the coccygeus muscle, forms the **pelvic diaphragm**. *2, 3 and 4* - This option incorrectly includes the **sacrococcygeus** muscle, which is not part of the **levator ani** group. - The **sacrococcygeus** is a small, vestigial muscle found anterior to the sacrum and coccyx, and is separate from the pelvic diaphragm. - It excludes the **puborectalis**, which is an essential component of the levator ani [1]. *1, 3 and 4* - This option incorrectly includes the **sacrococcygeus** muscle, which is not a component of the **levator ani**. - It excludes the **pubococcygeus**, a major and essential component of the **levator ani** complex, critical for maintaining pelvic floor integrity and function [1]. *1, 2 and 3* - This option incorrectly includes the **sacrococcygeus** muscle and excludes the **iliococcygeus**. - The **iliococcygeus** muscle is a distinct and recognized part of the **levator ani** alongside the puborectalis and pubococcygeus [1].
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