Deck 23: The Perineum, the Female Genital Organs,and Childbirth

Question 1

The following anatomic statements concerning uterine prolapse are correct except which?

A) The most important support to the uterus is the tone of the levatores ani muscles.
B) The transverse cervical, pubocervical, and sacrocervical ligaments play an important role in supporting the uterus.
C) Damage to the levatores ani and the cervical ligaments during childbirth can be responsible for prolapse of the uterus.
D) Prolapse most commonly reveals itself before menopause.
E) Prolapse of the uterus is always accompanied by some prolapse of the vagina.

Answer 1

Prolapse most commonly reveals itself before menopause.

Question 2

A 25-year-old woman was seen in the emergency department complaining of severe pain in the right iliac region. Just before admission she had fainted. On physical examination, her abdominal wall was extremely tender on palpation in the lower right quadrant, and some rigidity and guarding of the lower abdominal muscles were noticed. A vaginal examination revealed a rather soft cervix with a circular external os. A tender "dough-like" mass could be felt through the posterior fornix. The patient had missed her last period.

-The following statements concerning this patient are correct except which?

A) A diagnosis of ruptured ectopic pregnancy was made.
B) Tubal pregnancies commonly occur where the ampulla narrows to join the isthmus.
C) Each uterine tube is situated in the base of the broad ligament.
D) An ectopic tubal pregnancy almost invariably results in rupture of the tube with severe intraperitoneal hemorrhage.
E) Tubal rupture occurs as a result of the eroding action of the trophoblast.
F) Once a tubal pregnancy dies the decidual lining of the uterus begins to be shed because of lack of hormonal support, and this causes vaginal bleeding.
G) The dough-like mass is produced by the accumulation of blood in the pouch of Douglas.

Answer 2

Each uterine tube is situated in the base of the broad ligament.

Question 3

A 35-year-old woman was seen by her gynecologist complaining of a swelling in the genital region. On examination, a tense cystic swelling was found beneath the posterior two thirds of the right labium majus and minus. A diagnosis of a cyst of the right greater vestibular gland (Bartholin's cyst) was made.

-The following statements concerning this case are probably correct except which?

A) The cyst of the greater vestibular gland is produced by the retention of secretion caused by the blockage of the duct.
B) Infection of the duct by the gonococcus is a common cause of the blockage.
C) Infection of the cyst may occur, forming a painful abscess.
D) The lymphatic drainage of this area is into the lateral group of superficial inguinal nodes.
E) A small tender swelling was detected below and medial to the inguinal ligament.

Answer 3

The lymphatic drainage of this area is into the lateral group of superficial inguinal nodes.

Question 4

In anatomic terms explain the procedure of culdocentesis.

Question 5

A 23-year-old woman was seen in the emergency department with severe vaginal bleeding. She was 35 weeks pregnant. On questioning she stated that she had slight bleeding a week previously but this had stopped spontaneously. There was absolutely no pain associated with the bleeding. On examining the abdomen, it was found that the fetal head was high, and it was not possible to make it enter the pelvis. The uterus had a normal consistency and was not tender. On examination of the genital organs, no cause for the bleeding could be determined. A diagnosis of placenta previa was made. What is placenta previa? What is the cause of the bleeding? Why is the bleeding painless?

Question 6

What is believed to be the cause of pain in labor? Describe the pathways taken by the afferent pain fibers in labor and explain the distribution of the areas of referred pain.

Question 7

The postnatal vaginal examination of a young woman revealed that the fundus and body of the uterus could be palpated in the rectouterine pouch (pouch of Douglas). What is the normal position of the uterus?

Question 8

A multiparous 57-year-old woman visited her physician complaining of a "bearing-down" feeling in the pelvis and of low backache, both of which were worse when she was tired. On vaginal examination, the external os of the cervix was found to be located just within the vaginal orifice. A diagnosis of uterine prolapse was made. What are the main supports of the uterus?

Question 9

During the vaginal examination of a multiparous woman, she was asked to strain downward. The anterior wall of the vagina was found to sag downward. A diagnosis of prolapsed anterior vaginal wall was made. What structures lie anterior to the vagina and will sag downward with the vaginal wall?

Question 10

A 65-year-old woman went to her physician complaining of irritation, discharge, and bleeding of the genital region. On physical examination, a hard-based ulcer was found on the medial aspect of the right labium
majus. A diagnosis of squamous cell carcinoma of the
skin was made. What is the lymphatic drainage of this
region, and which group of lymph nodes would you
therefore examine for evidence of metastases?

Question 11

A mother took her 15-year-old daughter to a physician because she had failed to start to menstruate. On examination the child was noted to be short and stocky with a webbed neck. She had an abnormally large carrying angle of the elbow (cubitus valgus), a broad chest with lack of breast development, and an absence of pubic and axillary hair. No further abnormalities were found on physical examination. What is your diagnosis? What investigations would you undertake to confirm your diagnosis? How would you treat this patient?

Question 12

During the third stage of labor, the placenta and fetal membranes are expelled from the uterus. The obstetrician or midwife must carefully examine the placenta and the membranes to make sure that no part of them has been retained in the uterus. What is the approximate diameter and thickness of a normal placenta? Describe the appearance of the maternal and fetal surfaces of a full-term placenta. Is it possible to separate the amnion from the chorion?

Question 13

A 12-year-old girl was taken to a pediatrician because she experienced cyclic monthly pain, but there was no actual menstrual flow. On physical examination of the vulva, the hymen was seen as a bulging septum. No vaginal orifice could be detected. What is your diagnosis? How would you explain this condition embryologically? How would you treat this patient?