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NBME 20 Answers

nbme20/Block 2/Question#12 (41.5 difficulty score)
An 80-year-old man with type 2 diabetes ...
Pelvic splanchnicπŸ”

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submitted by johnthurtjr(139),
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92FA01 p 735 no anisrstGntloatei ldoob yplpsu nad tpiatacpehymars voirinentan:

  • rgeuFto gt-&;- alccie ytre,ra suagv eavitninnor
  • gMuitd t--&;g S,MA uavsg
  • tngiuHd -g-;t& I,MA cpliev entanorivni
neovanilla  Don't force it out, you gotta relax and it'll come out naturally ;) +  
mysteriousmantyping  Why couldn't the answer be Inferior rectal nerve since that controls the external anal sphincter? +1  
draykid  @mysteriousmantyping I think this question is looking at complications of T2DM, more specifically diabetic autonomic neuropathy. Patient more than likely has diabetic gastroparesis which may explain his constipation and abdominal distension. +1  
cuthbertallg0od  Pudendal nerve controls external anal sphincter (per FA), and gastroparesis wouldn't have anything to do w pelvic splanchnics but instead vagus nerve... Don't know why pudendal nerve couldn't be right if he was just clogged up from not being able to relax his sphincter anymore ---- is parasympathetic just more likely to be the issue statistically or something? +1  
cuthbertallg0od  Or would losing pudendal nerve result in incontinence... Its never been clear to me if activation/inactivation opens/closes sphincters... +1  
cuthbertallg0od  Just realized that says perineal... whoops +2  
vivijujubebe  External sphincter is innervated by pudendal nerve, more often damaged during labor. DM patients have autonomic neuropathy with parasympathetic/sympathetic nerves more likely damaged +  

submitted by weenathon(34),

Diabetics get peripheral neuropathy from glucose damaging Schwann cells. For what I believe is an unconfirmed reason, T2DM patients tend to see parasympathetic autonomic neuropathy before sympathetic.

The hypogastric nerve carries sympathetic innervation to the posterior urethra and is responsible for ejaculation.

Inferior rectal nerve is a branch of the pudendal nerve that innervates the external anal sphincter and provides sensation below the pectinate line. A peripheral nerve problem with this nerve would cause the sphincter to remain relaxed and cause incontinence, not constipation.

Pelvic splanchnic nerves are parasympathetics (craniosacral outflow). If he is constipated, his rest and digest (parasympathetic) system is not working.

Perineal nerve is a branch of the pudendal nerve. It has both motor and sensory, is involved in the external anal sphincter, urethral sphincter, and is responsible for conscious sensation of the need to urinate.

Sacral sympathetic inhibits peristalsis, and contracts internal anal sphincter to maintain continence.

spaceboy98  Amazing man, thank you for this +  

submitted by hayayah(1056),
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iclPev scnhcnailp veersn era ratp fo het tpahpcsaietymra .ysmets

masonkingcobra  The inferior hypogastric plexus innervates internal pelvic viscera; has both sympathetic and parasympathetic components; parasympathetic contribution helps stimulate detrusor of bladder (along with pelvic splanchnic nerves), sympathetic contribution helps stimulate internal urethral sphincter +3