|
Surgical Conditions of
the Ovaries.
2
Congenital Anomalies
2
Ovarian agenesis
2
Ovarian hypoplasia..........
2
Supernumerary ovaries
2
True hermaphroditism
2
Pseudohermaphroditism.....
2
Ovarian Cysts......
2
Follicular cysts...
2
Luteal cysts...
3
Parovarian cysts
3
Ovarian Neoplasia
3
Surgical Conditions of the Uterus...
4
Pyometra
4
Hydrometra/Mucometra
5
Subinvolution of Placental Sites.......
5
Metritis....
5
Uterine Torsion...
5
Uterine Prolapse.
5
Uterine Rupture...
6
Uterine Neoplasia
6
Common Surgeries of the Uterus...
6
Ovariohysterectomy (OHE or OVH).......
6
Indications..........
6
Preoperative evaluation............
6
Complications.....
7
Cesarean Section...
7
Indications..........
7
Preoperative care
7
Anesthetic protocols............
8
Surgical technique............
8
Surgical Conditions of the Vagina, Vestibule, and Vulva...........
9
Congenital Abnormalities..............
9
Segmental Vaginal Aplasia or Hypoplasia..........
9
Persistent Hymen.
9
Rectovaginal/Rectovestibular Fistula
10
Acquired Abnormalities............
10
Vaginal Edema (vaginal hyperplasia).......
10
Vaginal Prolapse..........
10
Vaginal Neoplasia..........
11
Vulvar Hypertrophy......
11
Vulvar Hypoplasia / Infantile Vulva.
11
Mammary Neoplasia.
12
List of textbook references
13
OBJECTIVES
·
Know the signs and diagnostic findings for ovarian
neoplasia
·
Know how to diagnose and treat pyometra.
·
Understand how the signs and diagnostic findings of
metritis differ from pyometra.
·
Know how to diagnose and treat uterine prolapse.
·
Know the indications for and complications of
ovariohysterectomy.
·
Know the indications for and complications of cesarean
section.
·
Understand the surgical treatment options for
persistent hymen.
·
Understand how the signs of vaginal edema, vaginal
prolapse, and vaginal neoplasia differ.
·
Be familiar with the 3 main vaginal neoplasias.
·
Understand how the behavior of
mammary neoplasia differs between the dog and cat.
·
Be familiar with the various treatment options for
mammary neoplasia.
Note: References to
textbook illustrations have been provided and are marked by “ILL”,
for those who are interested. Use of these references is optional
and only provided for your convenience. A list of textbook
references is provided at the end of these notes. If you are
planning to work with small animals, you should consider owning at
least one of these textbooks as a reference.
(uncommon)
ovaries absent unilaterally or bilaterally.
underdeveloped ovaries.
both ovarian and testicular tissue in the same
individual.
the external genitalia is of the opposite sex
as the gonads
Signs
may be no overt problems
Surgical Treatment
Remove gonads.
May do cosmetic surgery on external genitalia.
most common type. single or multiple. may
develop after incomplete removal at spay.
Signs:
persistent
heat, mammary hyperplasia, or none.
Diagnosis:
visualizing cyst at laparoscopy or laparotomy
Surgical Treatment:
excision
or rupture of cyst (or hormonal treatment) ovariohysterectomy (OHE)
release progesterone.
usually multiple
Signs:
persistent anestrus, cystic endometrial
hyperplasia, or pyometra.
Surgical Treatment:
excise cyst or ovary (or hormonal treatment)
OHE
usually an incidental finding during routine
spay.
(uncommon)
more frequent in older, nulliparous bitches.
Signs
- if increased production of progesterone result is cystic endometrial hyperplasia or
pyometra.
- if increased production of estrogen result is
persistent heat, aplastic anemia.
- enlarged abdomen due to large tumor or to
ascites from peritoneal
metastasis.
- may have neurologic abnormalities if
metastasis to CNS
Diagnosis
physical/neurologic exam (palpate mass in
abdomen), vaginal cytology (cornification due to estrogen), serum
progesterone (>2 ng/ml), CBC +/- bone marrow biopsy (anemia),
abdominal and thoracic radiographs (primary tumor and/or
metastasis), abdominal ultrasound, biopsy
Surgical Treatment
OHE.
if young, breeding dog with large calcified tumor (suspect teratoma),
you may just excise the affected ovary.
Prognosis
good if benign and no aplastic anemia.
poor if metastasis or bone marrow suppression.
Adenoma/Cystadenoma
- may cause increased progesterone
Adenocarcinoma/Cystadenocarcinoma
- most common ovarian tumor in bitches.
may have metastasis to abdominal organs and lungs causing ascites
and hydrothorax
Granulosa cell tumor
- increased estrogen or progesterone. most common ovarian tumor
in queens.
may metastasize to abdominal organs or CNS. tends to be
benign in bitch and malignant in queen.
Dysgerminoma - rarely cause signs. may metastasize to adjacent
organs.
Teratoma
(Dermoid cyst) - may be asymptomatic or present for suspected
pregnancy.
may be calcified.
Teratocarcinoma
- often calcified. metastasizes regionally to bone so may be lame.
Pyometra is inflammation of the uterus.
Etiopathogenesis is not clear, but progesterone plays a key
role by increasing uterine secretions, decreasing contractions, and
closing the cervix.
(Repeated estrous cycles can lead to cystic endometrial
hyperplasia (CEH). However, pyometra can occur without CEH.)The
uterus becomes more susceptible to infection -
E. coli the most common, but other aerobes and anaerobes can
also be isolated.
Signs
anorexia,
PU/PD, depression, +/- vaginal discharge, vomiting, diarrhea,
shock.
Diagnosis
Signalment and history - usually occurs in bitches >6 yrs old,
and usually within
8 weeks of estrus.
Physical
exam - temperature may be normal. purulent or sanguineous
vaginal discharge if cervix is open (open pyometra), no discharge if
cervix is closed (closed pyometra).
+/- palpate enlarged uterus.
Lab data
– may be normal, but usually have
leukocytosis +/- left shift and
hyperglobulinemia
which indicate inflammation.
may have hypoalbuminemia due to decreased production, decreased
intake, or loss in utero.
may have nonregenerative anemia due to loss of RBC's into lumen and toxic
depression of production. may have prerenal azotemia. may have low urine specific gravity - (how pyometra affects
the kidneys is not clear.
one theory is that E. coli endotoxin or other toxins affect the
ability of the renal tubules to reabsorb water. Antigen-antibody
complex glomerulopathy? Direct effect of endotoxins?).
may
have urinary tract infection.
SAP can be elevated. can have metabolic acidosis.
Diagnostic imaging
- may see tubular soft
tissue density on survey abdominal films.
radiographs may be nondiagnostic, but can usually identify fluid-filled tubular structure on abdominal ultrasound.
[ILL. Hedlund (2002) Fig 28-15 radiograph]
Surgical Treatment
Ovariohysterectomy
- Same as a routine OHE but the uterus is more friable (and may
be filled with pus), so pack it off with laparotomy sponges to
prevent contamination.
Culture the uterus!
Don't leave any uterine body in the dog.
Lavage the uterine stump with sterile saline and consider oversewing
the end of the stump if mucosa is protruding - this can be done with
interrupted Lembert sutures or a Parker-Kerr oversew. Disadvantages
of oversewing are the potential for uterine stump granuloma or
abscess.
Post op care:
Continue antibiotics for 7-10 days based on culture and sensitivity
results.
Prognosis
usually good.
If death occurs, it is usually due to septicemia.
Medical Treatment
Not
recommended.
Can be attempted if cervix is open and dog is a valuable
breeding bitch.
Use antibiotics and PGF2a (not approved for use in dogs) to
contract the myometrium, relax the cervix, and lyse the CL.
(antibiotics can resolve bacterial infection, but medication does
not alter any underlying CEH.)
Potential side effects include restlessness, salivation,
vomiting, defecation, forcing pus through the oviducts into the
peritoneal cavity, and uterine rupture.
Recurrence of pyometra is likely so she should be bred at the next
estrus.
accumulation of sterile fluid in the uterus -
uncommon and usually an incidental finding.
Placental
sites do not degenerate and serosanguineous drainage is noted 7-12
weeks post partum. It
usually occurs in dogs <2 1/2 yrs old, with first or second litter.
Signs
anemia due to hemorrhage, palpate enlarged
uterine horns. R/O metritis, vaginitis, neoplasia.
Treatment
OHE to stop blood loss. Spontaneous recovery is
common.
Medical management may be tried using ergonovine, but success
varies.
Similar
to pyometra but metritis usually occurs postpartum and is associated
with dystocia, obstetrical manipulation, or retained fetus or
placenta.
Signs
anorexia, depression, vomiting, vaginal
discharge, fever, mastitis.
(Differs from pyometra in that there is no PU/PD.)
Diagnosis
Signalment and history - usually occurs
immediately postpartum.
Physical
exam - fever. malodorous, mucopurulent vaginal discharge
Lab data
- usually have leukocytosis
with degenerative left shift.
see degenerate PMNs and bacteria on cytology of the discharge.
Surgical Treatment
OHE is recommended if not a breeding animal or
if she has severe systemic signs. Perform surgery and post op care
as for pyometra.
Medical Treatment
consider
if she is not too sick and is a breeding animal. Use systemic
antibiotics and drain the uterus daily.
A soft rubber catheter can be passed if the cervix is dilated.
If a catheter cannot be passed, the uterus can be drained by
laparotomy and hysterotomy.
You can also use ergonovine maleate or PGF2α as for pyometra.
Usually occurs in a gravid uterus, etiology
unknown.
Signs
acute abdominal pain, vomiting, severe
depression and collapse, shock.
Diagnosis
supposedly can feel rotation on vaginal exam,
but more likely to be diagnosed on exploratory.
Treatment
OHE +/- cesarean section.
Do not derotate the uterus.
Prognosis
High mortality, especially if in DIC or
peritonitis due to rupture.
rare
Usually occurs at labor or within 48 hrs.
Signs
one or two tubular masses protruding from
vulva. May be in shock if intra-abdominal bleeding.
Treatment
- If uterus looks healthy, flush with warm
saline and lubricate with a water soluble jelly.
Gently manipulate uterus to manually reduce. Recurrence is rare.
- If manual reduction fails or the uterus is
necrotic, amputate the uterus.
A smooth, cylindrical object is placed in the uterine lumen and 4
stay sutures are placed at equidistant points around the prolapsed
uterus. Incise through all layers to the inserted object, one
quadrant at a time.
Immediately after incising one quadrant, anastomose the inner and
outer layers of the prolapsed uterus with simple interrupted
absorbable suture before incising the next quadrant.
- If uterus is replaced but uterine tissue is
damaged or there is internal bleeding, may need OHE.
May occur secondary to pregnancy or pyometra.
Can cause peritonitis.
If the tear is sutured, it may recur or fibrose, so do OHE or
unilateral OHE.
(rare)
Leiomyoma is the most common canine uterine
neoplasia.
Adenocarcinoma is the most common feline uterine tumor. It
may metastasis regionally, or to lungs, brain, or eyes.
Signs
depends on tumor type, size and pattern of
metastasis.
Illness is usually related to metastatic disease.
Diagnosis
usually at OHE or necropsy.
May find in patient suspected of having pyometra.
Treatment
OHE after checking for metastasis. Can try chemotherapy
for metastatic dz.
Prognosis
good for benign tumors.
poor for malignant tumors.
·
elective sterilization. This is recommended before 1st
estrus to reduce risk of mammary neoplasia. May be done as early as
7 weeks in spay-neuter programs designed to reduce pet
overpopulation problems. Main points to remember for early spay are
to avoid hypothermia and hypoglycemia.
·
ovarian dz (cysts or neoplasia)
·
uterine disease (pyometra, subinvolution, metritis,
torsion, rupture, neoplasia)
·
diseases related to hormone production (prevent
mammary tumors, prevent vaginal edema, vaginal prolapse, help
control unregulated diabetics)
·
physical exam
·
extent of diagnostic evaluation is related to animal's
age and reason for surgery
Hemorrhage
during surgery or post operative (bleed into
abdomen or vagina). More potential problems if OHE performed during
estrus.
Recurrent estrus
due to incomplete ovary removal – e.g. if
ligature placement is incorrect. If ovarian tissue is accidentally
dropped into the abdomen it can revascularize or reimplant and be
functional. Can diagnose by identifying cornified vaginal epithelial
cells and/or increased serum progesterone (>2 ng/ml). Explore while
there are signs of estrus when the tissue is enlarged and easier to
find.
Uterine stump infection
especially if progesterone is present from
ovary or exogenous source
Uterine or ovarian stump granuloma with or without fistulous
tracts
may
occur secondary to braided nonabsorbable suture (Vetafil, silk)
Ligation of ureter
will develop unilateral hydronephrosis.
If you ligate both ureters, the dog will go into anuric renal
failure.
The ureters are usually damaged so they must be transected
and reimplanted into the bladder.
Urinary incontinence
estrogen responsive incontinence may occur and
can be treated with diethlystilbesterol or phenylpropanolamine. No
difference in incidence of this between animals spayed in an early
spay-neuter program as compared to those spayed later.
Eunuchoid syndrome
decreased aggression and stamina.? Not proven
Weight gain
not a problem if diet and exercise are
regulated.
Infantile vulva
Can occur
for animals who have surgery at 7 weeks of age, but generally has no
clinical significance. (Males castrated young will also have smaller
penis than those castrated later.)
·
complete primary uterine inertia (dachshunds and
Scotties)
·
incomplete primary uterine inertia refractory to
medical therapy
·
secondary uterine inertia (St. Bernards)
·
relative or absolute fetal oversize (brachycephalic
fetus tend to have large head/shoulders)
·
anatomic abnormalities of pelvic canal (old pelvic
fractures)
·
uncorrectable fetal malpresentation (transverse
presentation)
·
fetal death with putrefaction (greyhounds)
·
toxemia (fetal death, uterine torsion, uterine
rupture)
warm IV fluids - correct any deficits prior to anesthesia, if
possible (hypoglycemia, hypocalcemia)
antibiotics - if
uterine infection, dead fetus, or manual manipulation
steroids - if septic shock
clip and scrub surgical site prior to anesthesia
- if possible without exciting bitch.
surgery table should be warm and level
(doesn't need to be tilted)
final scrub under anesthesia
want optimum analgesia and immobilization of
bitch with minimal compromise of fetuses.
Check your anesthesia notes for details on
this. From a surgical standpoint, you want to be very efficient – so
plan ahead and keep moving!
approach:
ventral midline abdominal.
(can also use flank approach to avoid mammary glands, but is
more vascular, less familiar, and less exposure.)
pack off uterus with laparotomy sponges.
hysterotomy:
longitudinal incision through avascular region
of uterine body. Gently
advance fetus to incision, open amniotic sac, pull out puppy, clamp
umbilical cord, place puppy on sterile towel and hand to nonsterile
assistant.
Use gentle traction to remove placenta.
If it's firmly adhered, leave it.
Check to be sure uterus is empty of fetuses and placentas.
Can give oxytocin to stimulate uterine contractions and to
help control bleeding.
close uterus with 1 or 2 layers, using continuous inverting suture
pattern (Cushings or Lembert) with absorbable suture.
[ILL. Hedlund (2002) Fig
28-7 and 28-8 photos]
[ILL. Gilson (2003) Fig
101-1, 101-2, 101-3 drawings]
[ILL. Probst (1998) Fig
30-9 thru 30-13 drawings]
en bloc ovariohysterectomy:
This is an alternative to hysterotomy if the
animal is to be spayed as well. Isolate the ovarian pedicles. break
down the broad ligament between the ovary and cervix on both sides
of the uterus. manipulate any fetuses from the cervix and vagina
into the uterine body. Double clamp both ovarian pedicles and the
uterus just cranial to the cervix. cut between the clamps and pass
the ovaries and uterus to a team of nonsterile assistants, who can
immediately open the uterus and resuscitate the neonates. double
ligate the pedicles. The advantages of this procedure are that there
is less chance for contamination by the uterine fluids, and it
shortens the anesthesia time. A potential disadvantage is that you
need enough assistants to resuscitate the entire litter at once.
[ILL. Mullen (1998) Fig
30-14 thru 30-17 drawings]
closure:
obtain sample for culture and sensitivity
followed by abdominal lavage if any spillage from uterus.
routine abdominal closure.
neonatal resuscitation:
clean membranes and fluid from oral cavity and
nostrils by swab or suction. can swing body and head in downward arc
to clear fluid from airway. rub neonate with towel to stimulate
respiration and to
dry. check for heartbeat and breathing (can give atropine or
doxapram sublingual or by umbilical vein). give few drops of 50%
glucose if not responding well. can give naloxone if bitch had
narcotics. ligate umbilical cord if it bleeds when clamp is removed.
keep warm. check for congenital defects.
post operative care:
clean incision. observe for hypothermia,
depression, shock, excess vaginal bleeding. put puppies with bitch
as soon as she is awake and watch for behavioral problems. puppies
need colostrum and nursing stimulates oxytocin to promote uterine
contraction. send home ASAP.
complications:
hypovolemia/hypotension
- due to blood loss, shock, anesthesia. treat with fluids and
transfusions as needed.
uterine
hemorrhage
- check for coagulopathies. control with oxytocin or ergonovine
maleate. transfuse if necessary.
may need OHE.
peritonitis - due to break in
technique or sepsis
metritis
uterine
scarring and adhesions - by third C sect may have decreased
litter size and difficult to exteriorize the uterus. if the horn was
incised, it may scar and prevent further placentation or cause
abnormal fetal development.
agalactia - usually milk within 24 hrs.
oxytocin will stimulate milk let-down but not milk production.
prolapsed uterus
mastitis
- enlarged, hot, painful mammary gland, fever, anorexia. Tx warm
soaks.
retained
placenta
- will usually come out on its own. if not, may lead to septic
metritis.
eclampsia - see trembling, weakness, convulsions, fever 2-4 wks
post partum. usually small breeds with large litters. Tx Ca
gluconate and vitamin D
subinvolution of placental sites - serosanguineous discharge.
treat as for hemorrhage.
segmental vaginal aplasia - complete occlusion
and retention of uterine fluids
vaginal hypoplasia - partial occlusion
Signs
asymptomatic, vaginitis, inability to tie
Diagnosis
digital palpation, vaginoscopy, vaginography
Treatment options
- breeding bitch- can resect caudal and
midvaginal strictures. incise longitudinally and suture
transversely.
- nonbreeding symptomatic - OHE or vaginectomy
- nonbreeding asymptomatic - no Tx
vertical septum or annular stricture at
vestibulovaginal junction
Signs
difficulty breeding, chronic vaginitis, urine
pooling, mucometra
Diagnosis
palpation, vaginogram, vaginoscopy
Treatment
- episiotomy - incise from dorsal vulvar
commissure toward anus along median raphe. incise fascia and vulvar
muscles, then mucosa. place urinary catheter.
resect septum.
close episiotomy in 3 layers.
- abdominal approach is needed if septum is > 2
cm cranial.
- vaginectomy is indicated if the stricture is
cranial, if urine pools after the septum has been removed, or if
surgical relief of the stricture was unsuccessful.
Prognosis
guarded if surgery site strictures post
operatively
[ILL. Hedlund (2002) Fig
28-9 drawing of episiotomy]
[ILL. Manfra Marretta
(1998) Fig 31-8 thru 31-11drawing of episiotomy]
[ILL. Wykes (2003) Fig
99-2 photo of persistent hymen]
often associated with imperforate anus. if
large fistula - do okay until start on solid food, then may develop
megacolon.
Signs
feces from vulva or urine from anus. vaginitis,
cystitis, frequent urination
Diagnosis
barium enema or barium in vagina
Treatment
ligate or oversew fistula. reconstruct wall.
Complications
incontinence. especially if had imperforate
anus.
[ILL. Wykes (2003) Fig
99-5 drawing]
occurs during follicular phase, usually during
first estrus and may recur. may also recur at parturition and cause
problems.
brachycephalics are predisposed.
Signs
mass cranial to urethral papilla, may protrude
through vulvar labia. can desiccate or become traumatized. urethra
is easily catheterized.
Treatment options
-
if mild, keep moist with soluble jelly until it reduces during
diestrus. megestrol acetate (progesterone) to prevent, but also
prevents ovulation.
- GnRH - can cause cysts.
-
surgical resection - episiotomy and resect at base, close vaginal
mucosa. may recur at next heat
- OHE - Tx of choice if not a breeding bitch
[ILL. Wykes (2003) Fig
99-6 drawing]
[ILL. Pettit (1998) Fig
31-1 drawing]
(uncommon)
may be hereditary. brachycephalics are
predisposed. may precede uterine prolapse. occurs during periods of
increased estrogen. rare during pregnancy
Diagnosis
donut shaped eversion of vagina, may see
urethral papilla
Treatment options
-
if mild, will spontaneously regress during diestrus - keep moist
- replace. may suture uterus or broad ligament
to abdominal wall, or suture labia
- resect devitalized tissue (first do
episiotomy and place urinary catheter)
- OHE is curative - will cause regression if
not a chronic prolapse.
[ILL. Wykes (2003) Fig
99-7 drawing]
[ILL. Pettit (1998) Fig
31-2 drawing]
Most common location for female (intact or
spayed) reproductive tract tumors.
Predisposition for boxer, poodle, and German shepherd.
Most are leiomyoma or transmissible venereal tumor (TVT).
Signs
bulging of perineum, vaginal prolapse,
tenesmus, dysuria, urinary incontinence, difficulty copulating,
sanguinous or purulent discharge
Diagnosis
vaginoscopy, digital vaginal exam, rectal
palpation in small dogs, cytology.
Abdominal and thoracic radiographs.
Treatment
Surgical excision - usually easy to remove with
episiotomy.
Prognosis
good for completely removed leiomyoma or for
TVT
Leiomyoma - often multiparous bitches.
Tumor is slow growing and associated with tenesmus and dysuria.
usually completely encapsulated and can be excised. Sessile or
pedunculated. Often reported with chronic estrogen (ovarian tumor or
follicular cyst). do not usually metastasize.
Leiomyosarcoma - metastasize to lymph nodes, spleen, lungs, or
cervical spinal cord and may recur without metastasis
Transmissible Venereal Tumor (TVT) - transmission, growth, and
metastasis depends on immune status of recipient.
May regress or grow slowly in normal animal, may grow quickly and
metastasize in immunosuppressed animal.
Treatment for TVT depends on tumor location, presence of metastasis,
and availability of treatment modalities.
Sx excision of TVT is associated with high rate of recurrence.
Chemotherapy using vincristine has a high cure rate and is useful
for metastatic disease.
Orthovoltage radiation therapy works for local tumors.
may persist with prolonged estrogen due to
cystic ovaries, granulosa cell tumor
Treatment
OHE
(recessed vulva, vulvar inversion)
may be more common in dogs that are spayed at
an early age, but not proven. Has also been described in intact
females. Obesity may also be a factor.
Signs
vulva is hidden into folds of adjacent skin,
perivulvar dermatitis. Has also been associated with chronic urinary
tract infections, urinary incontinence, and vaginitis.
Treatment
weight loss is indicated if the animal is
obese.
local cleaning of the skin.
episioplasty - crescent shaped bilateral piece
of skin removed dorsal and lateral to vulva. remove underlying fat.
close subcutaneous tissue and skin.
[ILL. Hedlund (2002) Fig
28-10 drawing of episioplasty]
[ILL. Manfra Marretta
(1998) Fig 31-4 thru 31-7drawing of episioplasty]
Incidence
dogs:
most common neoplasia. most commonly in caudal 2 glands.
intact females have 3-7 x increased risk compared to spayed.
spaying has no protective effect after 2.5 yrs or 4 estrus
cycles.
[ILL. Hedlund (2002) Fig 28-13 photo]
cats: 3rd most common neoplasia. all glands at
equal risk.
intact female has 7x increased risk as compared to spayed.
Siamese cats are predisposed.
Tumor type and Metastasis
dogs:
about 50% benign. (fibroadenoma) most malignant are adenocarcinoma
and have mets
to lungs or lymph nodes.
cats: 90% are malignant (adenocarcinoma, also
sarcoma and inflammatory carcinoma) and most have mets - lungs and
regional nodes.
Influence of Reproductive Hormones on
Occurrence
estrogen and progesterone have role in
etiology. bind protein receptors in target tissue. patients with
receptor rich tumors have greater survival than patients with
receptor poor tumors.
Diagnosis
history, signalment, physical exam
cytology
abdominal and thoracic radiographs and
abdominal ultrasound
histopathology
Treatment Options
Surgical excision
lumpectomy - remove tumor
simple mastectomy
(mammectomy)
- remove affected gland
en bloc resection -
remove affected gland, regional LN, and all glands in between
unilateral mastectomy
- remove all glands on affected side and associated LN
bilateral mastectomy
[ILL. Hedlund (2002) Fig
28-14 drawing]
Use an elliptical incision, as for any mass
removal. Be careful not to get too wide or may have trouble closing.
Depth of excision should be to pectoral muscles/abdominal wall
fascia. Use good hemostatis and use walking sutures to eliminate
dead space and tension. Bilateral mastectomies may need to be
staged, removing the second mammary chain 2-4 weeks after the first.
Type of surgery does not affect survival time
or cancer free time, so lumpectomy or simple mastectomy of affected
glands may be Tx of choice. The most important thing is to get clean
margins. 44% of dogs have receptor rich malignant tumors and
concurrent OHE of these bitches will increase survival time. (OHE is
cheaper than steroid receptor assay.)
cats- unilateral mastectomy have better disease
free interval than simple mastectomy but
no difference in survival. OHE is not indicated because cat mammary
tumors are receptor poor.
Other therapy:
-Chemotherapy
-Radiation therapy
-Immuinotherapy
Prognosis
dogs: depends on tumor size, type, mode of
growth and clinical stage. < 5 cm diameter, no invasion or mets -
survival same as for benign.
75% of dogs with simple mastectomy
or enbloc did not survive >2 yrs
cats:
average survival 1 year
either species: tumors with lymphatic
infiltration, metastasis, body wall invasion, rapid growth, or
recurrence have a
poor prognosis
Gilson SD.
Cesarean section In: D. Slatter, ed.
Textbook of Small Animal Surgery. 3rd ed. Philadelphia:
Saunders, 2003;1517-1520.
Hedlund CS.
Surgery of the reproductive and genital systems In: T. W. Fossum,
ed. Small Animal Surgery. 2nd ed. St Louis: Mosby, 2002;610-674.
Manfra Marretta
S. Episioplasty In: M. J. Bojrab, ed.
Current Techniques in Small Animal Surgery. 4 ed. Baltimore:
Williams and Wilkins, 1998;506-508.
Manfra Marretta
S. Episiotomy In: M. J. Bojrab, ed.
Current Techniques in Small Animal Surgery. 4 ed. Baltimore:
Williams and Wilkins, 1998;508-510.
Mullen HS.
Cesarean section by ovariohysterectomy In: M. J. Bojrab, ed.
Current Techniques in Veterinary Surgery. 4 ed. Baltimore:
Williams and Wilkins, 1998;500-502.
Pettit GD.
Surgical treatment of vaginal and vulvar masses In: M. J. Bojrab,
ed. Current Techniques in Small Animal Surgery. 4 ed. Baltimore:
Williams and Wilkins, 1998;503-506.
Probst CW.
Cesarean section In: M. J. Bojrab, ed.
Current Techniques in Small Animal Surgery. 4 ed. Baltimore:
Williams and Wilkins, 1998;496-500.
Wykes PM, Olson
PN. Vagina, vestibule, and vulva In: D. Slatter, ed.
Textbook of Small Animal Surgery. 3rd ed. Philadelphia:
Saunders, 2003;1502-1510.
Theriogenology VMED 5361
SURGERY OF THE MALE REPRODUCTIVE SYSTEM
Fall 2002
Dr. J. Davidson
OUTLINE
SURGICAL CONDITIONS
OF THE PROSTATE.
2
General Evaluation of Prostatic Disorders.
2
Benign Prostatic Hyperplasia and Cystic Hyperplasia.
3
Suppurative Prostatitis and Prostatic Abscessation.
3
Prostatic Cysts and Paraprostatic Cysts.
4
Prostatic Neoplasia.
5
TECHNIQUES FOR SURGERY OF THE PROSTATE.
6
General Considerations for Prostatic Surgery.
6
Prostatic Biopsy.
6
Prostatic Drainage.
6
Marsupialization.
6
Prostatic Omentalization.
7
Partial Prostatectomy.
7
Complete Prostatectomy.
7
SURGICAL CONDITIONS OF THE TESTES.
7
Testicular Hypoplasia.
7
Cryptorchidism..
7
Orchitis.
8
Testicular Neoplasia.
8
Testicular Trauma.
9
Testicular Torsion.
9
COMMON SURGICAL PROCEDURES OF THE TESTICLES.
10
Testicular Biopsy.
10
Orchiectomy.
10
Scrotal Ablation.
11
SURGICAL CONDITIONS OF THE PENIS AND PREPUCE.
11
Hypospadias.
11
Balanoposthitis.
11
Persistent Penile Frenulum..
12
Phimosis.
12
Paraphimosis.
12
Priapism..
13
Penile Wounds.
13
Fractured Os Penis.
13
Strangulation.
13
Penile and Preputial Neoplasia.
14
List of references.
14
OBJECTIVES
- Be able to diagnose the
prostatic diseases based on clinical signs and test results.
- Know how to treat
prostatic hyperplasia.
- Know how to treat
prostatic abscesses.
- Understand the surgical
treatment options for prostatic cysts.
- Be able to diagnose
prostatic neoplasia and counsel a client about it.
- Know the definition of
cryptorchidism and the reasons for castration.
- Be familiar with the
three testicular neoplasias.
- Know the indications for
and complications of orchiectomy.
- Know how to perform
prostatic and testicular biopsies.
- Know how to perform a
scrotal ablation and cryptorchid surgery.
- Understand the difference
between paraphimosis, priapism, and phimosis.
- Recall some penile and
preputial neoplasia and recommendations for treatment.
Note:
Since most of my illustrations have been borrowed and some have been
published, reproducing them would be in violation of copyright laws.
References to textbook illustrations have been provided and are marked
by “ILL”, for those who are interested. Use of these references is entirely
optional and only provided for your convenience. A list of textbook
references is provided at the end of these notes.
History (Hx)
hematuria,
pyuria, stranguria, discharge at end of urination, urine retention,
constipation, tenesmus, fever, lethargy, anorexia, dehydration,
vomiting, weight loss, pain.
Physical Exam (PE)
abdominal
and rectal palpation. Note prostatic position, pain, contour, texture,
mobility, symmetry, and size. Check for enlarged iliac lymph nodes and
testicular tumors.
Clinical Pathology
complete
blood count (CBC), serum chemistries, Brucella titer, urinalysis (UA).
Obtain prostatic fluid by ejaculate, prostatic wash or fine needle
aspirate (FNA). FNA (perirectal or transabdominal) is usually the most
accurate and diagnostic method.
Radiographs (Rads)
Survey films
may show size and position of prostate. It may be abdominal with
increased prostatic size, obesity or enlarged bladder. Look for
metastasis (mets) in the lumbar vertebrae, regional organs and lungs.
Positive contrast cystourethrography may be helpful.
[ILL.
Basinger (1993) Fig 99-1 radiograph]
Ultrasound (US)
Note
prostatic size, shape, symmetry, echogenicity, and cavitational areas.
You may see the iliac lymph nodes if they are enlarged.
[ILL.
Basinger (1993) Fig 99-2 thru 99-4 sonograms]
Biopsy (Bx)
Percutaneous
bx (transabdominal or perineal) can be done with Tru-Cut or other
biopsy needle. US guided is preferred to get a representative sample
and avoid the urethra. Needle biopsy is generally avoided if prostatic
abscess is suspected.
Wedge bx may be obtained through a caudal abdominal incision.
Prostatic
hyperplasia is an aging change that is seen histologically in 80% of
intact 6 year old dogs and 95% of 9 year olds. It is related to
elevated testosterone and estrogen.
Signs
most dogs
are asymptomatic. constipation,
tenesmus, dyschezia, hemorrhagic urethral discharge, incontinence,
stranguria, dysuria, urine retention (uncommon).
Diagnosis (Dx)
Rectal
palpation reveals symmetrically
enlarged, nonpainful prostate of normal spongy consistency.
UA -
hemorrhage but no bacteria.
Rads -
enlarged prostate may displace bladder cranially and colon dorsally.
US -
hyperechoic if benign hyperplasia, small (1-10 mm) cysts if cystic
hyperplasia.
Bx-
definitive, but may not be necessary if dog responds to treatment.
Treatment (Tx)
Castration
is Tx of choice. Prostate will decrease size in 3 wks. Give bulk
laxative and low residue diet for constipation. In extreme cases, an
indwelling catheter may be needed for urinary retention.
Estrogen will
decrease prostatic size but can also cause aplastic anemia and
squamous metaplasia of the prostate (which can promote prostatic
cysts). Progestin and finasteride may be alternatives to estrogen
therapy.
Prognosis
Excellent following castration.
The source
of prostatic infection is usually via the urethra, although it may be
hematogenous. Common infectious organisms include E. coli,
Pseudomonas, Staph, Strep, and Proteus.
Normal defense mechanisms include: mechanical flushing, urethral high
pressure zone, mucosa, peristalsis, Zn associated antibacterial factor
of prostatic fluid.
If the bacteria are not cleared, prostatic infection may
progress to microabscessation and then to larger abscesses.
Signs
acute prostatitis
- lethargy, straining to urinate or defecate, hematuria, abdominal
pain.
chronic prostatitis
- May have few signs or recurrent urinary tract infections. May have
episodes resembling acute prostatitis but milder.
prostatic abscess
- Starts out as chronic prostatitis. As abscesses develop, see signs
of acute prostatitis but septicemic signs may predominate (fever,
anorexia, vomiting, diarrhea, dehydration). If an abscess ruptures,
dog may show signs of acute peritonitis with shock (tachycardia, slow
CRT, weak pulses, pale mm, severe abdominal pain).
Diagnosis
acute prostatitis
- Prostate painful and
symmetrically enlarged. There may be hindlimb edema from
interference of lymph and venous drainage. May have enlarged lymph
nodes. CBC: leukocytosis with left shift or leukopenia with
degenerative left shift. Prostatic fluid: septic, suppurative. UA:
hematuria, pyuria. US: normal or hyperechoic prostate.
chronic prostatitis
- Prostate is nonpainful, firm,
symmetrically enlarged. CBC: normal or mild elevation of WBC.
Prostatic fluid, UA, and US are similar to acute prostatitis.
prostatic abscess
- Small abscess may be palpated as
single or multiple soft foci within a firm gland. As the abscesses
develop, the prostate becomes painful, large and asymmetrical
(fluctuant areas of pus and firm areas of fibrosis). CBC,
prostatic fluid, and UA are similar to acute prostatitis. US: fluid
filled areas (>1 cm diameter), decreased echogenicity in surrounding
parenchyma, indistinct prostatic borders.
Treatment
acute prostatitis
- Antibiotics for 3
weeks, based on culture and sensitivity. Castration is also
recommended if the dog is not systemically ill, since prostatitis may
be related to benign hypertrophy.
chronic prostatitis
- Same Tx as for acute prostatitis, but antibiotics for 4-8 weeks.
prostatic abscess
- If abscesses are small, treat as chronic prostatitis. If dog is
systemically ill, supportive care or shock therapy may be needed.
Large prostatic abscesses are less likely to respond to medical Tx
alone and must also be surgically drained or resected (when the
patient is stable). Partial prostatectomy provides more complete
resolution of infection with shorter hospitalization as compared to
surgical drainage and may also be indicated for recurrent abscesses.
Prostatic omentalization may also be tried. The dog should also be
castrated. At surgery, get prostatic bx and aerobic and anaerobic
cultures.
Also culture the urine for aerobic infection.
Complications
short term
- sepsis and shock, hypoproteinemia, urinary incontinence, and death.
High mortality rate of prostatic abscesses (51%) is usually due to
sepsis.
long term
- urinary incontinence, recurrent urinary tract infections, recurrent
abscessation. hypokalemia, hypoglycemia, anemia, peripheral edema,
PU/PD, diarrhea, wound infection, ventricular arrhythmias,
hemorrhage.
Prognosis
acute prostatitis
- good if therapy is aggressive and instituted early.
chronic prostatitis
- good.
prostatic abscess
– good for small abscesses. guarded for abscesses large enough to
require abdominal drainage - postoperative mortality is as high as
25%. Mortality is close to 50% for ruptured abscesses.
Prostatic
cysts develop within prostate due to some type of
obstruction (squamous metaplasia or functional obstruction by gland
oversecretion), although the pathophysiology is uncertain. They may be
seen as cavitations within the prostate.
Paraprostatic cysts are of embryonal origin and do not communicate
with the prostate. Therefore, they are less likely to be secondarily
infected. They are often seen as large structures in the abdominal
cavity or pelvic canal.
Signs
Dogs are
usually bright and alert and may be asymptomatic. Most signs are
related to compression of adjacent tissues (tenesmus, stranguria).
Other signs include inappetence, constipation, incontinence, urine
retention. Palpate asymmetrically enlarged, nonpainful, fluctuant
prostate. Usually nonpainful but may have inflammation with
adhesions and pain. May palpate abdominal mass. Be sure to check for
concurrent Sertoli cell tumor. UA: normal or hematuria. Rads: may be
calcified areas in the wall – especially for paraprostatic cysts. FNA:
modified transudate with RBCs and epithelial and inflammatory cells.
Culture: negative unless secondarily infected/abscessed. US: fluid
filled areas, >1 cm diameter.
[ILL.
Hedlund (2002) Fig 28-20 photo]
Treatment
Castration
should be performed for small parenchymal cysts. For large cysts or
paraprostatic cysts, castrate and also perform one of the following:
drain
- Multiple drains can be
placed surgically if the cyst is not respectable.
marsupialize
-Advantages include continuous drainage, can treat interior of cyst,
and decreased morbidity. It is often the treatment of choice.
Complications include UTI, abscessation, urinary incontinence, and
chronic drainage.
resect cyst
- Discrete paraprostatic cysts or true cysts with narrow attachment
may be resected with a partial prostatectomy. Incomplete cyst
resection is preferable to causing incontinence or detrusor atony
(avoid aggressive dissection of the dorsolateral bladder neck,
prostate, and pelvic urethra).
omentalization
– Packing omentum into the cystic cavity is a recently described
technique which shows promise.
partial or complete prostatectomy - This surgery is difficult (i.e. do not try this
at home!
J) and
usually results in incontinence, so it’s rarely indicated.
Prognosis
Good to
fair. Recurrence can be a problem.
Adenocarcinoma and transitional cell carcinoma are the most common
types. Castration does not prevent neoplasia. Castrated dogs are more
likely to have neoplasia than any other prostatic disease. Prostatic
neoplasia commonly mets to iliac lymph nodes, but can also spread to
the bladder, rectum, pelvis, lumbar vertebrae, and pelvic musculature.
Signs
hindlimb
weakness, stranguria, dysuria, tenesmus, dyschezia, PU/PD, cachexia,
hematuria, incontinence, hind limb edema.
Dx
Palpation of prostate: often
asymmetrically enlarged, usually painful, firm, fixed, and cystic or
irregularly nodular. May be able to palpate enlarged lymph nodes.
Rads: prostate may have mineral density. Look for enlarged
sublumbar lymph nodes and mets to lumbar vertebrae.
US:
increased, decreased or mixed pattern of echogenicity.
cytology
of prostatic fluid may not be diagnostic, but
bx
is diagnostic.
Tx
Efficacy of
chemotherapy or radiation therapy is uncertain. Castration may help
temporarily.
Can do complete prostatectomy if no metastasis, but will be
incontinent and will not increase survival time. Intraoperative
radiation may improve survival time in patients with no metastatic
disease.
Prognosis
poor.
Prostatic carcinoma grows fast and mets early so the dog is
usually beyond help by the time it’s diagnosed.
Flush the
prepuce with 0.1% povidone iodine or 1:4 dilution of 2% chlorhexidine
diacetate before surgical scrub. The surgical approach is a caudal
laparotomy lateral to the prepuce and through midline of the abdominal
wall. The incision must extend caudally to the pubis.
Retract the bladder cranially with stay sutures. A pubic osteotomy may
be needed in some cases. (Cut through the craniomedial third of each
pubis to the obturator foramen and then make one cut connecting both
foramina to reflect the pubis. To close the pubis is wired back with
wire passed through holes drilled in the bones.)
A scalpel is
used to cut a wedge from the lateral aspect of the prostate, avoiding
the urethra. The capsule may be closed with absorbable suture material
to help control hemorrhage. An alternative is to use a Tru-Cut biopsy
needle.
[ILL.
Rawlings (1998) Fig 29-1drawing]
Drains may
be placed for the treatment of abscesses or cysts. A stab incision is
made in the ventrolateral aspect of the abscess or cyst. After
cultures and biopsies are obtained, the area is lavaged. Digital
manipulation of the prostatic parenchyma is performed to connect all
abscessed or cystic areas to create one large cavity if possible.
One or two penrose drains or closed suction drains are placed in each
area that requires drainage. Drains are exited through the abdominal
wall lateral to the abdominal incision. After surgery the drains are
bandaged to prevent ascending infection. Drains are removed as soon as
drainage decreases - usually within 1-3 weeks. Complications include
dermatitis around the drains, SQ edema, premature drain removal by the
patient, and fistula formation.
[ILL.
Hedlund (2002) Fig 28-18 drawing]
[ILL.
Basinger (1993) Fig 99-8 drawing]
Marsupialization is most commonly used for prostatic cysts. The cyst
must be tough enough be sutured and big enough to reach the body wall.
Explore the cyst and break down any loculations to make one large
cavity. Make a 2-3 cm oval stoma in the skin lateral to the prepuce.
Dissect bluntly through the muscle and pull the cyst capsule through
the abdominal wall. Suture the cyst to the external rectus and the
edges of the cyst to the skin. Irrigate with dilute iodine or saline
for several days. Drainage usually decreases after 1 week but may
drain for up to 3-4 months.
Complications include premature closure or permanent fistula.
[ILL.
Hedlund (2002) Fig 28-22 drawing]
[ILL.
Basinger (1993) Fig 99-9 drawing]
Omentalization is a newer procedure that has
been described for prostatic cysts or abscesses. After obtaining
samples for culture and biopsy, the cyst or abscess is explored and
transformed into one large pocket as described for placement of
prostatic drains and marsupialization. A leaf of the omentum is then
tacked into this area.
[ILL.
Rawlings (1998) Fig 29-4 thru 29-10drawing]
intracapsular technique - removes 80% of parenchyma. Use an electroscalpel
or ultrasonic surgical aspirator to remove all the parenchyma except
2-3 mm lining the capsule and the tissue dorsal to the prostatic
urethra. The prostatic capsule is closed.
fillet
technique – Use a scalpel, electroscalpel or laser to remove
all tissue except a rim around urethra using successive passes.
Defects in urethral lumen don't need to be sutured. A paraprostatic
drain may be placed.
Complications of partial prostatectomy include urine leakage, and
incontinence.
[ILL.
Hedlund (2002) Fig 28-12 drawing]
[ILL.
Basinger (1993) Fig 99-11 drawing]
[ILL.
Rawlings (1998) Fig 29-3drawing]
Surgical
exposure usually requires a caudal abdominal midline approach and a
pubic osteotomy. Nerves and vessels to the bladder should be
identified and avoided. The vasa deferentia are ligated and divided.
The urethra is transected cranial and caudal to the prostate. The
urethra is anastomosed with 8-12 sutures. A temporary cystostomy
catheter may be placed for 6-7 days if there is tension on the suture
line or delayed healing is anticipated. These dogs are usually
incontinent and do not respond to medical Tx. Other complications
include shock and oliguria.
[ILL.
Hedlund (2002) Fig 28-11 drawing]
[ILL.
Basinger (1993) Fig 99-10 drawing]
[ILL.
Rawlings (1998) Fig 29-2drawing]
Hypoplasia
may be unilateral or bilateral and generally these testicles produce
androgens but not sperm. Treatment is castration.
Cryptorchidism is a unilateral or bilateral undescended testicle.
Anorchism (absence of both testes) and monorchism (absence of one
testicle) are rare, so if a testicle is absent it’s probably
cryptorchid. The testicle may be intrabdominal or in the inguinal
canal. The animal will have normal secondary sex characteristics (cats
will have barbs on the penis) due to testosterone, but they will have
decreased fertility. Abdominal testicles have a much greater risk of
torsion and neoplasia. There is a higher incidence of cryptorchidism
among small dogs and Persian cats. It is heredity.
Signs
Normal
secondary sex characteristics and libido, will be sterile if
bilateral.
Dx
Testicles
have not descended by 6 months of age.
Tx
These
animals should be castrated to decrease the risk of neoplasia and to
prevent them from breeding. If the testicle is palpated in the
inguinal region - incise directly over it. If it is not palpable, open
the caudal abdomen. The testicle can be found by tracing the ductus
deferens from the prostate. The ductus deferens is ligated and
divided. The testicular vessels are also ligated and divided. The
testicles should be submitted for histological exam. Orchiopexy may be
done instead of castration but is not very successful, and not
condoned for ethical reasons.
Prognosis
good, even
with neoplasia
Infection of
the testicle usually originates from the bladder or prostate and gains
access to the testicle via the ductus deferens.
Common infectious agents include E coli, proteus, staph, strep and
occasionally Brucella. Orchitis may be unilateral or bilateral.
Signs
acute
- stiff gait, fever,
depression, vomiting, scrotal edema, leukocytosis. palpate firm, hot,
painful, swollen testes
chronic
- palpate small, firm, irregular testes with enlarged epididymis.
Scrotal contents may adhere to tunics. decreased fertility, sterile if
bilateral.
Dx
culture and
aspirate or biopsy of testis
Tx
Medical
treatment if not severe - antibiotics, local hypothermia,
antiinflammatories.
Castration
is treatment of choice for nonbreeding animal.
Prognosis
guarded for
fertility
Seminoma,
interstitial cell, Sertoli cell all have equal frequency and it is
common to have more than one tumor of the same or different types in a
testicle. Testicular neoplasia is associated with increased incidence
of prostatic inflammation and neoplasia, perineal hernia, perianal
adenoma and subfertility.
Sertoli cell tumors
- largest, most likely to be in ectopic testis and most likely
to secrete estrogens and cause paraneoplastic syndrome:
feminization (gynecomastia +/- gland secretion, pendulous prepuce,
attract males, loss of libido, alopecia), blood dyscrasia (anemia,
thrombocytopenia, and leukocytosis followed by pancytopenia),
prostatic squamous metaplasia. this syndrome is not seen in cats. mets
to lymph nodes, lungs, liver, spleen, pancreas, and kidney.
Seminoma
(not in cats) - usually < 2 cm, but can be bigger. may be locally
invasive. more common in cryptorchid testes. rarely have hormone
secretion. usually benign
Interstitial cell tumor (not in cats) - 1-2 cm diameter, single or
multiple. may be incidental finding. Usually in a scrotal testes and
usually benign.
Signs
Most are
asymptomatic.
Feminization signs occur if the tumor is functional.
Dx
Firm,
nodular enlargement in scrotum. testicular biopsy
Tx
castration.
If the tumor is adhered to scrotum, do scrotal ablation as well.
Can do a hemicastration for a breeding animal if the other
testicle is clean and has viable sperm. Signs of feminization
disappear within 2-6 wks if there're no functional mets.
Prognosis
good if no
mets or blood dyscrasias. metastasis is uncommon (<10%)
(uncommon)
Signs
local pain
and swelling, local hypothermia, hindlimb lameness, scrotal hematoma,
hemorrhage, spermatic granuloma, infertility
Treatment
medical
- cold compress, supportive bandage, antibiotics, corticosteroids,
analgesics, diuretics, aspirate fluid
surgical
- If continued hemorrhage, incise scrotum cranially, remove fluid and
explore.
Ligate bleeders and suture tears in tunica albuginea.
Orchiectomy is indicated for severe trauma.
Signs
intraabdominal testicle – (uncommon condition) anorexia, depression,
painful abdominal mass, posterior stiffness, dehydration, emesis.
scrotal testicle
– (rare condition) anorexia, depression, sudden onset of pain, scrotal
swelling, emesis.
Tx
orchiectomy
with biopsy of testicle.
Indications
evaluate
infertility or localized testicular lesion
Technique
Open
incisional biopsy is least traumatic and most precise. Make the
approach as for a castration. Incise the parietal vaginal tunic and
place stay sutures in its edges. Take a thin wedge of testicle using a
sharp blade. May take sample for culture, cytology and histopathology.
Check with your pathologist prior to surgery to see which fixative
they prefer – it’s usually Bouin’s or something else other than
formalin. Close the tunica albuginea, parietal tunic, subcutaneous
tissue, and skin.
Complications
hemorrhage,
inflammation, increased intratesticular pressure, hyperthermia,
infection, adhesions, transient subfertility or permanent infertility.
(a.k.a. orchidectomy
or castration)
Indications
- sterilization
- prevent objectionable
behavior (aggression, roaming, urine marking, mounting)
- testicular or epididymal
diseases (testicular hypoplasia, cryptorchidism, severe orchitis,
epididymitis, severe testicular trauma, testicular or epididymal
neoplasia)
- scrotal diseases (severe
trauma or dermatitis, neoplasia)
- diseases related to
hormone production ( perianal adenoma, perineal hernia, benign prostatic hyperplasia)
Preoperative evaluation
Physical
examination
Diagnostic
evaluation is related to animal’s age and reason for surgery
Surgical technique
Refer to
Laboratory notes from VMED 5360
Postoperative care
Prevent
excessive licking of suture line and watch for swelling or drainage.
Remove
sutures in 7-10 days for dogs.
Use shredded
paper instead of litter for 3-5 days for cats.
Complications
scrotal hematoma
- Scrotum fills with blood due to poor hemostasis.
Tx: benign
neglect, surgical drainage or scrotal ablation.
intraabdominal hemorrhage- spermatic vessels retract into abdomen.
Tx:
abdominal surgery to ligate vessels. Fluids or blood transfusion PRN.
scrotal abscess
- Tx: surgical drainage or scrotal ablation, and antibiotics
scrotal dermatitis
- due to irritation from scrub or clipper burns.
Tx: topical
zinc oxide cream or antibiotic steroid cream. scrotal ablation in
severe cases.
Indications
scrotal
hematoma or abscess, scrotal dermatitis, castration of old dog with
pendulous scrotum, adherent testicular tumor, scrotal trauma or
neoplasia (mast cell tumor, melanoma), scrotal urethrostomy in dog or
perineal urethrostomy in cat.
Technique
Make curved
incisions on either side of the base of scrotum. Incisions should
curve toward the testicle to allow plenty of skin for closure. Close
SQ and skin.
[ILL.
Boothe (1993) Fig 97-9 drawing]
Hypospadias
is a rare congenital condition in which there is incomplete formation
of the penile urethra. The urethral opening is identified on the
ventral aspect of the penis anywhere from the tip to the perineal
region. There is usually underdevelopment of the penis and the prepuce
may be incomplete ventrally. The scrotum may be divided.
Signs
There may be
none if the lesion is distal and the prepuce is okay. Some dogs have
urine scald dermatitis. If the penis is underdeveloped urine may pool
in the prepuce. Abnormal preputial development may result in chronic
exposure of the penis.
Tx
Urine scald
can be treated by frequent cleaning and topical ointment. Problems
with urine pooling can be treated by daily preputial flushing. Exposed
penile mucosa should be kept moist with ointment. Preputial
reconstruction is needed in some cases to alleviate penile exposure.
For major defects penile amputation and urethrostomy is recommended.
[ILL.
Hedlund (2002) Fig 28-23 drawing]
[ILL.
Boothe (1993) Fig 98-6 photo and 98-7 drawing]
[ILL.
Hobson (1998) Fig 33-5 thru 33-7 drawing of hypospadias]
[ILL.
Hobson (1998) Fig 33-10 drawing of preputial reconstruction OR Fowler
(1998) Fig 33-14]
infection of
penis and prepuce
Signs
copious
yellow or blood tinged discharge. inflamed, thickened mucosa. enlarged
lymph nodes near fornix. adhesions between penis and prepuce in severe
cases.
Tx
eliminate
underlying cause (injury, phimosis, foreign body, neoplasia)
Prognosis
guarded.
tends to recur
Signs
pain when
attempt to extrude penis, ventral deviation of penis, balanoposthitis,
urine scald. May be asymptomatic. predisposition in cockers, poodles,
and pekes.
Tx
cut with
sharp scissors
Prognosis
good
[ILL.
Boothe (1993) Fig 98-14 photo]
Inability to
protrude penis due to congenital or acquired stricture of the orifice.
Signs
congenital
- distended prepuce and can't urinate normally (drops or small
stream). balanoposthitis and ulceration.
acquired
- scarring of prepuce secondary to trauma or neoplasia preventing
extrusion. Signs of balanoposthitis.
Tx
correct
primary cause and surgically enlarge orifice - excise full thickness
triangle from the dorsal prepuce (base of the triangle is along the
margin of the orifice).
suture parietal mucosa to skin.
[ILL.
Hedlund (2002) Fig 28-25 and 28-26 drawing]
[ILL.
Hobson (1998) Fig 33-8 drawing]
[ILL.
Fowler (1998) Fig 33-12 drawing]
Prognosis
congenital
- good. may need second surgery after full grown.
acquired
- tumor regrowth, post op fibrosis, paraphimosis
inability to
retract penis into prepuce. It may be congenital (narrow preputial
orifice and short prepuce) or acquired (mating, trauma, neoplasia,
balanoposthitis, foreign bodies, priapism, tangled preputial hairs).
Signs
inflammation
of glans leads to desiccation, excoriation, necrosis and urethral
obstruction. Exposed penis is swollen and painful.
Tx options
- lubricate
and hot/cold packs before replacing. check for preputial hairs.
-
preputiotomy: temporary or permanent enlargement of orifice may be
needed- as for phimosis.
-
preputioplasty: If the prepuce is too short it may be lengthened.
- myorrhaphy:
shortening of the preputial or retractor penis muscles.
- phallopexy:
create adhesion between penis and preputial mucosa.
- amputation
if penis is necrotic
[ILL.
Hedlund (2002) Fig 28-28 drawing]
[ILL.
Boothe (1993) Fig 98-8 photo]
Prognosis
guarded.
recurrence is common if animal is not castrated.
persistent
erection (without sexual excitement) due to spinal cord injury,
constipation, genitourinary infection
Signs
distinguish
from paraphimosis because penis can be replaced. Can result in
paraphimosis if unresolved.
Tx
eliminate
primary cause
Signs
intermittent, profuse hemorrhage. (irritation of injury causes penile
erection and repeated hemorrhage), may have urine extravasation if
ruptured urethra.
Tx
pressure
hemostasis, lavage, and antibiotics if small wound. ligate large
vessels and suture tunica albuginea for cavernous bleeding, sedate to
prevent erection.
partial or
total penile amputation for very severe or necrotic wounds.
partial amputation:
catheterize the urethra and place a tourniquet caudal to the
amputation site. incise lateral to the urethra and os penis. dissect
the urethra from the os penis and transect both such that the urethra
extends beyond the os penis. the urethra is spatulated and sutured to
the penile mucosa. (to shorten the prepuce, remove a full thickness
rectangle ventrally, slide prepuce back and suture mucosa to skin.)
total amputation:
dissect out the entire penis and ligate vessels at the base. transect
the penis and make a permanent urethrostomy (scrotal or perineal).
[ILL.
Hedlund (2002) Fig 28-24 drawing of amputation]
[ILL.
Boothe (1993) Fig 97-9 thru 97-12 drawing of partial amputation]
[ILL.
Hobson (1998) Fig 33-1 and 33-2 drawing of partial amputation]
(rare) it’s
usually a transverse fracture with limited soft tissue damage.
Signs
signs may
include dysuria, hematuria, urethral obstruction, urine extravasation.
Tx options
- nothing -
os penis is surrounded by tough fibrous tissue.
- urethral
catheter for 5-7 days as a stent if urethral obstruction.
- open
reduction with finger plate if catheter can not be passed or os penis
is unstable.
- amputation
for severe fracture with urethral obstruction that can not be
relieved.
results from
entangled preputial hairs or rubber band placed maliciously
Signs
dysuria,
swelling, may be necrosis
Tx
remove cause
and apply topical antibiotics. Partial penile amputation may be
indicated for severe tissue damage.
Neoplasia of the penis and preputial mucosa include
transmissible venereal tumor (TVT), squamous cell carcinoma,
hemangiosarcoma, fibrosarcoma, and papillomas. Any skin neoplasia can
occur on the preputial skin (mast cell tumor, melanoma,
hemangiosarcoma, squamous cell carcinoma, hemangioma, papilloma,
histiocytoma)
Signs
hemorrhage,
decreased libido, phimosis or paraphimosis, balanoposthitis,
stranguria, palpable mass. May be asymptomatic.
[ILL.
Hedlund (2002) Fig 28-31 photo of TVT]
Dx
cytology or
histopathology
Tx
TVT
responds well to chemotherapy or radiation (surgery can be considered
if the mass is small). Any other penile or preputial neoplasia should
be surgically excised. To obtain margins on any malignant neoplasia a
partial or total penile amputation with urethrostomy is usually
required.
[ILL.
Hedlund (2002) Fig 28-24 and 28-29 drawing]
Prognosis
good for TVT
and benign tumors. poor for carcinomas, sarcomas
Basinger. (1993). In “Textbook of Small Animal Surgery” 2nd
ed. (Slatter, ed.), Vol. 2, pp. 1349-1367. W. B. Saunders,
Philadelphia.
Boothe, H. W. (1993). In “Textbook of Small Animal Surgery” 2nd
ed. (D. Slatter, ed.), Vol. 2, pp. 1325-1336. WB Saunders,
Philadelphia.
Boothe, H. W. (1993). In “Textbook of Small Animal Surgery” 2nd
ed. (D. Slatter, ed.), Vol. 2, pp. 1336-1348. W. B. Saunders,
Philadelphia.
Fowler, J. D. (1998). In “Current Techniques in Small Animal
Surgery” 4th
ed. (M. J. Bojrab, ed.), pp. 534-537. Williams and Wilkins, Baltimore.
Hedlund, C. S. (2002). In “Small Animal Surgery” (T. W. Fossum,
ed.), pp. 610-674. Mosby, St Louis.
Hobson, H. P. (1998). In “Current Techniques in Small Animal
Surgery” 4th
ed. (M. J. Bojrab, ed.), pp. 527-534. Williams and Wilkins, Baltimore.
Rawlings, C. A. (1998). In “Current Techniques in Small Animal
Surgery” 4th
ed. (M. J. Bojrab, ed.), pp. 479-487. Williams and Wilkins, Baltimore.
 Canine
Index
contributed by Bruce E Eilts on 19-Aug-98 at 10:39 AM
modified by Jacqueline R Davidson on 29-Aug-99 at 06:12 PM
|
