Theriogenology VMED 5361
SURGERY OF THE FEMALE REPRODUCTIVE SYSTEM
Fall 2003
Dr. J. Davidson
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.
Surgical Conditions of the Ovaries
Congenital Anomalies
(uncommon)
Ovarian agenesis
ovaries absent unilaterally or bilaterally.
Ovarian hypoplasia
underdeveloped ovaries.
Supernumerary ovaries
True hermaphroditism
both ovarian and testicular tissue in the same individual.
Pseudohermaphroditism
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.
Ovarian Cysts
Follicular cysts
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)
Luteal cysts
release progesterone. usually multiple
Signs:
persistent anestrus, cystic endometrial hyperplasia, or pyometra.
Surgical Treatment:
excise cyst or ovary (or hormonal treatment) OHE
Parovarian cysts
usually an incidental finding during routine spay.
Ovarian Neoplasia
(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.
Surgical Conditions of the Uterus
Pyometra
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.
Hydrometra/Mucometra
accumulation of sterile fluid in the uterus - uncommon and usually an incidental finding.
Subinvolution of Placental Sites
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.
Metritis
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.
Uterine Torsion
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.
Uterine Prolapse
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.
Uterine Rupture
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.
Uterine Neoplasia
(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.
Common Surgeries of the Uterus
Ovariohysterectomy (OHE or OVH)
Indications
· 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)
Preoperative evaluation
· physical exam
· extent of diagnostic evaluation is related to animal's age and reason for surgery
Complications
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.)
Cesarean Section
Indications
· 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)
Preoperative care
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
Anesthetic protocols
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!
Surgical technique
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.
Surgical Conditions of the Vagina, Vestibule, and Vulva
Congenital Abnormalities
Segmental Vaginal Aplasia or Hypoplasia
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
Persistent Hymen
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]
Rectovaginal/Rectovestibular Fistula
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]
Acquired Abnormalities
Vaginal Edema (vaginal hyperplasia)
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]
Vaginal Prolapse
(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]
Vaginal Neoplasia
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.
Vulvar Hypertrophy
may persist with prolonged estrogen due to cystic ovaries, granulosa cell tumor
Treatment
OHE
Vulvar Hypoplasia / Infantile Vulva
(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]
Mammary Neoplasia
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
List of textbook references
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
General
Evaluation of Prostatic Disorders
Benign
Prostatic Hyperplasia and Cystic Hyperplasia
Suppurative
Prostatitis and Prostatic Abscessation
Prostatic
Cysts and Paraprostatic Cysts
TECHNIQUES
FOR SURGERY OF THE PROSTATE
General
Considerations for Prostatic Surgery
SURGICAL
CONDITIONS OF THE TESTES
COMMON
SURGICAL PROCEDURES OF THE TESTICLES
SURGICAL
CONDITIONS OF THE PENIS AND PREPUCE
Penile
and Preputial Neoplasia
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.
SURGICAL CONDITIONS OF THE PROSTATE
General Evaluation of Prostatic Disorders
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.
Benign Prostatic Hyperplasia and Cystic Hyperplasia
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.
Suppurative Prostatitis and Prostatic Abscessation
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 and Paraprostatic Cysts
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.
Prostatic Neoplasia
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.
TECHNIQUES FOR SURGERY OF THE PROSTATE
General Considerations for Prostatic Surgery
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.)
Prostatic Biopsy
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]
Prostatic Drainage
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
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]
Prostatic Omentalization
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]
Partial Prostatectomy
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]
Complete Prostatectomy
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]
SURGICAL CONDITIONS OF THE TESTES
Testicular Hypoplasia
Hypoplasia
may be unilateral or bilateral and generally these testicles produce androgens
but not sperm. Treatment is castration.
Cryptorchidism
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
Orchitis
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
Testicular Neoplasia
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%)
Testicular Trauma
(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.
Testicular Torsion
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.
COMMON SURGICAL PROCEDURES OF THE TESTICLES
Testicular Biopsy
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.
Orchiectomy
(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.
Scrotal Ablation
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]
SURGICAL CONDITIONS OF THE PENIS AND PREPUCE
Hypospadias
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]
Balanoposthitis
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
Persistent Penile Frenulum
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]
Phimosis
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
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.
Priapism
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
Penile Wounds
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]
Fractured Os Penis
(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.
Strangulation
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.
Penile and Preputial Neoplasia
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
List of references
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
Indexmodified by Jacqueline R Davidson on 29-Aug-99 at 06:12 PM
