PENILE AND PREPUTIAL PROBLEMS
IN THE BULL

M.S. GILL, D.V.M., M.S.


SURGERY OF THE PENIS

Penile Neoplasia
  • Fibropapilloma of the penis is common and is caused by the bovine papilloma virus. 
  • The virus gains entrance into the skin through wounds and causes neoplastic growth of fibroblasts. 
  • There is no associated metastasis or local invasion. 
  • The condition occurs as a result of homosexual tendencies of young bulls (1-3 years) housed together. 
  • The warts may be single or multiple and usually occur on the glans and free portion of the penis. 
  • The earliest clinical sign of penile papillomas is either slight hemorrhage from the preputial cavity following coitus or a hesitancy or refusal of the bull to breed. 
  • Large tumors can lead to either paraphimosis or phimosis.
  • Removal is achieved with the bull restrained in a chute or with the use of tranquilization (acepromazine) to facilitate extension of the penis. 
    • Towel forceps in the dorsum of the penis under the dorsal apical ligament help extend the penis during surgery. 
    • The area is surgically prepared and analgesia is provided by a ring block proximal to the lesion using 2% lidocaine or local infiltration around the dorsal nerves (5-10cc of 2% lidocaine) across the dorsum of the penis near the preputial orifice. 
    • A gauze tourniquet can be placed proximal to the surgery site to provide some hemostasis. 
    • For warts that occur close to the urethral groove, passage of a urinary catheter is helpful prior to surgery. 
    • The papillomas are removed by dissecting through the epithelium at the base of the growth. 
    • Small vessels are ligated and the epithelium is closed with #2-0 absorbable suture material. 
    • Sexual rest is provided for 2-4 weeks after surgery. 
    • Recurrence is common if the bull is in an active stage of the disease. 
  • Administration of a wart vaccine (commercial or autogenous) may reduce recurrence.

    Persistent frenulum
  • This condition is characterized by a fibrous band attaching the prepuce to the free portion of the penis along the median raphe immediately caudal to the glans. 
  • It manifests as a marked ventral deviation of the bull's penis during attempts at coitus. 
  • It is noted chiefly in Angus and Shorthorn bulls (also reported in Brangus, Santa Gertrudis, Beefmaster, and Hereford). 
  • This condition prevents intromission in Bos taurus breeds but may not interfere with breeding in Bos indicus bulls due to the length of the prepuce. 
  • The anomaly is congenital and suspected to be a heritable condition. 
  • The epithelial surfaces of the penis and prepuce of bulls are fused at birth. 
    • At approximately 4 months, the penis and prepuce begin to separate under the influence of male hormones. 
    • Separation should be complete by 8 to 11 months of age. 
    • The frenulum normally ruptures during separation of the penis from the prepuce. 
  • The condition can be easily surgically corrected but owners should be advised of the possibility that this is a heritable condition. 
  • To surgically correct this condition the bull is restrained in a chute and the penis is extended. 
    • The frenulum is infiltrated with 5 cc of 2% lidocaine at the penile and preputial attachments. 
    • It is then ligated at each end with #2-0 absorbable suture material and excised. 
  • Sexual rest is allowed for 2 weeks.



Penile deviations

  • 1. types of deviations
    •  - the majority of deviations occur in the polled beef breeds - polled Hereford and Angus
      • a. spiral or corkscrew - the most common deviation observed - occurs in bulls between 2 and 5 years of age. 
        • Spiral deviation occurs at the peak of erection. 
        • The spiral configuration is caused by the dorsal apical ligament slipping off to the left hand side of the penis resulting in a counter clockwise spiral as viewed from the rear. 
        • Up to 50% of normal bulls have been shown to develop spiral deviation during copulation. 
        • The condition is often noticed in normal bulls during masturbation, following intromission and when erection is produced by an electroejaculator. 
        • It is not considered pathologic until its occurrence is observed on repeated natural breeding trials in which it occurs prior to entrance into the vulva and thereby prevents intromission.

      • b. ventral or rainbow deviation - 
        • less common than spiral - 
        • ventral deviation prevents intromission - 
        • this condition can be diagnosed by electroejaculation - 
        • occurs when the ligament is thin and stretched to the point that it is incapable of holding up the distal portion of the penis during erection.


      • c. S-shaped deviation
        •  - relatively rare - 
        • usually occurs in older bulls with an excessively long penis. 
        • The apical ligament is sufficient in strength but insufficient in length, and the S-shape results during erection - 
        • no surgical techniques have been described for this deviation.

          d. lateral deviations - may occur secondary to trauma of the penis or prepuce - scars or adhesions of the elastic tissue pulls the penis to one side or the other.

      • 2. fascia lata implant technique - used for repair of both spiral and ventral penile deviation - 
        • the objective of the technique is to create a firm union of the dorsal apical ligament to the tunica albuginea to prevent its slippage.
        • Surgical technique: 
          • Withhold food and water for 48 hours, 
          • general anesthesia, 
          • right lateral recumbency, 
          • the preputial hairs are clipped, 
          • penis extended manually, and 
          • a towel clamp is placed 5 cm from the apex of the penis under the dorsal apical ligament (avoid penetration of the urethra and glans penis). 
          • The penis is scrubbed and prepared for surgery then allowed to retract into normal position while the fascia lata is harvested and prepared. 
          • A site over the left lateral thigh from the patella to the tuber coxae is surgically prepared (20 X 40 cm). 
          • A skin incision is made starting 10 cm proximal to the cranial lateral aspect of the patella and extending 20 cm toward a point halfway between the tuber coxae and greater trochanter.
          • The incision is extended through the superficial fascia until the thicker deep layer of fascia lata is reached. 
          • A 3 X 15 cm section of fascia lata is removed over the vastus lateralis m. and placed in warm saline. 
          • The fascia is closed with #2 vicryl and the skin is closed with 0.6 mm Vetafil (caprolactam). 
          • The strip of fascia lata is prepared by removing all loose connective tissue and fat from both sides and it is then returned to the warm saline solution.
          • The penis is again extended and held in that position for the remainder of the surgical procedure. 
          • A 15-18 cm incision is made on the absolute dorsum of the penis (1800 opposite the urethral groove). 
          • This incision should be centered at the preputial reflection.
          • The incision is extended, through the loose fascial layers in the free portion of the penis and the thin elastic layers in the preputial portion, to expose the apical ligament. 
          • The apical ligament is incised throughout its length along the dorsum of the penis. 
          • This exposes the tunica albuginea of the penis. 
          • The ligament is reflected on both sides to create a bed for the fascia lata and to remove the thin fascia separating it from the tunica albuginea. 
          • Care should be taken to avoid damage to the terminal branches of the dorsal vessel and nerve on the right side - these vessels must not be covered by implant. 
          • The fascia lata implant is placed between the apical ligament and tunica albuginea beginning as far proximally as possible.
          • Four simple interrupted #0 vicryl sutures are placed through the fascia lata and into the tunica albuginea at the proximal aspect. 
          • Interrupted sutures are placed along the lateral margin of the implant at 2-cm intervals, stretching the fascia lata in both directions. 
          • The implant is then sutured at the distal end under mild tension with three interrupted sutures. 
          • The apical ligament is sutured (#0 vicryl) over the fascia lata graft in a continuous pattern including the fascia lata in every second or third suture. 
          • The elastic layers are closed in the preputial area with 3-0 vicryl and the epithelium of the prepuce and free portion of the penis are closed with simple interrupted 2-0 vicryl. 
          • The penis is allowed to retract into the preputial cavity.
          • Postop antibiotics are administered for 5 days. 
          • The penis is manually extended and sutures removed at 10 days. 
          • The fascia lata implant becomes homogenous with both the dorsal apical ligament and the tunica albuginea as early as 30 days post-surgically and is complete by 60 days. 
          • These bulls can be used for breeding at 60 days post-op. 
        • The prognosis for return to breeding soundness is considered more favorable with spiral than ventral deviations.

Hematoma of the penis

  • Hematoma of the penis is also referred to as "ruptured penis", "broken penis" or "fractured penis" - 
  • common in bovine species and rare in others - 
  • occurs during coitus when the cow slips or goes down under the weight of the bull or when the penis is thrust against the escutcheon of the cow during breeding attempts. 
  • The corpus cavernosum penis (CCP) is a closed system and during erection, blood pressures within the CCP may exceed 14,000 mm of Hg. 
  • Sudden angulation of the penis may increase the blood pressure and result in a hematoma. 
  • Penile hematoma results from a tear of the tunica albuginea into the CCP. 
  • The tear usually occurs on the dorsum of the penis at the distal sigmoid flexure opposite the insertion of the retractor penis muscles; the tunica albuginea is thinner in this area. 
  • The tear is usually 2-7.5 cm long and transverse - these tears usually do not extend over 180E circumferentially. 
  • The swelling due to hematoma is a result of blood from the CCP being forced into the peripenile tissues. 
  • The owner frequently first notices the presence of a prolapsed prepuce which may result secondary to the swelling. 
  • Diagnosis is based on physical exam and the presence of a large swelling immediately cranial to the scrotum. 
  • The swelling is soft until the clot begins to form by about the fourth day.
  • By 10 days the clot begins to organize and the swelling becomes quite firm. 
  • Bruising of the skin over the hematoma may be apparent. 
  • Size of the hematoma is not related to the length of the tear in the tunica albuginea but to the number of coital attempts the bull makes following rupture.
  • Treatment:
    • 1. Medical - spontaneous recovery occurs in >50% of the cases given 90 days sexual rest - 
      • therapy includes parenteral antibiotics (1 week), 
      • warm local hydrotherapy (2-3 weeks), and 
      • sexual rest for 60-90 days.
    • 2. Surgical - 
      • should be performed between 5 and 10 days post-trauma,
      • surgical repair probably reduces the incidence of complications. 
      • A second chance for surgical repair is after 21 days when fibrosis dissipates.
      • Surgical technique - 
        • fast 48-72 hrs. prior to surgery, 
        • right lateral recumbency, 
        • general anesthesia or heavy sedation/local analgesia,
        • surgical prep of area. 
        • A 20 cm skin incision is made over the swelling cranial and parallel to the rudimentary teats. 
        • The incision is extended through the subcutaneous tissues until the hematoma is encountered dorsal to the penis. 
        • The hematoma is incised and the clot manually removed. 
        • The remaining cavity is flushed with dilute Betadine in sterile saline. 
        • The penis and surrounding elastic tissue are exteriorized through the skin incision. 
        • The retractor penis muscles and urethral groove should be located to aid orientation. 
        • The elastic layers are incised longitudinally on the left lateral aspect of the penis to permit exteriorization of the tunica albuginea. 
        • The rent is debrided and then apposed with #1 vicryl in a bootlace pattern which is a widely spaced simple continuous reversed upon itself. 
        • The elastic layer is apposed over the penis and sutured with 3-0 vicryl, simple continuous pattern. 
        • The penis is returned to normal position and the cavity flushed again with dilute Betadine in saline and dried with sterile towels. 
        • The subcutaneous layers are closed using a continuous pattern with #0 vicryl, the skin is closed with 0.6 mm vetafil. 
        • Postop antibiotics are given for 5 days. Seroma formation will occur and should subside about 10 days after the surgery. 
        • Skin sutures are removed 10 days post-op. 
        • Sexual rest is provided for 60 days.

        • Undesirable sequella:
          • 1. recurrence of the hematoma - common, but surgical repair lessens the risk - 50% recur with medical treatment, 25% recur with surgical treatment.
          • 2. adhesions of elastic layers to the tunica albuginea or to the skin preventing complete extension of the penis.
          • 3. analgesia of the penis due to damage of the dorsal penile nerve may occur
            • a. at time of hematoma.
            • b. several months later due to fibrous tissue impingement.
            • c. or, when breeding resumes and nerves are stretched.
          • 4. abscessation
            • a. hematogenous route.
            • b. break in aseptic technique during surgery, abscessation may then lead to adhesions or septic cavernitis.
          • 5. vascular shunts 
            • - between CCP and dorsal vessels - 
          • no longer a closed system in the CCP---> erection failure.

           

SURGERY OF THE PREPUCE


  • Preputial trauma/laceration/prolapse
    • Habitual prolapse of the prepuce is common especially in the following breeds: 
      • Brahman, 
      • Brahman cross, 
      • Angus, and 
      • polled Hereford. 
    • The predisposition to preputial prolapse probably involves four anatomic features:
      • 1. pendulousness of the sheath (prepuce below the carpus, low preputial angle)
      • 2. length of the prepuce
      • 3. size of the preputial orifice
      • 4. presence of retractor prepuce muscles 
        • (frequently absent in polled breeds - 
      • 1/3 of all polled bulls lack these small paired muscles)

       

    • The sheath and prepuce of Bos indicus bulls are more pendulous averaging 5.5 cm longer than Bos taurus breeds.
    • Preputial prolapse and trauma often occurs one of two ways. 
      • Bulls which frequently have some prepuce exposed may develop abrasions and lacerations of the prepuce from exposure to environmental factors (including frostbite). 
        • This may lead to edema, further prolapse, more trauma, abscessation and eventually fibrosis of the preputial tissue. 
      • Or, a laceration of the prepuce during breeding may occur which usually leads to preputial prolapse. 
        • Lacerations of this type occur when there is a "bunching" of excess preputial tissue immediately prior to the breeding lunge. 
        • The tissue usually bursts ventrally in a longitudinal direction when the prepuce impacts upon the pubis of the cow.
        •  Because of the elastic layers and retraction of the penis there is a marked tendency for healing to occur in a transverse manner which shortens the effective length of the prepuce as it heals. 
        • The traumatic injury results in edema formation and preputial prolapse. 
          • Treatment is initially aimed at medical management. 
            • The prepuce should be soaked in a warm dilute betadine/epsom salt solution. 
            • Coat the prepuce with "petermycin" (lanolin + scarlet oil + tetracycline). 
            • If the prepuce can be replaced, a sterile drain tube (3/4-1" x 5-6") is placed in the preputial cavity to hold the prepuce in place. 
            • The tube is taped in place with elasticon taping to the haired sheath only. 
            • The wrap should be changed daily, initially, then as needed. 
            • If the prepuce can not be replaced at first it can be treated as above and the exposed portion covered with a stockinette. 
              • A drain tube is inserted in the preputial cavity and must extend above the proximal part of the wrap to allow for urine egress. 
              • The prepuce (covered by stockinette) is wrapped with elasticon applying even pressure. 
              • This pressure wrap will decrease the edema and swelling usually making the prolapse reducible in 1-2 days. 
              • Change wrap daily, then as needed. 
              • The object of medical treatment is to get control of edema, cellulitis and necrosis and establish a healthy bed of granulation tissue.
            • Surgery is indicated if fibrous tissue development prevents normal extension of the prepuce or if there is habitual prolapse of the prepuce. 
            • If the value of the bull does not warrant surgery, salvage is an option. 
            • The most commonly performed surgical technique is the reefing procedure (resection-anastomosis). 
              • This technique is employed to revise damaged preputial tissues. 
              • General anesthesia, or tranquilization with a pudental nerve block or ring block may be used. 
              • A penrose drain tourniquet is tied near the preputial orifice and towel clamps are placed under the dorsal apical ligament to allow extension of the penis and prepuce during surgery. 
              • The site is surgically prepared and aseptic technique is utilized. 
              • Two circumferential incisions are made a sufficient distance apart to excise the affected tissues. 
              • The prepuce is measured prior to incision to assure that the final preputial length will be at least twice (2X) the length of the free portion of the penis. 
              • The circumferential incisions are connected by a longitudinal incision and the affected portion of prepuce is sharply dissected from the underlying elastic tissues. 
              • Dissection should be as superficial as possible but as deep as necessary in the areas of scar tissue formation. 
              • Hemostasis is important and after completion of dissection the tourniquet is removed and every effort is made to control hemorrhage to prevent subsequent hematoma/seroma formation. 
              • Closure is in two layers, elastic tissue and skin. 
              • An interrupted suture pattern using 2-0 vicryl is used for both layers. 
              • A penrose drain is sutured over the free end of the penis to prevent urine contamination during healing. 
              • The penis is allowed to return to the preputial cavity and a sterile soft rubber tube (with the penrose threaded through its lumen) is bandaged in place to retain the prepuce during healing. 
              • The bandage is removed in 5 days. 
              • At 10-14 days the penis is extended and any remaining sutures removed. 
              • Sexual rest is recommended for at least 60 days.



Preputial avulsion

  • Preputial avulsion usually occurs during semen collection with an artificial vagina (AV). 
  • If the AV is too tight, a transverse or oblique laceration may occur at the dorsum of the preputial ring or fornix. 
  • These injuries should be sutured immediately using 2-0 vicryl in an interrupted pattern. 
  • Allow 60-90 days of sexual rest.

    Retropreputial abscess

  • This is a frequent sequella to preputial laceration in Bos taurus bulls. 
  • The bull retracts the prepuce into the preputial cavity after injury. 
  • Drainage is impaired causing abscess formation and the abscess dissects into the elastic layers. 
  • Prognosis is guarded; there is less than 30% chance of return to service.
  • Conservative approaches include immediate salvage or 6 months pasture rest and re-examination; abscesses will occasionally effectively heal on their own. 
  • More aggressive treatment is drainage of the abscess into the preputial cavity followed by antiseptic flushes. 
  • If the abscess is drained through the skin, adhesions almost always develop which will eventually prevent penile extension. 
  • Systemic antibiotics are not that useful once the abscess is formed but may be of help if cellulitis is present. 
  • Actinomyces pyogenes is most frequently isolated from such abscesses, therefore, penicillin is the antibiotic of choice. 
  • Regardless of the method of treatment, possible complications include stricture formation and adhesion formation resulting in a useless breeding animal.


contributed by Marge Gill  on 22-Auguste-03 

Male Index


contributed by Bruce E Eilts on 25 September 2012




 

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