Bits Hanging Out

Question 1

describe vaginal prolapse and uterine prolapse (3)

Answer 1

1. vaginal prolapse:
   -360 degree protrusion of vaginal mucosa
   -vaginal fold prolapse also possible
2. uterine prolapse:
   -partial or complete eversion and protrusion of the uterus into the vaginal canal or externally through the vulva
3. dogs: vaginal > uterine
   -cats: uterine > vaginal

Question 2

describe the clinical presentation of vaginal prolapse (3)

Answer 2

1. signalment:
   -large breed dogs
   -VERY rare in cats
   -less than 2 years old, during one of the first estrus cycles
   -seems like there is a genetic component, so don’t breed these bitchez
2. history:
   -“mass” like protrusion
   -discharge or bleeding
3. physical exam findings:
   -looks like a shiny pink rolled up sock if it’s fresh
   -starts to dry out then can look leathery and ulcerated

Question 3

describe the pathophysiology of vaginal prolapse (3)

Answer 3

1. estrogen related (1st or 2nd heat cycle)
   -naturally increased estrogen levels: usually during estrus and proestrus
   -ingestion of estrogen supplements or licking estrogen cream
   -estrogen stimulates vaginal tissue to become hyperemic, edematous, and keratinized
2. non-estrogen related:
   -tenesmus
   -dystocia
   -vaginal masses
   -trauma: do NOT separate dogs that are “tied”
3. types:
   -type I: slight to moderate eversion of the vaginal mucosa cranial to the urethral orifice
   -type II: protrusion of the vaginal mucosa through the vulva
   -type III: complete protrusion of the entire circumference of vaginal mucosa

Question 4

describe medical management of vaginal prolapse (2)

Answer 4

1. type I and II: might seld resolve as estrogen decreases
   -keep it clean, keep it moist
   -lube and e-collar
2. type III: manual reduction
   -hyperosmotic therapy: 50% dextrose, 7.2% or 21% NaCl, SUGAR
   -purse string suture: NOT recommended!!!
   –will cause trauma and just going to happen again

Question 5

describe surgical management of vaginal prolapse (4)

Answer 5

1. indications:
   -failure of medical management: same heat cycle
   -recurrence of prolapse: in a separate heat cycle
   -damaged or necrotic prolapsed tissue
   -chronic prolapse
2. OHE should be performed at same time
   -removal of estrogen source
3. episiotomy likely necessary for better visualization if amputation or resection needed
   -purse string anus
   -urinary catheter to protect urethra
4. success rate:
   -almost 100% success rate if OHE performed
   -almost 100% recurrence if medical management and NO OHE

Question 6

describe clinical presentation of uterine prolapse (3)

Answer 6

1. signalment:
   -any age, no breed disposition
   -cats > dogs
2. history:
   -occurs during or shortly after parturition
   -usually excessive straining or dystocia: licking, abnormal posture, pain, dysuria
3. physical exam findings:
   -may have to do vaginal exam if not visible
   -may see perineal bulging

Question 7

describe pathophysiology of uterine prolapse (4)

Answer 7

1. associated with parturition (prolonged labor)
2. cervix must be dilated
3. one or both horns may prolapse
   -can be in the vagina or everted through the vulva
4. patients can present in shock if uterine or ovarian arteries are torn during prolapse!

Question 8

describe medical management of uterine prolapse (4)

Answer 8

1. rarely successful for uterus
   -must be 100% healthy tissue to try
2. approach similarly to vaginal prolapse
   -hyperosmotic therapy
   -manual reduction
   -no purse string
3. would need concurrent abdominal manipulation
   -will likely need something intra-vaginally as well
4. could administer oxytocin to promote uterine involution and closure of the cervix

Question 9

describe surgical management of uterine prolapse (3)

Answer 9

1. necessary if part or all of uterus is devitalized or if medical management failed
   -recommended to perform OHE at same time
2. approach 1: external
   -amputate the uterus externally and reduce the stump (+/- ovaries)
3. approach 2: internal:
   -pull the uterus back in and perform routine OHE

Question 10

describe urethral prolapse, paraphimosis, and phimosis

Answer 10

urethral prolapse: urethral mucosa everts beyond external urethral orifice

paraphimosis: inability to retract the penis into the prepuce

phimosis: inability of the penis to protrude from the prepuce
-we see zero bits

Question 11

describe clinical presentation and pathophysiology of urethral prolapse (4)

Answer 11

1. signalment:
   -male dogs
   -english bulldogs, because of course
2. history:
   -hematuria or blood dripping from penis
   -licking at area
   -red, purple mass at tip of penis
3. PE findings: please wear gloves
   -red, purple mass at tip of penis
4. pathophysiology: unknown
   -theories: respiratory difficulty (bulldogs), sexual excitement, urinary calculi or prostatic enlargement, increased abdominal pressure secondary to chronic upper airway obstruction

Question 12

describe medical management of a urethral prolapse (3)

Answer 12

1. stop the bleeding and prevent self trauma
   -sedation/analgesia
   -e collar
2. reduce the prolapse
3. plase a purse string suture

*medical management is definitely worth a short but clients need to be warned that this may happen again

Question 13

describe surgical mangement of urethral prolapse (4)

Answer 13

1. indicated after failure of medical management or excessive bleeding
2. 3 options:
   -surgical resection of prolapsed urethra
   -urethropexy
   -resection and pexy
3. neutering is recommended at the time of surgery although there is no real link between recurrence and testicles
4. most common complications: continued bleeding and recurrence of prolapse

Question 14

describe clinical presentation of paraphimosis

Answer 14

1. signalment:
   -dogs > cats
   -sexual hyperactivity generally associated with younger dogs
2. history:
   -dogs: most commonly occurs after an erection
   -cats: can get tangled in long hair
3. PE findings
   -it’s out

*priapism: persistent erection of the penis without excitement

Question 15

describe pathophysiology of paraphimosis

Answer 15

1. causes:
   -copulation
   -trauma
   -neoplasia
   -neuro deficits
   -foreign bodies
   -hair rings
   -sometimes the prepuce rolls in on itself and therefore the preputial orifice is smaller than it would normally be
2. paraphimosis causes impaired circulation which leads to edema and necrosis

Question 16

describe medical management of paraphimosis

Answer 16

1. retract prepuce until mucocutaneous junction is visualized
2. examine site
3. keep it clean, keep it moist
4. hyperosmotic agents:
   -50% dextose, hypertonic saline, sugar
5. make sure it’s clean!!!

*medical management is generally successful

Question 17

describe surgical management of paraphimosis

Answer 17

1. preputiotomy or preputial reconstruction
   -cranial advancement if mild
2. phallopexy
3. penile amputation:
   -partial is most common: cranial to os penis
4. castration is recommended at the same time

Question 18

describe rectal prolapse and clinical presentation

Answer 18

rectal prolapse: one or more layers of the rectum protrudes through the anus

clinical presentation:
1. signalment: usually young animals

2. history:
   -diarrhea or tenesmus
   -straining to defecate
3. PE findings:
   -elongated, cylindrical mass protruding through the anal orificed

Question 19

describe the pathophysiology of rectal prolapse

Answer 19

1. most commonly: severe diarrhea or tenesmus
2. in young animals can be due to parasitism or severe enteritis (parvovirus)
3. older animals can be due to neoplasia
4. any age:
   -dystocia
   -urolithiasis or urethral obstruction

Question 20

describe medical management of a rectal prolapse

Answer 20

1. keep it clean keep it moist
2. hyperosmotic agens
3. purse string suture: get a helper or a syringe case
4. stool softener to go home with patient
5. must treat the underlying cause at the same time!

Question 21

describe surgical management of a rectal prolapse

Answer 21

1. indicated when medical management has been failed or there is a distal rectal mass
2. rectal resection and anastomosis if tissue necrosis
3. rectal pull through

4, colopexy may be required