History
A 10-month-old 488-kg (1,074-lb) Brown Swiss bull that was intended for use as a breeding animal was admitted to the Cornell University College of Veterinary Medicine Farm Animal Hospital and examined because of severe swelling of the prepuce and ventral abdomen as well as straining to urinate. Four weeks before admission, the bull had attempted to jump over a fence but became suspended on the wire; there was blunt trauma to the prepuce and caudal portion of the ventral abdomen. Initially, swelling in the injured region was moderate and the bull was able to urinate normally. Treatment of the bull on the farm by the referring veterinarian included administration of dexamethasone and flunixin meglumine (dose, route, and frequency unknown) and frequent application of ice to the region. This treatment was initially successful in resolving the clinical signs. However, 1 day before admission to our facility, the prepuce became markedly enlarged and urination was impaired. The referring veterinarian aspirated approximately 50 mL of bloody fluid from the preputial swelling, and the bull was referred for further evaluation.
On arrival at our facility, a complete physical examination was performed. The bull stood quietly and was alert and responsive. Tachypnea and tachycardia were detected. Severe edema of the entire ventral aspect of the abdomen was evident; this was confirmed by transabdominal ultrasonography. Results of palpation and ultrasonography performed per rectum were within anticipated limits, although the bladder was not identified. Blood samples were collected for measurement of PCV. Total plasma protein concentration was determined, and a CBC, patient-side biochemical analysis, and measurement of electrolyte concentrations were performed.a All values were within reference limits, except for a slight increase in blood pH (7.49; reference range, 7.32 to 7.44).
Treatment included administration of ceftiofur sodium (2.2 mg/kg [1 mg/lb], IV, q 12 h), penicillin G procaine (22,000 U/kg [10,000 U/lb], IM, q 12 h), and flunixin meglumine (1.1 mg/kg [0.5 mg/lb], IV, q 12 h). Exploratory surgery of the prepuce and penis was scheduled for the following day.
To evaluate the prepuce and penis, a 25-cm incision was made on the ventral midline. The incision began 10 cm caudal to the preputial orifice and was extended caudally. A 10-cm section of the prepuce located 20 cm caudal to the preputial orifice was damaged and necrotic with evidence of fibrosis and stricture formation (Figure 1). The penis and urethra were not damaged, and no evidence of a hematoma or an abscess was evident. Although the penis was not adhered to the damaged prepuce, manual extrusion of the penis through the preputial opening was not possible because of severe edema surrounding the sigmoid flexure that limited movement of the penis.
Photograph of a 10-cm section of prepuce located approximately 20 cm caudal to the preputial orifice of a 10-month-old Brown Swiss bull 4 weeks after the bull was injured while attempting to jump over a fence. Cranial is to the right.
Citation: Journal of the American Veterinary Medical Association 241, 4; 10.2460/javma.241.4.439
Photograph of a 10-cm section of prepuce located approximately 20 cm caudal to the preputial orifice of a 10-month-old Brown Swiss bull 4 weeks after the bull was injured while attempting to jump over a fence. Cranial is to the right.
Citation: Journal of the American Veterinary Medical Association 241, 4; 10.2460/javma.241.4.439
Photograph of a 10-cm section of prepuce located approximately 20 cm caudal to the preputial orifice of a 10-month-old Brown Swiss bull 4 weeks after the bull was injured while attempting to jump over a fence. Cranial is to the right.
Citation: Journal of the American Veterinary Medical Association 241, 4; 10.2460/javma.241.4.439
We postulated that the initial injury resulted in delayed development of a stricture of the prepuce, which ultimately impeded urine drainage. Accumulation of urine in the preputial cavity eventually led to rupture of the lamina interna and dissemination of urine into the subcutaneous tissues. Alternatively, the devitalized epithelium of the prepuce may have allowed extravasation of urine into the peripreputial elastic and subcutaneous tissues. Regardless of the cause, urine accumulation in the surrounding soft tissues was the source of the severe preputial and peripreputial edema.
Question
What treatment provides the bull with the best chance for future use as a breeding animal? Please turn the page.
Answer
Surgical resection and anastomosis of the damaged prepuce (circumcision [reefing operation]) and, if necessary, secondary preputial reconstruction.
Results
Resection and anastomosis of the damaged prepuce (ie, circumcision) was performed to remove the necrotic segment of preputial tissue. The procedure involved resection of the damaged preputial lamina interna and subsequent closure of the elastic tissues and anastomosis of the lamina interna of the prepuce to the penis with 2–0 polyglecaprone 25b (Figure 2). A preputial liner, consisting of a 2.5-cm Penrose drain, was anchored to the penis with 3–0 polyglecaprone 2b prior to completion of the anastomosis to facilitate voiding of urine. Urine extravasation into the peripreputial tissues associated with formation of the stricture and the subsequent rupture of the prepuce in this bull led to severe edema and necrosis of the subcutaneous tissues of the ventral abdominal wall. Therefore, multiple large incisions were made through the skin into the peripreputial tissues and connected with 2.5-cm Penrose drains to promote drainage following repair of the preputial injury. Postsurgical care included continuation of the preoperative antimicrobials (ceftiofur sodium and penicillin G procaine) and anti-inflammatory medication (flunixin meglumine); flunixin meglumine was discontinued after 3 days. Cold-water hydrotherapy of the swollen preputial region was performed once daily for 2 weeks, and the Penrose drains were removed 8 days after surgery.
Photograph of the completed anastomosis of the lamina interna of the prepuce with the penis within the sheath. The right end of the incision is toward the preputial orifice. Cranial is to the right.
Citation: Journal of the American Veterinary Medical Association 241, 4; 10.2460/javma.241.4.439
Photograph of the completed anastomosis of the lamina interna of the prepuce with the penis within the sheath. The right end of the incision is toward the preputial orifice. Cranial is to the right.
Citation: Journal of the American Veterinary Medical Association 241, 4; 10.2460/javma.241.4.439
Photograph of the completed anastomosis of the lamina interna of the prepuce with the penis within the sheath. The right end of the incision is toward the preputial orifice. Cranial is to the right.
Citation: Journal of the American Veterinary Medical Association 241, 4; 10.2460/javma.241.4.439
Eighteen days after the surgery, examination of the bull revealed that the Penrose drain had become disconnected from the penis and there was restricted movement of the penis within the damaged prepuce and secondary fibrosis of ventral abdominal tissue resulting from urine leakage into the subcutaneous tissues. Thus, it was determined that preputial revision surgery was necessary. The purpose of the second surgical intervention was to create a new preputial opening at a location caudal to the abnormal fibrotic tissue and remnant of the original preputial orifice; this new preputial opening would be consistent with the length of the remaining healthy lamina interna.
Stage 1 of the preputial revision surgery involved creation of a 3-cm circular stoma on the ventral midline in healthy skin approximately 20 cm caudal to the preputial orifice. The preputial elastic tissues and lamina interna were sutured with 2–0 polyglecaprone 25 to the subcutaneous tissues and skin, respectively (Figure 3). A 2.5-cm Penrose drain again was sutured to the penile epithelium with 3–0 polyglecaprone 25 to function as a preputial liner and to facilitate voiding of urine, thereby protecting the healing penis from damage and desiccation. Postsurgical care included perioperative administration of antimicrobials (ceftiofur sodium and penicillin G procaine) and anti-inflammatory medication (flunixin meglumine).
Photograph of the reconstructed preputial opening in the bull of Figure 1. A 3-cm circular skin incision was made in a paramedian location on the ventral aspect of the abdomen for creation of the preputial opening. The preputial elastic tissues and lamina interna were sutured with 2–0 polyglecaprone 25 to the subcutaneous tissues and skin, respectively. The reconstructed preputial opening was located approximately 20 cm caudal to the original preputial orifice. Cranial is to the right.
Citation: Journal of the American Veterinary Medical Association 241, 4; 10.2460/javma.241.4.439
Photograph of the reconstructed preputial opening in the bull of Figure 1. A 3-cm circular skin incision was made in a paramedian location on the ventral aspect of the abdomen for creation of the preputial opening. The preputial elastic tissues and lamina interna were sutured with 2–0 polyglecaprone 25 to the subcutaneous tissues and skin, respectively. The reconstructed preputial opening was located approximately 20 cm caudal to the original preputial orifice. Cranial is to the right.
Citation: Journal of the American Veterinary Medical Association 241, 4; 10.2460/javma.241.4.439
Photograph of the reconstructed preputial opening in the bull of Figure 1. A 3-cm circular skin incision was made in a paramedian location on the ventral aspect of the abdomen for creation of the preputial opening. The preputial elastic tissues and lamina interna were sutured with 2–0 polyglecaprone 25 to the subcutaneous tissues and skin, respectively. The reconstructed preputial opening was located approximately 20 cm caudal to the original preputial orifice. Cranial is to the right.
Citation: Journal of the American Veterinary Medical Association 241, 4; 10.2460/javma.241.4.439
Stage 2 of the preputial revision was performed 3 weeks after the stage 1 surgery. Although urination did not appear to be impeded in the bull at this time, the position of the preputial opening created during stage 1 did not allow complete retraction of the penis, which protruded constantly and was exposed to desiccation and injury. Therefore, the preputial opening created during stage 1 was translocated craniad and closer to the original location of the preputial orifice. Approximately 5 weeks later, a final surgery was performed to again translocate the created preputial opening craniad, with the goal of slowly stretching the lamina interna. However, the preputial opening could not be moved to the original location of the preputial orifice because of severe fibrosis of the ventral abdominal wall; therefore, despite surgery, the artificially created preputial orifice remained in an abnormal, caudal, and slightly lateral location on the abdomen.
A breeding soundness examination was performed prior to discharge of the bull from the hospital. Scrotal circumference was 35 cm. Manual massage per rectum was used for collection of a semen sample. Examination of the sample revealed that results for semen variables were within reference limits.
Discussion
The most common causes of preputial swelling in bulls include urethral trauma or rupture secondary to urethral obstruction, penile hematoma, and preputial trauma, prolapse, or abscess formation.1–6 Obstructive urolithiasis is detected most frequently at the distal sigmoid flexure of the penis, where there is marked narrowing of the urethra, and may result in rupture of the urinary bladder or urethra.4 Rupture of the bladder usually results in progressive abdominal distention secondary to urine accumulation within the abdomen.7 Urethral rupture occurs more commonly in steers than in bulls and causes obvious clinical signs of severe ventral edema and necrosis as urine permeates the peripreputial tissues. Although the bull of the present report did not have a urethral rupture, it was a differential diagnosis because of the severe peripreputial swelling at the time of admission. Rupture of the urethra usually follows calculi-induced urinary obstruction, although traumatic injury to the penis has been reported as a cause of urethral rupture in bulls.8 Several surgical techniques are available for the management of obstructive urolithiasis in cattle. These include urinary diversion by ischial urethrostomy, calculus removal by urethrotomy, and penile amputation.4,5 The choice of procedure depends on the extent of localized tissue damage, site of obstruction, and value and intended use of the animal. Most bulls with bladder or urethral rupture have a poor prognosis for use as breeding animals and are salvaged for slaughter via a urinary diversion surgery.
Hematoma of the penis after rupture of the tunica albuginea is a frequent sequela in bulls in association with breeding trauma.4,5 Acute swelling in the prepuce immediately cranial to the base of the scrotum develops rapidly following injury, and the penis is unable to be extruded from the prepuce because of the swelling. The size of the swelling may differ depending on the number of breeding attempts made by the bull after tunica albuginea rupture.4,5 Swelling located along the dorsal aspect of the penis near the base of the scrotum is characteristic because rupture occurs predominantly at the dorsal aspect of the distal sigmoid flexure.4,5 Prolapse of the prepuce is often associated with penile hematoma because blood and edema migrate ventrally. The ventral aspect of the abdomen may also have bruises associated with hemorrhage, which may be especially evident in light-colored bulls. For injuries in which the swelling is < 15 cm in diameter, conservative management consisting of sexual rest, administration of antimicrobial and anti-inflammatory medications, and hydrotherapy and massage is often successful for allowing healing and subsequent use as a breeding animal.4 For larger areas of damage, whereby adhesions and abscesses are more likely, surgical treatment involving primary closure of the tunica albuginea between 3 and 7 days after injury is preferred.4,5
Preputial trauma in bulls is also commonly associated with breeding injuries. Such injuries occur most frequently in breeding bulls in pasture settings, although bulls in stud facilities may also be injured.2 Primary preputial prolapse usually follows a breeding injury or herpes viral infection, whereas secondary prolapse is common following penile hematoma.5 The Bos indicus breeds are most commonly affected because of their pendulous sheaths, excessive prepuce, large preputial orifices, and absence of retractor prepuce muscles. Although Bos taurus bulls may have preputial prolapse following preputial injury, these bulls may also retract the damaged prepuce back into the preputial cavity where it may remain unnoticed until inflammation, infection, or stenosis develops.5
The degree of preputial prolapse, trauma, laceration, necrosis, and fibrosis determines whether medical or surgical treatment is indicated and the prognosis for subsequent use as a breeding animal.5 Many preputial injuries can be managed medically with a good prognosis for future fertility; however, some require surgical reconstruction after 2 to 8 weeks of medical treatment.2 The success of surgical intervention has been correlated with the ability to fully extend the penis prior to surgery.3 The most crucial factors for determining the prognosis are the length of the lacerated prepuce and the amount of damage to the peripenile elastic tissues.5 Blunt trauma, similar to that in the bull of the present report, occurs less commonly but may be associated with preputial swelling, necrosis, fibrosis, and prolapse. Complications of preputial injury include stricture, adhesions, fibrosis of the prepuce, retropreputial abscesses, phimosis, and paraphimosis.4–6
Both medical and surgical treatments may be used for the treatment of preputial injury in bulls.1–6 A minimum of 60 days of sexual rest is indicated during healing regardless of the method of treatment.2,5 Medical treatment of preputial trauma and prolapse is aimed at decreasing swelling and preventing secondary injury.4,5 Management consists of cleaning damaged tissues, application of an emollient antiseptic ointment, and the use of support bandages. Surgical treatment involves preputial resection and anastomosis or amputation and is indicated for most animals with preputial prolapse and animals in which preputial damage prevents normal urination or extrusion of the penis.1–6 Resection and anastomosis of the damaged prepuce (ie, circumcision) provides the highest rate of return to breeding soundness.5 Preputial amputation may be indicated for animals with extensive preputial damage in which exteriorization of the penis is not possible.2 The maximum amount of prepuce that can safely be removed to allow the bull to completely extend the penis after surgery should be a minimum of 1.5 times the remaining prepuce, compared with the length of the free portion of the penis.5 Acute lacerations of the prepuce should not be sutured because contamination of the peripreputial tissues often leads to abscess formation. Avulsion injury of the lamina interna of the prepuce from the penile attachment at the fornix is an exception and may be sutured immediately because these wounds are relatively clean and primary closure provides excellent healing.4 Reconstruction or translocation of the prepuce or the preputial orifice may be indicated in animals with preputial injury in which anastomotic healing is unacceptable or complications such as tissue necrosis, adhesions, fibrosis, or stricture prevent normal penile movement in the prepuce. The objective of the initial surgical treatment (resection and anastomosis of the damaged prepuce) in the bull of the present report was to enable the bull to subsequently mate with female cattle. However, the complications of urine leakage from the initial preputial rupture and subsequent preputial fibrosis and stricture required preputial revision surgery with the objective of enabling the bull to be used for semen collection for artificial insemination.
Outcome
In the bull of the present report, 4 surgical procedures were performed (initial circumcision of the damaged preputial tissue, reconstruction of the preputial lamina interna through creation of a new preputial opening, and 2 subsequent translocations of the newly created preputial opening). After the last procedure, the bull was able to extend and retract the penis within the prepuce and urinate normally and was discharged from the hospital. The bull was allowed 6 months of sexual rest, after which semen was collected for use in artificial insemination because of the resultant abnormal location of the preputial opening.
References
1 Wheat JD. Diseases of the penis and prepuce of the bull requiring surgery. J Am Vet Med Assoc 1951; 118:295–298.
2 Anderson DE. Surgery of the prepuce and penis. Vet Clin North Am Food Anim Pract 2008; 24:245–251.
3 Desrochers A, St-Jean G, Anderson DE. Surgical management of preputial injuries in bulls: 51 cases (1986-1994). J Can Vet 1995; 36:553–556.
4 Gilbert RO. Penile surgery; preputial surgery. In: Fubini SL, Ducharme NG, eds. Farm animal surgery. St Louis: WB Saunders Co, 2004;366-379.
5 Wolfe DF, Beckett SD, Carson SL. Acquired conditions of the penis and prepuce. In: Wolfe DF, Moll HD, eds. Large animal urogenital surgery. 2nd ed. Baltimore: Williams & Wilkins, 1998;237–272.
6 Baxter GM, Allen D, Wallace CE. Breeding soundness of beef bulls after circumcision: 33 cases (1980-1986). J Am Vet Med Assoc 1989; 194:948–952.
7 Ogaa JS, Agumbah GJO, Patel JH, et al. Massive obstructive urolithiasis in a bull used for artificial insemination. Vet Rec 1985; 117:664–666.
8 Wolfe DF, Mysinger PW, Hudson RS, et al. Ventral rupture of the penile tunica albuginea and urethra distal to the sigmoid flexure in a bull. J Am Vet Med Assoc 1987; 190:1313–1314.
