Clinical characteristics, classification, and surgical outcome for kittens with phimosis: 8 cases (2009–2017)

Annemarieke de Vlaming 1Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, FL 32608

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Mandy L. Wallace 2Department of Small Animal Medicine and Surgery, College of Veterinary Medicine, University of Georgia, Athens, GA 30602

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Gary W. Ellison 1Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, FL 32608

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Abstract

OBJECTIVE

To describe clinical characteristics and surgical outcomes for kittens with phimosis and to develop a system to classify phimosis on the basis of gross pathological lesions.

ANIMALS

8 kittens with phimosis.

PROCEDURES

Medical record databases of 2 veterinary teaching hospitals were searched to identify records of cats ≤ 20 weeks old (ie, kittens) with phimosis that underwent surgical intervention between 2009 and 2017. For each kitten, information extracted from the record included signalment, history, clinical signs, physical examination findings, treatments, and details regarding the surgical procedure performed, postoperative complications, and outcome.

RESULTS

The most common clinical signs were stranguria (n = 6), marked preputial swelling (5), and a small (6) or inevident (2) preputial orifice. Six kittens had type 1 phimosis (generalized preputial swelling owing to urine pooling without penile-preputial adhesions) and underwent circumferential preputioplasty. Two kittens had type 2 phimosis (focal preputial swelling and urine pooling in the presence of penile-preputial adhesions) and underwent preputial urethrostomy. No postoperative complications were recorded for kittens that underwent preputial urethrostomy. All 6 kittens that underwent circumferential preputioplasty had some exposure of the tip of the penis immediately after surgery, which typically resolved over time. At the time of last follow-up (mean, 1.4 years after surgery), all 8 patients were able to urinate and had no signs of phimosis recurrence.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggested that circumferential preputioplasty and preputial urethrostomy could be used to successfully manage kittens with type 1 and type 2 phimosis, respectively.

Abstract

OBJECTIVE

To describe clinical characteristics and surgical outcomes for kittens with phimosis and to develop a system to classify phimosis on the basis of gross pathological lesions.

ANIMALS

8 kittens with phimosis.

PROCEDURES

Medical record databases of 2 veterinary teaching hospitals were searched to identify records of cats ≤ 20 weeks old (ie, kittens) with phimosis that underwent surgical intervention between 2009 and 2017. For each kitten, information extracted from the record included signalment, history, clinical signs, physical examination findings, treatments, and details regarding the surgical procedure performed, postoperative complications, and outcome.

RESULTS

The most common clinical signs were stranguria (n = 6), marked preputial swelling (5), and a small (6) or inevident (2) preputial orifice. Six kittens had type 1 phimosis (generalized preputial swelling owing to urine pooling without penile-preputial adhesions) and underwent circumferential preputioplasty. Two kittens had type 2 phimosis (focal preputial swelling and urine pooling in the presence of penile-preputial adhesions) and underwent preputial urethrostomy. No postoperative complications were recorded for kittens that underwent preputial urethrostomy. All 6 kittens that underwent circumferential preputioplasty had some exposure of the tip of the penis immediately after surgery, which typically resolved over time. At the time of last follow-up (mean, 1.4 years after surgery), all 8 patients were able to urinate and had no signs of phimosis recurrence.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggested that circumferential preputioplasty and preputial urethrostomy could be used to successfully manage kittens with type 1 and type 2 phimosis, respectively.

Phimosis is characterized as an inability to extrude the penis through the prepuce, typically owing to a narrowing of the preputial orifice.1–3 It is described as either a congenital or acquired condition in both dogs and cats.1,3–9 Acquired phimosis is believed to result most commonly from trauma, such as excessive grooming, but has been described as a sequela to lower UTI, neoplasia, or cellulitis.1,3,4,6,9 Excessive perineal cleaning by the dam and redirected or aberrant suckling behavior of littermates toward the prepuce of male puppies or kittens can cause inflammation and narrowing of the preputial orifice and subsequently phimosis.4,6,7,9 Clinical signs associated with phimosis in dogs and cats include pollakiuria, stranguria, urine dribbling, excessive preputial licking, vocalization, preputial distension secondary to urine retention, balanoposthitis, and in severe cases, skin ulceration.1,3–9

To our knowledge, regarding cats, phimosis has been described only in studies4,5,7 involving both kittens and adult cats and has not been further characterized on the basis of clinical signs and findings. The goals of the study reported here were to describe the clinical characteristics of and surgical outcomes for kittens with phimosis and to develop a system to classify phimosis on the basis of gross pathological lesions.

Materials and Methods

Case selection criteria

The electronic medical record databases of the veterinary medical teaching hospitals at the University of Florida and University of Georgia were searched to identify records of cats that were examined and underwent surgical intervention for phimosis between 2009 and 2017. To be included in the study, the cats had to be ≤ 20 weeks old (ie, kittens) at the time of initial examination. Cats that were > 20 weeks old and that did not undergo surgical intervention to correct phimosis were excluded from the study.

Medical records review

For kittens eligible for study inclusion, data extracted from the medical record included signalment, history, age at the time of surgery, clinical signs, physical examination findings (particularly for the penis and prepuce), information regarding trauma to the preputial area, treatments administered, surgical procedure performed, postoperative complications, and outcome. Follow-up information was obtained at the time of suture removal, during additional recheck examinations, and by telephone conversations with patient owners.

Phimosis classification

Each kitten was classified as having either type 1 or type 2 phimosis. Type 1 phimosis was defined as a narrowed preputial orifice with generalized swelling or outward ballooning of the prepuce owing to urine pooling within the prepuce in the absence of adhesions between the penis and prepuce (penile-preputial adhesions). Type 2 phimosis was defined as a narrowed preputial orifice, penile-preputial adhesions, and urine pooling that was more focal than that for type I, which resulted in more discrete preputial swelling (Figure 1).

Figure 1—
Figure 1—

Illustrations of a sagittal section of the distal aspect of the penis, urethra, and prepuce of male cats that depict the 2 classifications (types 1 and 2) of phimosis as defined for a retrospective case series of kittens (age, ≤ 20 weeks) with the condition along with schematic representations of the surgical procedures used to correct each type of phimosis. Type 1 phimosis was defined as generalized swelling of the preputial area owing to urine pooling within the prepuce and the absence of penile-preputial adhesions. Kittens with type 1 phimosis underwent circumferential preputioplasty, during which a 360° incision was made around the preputial orifice with care taken to avoid excessive enlargement of the preputial orifice and penile exposure. The skin surrounding the existing preputial orifice was extirpated, and the preputial mucosa was sutured to the skin with small-gauge (5–0 to 7–0) absorbable suture in a simple interrupted pattern. This created a new 360° preputial opening (inset). Type 2 phimosis was defined as focal preputial swelling and urine pooling in the presence of adhesions between the penis and preputial mucosa. Kittens with type 2 phimosis underwent a modified preputial urethrostomy, during which a teardrop-shaped incision was made at the dorsal aspect of the prepuce so that the distal aspect of the penis could be visually observed. The distal aspect of the penis was mobilized by use of blunt dissection to break down penile-preputial adhesions. An incision was made in the dorsal midline of the penile urethra that extended from the urethral opening proximally for approximately 5 mm. The incised portion of the urethra was splayed open, and the urethral mucosa was sutured to the skin with small-gauge suture in a simple interrupted pattern (inset). (Medical illustrations by J. Samson © 2017 University of Georgia).

Citation: Journal of the American Veterinary Medical Association 255, 9; 10.2460/javma.255.9.1039

Surgical procedures

Kittens typically received oral medications and topical or mechanical remedies aimed at reducing preputial swelling prior to surgery at the discretion of the attending clinician. The preoperative venous PCV and total solids concentration were determined for some but not all kittens. The anesthetic protocol was determined by the attending anesthetist and varied among kittens; however, all anesthetic protocols included premedication, general (inhalation) anesthesia, and postoperative analgesia. All surgical procedures were performed by a board-certified veterinary surgeon or surgical residents in training under the supervision of a board-certified veterinary surgeon. Surgical loupes were used for all surgical procedures.

Once anesthetized, each kitten was positioned in dorsal recumbency with the pelvic limbs pulled cranially. The prepuce and caudoventral aspect of the abdomen were clipped and aseptically prepared with 4% chlorhexidine scrub and sterile saline (0.9% NaCl) solution in a routine manner. For patients in which the preputial opening could be identified, a pair of small hemostats was used to try to expand the opening. If the preputial orifice could not be expanded with the hemostats, an incision was made with a No. 15 scalpel blade beginning at the preputial opening and extending in a proximoventral direction for approximately 5 mm. Blunt dissection was used to expand the incision and determine whether the penis was adhered to the preputial mucosa. Phimosis was classified as type 1 or 2 on the basis of the absence or presence of penile-preputial adhesions, respectively.

For patients with type 1 phimosis (ie, no penile-preputial adhesions), a circumferential preputioplasty was performed as described.7 Briefly, a No. 15 scalpel blade was used to make a 360° incision around the preputial orifice with care taken to avoid excessive enlargement of the preputial opening and penile exposure. The skin surrounding the existing preputial orifice was extirpated, and the preputial mucosa was sutured to the skin with small-gauge (5–0 to 7–0) absorbable suture (polydioxanone or poliglecaprone 25) in a simple interrupted pattern. This created a new preputial opening (Figure 1).

For patients with type 2 phimosis, the penis was generally adhered to the preputial mucosa in a circumferential manner. The distal aspect of the penis was mobilized by the use of blunt dissection to break down the adhesions in preparation for a preputial urethrostomy as described.10 Briefly, a 24-gauge over-the-needle catheter was inserted into the penile urethral opening to facilitate identification of the distal aspect of the urethral lumen. A teardrop-shaped incision was made at the dorsal aspect of the prepuce so that the distal aspect of the penis could be visually observed and mobilized. A No. 15 scalpel blade was used to make an incision in the dorsal midline of the penile urethra that extended from the urethral opening proximally for approximately 5 mm. Then, the urethral incision was splayed open, and the urethral mucosa was sutured to the skin with small-gauge (5–0 to 7–0) absorbable suture (polydioxanone or poliglecaprone 25) in a simple interrupted pattern (Figure 1).

Postoperative management was similar for all kittens, although drugs and dosages varied on the basis of the preferences of the attending clinicians. Typically, kittens received an antimicrobial (ampicillin or ampicillin-sulbactam, IV) for 24 hours after surgery and buprenorphine (parenterally or PO) for 48 to 72 hours after surgery. Petrolatum or triple antibiotic ointment was topically applied to the prepuce for 7 days. Additionally, it was prescribed that kittens wear an Elizabethan collar and use paper litter for 10 days after surgery.

Results

Kittens

Eight kittens from multiple litters met the inclusion criteria and were evaluated in the study. All 8 kittens were classified as domestic shorthair or medium-hair cats. Four kittens were from shelters, and 4 were privately owned. One kitten and a female littermate were orphaned at birth, and the 2 kittens were observed suckling each other. Another kitten was separated from its dam because the queen was observed to excessively groom the preputial area of the kitten. Information regarding age at shelter intake or owner adoption, interaction with littermates, and weaning status was unavailable or incomplete for the remaining 6 kittens. Three of the 4 affected kittens from shelters were littermates as were 2 of the 4 affected privately owned kittens.

The kittens had a mean age of 10.5 weeks (range, 4 to 16 weeks) and body weight of 1.56 kg (3.43 lb; range, 0.75 to 2.22 kg [1.65 to 4.88 lb]) at the time of surgical alleviation of phimosis (phimosis surgery).

Of the 8 kittens, 3 were castrated 2 weeks prior to and 2 were castrated at the same time as the phimosis surgery. The remaining 3 kittens were castrated when they were between 7 and 8 months old. Each of 2 kittens had a unilateral inguinal cryptorchid testicle, which was removed by means of an inguinal surgical approach. All other testicles were removed by means of a standard scrotal approach.

Clinical signs and treatment

Six of the 8 kittens were examined because of stranguria. On physical examination, 5 kittens had markedly erythematous preputial swelling, whereas 1 kitten had only mild preputial swelling, owing to urine pooling within the prepuce. At the time of surgery, the preputial orifice could not be identified or was abnormally small for 2 and 6 kittens, respectively. Phimosis was classified as type 1 (absence of penile-preputial adhesions) for 6 kittens and as type 2 (presence of penile-preputial adhesions) for 2 kittens.

Three of the 6 kittens with type 1 phimosis and 1 of the 2 kittens with type 2 phimosis underwent minor surgical manipulations prior to phimosis surgery. For each of the 3 kittens with type 1 phimosis, an attempt was made to dilate or enlarge the preputial orifice with either hemostats (n = 2 kittens) or an incision (1) at a mean of 26 days (range, 19 to 30 days) prior to phimosis surgery. At the time of phimosis surgery, the penis could still be extruded from the prepuce for 1 of the 2 kittens in which the preputial orifice was dilated with hemostats; the penis could not be extruded from the prepuce of the other 2 kittens. The kitten with type 2 phimosis had mucopurulent material drained from the prepuce 2 months prior to phimosis surgery and underwent another minor surgical procedure 26 days before the phimosis surgery. That procedure involved incising the prepuce and suturing the base of the penis to the skin in an attempt to keep it exteriorized.

The 4 kittens that underwent minor surgical manipulations prior to phimosis surgery also received medical treatment until the phimosis surgery was performed. That treatment included prednisolone (0.5 to 1 mg/kg/d [0.23 to 0.45 mg/lb/d], PO) and topical application of a steroid ointment to the preputial area. One kitten received meloxicam (0.1 mg/kg [0.05 mg/lb], PO, q 24 h for 7 days) instead of prednisolone for a short period. The kitten with type 2 phimosis received ampicillin-sulbactam (30 mg/kg [13.6 mg/lb], SC, once) and amoxicillin–clavulanic acid (20 mg/kg [9.1 mg/lb], PO, q 12 h) owing to concerns about a preputial abscess in addition to intermittent topical application of warm compresses and dextrose to the preputial area in an attempt to reduce preputial swelling as well as silver sulfadiazine cream. That kitten also received buprenorphine (0.016 mg/kg [0.007 mg/lb], buccally, q 8 to 12 h) for analgesia as necessary. The mean duration of medical management was 42 days for those 4 kittens.

The 6 kittens with type 1 phimosis underwent circumferential preputioplasty (Figure 2), and the 2 kittens with type 2 phimosis underwent preputial urethrostomy without aggressive mobilization of the penis (Figure 3). Surgery was performed on an outpatient basis for 5 kittens, whereas the 3 remaining kittens were hospitalized overnight and discharged from the hospital the day after surgery.

Figure 2—
Figure 2—

Photographs of the preputial region of a young (≤ 20 weeks old) male domestic medium-hair kitten immediately (A) and 10 days (B and C) after circumferential preputioplasty was performed to alleviate type 1 phimosis. Exposure of the distal tip of the penis (most evident in panel C) was commonly observed following that procedure but generally resolved over time. The anus is to the bottom in panels A and B and to the left in panel C. See Figure 1 for remainder of key.

Citation: Journal of the American Veterinary Medical Association 255, 9; 10.2460/javma.255.9.1039

Figure 3—
Figure 3—

Photographs of the preputial region of a young (≤ 20 weeks old) male domestic shorthair kitten immediately (A) and 10 days (B) after a modified preputial urethrostomy was performed to alleviate type 2 phimosis. In panel A, a 3.5F red rubber catheter has been inserted into the bladder through the newly created urethral opening to show the location of the new urethral opening. The catheter was removed immediately after surgery. The anus is to the bottom in both panels. See Figure 1 for remainder of key.

Citation: Journal of the American Veterinary Medical Association 255, 9; 10.2460/javma.255.9.1039

No postoperative complications were reported for the 2 kittens with type 2 phimosis that underwent preputial urethrostomy. Complications associated with circumferential preputioplasty included exposure of the tip of the penis (n = 6) and UTI (2). All 6 kittens that underwent circumferential preputioplasty had some degree of penis exposure immediately following surgery. The extent to which the tip of the penis was exposed decreased over time for all 6 kittens. For 4 kittens, the penis was no longer exposed at the time of the first postoperative recheck examination (mean duration after surgery, 9.5 days; range, 24 hours to 23 days). For the remaining 2 kittens, 1 to 2 mm of the penis remained exposed at the time of the last recheck examination (25 days and 7 months after surgery).

Two of the 6 kittens that underwent circumferential preputioplasty developed signs of a UTI, such as dysuria, hematuria, and stranguria, approximately 7 months after surgery. A urine sample from only one of those kittens was submitted for bacterial culture, which yielded growth of Staphylococcus pseudintermedius (100,000 colonies/mL). Both kittens were treated with amoxicillin–clavulanic acid (62.5 mg, PO, q 12 h for 14 days), and 1 also received prazosin (0.15 mg/kg [0.07 mg/lb], PO, q 12 h for 7 days). One kitten developed signs of a urinary tract obstruction which was medically resolved before the kitten was subsequently lost to follow-up 2 months thereafter. The other kitten recovered and was reportedly doing well 4 years after surgery, which was the time of the last communication with the owner.

Patient outcome

Follow-up information was obtained by either recheck physical examination or telephone communication with the owner for each of the 8 kittens. Only 1 kitten was visually assessed after the initial recheck examination at 2 to 4 weeks after surgery. That kitten underwent circumferential preputioplasty and had persistent exposure of the tip of the penis up to 7 months after surgery, at which time it was lost to follow-up. The tip of the penis was dry, but no other clinically relevant findings were recorded. Another kitten was lost to follow-up 23 days after phimosis surgery but was doing well with no stricture formation or dysuria at that time. The remaining 6 kittens were reportedly doing well at home with no clinical concerns at least 6 months after surgery, and 2 of those patients continued to do well for 4 years after surgery.

Discussion

In the present retrospective study, the clinical characteristics and surgical outcomes were described for kittens with 2 distinct types of phimosis. Six of the 8 kittens evaluated had type 1 phimosis, which was defined as phimosis accompanied by preputial swelling owing to urine pooling within the prepuce without any penile-preputial adhesions. The remaining 2 kittens had type 2 phimosis, which was defined as phimosis caused by the presence of penile-preputial adhesions and focal preputial swelling and urine pooling. The underlying cause for phimosis could not be determined for the kittens of the present study; however, the erythematous and swollen nature of the prepuce in kittens that were orphaned at a young age suggested some kind of acquired trauma as the inciting cause. Excessive grooming of the preputial area of male kittens by the queen has been reported to contribute to phimosis formation9 and was observed for 1 kitten of the present study. Another kitten of the present study developed phimosis after a littermate was observed suckling its prepuce. That type of aberrant suckling is not uncommon in orphaned kittens.11 In the present study, 3 kittens that were littermates developed phimosis at a young age. It was suspected that aberrant suckling of the prepuce was the cause of phimosis in those 3 kittens, but we were unable to definitively determine whether phimosis was caused by aberrant suckling, excessive grooming by the queen, or some type of heritable congenital etiology on the basis of the information recorded in the medical records. Two of the 8 study kittens had a unilateral inguinal cryptorchid testicle, which increased the index of suspicion that those kittens might have other congenital abnormalities; however, the dam of one of those kittens was observed to excessively groom the kitten's prepuce. For the 8 kittens with phimosis evaluated in the present study, the most common clinical sign was stranguria (n = 6 kittens) followed by marked preputial swelling (5) and a small (6) or inevident (2) preputial orifice, all of which were consistent with other reports1,3–7,9 of cats with phimosis.

To our knowledge, although the gross characteristics of cats with phimosis have been described,3–6,9 the present study was the first to propose a classification system to more accurately distinguish the condition into 2 types on the basis of the pathological lesions present. The classification system described in the present study clarified the distinct appearance of each type of phimosis, which facilitated appropriate surgical management. Kittens with type 1 phimosis (generalized urine pooling within the prepuce with no penile-preputial adhesions) underwent a circumferential preputioplasty similar to that described by Yoon and Jeong.7 That procedure created a new preputial orifice and allowed for accurate mucosa-to-skin apposition.7 The advantage of that procedure is that it results in the creation of an opening large enough to prevent paraphimosis and decreases the risk for stricture formation and subsequent recurrent phimosis. In kittens with type 2 phimosis, penile-preputial adhesions limited visual assessment of the penis, and even after the adhesions were bluntly dissected, there was insufficient preputial mucosa available to perform a preputioplasty. Therefore, kittens with type 2 phimosis underwent a modified preputial urethrostomy similar to that described by Yeh and Chin.10 That procedure resulted in minimal penile mobilization and an incision of ≤ 5 mm in the distal aspect of the penile urethra. The urethral mucosa was precisely sutured to the skin with small-gauge suture in an effort to ensure lasting urethral patency and minimize the risk for complications. Although both kittens with type 2 phimosis in the present study were successfully managed with a modified preputial urethrostomy, it is possible a conventional perineal urethrostomy might be necessary for other cats with type 2 phimosis. Preputial urethrostomy was chosen for the kittens of the present study owing to their young age and because it is less invasive and requires less mobilization of the penis than a perineal urethrostomy.4,10 Use of preputial urethrostomy as the initial surgical intervention also left perineal urethrostomy as a backup alternative in the event that the preputial urethrostomy was unsuccessful or a stricture subsequently formed.

Results of the present study suggested that kittens with type 1 phimosis can be successfully managed with a circumferential preputioplasty and kittens with type 2 phimosis can be successfully managed with a modified preputial urethrostomy. The fact that all 8 kittens evaluated in this study continued to be able to urinate following phimosis surgery despite continued maturation and growth provided further support for the use of those procedures in young kittens. Seven of the 8 kittens were followed for at least 6 months after surgery, with 2 followed for 4 years; thus, most patients had attained adulthood at the time of last follow-up. These findings appeared to contradict an established reference,3 which suggests that kittens that undergo surgical correction of phimosis at a young age will likely require additional surgeries to maintain a patent urethra as they grow and mature.

All 8 kittens of the present study received medical treatment for phimosis for 1 to 2 months prior to surgical alleviation of the condition. Thus, it appeared that medical management is ineffective for the treatment of phimosis in kittens. This differs from human medicine in that topical application of corticosteroids can be an effective treatment for phimosis in boys.12 Physical dilation of the preputial orifice with hemostats and use of a ventral incision to expand the preputial orifice were likewise unsuccessful for long-term treatment of phimosis as evidenced by the fact that all 4 kittens that underwent those procedures had recurrence of the condition and required more extensive corrective surgery. For the kittens of this study, it was suspected that dilation of the preputial orifice in the absence of mucosa-to-skin apposition failed owing to subsequent stricture formation at the orifice. In a study by May and Hauptman,4 3 cats with phimosis underwent ventral releasing incisions to expand the preputial orifice with or without suturing of the preputial mucosa to the skin. One cat with penile hypoplasia continued to dribble urine and died 2 days after the surgery, but the other 2 cats survived and had no clinical signs of phimosis at 1 and 4 months after surgery.4 Also, in that study,4 5 other cats with phimosis underwent a ventral wedge preputioplasty, which differs from the circumferential preputioplasty procedure performed for the kittens of the present study. In the present study, 3 of the 6 kittens that underwent circumferential preputioplasty had previously undergone dilation of the preputial orifice with hemostats. That dilation may have caused radial tears in the preputial orifice, which resulted in recurrent preputial stenosis. A more liberal 360° preputioplasty was performed in those 3 kittens on the basis of the gross tissue changes observed at the time of surgery in the hope that the aggressive approach would prevent recurrence of phimosis. The study by May and Hauptman4 did not include any cats with type 2 phimosis; therefore, surgical procedures for correction of type 2 phimosis could not be compared.

In the present study, no postoperative complications were recorded for the 2 kittens with type 2 phimosis that underwent preputial urethrostomy, and complications for the 6 kittens with type 1 phimosis that underwent circumferential preputioplasty were minor. All 6 kittens that underwent circumferential preputioplasty had some exposure of the tip of the penis immediately after surgery, which typically resolved over time. Two of the 6 kittens had persistent penile exposure (1 to 2 mm) at the time of the last recheck examination. For 1 of those kittens, the last recheck examination was 25 days after surgery, and it was unknown whether penile exposure continued to improve after that time. However, the owner was contacted by telephone 6 months after surgery and reported that the kitten was able to urinate well with no signs of recurrent phimosis. These findings suggested that, in cats, minor exposure of the tip of the penis immediately after circumferential preputioplasty might be clinically irrelevant. For the other kitten with persistent exposure of the penis, the exposed portion of the penis was dry at the time of the last recheck examination 7 months after surgery. Information recorded in the medical record suggested that the persistent penile exposure was believed to be the result of the large circumferential incision that was made to remove thickened preputial tissue and prevent future stricture.

Although the term paraphimosis has been used to describe exposure of the penis owing to a short prepuce,9 we did not use that term to describe penile exposure observed in the kittens of the present study. In dogs, paraphimosis is fairly common and is characterized as the inability to retract the penis into the prepuce, often after an erection.3,8,9 For dogs with paraphimosis, the penis sometimes becomes entrapped in the inverted or narrowed preputial orifice, which impairs venous drainage from the penis and leads to swelling of the glans penis. For the kittens of the present study, the penis was described as having a grossly normal appearance with no entrapment; therefore, the term penile exposure seemed to be a more accurate descriptor. In dogs, penile exposure has been described following preputioplasty, and appropriate postoperative care should be implemented to prevent drying of the penile mucosa by the application of lubricant.6,9 Previous reports4,7 of preputioplasty in cats do not specifically discuss penile exposure, although postoperative images in those reports depict minor penile exposure similar to that observed for the kittens of the present study. Lubricant application to prevent drying of the penile mucosa was recommended for the kittens of the present study but was not needed long term because penile exposure resolved fairly quickly. For 2 kittens, triple antibiotic ointment rather than petrolatum ointment was applied to the incision site on the basis of the attending clinician's preference. Although triple antibiotic ophthalmic preparations have been associated with anaphylaxis in cats after topical ocular application,13 anaphylaxis was not observed in any of the kittens of the present study, likely owing to the nonocular administration location. In the present study, none of the owners reported excessive licking or the need to lubricate exposed penile tissue at the time of the last follow-up communication.

Development of preputial strictures following preputioplasty has been described in dogs with phimosis.3 Preputial stricture formation was not reported for any of the kittens of the present study; however, long-term follow-up information was typically obtained by telephone communication with owners, and the kittens were not visually reexamined to definitely exclude stricture formation. Moreover, none of the surgically extirpated tissues underwent histologic examination. Nevertheless, the lack of clinical signs of phimosis at the last follow-up communication suggested the absence or lack of clinically relevant preputial stricture formation for the kittens of this study.

Two kittens of the present study that underwent circumferential preputioplasty developed dysuria and signs consistent with a UTI approximately 7 months after surgery, which suggested that UTI should be considered a potential postoperative complication for the procedure. The small number of kittens evaluated in the present study made it difficult to meaningfully assess postoperative complications and complication rates. In another case-series report4 of 10 cats with phimosis, 1 cat developed a UTI 3 weeks after surgery and 2 cats had occasional inappropriate urination; however, those complications were believed to be environmental or behavioral in etiology. Urinary tract infection is a common postoperative complication associated with perineal urethrostomy, a procedure comparable to the preputial urethrostomy procedure performed in the 2 kittens with type 2 phimosis in the present study. In fact, any cat that undergoes surgical modification of the urethral opening is at increased risk for developing UTIs.14,15 In the present study, the study population and incidence rate of UTI were too small to compare the risk of postoperative UTI between kittens that underwent circumferential preputioplasty and those that underwent preputial urethrostomy. One kitten that underwent circumferential preputioplasty developed dysuria and underwent urethral catheterization to collect a urine sample for bacterial culture, which yielded growth of Staphylococcus pseudintermedius. For that kitten, the dysuria resolved following treatment with amoxicillin–clavulanic acid. Moreover, catheter-induced bacterial contamination of the urine sample could not be ruled out as the cause of the positive culture results because sterile cystitis is a common cause of signs of lower urinary tract disease in male cats.16

In the present retrospective study, phimosis in kittens was classified into 2 types on the basis of gross abnormalities. Results also suggested that surgical management was more effective than medical management for the treatment of phimosis in kittens and the surgical procedure performed was dependent on the type (1 or 2) of phimosis, or pathological lesions, present. Kittens with type 1 phimosis (generalized preputial swelling owing to urine pooling and the absence of penile-preputial adhesions) were successfully managed with a circumferential preputioplasty, and kittens with type 2 phimosis (focal preputial swelling and urine pooling with penile-preputial adhesions) were successfully managed with a modified preputial urethrostomy. Postoperative complications were minor and generally easily resolved. Limitations of the present study included its retrospective nature, the small number of kittens evaluated, and the limited postoperative follow-up period. A study involving a larger population with a longer and more detailed follow-up period than the population used in the present study is necessary to provide further insight into surgical processes, complications, and outcomes for kittens with phimosis.

Acknowledgments

The authors thank Joe Samson, MA, CMI, for the medical illustrations created for this manuscript and Dr. Patti Gordon of All Cats Healthcare Clinic, Gainesville, Fla, for referral of case material.

ABBREVIATIONS

UTI

Urinary tract infection

References

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  • 2. Traas AM. Feline reproduction. In: Ettinger SJ, Feldman EC, eds. Textbook of veterinary internal medicine: diseases of the dog and cat. 7th ed. St Louis: Saunders Elsevier, 2010;2:19461947.

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  • 3. Boothe HW. Penis, prepuce, and scrotum. In: Slatter DH, ed. Textbook of small animal surgery. 3rd ed. Philadelphia: Saunders, 2003;2:1539.

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  • 4. May LR, Hauptman JG. Phimosis in cats: 10 cases (2000–2008). J Am Anim Hosp Assoc 2009;45:277283.

  • 5. Bright SR, Mellanby RJ. Congenital phimosis in a cat. J Feline Med Surg 2004; 6:367370.

  • 6. Papazoglou LG, Kazakos GM. Surgical conditions of the canine penis and prepuce. Compend Contin Educ Pract Vet 2002;24:204218.

  • 7. Yoon H-Y, Jeong S-W. Surgical correction of a congenital or acquired phimosis in two cats. J Vet Clin 2013;30:123126.

  • 8. Johnston SD. Disorders of the canine penis and prepuce. In: Morrow DA, ed. Current therapy in theriogenology. 2nd ed. Philadelphia: WB Saunders Co, 1986;549550.

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  • 9. Hobson HP. Surgical pathophysiology of the penis. In: Bojrab MJ, ed. Disease mechanisms in small animal surgery. 2nd ed. Philadelphia: Lea and Febiger, 1993;552559.

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  • 10. Yeh LS, Chin SC. Modified perineal urethrostomy using preputial mucosa in cats. J Am Vet Med Assoc 2000;216:10921095.

  • 11. Little S. Playing mum: successful management of orphaned kittens. J Feline Med Surg 2013;15:201210.

  • 12. Moreno G, Corbalán J, Peñaloza B, et al. Topical corticosteroids for treating phimosis in boys. Cochrane Database Syst Rev 2014;9:CD008973.

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    • Export Citation
  • 13. Hume-Smith KM, Groth AD, Rishniw M, et al. Anaphylactic events observed within 4 h of ocular application of an antibiotic-containing ophthalmic preparation: 61 cats (1993–2010). J Feline Med Surg 2011;13:744751.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 14. Griffin DW, Gregory CR. Prevalence of bacterial urinary tract infection after perineal urethrostomy in cats. J Am Vet Med Assoc 1992;200:681684.

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    • Export Citation
  • 15. Bass M, Howard J, Gerber B, et al. Retrospective study of indications for and outcomes of perineal urethrostomy in cats. J Small Anim Pract 2005;46:227231.

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    • Search Google Scholar
    • Export Citation
  • 16. Dorsch R, Remer C, Sauter-Louise C, et al. Feline lower urinary tract disease in a German cat population. A retrospective analysis of demographic data, causes and clinical signs. Tierarztl Prax Ausg K Kleintiere Heimtiere 2014;42:231239.

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  • Figure 1—

    Illustrations of a sagittal section of the distal aspect of the penis, urethra, and prepuce of male cats that depict the 2 classifications (types 1 and 2) of phimosis as defined for a retrospective case series of kittens (age, ≤ 20 weeks) with the condition along with schematic representations of the surgical procedures used to correct each type of phimosis. Type 1 phimosis was defined as generalized swelling of the preputial area owing to urine pooling within the prepuce and the absence of penile-preputial adhesions. Kittens with type 1 phimosis underwent circumferential preputioplasty, during which a 360° incision was made around the preputial orifice with care taken to avoid excessive enlargement of the preputial orifice and penile exposure. The skin surrounding the existing preputial orifice was extirpated, and the preputial mucosa was sutured to the skin with small-gauge (5–0 to 7–0) absorbable suture in a simple interrupted pattern. This created a new 360° preputial opening (inset). Type 2 phimosis was defined as focal preputial swelling and urine pooling in the presence of adhesions between the penis and preputial mucosa. Kittens with type 2 phimosis underwent a modified preputial urethrostomy, during which a teardrop-shaped incision was made at the dorsal aspect of the prepuce so that the distal aspect of the penis could be visually observed. The distal aspect of the penis was mobilized by use of blunt dissection to break down penile-preputial adhesions. An incision was made in the dorsal midline of the penile urethra that extended from the urethral opening proximally for approximately 5 mm. The incised portion of the urethra was splayed open, and the urethral mucosa was sutured to the skin with small-gauge suture in a simple interrupted pattern (inset). (Medical illustrations by J. Samson © 2017 University of Georgia).

  • Figure 2—

    Photographs of the preputial region of a young (≤ 20 weeks old) male domestic medium-hair kitten immediately (A) and 10 days (B and C) after circumferential preputioplasty was performed to alleviate type 1 phimosis. Exposure of the distal tip of the penis (most evident in panel C) was commonly observed following that procedure but generally resolved over time. The anus is to the bottom in panels A and B and to the left in panel C. See Figure 1 for remainder of key.

  • Figure 3—

    Photographs of the preputial region of a young (≤ 20 weeks old) male domestic shorthair kitten immediately (A) and 10 days (B) after a modified preputial urethrostomy was performed to alleviate type 2 phimosis. In panel A, a 3.5F red rubber catheter has been inserted into the bladder through the newly created urethral opening to show the location of the new urethral opening. The catheter was removed immediately after surgery. The anus is to the bottom in both panels. See Figure 1 for remainder of key.

  • 1. MacPhail CM. Surgery of the male reproductive tract. In: Fossum TW, ed. Small animal surgery. 4th ed. St Louis: Elsevier Mosby, 2013;846848.

    • Search Google Scholar
    • Export Citation
  • 2. Traas AM. Feline reproduction. In: Ettinger SJ, Feldman EC, eds. Textbook of veterinary internal medicine: diseases of the dog and cat. 7th ed. St Louis: Saunders Elsevier, 2010;2:19461947.

    • Search Google Scholar
    • Export Citation
  • 3. Boothe HW. Penis, prepuce, and scrotum. In: Slatter DH, ed. Textbook of small animal surgery. 3rd ed. Philadelphia: Saunders, 2003;2:1539.

    • Search Google Scholar
    • Export Citation
  • 4. May LR, Hauptman JG. Phimosis in cats: 10 cases (2000–2008). J Am Anim Hosp Assoc 2009;45:277283.

  • 5. Bright SR, Mellanby RJ. Congenital phimosis in a cat. J Feline Med Surg 2004; 6:367370.

  • 6. Papazoglou LG, Kazakos GM. Surgical conditions of the canine penis and prepuce. Compend Contin Educ Pract Vet 2002;24:204218.

  • 7. Yoon H-Y, Jeong S-W. Surgical correction of a congenital or acquired phimosis in two cats. J Vet Clin 2013;30:123126.

  • 8. Johnston SD. Disorders of the canine penis and prepuce. In: Morrow DA, ed. Current therapy in theriogenology. 2nd ed. Philadelphia: WB Saunders Co, 1986;549550.

    • Search Google Scholar
    • Export Citation
  • 9. Hobson HP. Surgical pathophysiology of the penis. In: Bojrab MJ, ed. Disease mechanisms in small animal surgery. 2nd ed. Philadelphia: Lea and Febiger, 1993;552559.

    • Search Google Scholar
    • Export Citation
  • 10. Yeh LS, Chin SC. Modified perineal urethrostomy using preputial mucosa in cats. J Am Vet Med Assoc 2000;216:10921095.

  • 11. Little S. Playing mum: successful management of orphaned kittens. J Feline Med Surg 2013;15:201210.

  • 12. Moreno G, Corbalán J, Peñaloza B, et al. Topical corticosteroids for treating phimosis in boys. Cochrane Database Syst Rev 2014;9:CD008973.

    • Search Google Scholar
    • Export Citation
  • 13. Hume-Smith KM, Groth AD, Rishniw M, et al. Anaphylactic events observed within 4 h of ocular application of an antibiotic-containing ophthalmic preparation: 61 cats (1993–2010). J Feline Med Surg 2011;13:744751.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 14. Griffin DW, Gregory CR. Prevalence of bacterial urinary tract infection after perineal urethrostomy in cats. J Am Vet Med Assoc 1992;200:681684.

    • Search Google Scholar
    • Export Citation
  • 15. Bass M, Howard J, Gerber B, et al. Retrospective study of indications for and outcomes of perineal urethrostomy in cats. J Small Anim Pract 2005;46:227231.

    • Crossref
    • Search Google Scholar
    • Export Citation
  • 16. Dorsch R, Remer C, Sauter-Louise C, et al. Feline lower urinary tract disease in a German cat population. A retrospective analysis of demographic data, causes and clinical signs. Tierarztl Prax Ausg K Kleintiere Heimtiere 2014;42:231239.

    • Crossref
    • Search Google Scholar
    • Export Citation

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