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EQUINE VETERINARY EDUCATION / AE / OCTOBER 2014
Case Report
Perineal incision into the corpus spongiosum penis to resolve persistent post urination haemorrhage after partial phallectomy
K. Mählmann* and C. Koch Swiss Institute for Equine Medicine, Vetsuisse Faculty University of Berne; and ALP-Haras Avenches, Berne, Switzerland. *Corresponding author email:
kathrin.maehlmann@
vetsuisse.unibe.ch
Keywords: horse; phallectomy; post urination haemorrhage; squamous cell carcinoma; corpus spongiosum penis
Summary Partial phallectomy or en bloc resection are surgical methods to address pathological conditions of the penis and/or prepuce including neoplasia, trauma, habronemiasis, chronic paraphimosis or permanent penile paralysis, and priapism. Haemorrhage associated with urination is a common complication observed after penile surgery but usually resolves spontaneously without specific treatment. This report describes a case of post urination haemorrhage (PUH) that recurred with each urination and persisted without significant improvement for a period of 2 weeks following en bloc resection of the penis and the prepuce. A perineal incision (PI) into the corpus spongiosum of the penis (CSP) resolved PUH by decreasing the blood pressure in the CSP distal to the PI. We propose that PI of the CSP can be an effective method to address PUH after penile surgery and may decrease time of hospitalisation for horses affected with PUH after phallectomy procedures.
Introduction
Indications for partial phallectomy include penile and/or preputial neoplasia (Markel et al. 1988; Howarth et al. 1991; Mair et al. 2000; Doles et al. 2001; van den Top et al. 2008; Arnold et al. 2010; Rizk et al. 2013), trauma (Perkins et al. 2003; Arnold et al. 2010), and habronemiasis (Stick 1981) as well as chronic paraphimosis or permanent penile paralysis (Arnold et al. 2010), and priapism (Van Harreveld and Gaughan 1999). Techniques for partial phallectomy include those described by Scott (1976), Vinsot (Frank 1964), and Williams (1943). If neoplasia of the internal lamina of the prepuce is extensive or if the external lamina of the prepuce contains neoplastic lesions, en bloc resection of the penis and prepuce with or without penile retroversion is often advocated (Markel et al. 1988; Doles et al. 2001; Perkins et al. 2003; Archer and Edwards 2004).
Short-term complications associated with partial phallectomy include haemorrhage, pain, excessive oedema, infection, and dehiscence at the stoma or the site of amputation (Schumacher 2012). Haemorrhage from the penile stump is a frequent complication, particularly at the end of urination but usually subsides within a few days after surgery (Mair et al. 2000; Doles et al. 2001; Archer and Edwards 2004; Rizk et al. 2013). Stallions should be castrated at least 3 weeks prior to undergoing partial phallectomy to prevent erection that may lead to haemorrhage and dehiscence (Schumacher 2012). Post urination haemorrhage (PUH) most often emanates from the corpus spongiosum of the penis (CSP) and occurs at the mucocutaneous border of the
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urethral stoma (Doles et al. 2001), but is usually self-limiting (Mair et al. 2000; Rizk et al. 2013). In this report, we describe treatment of a pony stallion for
persistent PUH after en bloc resection of the penis and prepuce to address an extensive penile and preputial squamous cell carcinoma.
Case history
An 18-year-old, 180 kg, cremello, Welsh pony stallion was presented to the Swiss Institute of Equine Medicine in Berne, Switzerland for further investigation of crust formation and purulent exudation on the penis and prepuce. The pony had been administered antimicrobial therapy several times for this problem by the referring veterinarian during the year prior to presentation, but this therapy had been ineffective in resolving the crusts and exudate.
Clinical findings
The pony was bright, alert and responsive. Its heart rate was 28 beats/min, respiratory rate 12 breaths/min, and rectal temperature 38.2°C. During examination of its penis and prepuce, performed after the pony was sedated with xylazine HCl (0.4 mg/kg bwt, i.v.), a cauliflower-like, ulcerative lesion, approximately 4 cm in diameter and protruding 0.5 cm above the level of the integument, was present at the outer lamina of the preputial fold. Two spherical, dark pigmented masses measuring 0.5 cm in diameter were embedded within this lesion. Several reddened and irregular skin areas with crusts were present on the glans and preputial orifice (Fig 1). No other cutaneous lesions were found. The inguinal lymph nodes could neither be palpated nor visualised during transcutaneous, ultrasonographic examination of the inguinal region using a 7.5 mHz linear transducer. Results of a complete blood count and plasma biochemical analyses were within reference limits, except for a mild hypoalbuminaemia (29.2 g/l, reference range [rr] 32.2–39.9 g/l) and mild hypomagnesaemia (0.59 mmol/l, rr 0.71–0.92 mmol/l). The packed cell volume (PCV) was 35% (rr 0.31–0.47%), total protein 68 g/l (rr 52–78 g/l) and leucocyte count 8.26 × 109/l (rr 5.3–10.3 × 109/l).
Diagnosis
A preliminary diagnosis of squamous cell carcinoma of the prepuce was based on gross appearance. After en bloc resection, the diagnosis of a squamous cell carcinoma infiltrating was confirmed by histopathology. The neoplasia invaded the tunica albuginea and expanded in the underlying corpus cavernosum penis.
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