EQUINE VETERINARY EDUCATION / AE / OCTOBER 2014
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Fig 2: Persistent post urination haemorrhage 10 days after penile amputation and sheath ablation. Note the area covered with clear urine (highlighted by black outlining) with a delaminated zone of fresh blood (highlighted by white outlining) emerged at the end of urination.
Fig 1: Proximally located ulcerative lesion measuring about 4 cm in diameter (black arrow). Crusts and ulcers are encountered at the external preputial ring (white arrow).
Treatment
Because lesions were extensive and involved the external lamina of the prepuce, en bloc resection of the penis and prepuce was performed, and the stallion was castrated at the same time using an inguinal approach. Potassium penicillin (Penicillin-Natrium1, 30,000 iu/kg bwt, i.v.), gentamicin sulfate (Pargenta2, 6 mg/kg bwt, i.v.) and flunixin-meglumine (Fluniximin2, 1.1 mg/kg bwt, i.v.) were administered before the pony was sedated with romifidine (Sedivet3, 0.05 mg/kg bwt, i.v.) and levomethadone (L-Polamivet4, 0.05 mg/kg bwt, i.v.). Anaesthesia was induced by administering ketamine (Narketan5, 2.2 mg/kg bwt, i.v.) and propofol (Propofol6, 0.4 mg/kg bwt, i.v.), and maintained with isoflurane, vaporised in an air-oxygen mixture delivered through a circle system, and with a continuous i.v. infusion of a mixture of ketamine (0.6 mg/kg bwt/h) and lidocaine HCl (Lidocain1, 1.8 mg/kg bwt/h). The pudendal nerves were anaesthetised at the level of the ischium with lidocaine HCl (2%, 10 ml). The pony was positioned in dorsal recumbency, and its bladder was catheterised with a stallion catheter. The distal part of the penis was fixed with gauze to an overhead support. The pony underwent closed castration using an inguinal
approach, and the inguinal incisions were closed by suturing the subcutaneous tissue with a simple continuous suture, (polyglactin 910, [Vicryl]7, 2-0 USP, taper point needle) and the skin with an intradermal suture (poliglecaprone 25, [Monocryl]7, 2-0 USP, reverse cutting needle). The inguinal lymph nodes could not be palpated within the inguinal incisions. En bloc resection of the penis and prepuce was then performed using the technique described by Doles et al. (2001). Briefly, a fusiform incision was made around the external perpucial orifice extending 10 cm caudad. Blunt dissection was used to expose the penile shaft. After applying a tourniquet, the penis was amputated transversely. The
corpus cavernosum was closed with interrupted sutures (polyglactin 910, 1 USP, taper point needle). At the distal aspect of the remaining penile stump, a ventral incision was made through the retractor penis muscle, CSP and urethral mucosa. The CSP was closed with simple continuous sutures (polyglactin 910, 4-0 USP, reverse cutting needle). The tourniquet was removed and the penile stump was checked for haemorrhage. The urethral mucosa was apposed to the tunica albuginea with simple continuous sutures (polyglactin 910, 4-0 USP, reverse cutting needle). The penis was fixed to the linea alba with 5 interrupted sutures (polyglactin 910, 1 USP, reverse cutting needle) and the subcutaneous tissues were closed (polyglactin 910, 2-0 USP, taper point needle). Finally, a permanent urethral stoma was created by apposing urethral mucosa and skin with interrupted sutures (poliglecaprone 25, 3-0 USP, reverse cutting needle). Post operatively, the pony was administered potassium
penicillin (30,000 iu/kg bwt, q. 6 h i.v.), gentamicin sulfate (6 mg/kg bwt, once daily, i.v.), flunixin-meglumine (1.1 mg/kg bwt, q. 12 h i.v.) and a prophylactic dose of omeprazole (GastroGard8, 1 mg/kg bwt, once daily, per os) for one week and a balanced electrolyte solution (Ringer Lactat9, 50 ml/kg bwt/day, i.v.) for 24 h after surgery. The skin surrounding the urethral stoma was cleaned daily and covered with petroleum jelly to protect it from urine-induced contact dermatitis. The pony showed signs of moderate post operative pain
the day after surgery. It was mildly depressed and had a reduced appetite and an increased heart rate (44–52 beats/min). Haemorrhage from the mucocutaneous border of the urethral stoma was observed both during and immediately after urination the day after surgery. However, by the second day after surgery only PUH was observed (Fig 2). The pony gradually ceased to show signs of pain and depression but had an episode of fever (38.8°C) and leucocytosis (20 × 109/l [neutrophils, 17 × 109/l]) on the 5th day after surgery, which resolved after changing the antimicrobial therapy to trimethoprime and sulfadimidine (Rota-TS5, 2.5 mg/kg bwt, q. 12 h per os and 12.5 mg/kg bwt, q. 12 h per os). By this time, the urethral stoma exhibited signs of infection and had partially dehisced. The PUH remained unchanged. The PCV decreased to 16% by the 6th day and stabilised at values between 16 and 19% by 2 weeks. During this time the pony’s heart rate was 52–60 beats/min. Post urination haemorrhage continued unabated.
© 2014 EVJ Ltd
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