Approach to Examining the Female Tract Flashcards by Anna Burrows

Poppy started her first season in June 2018.

She had a routine ovariectomy in the first week in September 2018

In the second week of January 2019, she had vulval swelling but no discharge

Mammary gland enlargement was present last week

What diagnostic tests might be useful in the case?

•Look at history, there is some vulvar swelling – normal time between oestrous cycles in dogs is 7 months

–Common to be interval of 3 months or so after the end of oestrous to neuter

–Interval makes us suspicious of ovarian remnant maybe?

–Hormonal environment if she had come back into oestrus – high oestrogen in January. Ask questions about her behaviour, would she lick discharge away before we could see

–Behavioural changes – prooestrous vs oestrus, did she seek males? Any swelling?

–

–Mammary gland enlargement – at least 4 caudal glands are enlarged, so less likely. Hormonal environment that causes this – some aspect of prolactin that might cause behaviour changes but progesterone causes the enlargement of the glands.

–Almost certainly has an ovarian remnant as it has enlarged mammary glands, from progesterone! Which comes from ONLY the ovary – so we are suspicious on the history

–Could do a GnRH stimulation test or quite simply, measure progesterone! Will have high levels of progesterone for 2 months past oestrous. Could scan to look for it – can be difficult to see, but could try. If it was a cow/horse – might do rectal to see if we can feel it

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What things should you try to get from the clinical history when examining a female reproductive tract

History taking should be relevant and specific to the species, age and presentation of the clinical problem
What you say will be heard by the owner and will influence their opinion of you as a veterinary surgeon
Climate / nutrition / stress / teratogens may be implicated in reproductive disease in some species.The owner may not be aware of the impact/status of these parameters and this may require you to undertake further investigation

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What is some important information you want to get from the owner before performing the physical exam?

Has the animal previously been pregnant?
Could the animal currently be pregnant?

–Is it possible that it is currently too early to detect?

–If this is possible you MUST remember this during your examination, especially if you consider breaching the cervix

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If the female that has been recently mated, what stuff do yu want to do to find out about previous breeding records?

In the female that has been recently mated:

When were exact dates of mating?
Is the male of proven fertility (when was this performed)?
Has pregnancy been confirmed: how and by whom?
What clinical signs have been demonstrated?
Has any vulval discharge been noted / when and what colour was it?

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What do we want to know with regards to infectious disease risk in a female before any examination?

•Does this female pose or potentially pose a infectious disease risk?

–Could be infectious to us - zoonotic e.g.

Leptospiral abortion/stillbirth in cows
Brucella abortion in cows and sows

–Transmission of venereal / other pathogens as a result of clinical examination

•Could be transmissible to another female? By contaminating by examining this one and then going onto the next one etc.

–Could there be any requirement to report this condition or is it notifiable? e.g.

•Contagious equine metritis (CEM) [Taylorella] in mares

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Name a notifiable reproductive disease in the mare

Contagious equine metritis (CEM) [Taylorella]

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Name 2 zoonotic risks with a reproductive exam in cows and sows

–Could be infectious to us - zoonotic e.g.

Leptospiral abortion/stillbirth in cows
Brucella abortion in cows and sows

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If this female poses or potentially pose a infectious disease risk to other horses or ourselves, as the vet - what should we consider doing?

Consider:

–Tail bandages, tail ties, rectal sleeves on tail

–Disposable gloves

–Parturition gowns (N.B. sleeves of underclothes)

–Footwear

–Disposable/sterilisable instruments

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Before any physical examinations, what else should you consider that might be required?

•Is any bacteriological screening required?

–e.g. CEMO, Klebsiella, Pseudomonas in mares

•Is any virological screening required?

–e.g. FeLV in queens

•Are any genetic tests required?

–Cats: polycystic kidney disease

–Dogs: many eye disease (PLL, Cataract, PRA), von Willibrands, hip dysplasia etc.

–Arab horses: Severe Combined Immuno-Deficiency (SCID)

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What do we vaccinate horses again whilst they are pregnant?

Horses – vaccinate for herpes virus during pregnancy

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What do we vaccinate ewes again whilst they are pregnant?

Clostridial vaccination to pregnant ewes and pigs to prevent disease in neonates

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What is a relevant pre-mating vaccine in egg laying birds?

•Relevant pre-mating vaccination?

–e.g. Salmonella in egg laying birds

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When do we vaccinate for canine herpes virus with regards to pregnancy?

e.g. Canine herpes virus after mating (when required) to prevent abortion

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Why do we perform a general clinical examination before a reproductive exam

•To ensure that there are no diseases or defects that preclude from getting pregnant / successfully taking pregnancy to term

–Body size, body condition

–Dentition, feet (predisposition to disease)

–Ventral hernia

•And to rule out hereditary defects

–Hip dysplasia in dogs etc

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When we examine the mammary glands, what are we looking for?

Correct number of teats
Evidence of stage of the oestrous cycle
Presence of current disease
Evidence of previous disease

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When examining the perineum of a horse, what are we looking for - what is a common conformation problem?

The first line of defence
Normal alignment of the vulval lips
e.g. Mare – horses commonly have abnormal conformation of the vulvar and can be difficult to get pregnant and they often become infertile. In many horses, the anus (because of loss of fat) tends to sink inwards, and drags the vulvar with it – the angle of vulvar changes – no longer vertical, it becomes tilted. So when horse poos, get contamination of vulval lips – material can be aspirated into vestibule and can cause vaginitis and vestibulitis etc.

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What should the mares vulvar be like - what is its normal, correct conformation?

75% of vulva should be ventral to brim of pelvis
Vulval should be perpendicular to the ground and not slope more than 10 degrees
Labia should form a tight seal
There should be no entry of air into the vagina (no foam in the vagina, no noise when walking)
No contamination of the vuvla with faeces

When examining the perineum in a female, what are we looking for?

Evidence of vulval swelling
Presence of any discharge

–Noted at vulval lips

–Noted on underside of tail

•Evidence of venereal pathogens

–Coital exanthema in mares (Equine herpes 4)

–Infectious pustular vulvovaginitis of cows (Bovine herpes virus 1)

•Herpes virus frequently causes changes in the skin

When examining the perineum, what are some veneral pathogens we should look for?

–Coital exanthema in mares (Equine herpes 4)

–Infectious pustular vulvovaginitis of cows (Bovine herpes virus 1)

•Herpes virus frequently causes changes in the skin

When doing an examination of the vulvar, what should we be looking for?

•Normal or abnormal?

–Previous injury or surgery

–Smegma – normal in males

–Small mucoid discharge normal in females and is common in bitches through pregnancy

•Presence of normal or abnormal discharge?

–Normal discharge

What is normal in different species?
Presence of normal or abnormal discharge?

–Abnormal discharge

•A small volume slightly coloured mucoid discharge is very common in many species

When doing an examination of the vestibule, vagina and cervix, how can we perform a clean and thorough examination?

•Clean vulval lips and undertake a sterile manual / digital examination or speculum examination (n.b. different information is made available using these techniques)

–Direct visualisation

–Blind palpation

–Manual ‘scooping’ of contents and later inspection

When doing an examination of the vestibule and vagina, what should we be looking for?

Normal
Abnormal

–Fluid / discharge from external urethral orifice

–Fluid pooling within vagina

–Fluid discharge from cervix

•Do we expect discharge? When there is a dog in oestrus, there will be blood tinged discharge, don’t expect this in other species though

–Abnormalities of vestibular / vaginal wall

•Estimation of the stage of the cycle

–Vaginoscopy in the bitch

•Collection of specimens from the Vagina

–For estimation of stage of the cycle

Vaginal Cytology (bitch/queen)
Assessment of vaginal fluid Ferning (cow)
Measurement of vaginal fluid electrical resistance (fox)

When doing an examination of the cervix, what should we be looking for?

Evaluation of cervical opening (e.g. at parturition)
Estimation of the stage of the cycle
Normal
Abnormal

–Discharge

–Previous trauma / laceration

•E.g. maybe at foaling there was tearing, and now there is significant adhesion or fibrosis – might see on speculum exam or might feel it

–Fibrosis

When doing an examination of the cervix, when should you broach it?

Do not breach the cervix unless you are 100% sure that the animal is not pregnant

What are some ways we can examinate the uterus

* Trans-rectal palpation * Trans-abdominal palpation * Radiographic examination * Ultrasonographic examination * Endoscopic examination * Uterine biopsy

When palpating the uterus, what are we looking for and what is this useful for?

•Detection of: –Shape, Size, Position, Tone •Useful for: –Stage of the cycle –Pregnancy –Status of involution –Infection (endometritis / pyometra / metritis)

When radiographing the uterus, what are we looking for and what is this useful for?

•Detection of: –Size, Position, Opacity •Useful for: –Uterine enlargement (displacement of bowel) –Pregnancy detection (after mineralisation) –Counting foetal number / confirming retention –(confirming foetal death but signs take few days to establish)

When ultrasounding the uterus, what are we looking for and what is this useful for?

•Detection of: –Shape, Size, Number, Margination, Internal architecture •Useful for: –Stage of cycle –Diagnosis of pregnancy (early) –Uterine pathology –(Foetal development / foetal well-being)

Describe what can be seen here on the ultrasound of the uterus Is it normal or abnormal?

Ultrasound of normal oedema pattern of mares’ uterine horn during oestrus Uterus in oestrous, oedema pattern. Looks like a wheel. Uterus is oedematous due to rise of oestrogen, causing accumulation of fluid within endometrial folds – dark patches are these fluid folds

Describe what can be seen here on the ultrasound of the uterus Is it normal or abnormal?

Ultrasound of abnormal fluid in mares’ uterine horn – free luminal fluid in uterus – can see anechoic presence – indicating free fluid, which is ALWAYS ABNORMAL. Likely to be a puss like material or blood like, most likely pus – endometritis. Might take a sample to see whats there

What can we use uterine swabs to detect with regards to microbiology of the uterus? What are they useful for?

Uterine swabs * Care to ensure that uterus is not contaminated by the procedure * Detection of: –Commensal, opportunistic, pathogenic organisms –Their presence may vary in reln. to stage of cycle •Useful for –Screening –Selection of appropriate therapeutics

What can we use uterine swabs to detect with regards to cytology of the uterus? What are they useful for?

Uterine swabs (after microbiology sample taken) * Care to ensure that uterus is not contaminated by the procedure * Detection of: –Indicators of inflammation –Specific organisms (with suitable stains) •Useful for: –Screening for disease –Inidication of likely pathogen

What can we use uterine endoscopy to detect? What is it useful for?

* Usually pass a catheter first, unlikely to do it in a dog or cat as too small, so more common in horse and cow – looking for abnormal structures etc. * Performed after cytology as will itself cause contamination of the uterus * Detection of: –Uterine pathology (e.g. endometrial cysts, fibrosis in mare) •Useful for: –Diagnosis –Selected biopsy –Treatment (laser / cautery) of some lesions

What can we use a biopsy of the uterus to detect? What is it useful for?

Commonly performed blind with ‘basket-jaw’ instrument •Detection of: –Normality or infiltrative disease •Useful for –Documentation of pathology –Prognosis for fertility (mare) •Biopsy from inner surface – to look at histological appearance, is it likely to develop a normal placenta and support placenta throughout pregnancy

What are some ways we can examine the uterine tubes?

* Difficult to do this!! Difficult to identify diseases here by a lot of means mentioned * Inspection of papilla via uterine endoscopy –Mare •Phenol-sulphonphthalein tests –Infuse into uterine horn with foley catheter and collect urine (Cow) * Laparotomy / laparoscopy * (trans-rectal palpation)

What can we use rectal examination of the ovaries to detect? What is it useful for?

•Detection of: –Shape, Size, Position, Margination, Tone •Useful for: –Confirmation of normality –Detection of cyclicity –Estimation of the stage of the cycle –Prediction of ovulation –Detection of pathology

What can we use radiographic examination of the ovaries to detect? What is it useful for?

•Detection of: –Not normally visible –(Shape, Size, Position, Margination - if abnormal) •Useful for: –Documentation of some pathologies

What can we use ultrasound examination of the ovaries to detect? What is it useful for?

•Detection of: –Shape, Size, Position, Margination, Internal architecture •Useful for: –Confirmation of normality –Detection of cyclicity –Estimation of the stage of the cycle –Prediction of ovulation –Detection of pathology

How can we do confirmation of Functioning of Pituitary and Ovary or just Ovary?

* If animal has progesterone in its body, it will have an influence on its repro tract. * Progesterone – cervix closes, in horse – if tight cervix, likely to be progesterone dominated! * Oestrogen – animal may have behavioural signs of oestrus, swelling of vulvar, discharge etc. * Basically – can measure hormones but the hormone will often have an effect that we can visualise normally * Stimulation test: * Give GnRH, acts on Pit, causes rise in LH and FSH and if ovary present – will cause an increase of oestrogen – tells us that we have functioning ovary

What would administration of hCG do in anoestrous? Would do this when looking for confirmation of functioning of pituitary and ovary or just ovary

Administration of hCG (LH-like) will stimulate rise in oestrogen in anoestrus (No need to give in luteal phase as can just measure progesterone)

What would administration of GnRH do in anoestrous? Would do this when looking for confirmation of functioning of pituitary and ovary or just ovary

Administration of GnRH stimulates pituitary to produce LH and FSH. In anoestrus this causes a rise of oestrogen (No need to give in luteal phase as can just measure progesterone)

Holly had a routine ovariectomy in the November 2018 when she was 6 months old In the last week of January 2019 she started what the owner thought was calling behaviour. The behaviour disappeared but returned yesterday and can be elicited by grasping her neck. What diagnostic tests might be useful in the case?

–Do we need any test? This cat is showing oestrus behaviour – why else might a young female queen show these signs? Few reasons why: * Oestrogen secreting tumour – so an ovary * Adrenal tumour secreting oestrogen – but she young so this is unlikely * Has someone given it oestrogen? Unlikely, why would someone do this?! * Ovarian remnant likely. If unconvinced – measure oestrogen but an easier thing is to take vaginal smear to look for kornified cells. If uncertain or owner said she came calling last week, so cytology isn’t the best, could make her ovulate – give her short acting GnRH preparation or hCG, then progesterone will go up, and we can measure progesterone in 1-2 weeks time –Could get false negative if just measuring oestrogen as she may be in the part of oestrous where the levels are decreasing, depending when owner brings her to you