Clinical Disease - Repro SA Flashcards
1
Q
Common Problems Brought Up by Owners in Females
A
- some owners won’t realize that some of these signs are due to reproduction (ex: tom cat calling, alarming if people don’t know that it is a reproductive problem)
- Abdominal distension may be due to other diseases, not always a repro issue–> need further investigation
2
Q
Common Problems Brought Up by Owners in Males
A
- missing testicles or sizes upset owners
- discharges
- systemic illnesses and issues defecating are not normally instantly recognized by owner or vet immedietaly
3
Q
What is a logical approach to these problems in the repro tract?
A
- Education of owners will vary, some will know even more than you! (breeders are meant to know all reproductive business)
- History is the first place you should start, then clinical exam and more diagnostics if necessary
4
Q
History for these cases
A
- Need to get the owners take on the problem that they want sorted (the REASON they have come to see you)
- sex is vital in these cases and also neutered/spay/intact
- intentional or unintentional mating?
- has this animal had litters? do you want to breed from them?
- Used as a working dog?
- is the animal healthy? is it sick? or was this an incidental finding?
5
Q
Clinical Examination for Repro Issues
A
6
Q
Physical Examination and Abdominal Exam
A
- both of these are very important in both sexes
- are masses mid abdomen or caudal abdomen?
- visceral displacement? - is the bladder more caudal than normal? can you feel something that you arent sure if it is the bladder?
- inguinal hernia?
7
Q
Mammary Glands/scrotum
A
- are the expected structures felt?
- are the testis the same size?
8
Q
Vulva/Prepuce
A
- check position
- things may not be what they seem
- there are subtle variations in normal that can be relevant
- may find changes that indicate a more systemic disease
- may not be able to expose shaft on a cat unless they are under, but it is really important!
- echo
9
Q
Rectal and Vaginal Examinations
A
- rectal is generally well tolerated in dogs, but not vaginal
- neither by cats
- but it is important so they need to be adequately restrained
- gloves and plenty of lube
- check everything - anal sacs, urethra, male prostrate, enlarged lymph nodes, previous pelvic fractures or deformity
- may get more information from rectal than vaginal
- vaginal exam you cant go as cranially and it is much more resented
- rectal along with palpation of the abdomen can be useful - better in slimmer dogs, can be done under anasthesia
10
Q
Considerations in the Female
A
- hemorrhagic depending on where they are in oestrus
11
Q
Considerations for both sexes
A
12
Q
Problem List and Premliminary Differential Diagnosis List
A
- what are our top 3 or 4 things
- what can we do to test things to rule in or out?
13
Q
The Further Diagnositc Tests
A
- don’t throw everything at an animal or use them innappropriately (not fair to the owners - $$$)
- too much $$ on tests wont leave any for treatment
14
Q
Routine Clinical Pathology
A
- hypoglycaemia - maybe due to dehydration or a variety of other issues
- in male, if you have infection of the prostate you will most likely see a UTI as well as they are related in anatomy
15
Q
Hormonal Assays
A
- In the female, during neutering, can be quite difficult (new, not enough help, not a bit enough hole), you can leave a bit of ovary
- if a testicle was left behind, it is usually left as a whole solely because it may not have been found
- LINK: the hormonelab.com/handbook
16
Q
Diagnostic Imaging
A
- Ultrasound and Radiography are often very useful when done together
17
Q
Ultrasound
A
- Useful to do a centesis of an organ and get an aspirate
- never tell the number of puppies of kittens off ultrasound (will likely get # wrong)
- enlarged prostate will be identified separately from the bladder
18
Q
A
- left: some fetuses - be aware of ones that curl and don’t confuse as another fetus
- should see some movement, may see a heartbeat
- fluid filled testicle on top right (echo for name)
- bottom right: intraluminal biopsy of urethra - use to see forceps taking a bite of tissue
19
Q
Radiography
A
- allows for a much better idea of # of fetuses - can get hard if there are a lot, usually count skulls
- mainly want to know if an animal has a ton that could cause birthing difficulties (or health)
20
Q
A
top left- normal gravid bitch, puppy is approaching the birth canal appropriately
bottom left- can tell dead fetuses with radiography sometimes, see ephesema (see free gas) - can see some collapse of bones in some cases. may also be gas that results from the mother during birth and can lead to difficulties
tio right: prostatic carcinoma (looked abnormal and needed to take a biopsy)
bottom right: filling defects of the vagina, should normally look (echo) like the urethra –> ended up being a mummified fetus that had been there for years!
21
Q
Endoscopy
A
- can give good access to place a urinary cathether
- can use as a historoscopy–> look at uterine body (this is not commonly done in first opinion )
22
Q
Benefits of Endoscopy
A
23
Q
Vaginal Cytology
A
know why changes occur in different parts of oestrus
-use the resources!
24
Q
Aspirates and Biopsies
A
- May be diagnostic and therapeutic
- excisional: take a whole lump out (echo)
- core biopsy: take a slither of tissue
- grasping forceps: can be useful to pass up a male done if there is a lesion in the urethral lumen
- need to be detailed when you send off samples!
25
Q
Other Investigations
A
- persistent discharge may call for vaginal or preputial bacteriology - problem is that you grow something and you aren’t sure if it is really relevant to the case (not alway non useful, but not generally a good way to spend clients money)
- not really something we commonly do to collect semen anymore
- Prostatic wash: not generally done (echo for procedure) - not very specific and the results are hard to interpret. easier to stick a needle in the area of concern
26
Q
Vulval Discharge
A
- could be a manifestation of normal physiology so be aware of stage in oestrus cycle
- greeny black discharge: see that in placental separation in the dog –> may be normal as part of afterbirth (must happen when puppy is born), if it occurs at an inappropriate time then there is worry - puppy will then not be getting O2 and nutrients if it has not followed palcental separation
- In cats, the placental seperation is a browny/red color discharge
- The dicharge can be coming from the vagina, could be coming from the vestibule or the urethra (lots of options)
- Remember that the external urethral orifice is hidden often within the vulva ofthe cat or the dog- sometimes things can be coming from the urinary tract
- hard to know exactly where it is coming from - part of dianostics to make sure of suspicions if you think it is coming from the reproductive tract
27
Q
Some Causes of Vulval Discharge
A
- Anything causing bleeding is going to look red (most common)
- yellow - sometimes mucopyrulent can look a bit yellow, but if it is yellow and watery then it is likely urine (incontinence)
28
Q
Vaginitis
A
- very common in clinical practice
Often can be seen in healthy pre-pubital bitches
- Can be concerning to owners (social concern), the bitch will nipple and lick around vulva - long hair/fur can get really wet with secretions and they wipe it around
- related to puberty, repro tract becoming active –> getting secretion
- usually resolves spontaneously once you allow them to have a season so they can become hormonally mature
- Just make sure to have local hygiene measures
- avoid AB use as this case would be inappropriate
Adult Bitch
- much less common
- concern that there is a different underlying cause
- may have gotten something stuck up there (seeds or other foreign objects) - jsutification for investigation and then treat appropriately
- If there is no obvious cause, can take the conservative approach
- Can try and treat with exogenous estrogens if it is a big enough issue (owner concern or dog has irritation)
29
Q
Pyometra
A
- very important in SA practice!
- very common in dogs, affects both cats and dogs
- don’t see it often in cats as most females are neutered, but if cats are entire then they are just as prone as dogs (even possibly more likely)
- See in entire female dogs as their uterus needs to be intact for this to happen
- Usually presents in the luteal phase -where they are under the influence of progesterone, progesterone damps down the immune system –> very imp. in pregnancy (embryo is foreign and this is how the mother becomes immunotolerant to the fetus)
- Open: open cervix and this tends to be less severe as pus has somewhere to drain (where you see vaginal discharge - although it is coming from the uterus so it presents as vulval discharge, but is truly vaginal) - becuase it is draining, the uterus tends not to be too large
- Closed: If it is closed then the cervix is closed so actually we can pyometras where they don’t present with vulval discharge. This would be a more serious type of pyometra–> not getting drainage and the uterus can get really distended where there is a running risk of uterine rupture
- also due to the fact that it is not draining, they may present systemically more ill
30
Q
Causes of Pyometra
A
- Complex disease that requires a number of factors to develop
- happens in luteal phase and they need to be under the influence of progesterone: will only occur if they have an ovary and a CL
- Usually get it not only because they are under the influence of progesterone, but also after season they have had an open cervix, which can lead to an ascending infection ( usually uropathogenic bacteria –> E.Coli is most common, but can get other enteric bugs) - but getting a bacterial infection alone isnt enough to get pyometra
- Cystic Enometrial Hyperplasia: cysts within the endometrium (lining of the uterus) and its hyperplasia (pathological changes to the lining of the uterus)
- Note hyperplasia happens normally with dogs/cats as part of each season –> so typically see this condition just after season in entire bitches (ovaries/uterus) - they have has previous seasons so they have developed CEH
- may have mucopurulent vaginal discharge if it is open and bc it is an infection they are often pyrexic. PU/PD may be related to bacterial infection and toxins produced. could get as bad as collapsed and septic
- usually endotoxaemic, may be hypoglycemic as part of sepsis, may have coagulopathies and be anemic
31
Q
Pyometra
(Diagnosis and Treatment)
A
- usually diagnosed by Ultrasound (preferable)
- happening in luteal phase –> pyometra can often look similar to a gravid uterus (pregnancy) before you actually have got ossification of the skeleton - picture on top right is a pyometra (bladder is caudal and then you have these large folded soft tissue density loops in the caudal and mid abdomen) - look carefully and you can see some separation from the bladder and the colon/rectum by a soft tissue mass - also an indication that you have uterine involvement
- US you can rule out immediately, would not see any fetuses, would see a turbind fluid within the uterus
- soft tissue dense loops in the caudal abdomen
- looking for uterine enlargement
- uterine horns can be enlarged, distended, and discolored
- can treat medically, but most likely surgery is the best solution, would be an ovariohysterectomy (spay)
- cant get pyometra and pregnancy together, but possibly metritis (infection within the uterus - ex: pregnancy with fetal death)
- True Pyometra Can’t occur in animals that dont have ovaries - some will refer to a “stump pyometra” though
32
Q
Vaginal Trauma
A
- picture: iatrogenic vaginal rupture due to retrograde study in a bitch (less than perfect technique)
- Don’t separate mating dogs as they lock! - tied together, may cause severe injuries to both of them
- sometimes get wounds from non-accidental or maliceous wounding from owners
- Vagina has a really good blood supply, particularly under the influence of estrogens, so they will bleed profusely
- need to confirm the origin (usually based off history)
- generally treat conservatively by packing the vagina with a large tampon - as many as you can get. Give them broad spectrum AB’s
- On the rare occassion that we need to do surgery it is ususally a vaginectomy
33
Q
Vulval Mass
A
- If there is something sticking out of their rear end, owners get rightly very concerned about it
- does it contain a hole?
- where is it in relation to external urethral orifice?
34
Q
Vaginal/Vestibulo Neoplasia
A
- not exactly common but also not rare
- common is the bitch to get smooth muscle tumors (usually benign –> Leiomyomas, can occassionally be malignant leiomyosarcoma)
- typically slow growing smooth muscle tumors that just grow and reach a crisis point when they either cause swelling in the pelvis (bony box essentially) - can interfere with urination or defecation
- Or it will start to stick out of the perineum or the vulva
- can present in a variety of ways, just depends on where in the vagina this mass actually is
35
Q
Vaginal/Vestibulo Neoplasia
(Diagnosis and Treatment)
A
- #1: History and Physical Exam
- might not always endoscope them (it can be helpful but not always)
- radiography can be useful because we are always thinking about how close surgery may be to other structures such as the external urethral orifice - may potentially drive the treatment we are going to offer
- sometimes we will do an incisional biopsy - but if it is well demarcated we will tend to just take it out and do an excisional biopsy
- can approach from perineum as an episiotomy (open up the vagina)
- or we can go through ventrally where we do a pubic symphysiotomy (split the pelvis) to allow us to get access to the pelvic cavity and then excise the entire vagina with the mass in it
- In 3rd world countries there is a transmissible venereal tumor that is a very specific type of tumor that responds very well to a particular chemotherapy (cyclophosphamide)
36
Q
Vaginal Oedema and Prolapse
A
- see this in entire bitches, it is an excessive response
- not really sure as to why it happens
- happens before ovulation takes place in the follicular phase
- can see vaginal oedema (hyperplasia): get swelling of vaginal mucosa, excessive swelling that develops on the ventral floor of the vagina just cranial to the external urethral orifice.
- Very caudal part of the vaginal floor the can prolapse through the vulva
- Or we can actually get a prolapse of the vagina where the whole vagina becomes oedematous and has nowhere to go
- can tell the difference between these 2 if there is a hole in it
- vaginal prolapse –> expect to see a hole in the center
- Dog might be irritated by exposed tissue or they may get traumatized and risk infection
37
Q
Vaginal Oedema/Prolapse
(diagnosis/treatment)
A
- important to remember it tends to recur - need to have discussions of controlling oestrus/neuter - usually have time to think about it as it will be roughly another 5-6 months before that animal comes back into season
- management will depend on varying circumstances
- keep it moist, place back in and then keep in place with vulval sutures-make sure animal is able to urinate
- in extreme cases we may choose to treat it surgically –> may need to excise it locally, bit more involved to excise a prolapse but it can be done
38
Q
Ambiguous Genitalia
A
- not common but not really that rare
- little pug here, but common in Cocker Spaniels
- there tends to be a lot of different manifestations of intersexuality and quite a lot of different phenotypes can exist
- in a puppy: can tell if it is an enlarged clitoris or underdeveloped penis generally by seeing if there is a urethra running through it
- these animals present in some female in phenotype, but then as puberty hits and hormones start kicking in , testicular tissue present will kick in and produce testosterone - things male related will begin to grow and poke out of orifices
39
Q
Investigations of Ambiguous genitalia
A
- Mullerian Ducts and Wolffian ducts in embryology - become either or (depending on if you are an XX or an XY), but this leaves quite a capacity for things to go wrong
- Often suggest these animals are neutered adn then jdo histopathology on the removed gonads to see if they are testis or ovaries
- sometimes will see ovo-testis
- can do a karyotype if the owner is keen on spending money to look at the number of chromosomes and types
- also some DNA testing to look for the sex determing region Y gene which is located on the Y chromosome
40
Q
Management Ambiguous Genitalia
A
- might remove whatever is sticking out –> may be a penile amputation via an episiotomy
- need to take quite a flexible approach and problem solve as we go along
- may have urine incontinence: may be due to urine reflux putting urine into another viscus (ex: uterine horns attached to the urethra)
41
Q
Dystocia
A
- can be maternal causes, fetal causes or a combination of the two
42
Q
Parturition - What should be a cause of Concern?
A
- dam might not be very well
- second stage of labor can be quite long (prolonged depending on number of kittens or puppies needing to be born)
- If things are happening and then the progression stops (fetal fluids being passed and then no birth couple hours after)
- If dam is straining vigorously and nothing is coming out (20-30 min) –> definitely a cause for concern
- look for placental displacement –> greenish discharge (normally if puppy follows, but concern if nothing follows this discharge)
43
Q
Maternal Causes
A
- narrow birth canal: strictures, narrowing of the pelvis
- prolonged pregnancy or parturition
- sometime cause is clear and sometimes it is not
44
Q
Most common maternal causes of Dystocia
(2009)
A
- generally maternal related
- uterine inertia is a huge issue: not propelling uterus forward
45
Q
Foetal Cause
A
- brachiocephalic dogs head can actually be a fetal cause
- more likely to get dystocia with small litters
- Occassionaly you will see monstrocities - make them have an abnormal shape that makes them difficult to be born
46
Q
Uterine Inertia
(can be primary and secondary)
A
- secondary uterine inertia tends to be from exhaustion - stage 2 has already started but they just become worn out
- primary is more common: not enough stretch perhaps bc there the litter is small or even over stretched due to large litter
47
Q
Primary Uterine Inertia
A
- can also be disease of the damn or inherited predisposition
- behavior: may not feel safe
- dont have somehwere they can go and hide
- fisrt time mothers may struggle to get on with the birth
48
Q
Medical Management of Dystocia
A
- Need to be absolutely sure there is no obstruction - does require an examination
- exercising the bitch can actualy induce the birth of puppies easily! - but is part of getting to the bitch to surgery anyways ( a lot of puppies tend to be born on the way to the vet)
- feathering: trying to stimulate Fergunsons reflex –> get kitten or puppy moving (actually stimulate a contraction to get the puppy/kitten moving)
- check for hypocalcemia/hypoglycemic (can give dextrose or calcium if required)
- Some practices in Europe use a Tocospasmolytic drug (drug that relaxes but causes relaxation/coordinated contractions - quite popular in Germany)
- most of the animals seen in these cases - caesarean is going to be the most appropriate option
49
Q
Oxytocin
A
- Is the owner keen for live puppies or live kittens? (most breeding owners are)
- Or are they may more concerned about the dam or have financial concerns? (may then start with medical treatement and then have C-section if needed)
- Oxytocin would need to be used very carefully! (give much smaller doses than what is in the data sheet)
- Uterus can become refractory to too much oxytocin
- Also, if you give large doses then you can get severe myometrial contractions which are much more likely to result in dead offspring - due to compromise to the placenta
50
Q
Vulval Vaginal Abnormalities
A
- might be internal or external
- may be apparent after failed mating
- may be congenital or aquired
- may need to cross check with other strands (particularly skin conditions)
51
Q
Congenital Abnormalities
A
- another ambiguous genitalia, dog presented with incontinence, had avulva that looked like a low sling prepuce and it had a small hole - dog has a small penis where is was tought to be a vulva (top right) –> can see small defect in picture where it was urinating from
- anovulvar cleft: midline defect, failure of midline fusion
ex: cat in right hand picture, there is a lack of fusion of folds and we havent, can see the clitorus below
52
Q
A
- rectovaginal fistula: where feces was coming out of the vulva and atresia ani as well. docked at birth and nobody noticed
- vestibulo vaginal band: bitch that has had an episiotomy, extended from the dorsal comissure of the vulva up to the perineum so we have got access to the vagina and the catheter is placced in the urethra
- vestibulo vaginal stricture: be careful with diagnosis as it refers to a permanent closure not a spasm (difference radiographically)
53
Q
Acquired Abnormalities
A
- Vuval Hypertrophy: can get with juvenile bitches in their first season and they seem to be under the nfluence of estrogen for a very long time and get a very enlarged vulva that causes people to have concern - can also get with exogenous oestrogens
- can be traumatized
- or get tumors
54
Q
Abdominal Mass/Distension
A
55
Q
Ovarian Neoplasia
A
- granulosa cell tumors are usually estrogen producing
- often present with an abdominal mass and ascites (fluid in the abdomen)
- may be endocrinologically active - usually estrogen producing if presenting and it will present as pro- oestrous
- depends on type of tumor and stage the tumor is at
- aim to excise it butcan get seeding within the peritoneal cavity which is something that we can’t surgically excise –> not a great prognosis
56
Q
Hydrometra/Mucometra
A
- not infected, normal uterine secretions that can’t escape and can’t go anywhere
- can see this if you get closed loops of uterus
- can see in rare occassions from a tumor of the uterine horn
- see where you can get congetinal abnormality of the uterus–> segmental aplasia - segment of uterine horn or vagina (anywhere in tract) that hasn’t developed (aplastic) and you end up with upstream collection of uterine discharge
- can really have quite large viscouses in the abdomen
57
Q
Systemic Illness
A
- example of uterine torsion is a gravid cat
- Just make sure to remember the reproductive tract! -when dealing with an acute abdomen
58
Q
Pyometra
A
- Pyometra is defined as an infection in the uterus.
- Pyometrais considered a serious and life threatening condition that must be treated quickly and aggressively.
