Reproductive Tract Diagnostic Methods and Prostatic Disease in Males Flashcards
Charlie-Brown is a show dog. At the last show the judge noticed that one testicle was larger than the other
What do you think?
- Heterogenous mass with lesions around it – anechoic regions are more defined
- Sertoli cell tumour
- No obvious negative feedback effect at this point so the other testicle was the same size
- Often changes in testicular size from one testicle to another
- Could be changes in the tone of the testicle
What screening do we have for venereal pathogens in dogs?
•There is no routine screening for veneral pathogens
–Bacterial etc. might consider vaccination of male dogs against herpes virus but not well described if this will reduce virus shedding. Look for lesions on the penis instead.
•Lesions on the penis/prepuce mucosa might be viewed suspiciously for canine herpes virus
What screening do we have for venereal pathogens in tom cat?
•May be screened for FeLV prior to mating since this can be transmitted via close contact
–Both sexes screen for it
What sort of things should we look out for when observaing libido in dogs?
- Sniffing, jumping and playing
- First fraction ejaculated
- Bitch stands and deviates tail
- Rapid thrusting movements
- Penis partially eject but os penis maintains rigidity
- Erection starts after intromission
- Second fraction ejaculated
- Swelling of the bulbus glandis inside the vagina
- Dog turns to face caudally
- Penis twists 180 degrees
- Third fraction is ejaculated
What is there good correlations of testicular size with?
–Total sperm output
–Onset of puberty
–Testicular degeneration
–Advanced testicular pathology
–Compare between left and right and understand what might be normal volume for a dog of a particular body weight
When we are examining the scrotum, testes and epididymides, what should we be looking for?
- Freely moveable
- Some conditions may be suggestive of reproductive disease
–Scrotal dermatitis
- Testes have firm texture
- Testicular parenchyma and size best appreciated with ultrasound
What do normal testicles look like on ultrasound?
- Normal testes have moderately hypoechoic parenchyma with echogenic stippling
- Linear mediastinum testis in sagittal plane
- Circular mediastinum testis in transverse plane
- Usually bright echogenic parenchyma – similar to spleen
- Even and relatively homogenous
- Similar between L and R
What can focal testicular lesions on US be?
–Testicular cysts
–Testicular tumours
What can generalised testicular lesions on US be?
–Orchitis
What is wrong with this testicle?
orchitis – essentially oedema within parenchyma
What is wrong with this testicle?
testicular cyst, blocking outflow of sperm
When examining the sheath and the penis, what should we be looking for and looking at?
•Freely mobile, normal discharge
–Remember discharge can be significant in volume
•Spines and caudally-directed tom-cat penis
What can be seen here?
Lateral radiograph showing fractures os penis
When examining the urethra and perineum of the male, what should we be looking for?
- Normally via flexible endoscope or positive contrast urethro-cystography
- Clinical examination of the perineum and anus
Name ten diagnostic techniques for the prostate gland
- Rectal palpation
- Radiography
- Ultrasonography
- Prostatic massage
- Semen evaluation
- Urine analysis
- Prostatic aspiration
- Prostatic biopsy
- Haematology
- Blood culture
When using rectal palpation to assess the prostate gland, what are we assessing?
–Gland size
–Pain
•Normal should not have pain
–Moveability
•Normal should be moveable
–Sublumbar lymph nodes
–Other structures (rectal wall, pelvic wall)
What can be seen here?
Lateral pneumocystogram – injected air, can see air in cranial part of urethra and outline of bladder
What can be seen here?
- Extravasation of contrast is common in normal prostate and is not indicative of neoplasia
- Smooth outline of urethra
- Can also see flaring of contrast material – do see this in some normal prostates
What do we use prostatic massage for?
Identification of additional cellular material
What is semen evaluation useful for?
•Useful for assessment of first and third fractions of the ejaculate
–Colour
–Cellular content
–Bacteriology
–Some dogs aren’t used to being collected from and some may have pain so may not want to ejaculate
What is a common sequelae to prostatic disease?
Common sequelae is lower urinary tract infection which needs treatment
What are the different ejaculates in a dog and what does each contain?
•First fraction ejaculated during foreplay
–0.5 to 2.0 ml
–prostatic fluid
–contains no sperm
–flushes urethra clear of urine
•Second fraction ejaculated during intromission
–0.5 to 2.0 ml
–sperm rich
–deposited into cranial vagina
•Third fraction ejaculated during the tie
–15 to 20 ml
–prostatic fluid
–no sperm
–washes sperm into the uterus
What do we collect the 2nd fraction of ejaculate from a dog for?
2nd fraction for semen quality
What do we collect the 3rd fraction of ejaculate from a dog for?
3rd fraction to look for prostatic function
What kind of things can we do as part of a breeding soundness exam?
- Conformation and temperament
- External genitalia
- Libido – question owner carefully
- Semen evaluation
- Ultrasound of reproductive tract, particularly testes
- Endocrinological testing?
- Other diagnostic tests?
What is this and what is wrong?
Nice example of normal prostate gland in live dog. More echogenic
Butterfly, 2 lobed appearance
Dorsal aspect – can see colon which has some echogenic material in it casting an acoustic shadow
If difficult to identify – can push prostate with finger in rectum, so can identify it more
What is the most common prostate disease we will see in the dog?
Most common disease we will see in the dog
What is benign prostatic hyperplasia?
What can happen on in later life with this?
- Progressive enlargement of the prostate gland often with cysts, and these cysts increase in size, so prostate size increases. If it gets big, it might push dorsally onto the colon so dog may find it difficult to poo
- Hyperplasia of the prostatic epithelium begins early in life associated with altered androgen/oestrogen ratios
- Often present without clinical signs
- In later life the enlarged gland impinges on the pelvic viscera
–faecal tenesmus
–haematuria
–haemospermia
With benign prostatic hyperplasia, what can you see/feel on:
rectal palpation
radiography
?
- Rectal palpation; symmetrical, freely mobile, non-painful
- Radiography; prostatomegaly, dorsal displacement of colon, cranial displacement of bladder, narrowed prostatic urethra, urinary retention
With benign prostatic hyperplasia, what can you see/feel on ultrasound?
- Ultrasonography; prostatomegaly, hyperechoic regions, narrowed prostatic urethra, small cystic lesions
- Gland is bright than normal
- Development of fluid filled cystic structures
With benign prostatic hyperplasia, what do we see on:
prostatic massage
semen evaluation
prostatic aspiration?
- Prostatic massage; poor harvest of cells, normal prostatic epithelial cells (few)
- Semen evaluation; normal except haemospermia
- Prostatic aspiration; normal prostatic epithelial cells
- Some RBCs in background. Probably wouldn’t do an FNA or urine analysis as already have diagnosis on age and clinical features of this animal
What is the treatment for bening prostatic hyperplasia?
•Castration
–Its driven by hormones. Remove source of testosterone, the prostate will decrease in size very quickly
•Progestogens (e.g. osaterone [Ypozane], delmadinone [Tardak])
– -ve fedbcak, reduce LH so reduce steroidogenesis
•GnRH depot agonist (deslorelin [Suprelorin]
–Long action, short term stimulation and then down regulation – so no LH production
How can castration help BPH?
–Its driven by hormones. Remove source of testosterone, the prostate will decrease in size very quickly
How can progestogens help BPH?
-ve fedbcak, reduce LH so reduce steroidogenesis
How can GnRH depot agonist help BPH?
Long action, short term stimulation and then down regulation, so no LH production
Why are progestongens and GnRH depot agonist not ideal for breeding animals?
Reduced steroidogenesis and spermatogenesis so the dog may become infertile as a result of these – not ideal in breeding animal
What is a potential drug of the future for treating BPH?
Why is it better than the drugs we use currently (progestogens and GnRH depot agonist)?
•Finasteride (a specific 5-alpha reductase inhibitor which prevents the conversion of testosterone into dihydrotestosterone – marked as Proscar).works well in terms of reducing size of prostate gland and has minimal effect on ejaculate quality (unlike current drugs)
–Human market
–Control BPH and allow to carry on breeding at least for a period of time
Which dogs is acute bacterial prostatitis common in?
What often causes it?
- Often young adult dogs, most likely to be ascending infection – commensal organisms move up and cause inflammatory response. End up with swollen, painful prostate gland.
- Or, superimposed on another pathology
- Ascending infection commonly E. coli.
What are some clinical signs of acute bacterial prostatitis?
Clinical signs include systemic illness, with vomiting and caudal abdominal pain. May even be low grade peritonitis in caudal abdomen
With acute bacterial prostatitis, what do we see on:
rectal palpation
radiography
?
- Rectal palpation; asymetrical, moveable associated with great pain
- Radiography; normal size or marginally increased, loss of detail in caudal abdomen indicating local peritonitis
With acute bacterial prostatitis, what do we see on ultrasound?
Ultrasonography; large, hypoechochoic / marbled, sub-capsular oedema. Blacker than you would expect to see in normal animal
- Increased volume
- Sub-capsular oedema
- ‘Marbled’ parenchyma
- Gland is mottled in appearance – marbling associated with oedema accumulation
With acute bacterial prostatitis, what do we see on:
prostatic massage
semen evaluation
urinalysis
Prostatic aspiration and biopsy
haematology
blood culture
?
- Prostatic massage; painful
- Semen evaluation; usually not capable of producing an ejaculate
- Urinalysis; often many bacteria present
- Prostatic aspiration; high white cell count, bacteria (usually Ecoli)
- Prostatic biospy; not indicated
- Haematology; acute and profound leucocytosis
- Blood culture; positive if patient has become bacteraemic
- Will find lots of neutrophils and bacteria and likely wouldn’t biopsy or FNA as will have enough info to make a diagnosis
What is the treatment for acute bacterial prostatitis?
•3-4 week duration antibiotic therapy
–Blood/prostatic fluid barrier not intact therefore good antibiotic penetration
–Don’t always get good penetration into prostate gland. TMPS, cephalosporins etc. generate well
–Treat for 3-4 weeks to guard against this condition becoming chronic.
- Urinalysis and examination of prostatic fluid to ensure that does not become chronic infection
- Castration
What can cause chronic bacterial prostaitis?
If acute prostatitis doesn’t resolve or isn’t treated for a long enough time, can end up with this
What can happen to acute lesions from bacterial prostatitis to turn into chronic?
What are the signs of chronic bacterial prostatitis?
•Acute lesions may become chronic, and pockets of purrulent exudate form
–Fluid filled/puss filled cavities
–Can co-ales together, becoming bigger abscesses or the prostate gland itself can become a cavitated abscess
•Often in the form of micro-abscesses and diffuse inflammation
(May later lead to prostatic abscessation)
•Signs are often recurrent cystitis
With chronic bacterial prostatitis, what do you see/feel on:
rectal palpation
Radiography
?
- Rectal palpation; firm and fibrotic in parts, moveable eliciting some pain,
- Radiography; irregular outline, local peritonitis, prostatic gas, narrowed urethra (contrast)
- Might be history of acute prostatitis
- If you palpate these animals in caudal abbomen, may be pain
- Likely to be large and no longer symmetrical
- If you feel underneath the vertebra, may feel LN enlargement
- Radiograph – gas present
With chronic bacterial prostatitis, what do you see/feel on:
ultrasonography?
- Ultrasonography; normal or slight increase in size, focal microabscesses, areas of increased and decreased echogenicity
- Occasionally significant calcification
- Can see coalescing lesions
- Regions of gas, white areas with acoustic shadowing underneath
- Can become really cavitated in later stages
What is wrong with this prostate?
Chronic Bacterial Prostatitis
Micro-abscesses in case of chronic prostatitis
With chronic bacterial prostatitis, what do you see/feel on:
Prostatic massage
Semen evaluation
Urinalysis
- Prostatic massage; painful, white cells and bacteria harvested
- Semen evaluation; ideal if sample can be collected, bacteria
- Urinalysis; commonly there is lower urinary tract infection, pyuria, haematuria
With chronic bacterial prostatitis, what do you see/feel on:
Prostatic aspiration
prostatic biopsy
haematology
blood culture
- Prostatic aspiration; leucocytes and bacteria, bacteria difficult to culture and identify
- Prostatic biospy; not indicated unless there is index of suspicion that chronic infection is superimposed on neoplasia
- Haematology; compatible with chronic infection
- Blood culture; of little value unless recurrent pyrexia
What is the treatment for Chronic Bacterial Prostatitis?
•6 weeks antibiotic therapy
–Blood/prostatic fluid barrier often intact, often fluid is acidic thus potentiated sulphonamides are useful
–Usually with hormonal therapy or castration – trying to decrease size of the gland
- Hormonal therapy
- Castration
What is prostatic abscessation?
What are clinical signs similar to?
- Chronic prostatitis where purulent exudate accumulates in the parenchyma of the gland
- Clinical signs variable but can be similar to:
–Acute bacterial prostatitis although less fulminating
–Or, progress to exaggerated signs of chronic prostatitis
With prostatic abscessation, what do you see/feel with:
Rectal palpation
Radiography
?
- Rectal palpation; not always enlarged but normally, tender, movement elicits some pain
- Radiography; usually increased size, narrowed prostatic urethra, loss of definition in caudal abdomen, sub-lumbar lymphadenopathy
- Occasionally gas is present within the gland
With prostatic abscessation, what do you see/feel with:
ultrasonography?
- Ultrasonography; cavitating lesion or lesions present, sometimes with calcification
- Asymmetry
- Thick walls
- Calcification
- Cavitated
- Echogenic fluid
What is wrong with this prostate?
Thick-walled areas of prostatic abscessation
big cavitated structure. Pus filled region, fibrin strands, material quite echogenic so has sediment and bacteria
With prostatic abscessation, what do you see/feel with:
prostatic massage
semen evaluation
urinalysis?
- Prostatic massage; painful to perform, leucocytes harvested, some bacteria may be present
- Semen evaluation; unlikely to collect a sample
- Urinalysis; commonly there is urinary tract infection, pyuria, haematuria
With prostatic abscessation, what do you see/feel with:
prostatic aspiration
prostatic biopsy
haematology
blood culture
?
- Prostatic aspiration; leucocytes and bacteria, sampling may be some risk to the patient
- Prostatic biospy; not indicted unless there is index of suspicion that chronic infection is superimposed on neoplasia
- Haematology; compatible with chronic infection
- Blood culture; of little value unless recurrent pyrexia
What is the treatment for prostatic abscessation?
- Surgical debridement – omentalise it
- Omentalisation
- 6 weeks antibiotic therapy as previously described
With prostatic cysts, there are 2 types of cysts identified - what are they?
- Parenchymal retention cysts associated with blockage of the prostatic ducts
- Non-parenchymal cysts (found adjacent to the prostate, attached by small stalk-like adhesions)
What are parenchymal retention cysts? Where do they start?
- Start within the parenchyma of the prostate, causing distortion of its outline
- Usually there is an underlying prostatic disease (BPH or metaplasia (Sertoli cell tumour)
- Later the cyst enlarges and protrudes from beyond the margin of the prostate (although originating within the gland)
- Cannot tell it is a cyst on the radiograph but can see its structure, an US would pick this up
What are non-parenchymal retention cysts? Where are they?
•Cysts found adjacent to the prostate, attached by small stalk-like adhesions
–These are remnants of the uterus masculinus (vestigial Mullerian ducts)
•Small attachment between 2 structures
With Non-Parenchymal Prostatic Cysts, what do you see/feel on:
rectal palpation
Radiography
?
- Rectal palpation; generally prostatomegaly
- Radiography; size normal or marginally increased, often 3 soft tissue opacities seen
With late parenchymal or Non-Parenchymal Prostatic Cysts, what do you see/feel on:
ultrasonography?
•Ultrasonography; prostatomegaly, large fluid-filled and thin walled cyst
With Non-Parenchymal Prostatic Cysts, what do you see on:
prostatic aspiration?
leucocytes and bacteria. Fluid often has a characteristic (non-septic) green or straw-coloured thick fluid. If becomes septic, looks like puss
What is the treatment for prostatic cysts?
•Castration
–If puss like material in it, unlikely that the piss filled mass will resolve on its own – so frequently will result in surgery
- Surgical excision
- Omentalisation
What is the most common prostatic neoplasia?
- Adenocarcinoma are most common
- 5% of dogs with prostatic disease have neoplasia
Where is prostatic neoplasia likely to metastasise?
Is castration protective?
•Tend to metastasise to iliac and sub-lumbar lymph nodes, and to caudal lumbar vertebrae
Castration not protective
With prostatic neoplasia, what do you see/feel on:
rectal palpation?
Radiography?
- Rectal palpation; usually large and painful, may be sub-lumbar swelling
- Radiography; prostatomegaly, sub-lumbar swelling, vertebral involvement
With prostatic neoplasia, what can happen to the urethra at this point?
What about lymph nodes?
- Filling defect to prostatic urethra
- Reactive changes associated with sub-lumbar lymphadenopathy
With prostatic neoplasia, what do you see/feel on:
ultrasonography?
- Ultrasonography; disruption of normal architecture, areas of increased echogenicity, areas of fluid accumulation
- May be iliac lymph node involvement
- Areas of fluid, bright areas, echogenic – lost 2 lobed appearance. Just not what you would expect
What is pictured here on US of a prostate?
Prostatic neoplasia
Mixed echogenicity – disruption of normal architecture
With prostatic neoplasia, what do you see/feel on:
prostatic massage
prostatic aspiration
semen evaluation?
- Prostatic massage; painful, neoplastic cells recovered
- Prostatic aspiration; neoplastic cells, secondary prostatitis common
- Semen evaluation; usually not possible to collect a sample unless early in the disease
With prostatic neoplasia, what do you see/feel on:
urinalysis
prostatic biopsy
haematology
blood culture
?
- Urinalysis; commonly lower urinary tract infection, pyuria, haematuria
- Prostatic biospy; neoplastic cells, secondary prostatitis common
- Haematology; often compatible with chronic infection
- Blood culture; of little value unless recurrent pyrexia
What is the treatment for prostatic neoplasia?
- Palliative hormonal treatments
- NSAID’s
- (Intra-operative radiation treatment)
- (Prostatectomy)
Describe what can be seen here
- Positive contract urethrogram à
- A number of changes can be seen, poor serosal detail in caudal abdomen, some sort of local peritonitis, poor filling with prostatic urethra,
- Poor distention of prostatic urethra.
- Other changes – other lumbar vertebral changes. Periosteal reaction
- Colon – soft tissue opacity swelling ventral to L7/S1
Name the 4 most common prostate treatments
- Castration
- Progestogens
- GnRH agonist
- Possibility of this in the future: Finasteride
–is a specific 5-alpha reductase inhibitor which prevents the conversion of testosterone into dihydrotestosterone
