Ante-partum Prolapse/Cervico-Vaginal Prolapse (CVP)/Vaginal Prolapse

Prolapse of the vagina usually involves a prolapse of the floor, lateral wall and a portion of the
roof of the vagina through the vulva with the cervix and uterus moving caudal. It is a disorder of
ruminants normally in late gestation. CVP is seen in all species of animals but is more common
in cows, especially in large breeds of cattle (Hereford, H.F and Brown Swiss etc.). Occasionally
it is seen after parturition and rarely in non-pregnant animals. In non-pregnant animals there is
always the prolapse of vagina. In bitches hyperplasia of vaginal mucosa occurs at
proestrus/estrus, which may protrude through the vulva. It is practically unknown in cats but less
frequently occurs in pigs.

Classification of Prolapse as per the severity: Generally this classification is used in sheep

1. Stage 1: In this stage vaginal mucosa protrudes through the vulva when animal is
recumbent but disappear when animal stands.
2. Stage 2: In this stage protruding vaginal mucosa remains visible even when animal
stands. Cervix is not visible.
3. Stage 3: In this stage vagina protrudes out along with cervix.

In another system of classification, we take into account the duration of the prolapse, its
size and other organs contained within the prolapsed organ. Depending upon this system of
classification prolapse is classified into mild, moderate and severe. The bladder is most
frequently involved as it may reflect to occupy the vesicogenital peritoneal pouch. This can be
followed by complete or partial constriction of the urethra causing urinary retention. The uterine
horns and intestines can also be involved. Ultrasonography can be used to diagnose the contents
of the prolapse.

Etiology and Pathogenesis:

1. Hormonal Excess and Imbalances
2. Hypocalcaemia
3. Large fetal load (Twins or triplets)
4. Fat conditions
5. Thin conditions
6. Inadequate exercise
7. Excess dietary fiber
8. Sloping terrain
 9. Previous Dystocia
10. Inherited predisposition

Hormonal Excess and Imbalances: In cow during last 2-3 months of gestation, estrogen is
released from the placenta. This release of estrogen causes the relaxation of the pelvic ligaments and
adjacent structures and an edema and relaxation of the vulva and vulvar sphincter muscles. When
animals sits down there is increase in the intra-abdominal pressure which leads to CVP. Imbalanced
ratio of estrogen: progesterone can cause CVP.

Inherited predisposition: CVP is influenced by hereditary or genetic factors. E.g: Hereford and
other large breeds of cattle, boxer and bull dogs

Parity: It is more common in pluriparous than primiparous cow.

Previous Dystocia: Excessive traction while relieving dystocia can cause CVP.

Fat conditions: Excessive pelvic fat and over distension of the abdomen favors by increasing
intrapelvic passage.

Moldy corn or barley due to higher contents of estrogen can cause edema of vulva, relaxation
of pelvic ligament.

Cystic Ovaries: CVP is occasionally observed in cattle following parturition due to excessive
release of estrogen by cystic ovaries.

Prolonged feeding of subterranean clovers can cause CVP in ewes due to higher contents of
estrogen in clover.

Hypocalcaemia: Low level of calcium or imbalanced ration of Ca: P can cause CVP in cattle.

Symptoms: The symptoms may vary from a mild protrusion of the vaginal mucous membrane
through the vulvar lips when cow lies down, to severe necrotic CVP containing a greatly
distended bladder and complicated by prolapse of rectum due to constant straining.
In mild cases, the prolapsed vagina wall returns to its proper position when the cow rises.
The degree of vulvitis, vaginitis and cervicitis will vary depending on the length of time the
condition has existed and type of mechanical (dust, dirt, hay and grass etc) or infectious agent
acting upon the prolapsed mucus membrane. The symptoms of straining may be absent,
intermittent and mild, or severe and nearly constant. Straining depends upon degree of prolapse,
degree of inflammation, edema and irritation involving the genital canal and degree of distension
of urinary bladder. Edema of prolapsed vagina and cervix occurs because of the irritation and
trauma to the exposed mucus membrane, and because this portion drops over the ischial arch
thereby causing a passive venous congestion. This edema tends to accumulate in the submucosa
and cause a separation of the mucosa from underlying thin muscular vaginal wall.

Cervico-vaginal Prolapse in a buffalo (Left) and Cow (Right)

Cervico-vaginal Prolapse in a Sheep

The cervical seal usually remains intact. Sometimes the external portion of the seal may be
absent even when the cervix is prolapsed and inflamed. Occasionally the cervix may relax and
cervical seal is lost and abortion or premature parturition occurs within 24 to 72 hours. If cervical
seal is still intact, a per-rectal examination should be done to access the viability of fetus and
length of gestation.
In neglected cases the exposed mucus membrane is necrosed resulting in a toxemia and
septicemia. This together with exhaustion caused by constant straining may cause a fast, weak
pulse, anorexia, rapid loss of weight, general body weakness, death of the fetus, possibly uterine
infection and death of the animal. Necrosis and gangrene may even involve the cervix and caudal
portion of the uterus secondary to severe blockade of vascular supply.
Differential Diagnosis: It should be differentially diagnosed from other conditions such as
vulvar hematomas, prolapse or eversion of the urinary bladder, rupture of the vagina, prolapse of
the perivaginal fat and thick heavy fetal membranes.

Prognosis: Prognosis of CVP depends upon the severity of the condition and length of the time it
has existed. Except in extreme and severe cases, the prognosis is fair to good for the life of the
animal and fetus if the treatment is prompt and aftercare is good. The condition will recur again
at subsequent gestation periods unless suitable measures are used to prevent it.

In more extreme conditions complicated by prolapse of the rectum, death of the fetus,
impending abortion, septic metritis, severe necrosis of the prolapsed organs, exhaustion,
septicemia and toxemia, marked debility of the animal, or constant or violent straining, prognosis
is guarded to poor. In sheep prognosis is more guarded since 20 to 30 % of the ewes may die or
expel dead fetus.

Treatment: The method of treatment selected for handling of CVP and vaginal prolapse will
vary with species and breed of animal, the severity of the condition, the stage of pregnancy and
ability of the owner to care for and observe the animal until after parturition. Early prompt
treatments often permit the use of simple conservative methods and obviate the necessity of good
or heroic techniques. Treatment of CVP and vaginal prolapse should be done in following steps.

1. Put a clean cloth or towel below the prolapsed mass or a wooden smooth plank of about 1
meter length and diameter can be used as a base for the prolapse, if animal is sitting. If
animal is standing with prolapse then two assistants should hold the cloth in such a way
that prolapsed mass should be above the level of vulvar lips (this is done to prevent the
venous congestion, edema).
2. Epidural anesthesia should be used to prevent the straining if animal is straining. Epidural
anesthesia is achieved with the help of lignocaine HCl @ 1 ml per 100 kg body weight.
For the purpose lignocaine HCl with 2 % adrenalin should be used to potentiate the
regional anesthesia effect.
3. Removal of retained urine by holding the prolapse mass above the level of vulvar lips or
by passing Foley’s catheter or AI sheath. Raising the prolapse mass above the level of
vulvar lips reduce the sharp kink in the urethra and thus help in urination.
4. Clean the CVP with mild antiseptic such as potassium permanganate lotion or Alum
solution. Do not use strong antiseptics or wines asepsis as they may cause
burning/irritation of the mucus membrane of the CVP and become a reason for
continuous straining. Prolapse should be washed with ample quantity of water so that all
unwanted material (dust, dung, dirt, hay and grass etc.) sticking with prolapse should be
washed away. Washing with water for long period (at least 1-2 hours) results in reduction
in size and edema of the chronic prolapse. Ice cold water or ice covered with
drapes/gauge is comparatively better, if available than normal water as it cause faster
recovery of the edema and venous congestion.
5. After reduction in the size of prolapsed mass, replace it to its original position after
lubricating it with heavy liquid paraffin/Xylocaine jelly with 2 % Lignocaine HCl along
with some antibiotic ointment (Soframycin®). For replacement of prolapse use palm or
fist and do not use fingers as they can tear the prolapse.
6. For precautionary purpose raise the hind quarter or down the fore quarter of about 2-6
inch to avoid prolapse of vagina due to increased intra-abdominal pressure.
7. Use of Progesterone @ 500 mg total dose at an interval of 10 days is advocated for
prolapse of vagina or for CVP. Progesterone should not be used in animals showing
abortion (checked by examination of animal per-vaginally, if the cervix has started
opening that means abortion has initiated) or in the last month of the gestation as its use
in the last month can increase the gestation.
8. Vulvar truss are also applied to control the prolapse. These are more frequently used in
bovines and in sheep. Generally in bovine rope truss is used. Sometimes, long narrow
bottles or blunt round objects called pessaries are inserted into the vagina for replacement
of the prolapse.
 These pessaries or truss are held in position by a narrow piece of wood or metal placed
into bottle with a ring or loop on the end projecting out of the vulva. A rope is fastened
through this ring similar to ropes that hold a metal or leather truss in place.

9. Buhner’s sutures (Fig. 5.6) are also used to retain the prolapse. The perineal region
should be scrubbed and disinfected. Stab incisions should made 1 to 3 cm dorsal and
ventral to the vulva to facilitate entry and passage of a specially designed needle (Buhner
needle). The needle should be introduced into the ventral incision and forced
dorsolaterally to the vulva until it came out through the dorsal incision. Then the needle is
“threaded” with Povidone Iodine soaked bandage/ribbon and the needle is drawn back
ventrally to pull the bandage through. The procedure is repeated on the other side of the
vulva. The suture bandage is then tied at the area of the ventral incision. Tension should
be applied to permit entry of two fingers into the vulva, and a square knot should be used
to maintain the closure.
10. Modified Caslick operation: A vulva closing suture used most frequently in mares and
sometimes can be used in cattle. This technique is used in chronic prolapse of vagina 2
months or more before parturition or in post-partum prolapse. It has also proved very
much valuable in controlling straining associated with ‘windsucking’ and a highly
inflamed vaginal and vulvar mucous membrane. This operation is performed under
epidural anesthesia. After replacement of the prolapse mass, the caudal ¾ inch of mucous
membrane of both vulvar lips from and including the superior commissure to about 1-1/2
inch above the ventral commissure is removed with scissors. These raw areas of both
vulvar lips are sewn together with interrupted vertical mattress sutures of fine catgut,
nylon, silk or stainless steel sutures closely spaced. One or two deep horizontal mattress
vulvar sutures of umbilical tape are placed through the skin 2 to 3 inches lateral to the
vulva and through the vulvar muscles and mucous membrane to prevent the vaginal wall
being forced against the fine sutures in the vulvar lips and thus tearing them out if
straining occurs (Figure 1). After 10 days all sutures may be removed.
Figure 1: Modified Caslick Operation. A technique for the control of chronic prolapse of
vagina (Left) under epidural anesthesia a three quarter inch strip of mucosa is removed
from just inside the vulvar lips (Center). An interrupted vertical mattress suture is used to
draw the wound edges gently together (Right). If the animal is straining a deep mattress
suture is placed through both the vulvar lips cranial to suture line.

11. Winkler technique: In this technique vagina is fixed to the prepubic tendon. The
procedure minimize the straining, requires no aftercare during gestation or at parturion,
prevent recurrent prolapse at subsequent pregnancies and could be used in all types of
cases. Under epidural anesthesia the prolapsed mass is replaced after cleaning. A 3 to 4
inch half circle cutting edge suture needle is bent into a U-shape and threaded with 36 to
48 inches of heavy nylon or ‘vetafil’ non-capillary suture material. Umblical tape should
not be used. The needle and suture material is carried into the vagina. The bladder is
pushed laterally away from the midline. The needle is passed through the floor of the
vagina beneath the external os of the cervix into the prepubic tendon in a lateral to medial
direction just cranial to the pubic symphysis and then back up through the vaginal floor.
The sutures should include 1.5 to 2 inches of vaginal floor and ¾ to 1 inch of prepubic
tendon. The needle is then passed through the ventral half of the cervix at least one half
inch cranial to the external os. The suture is tied outside the vulva and knot carried
forward so the cervix is fastened closely to, but not necessarily tightly against, the floor
of the pelvis.
12. Daily use of systemic antibiotics for 5 to 7 days along with application of local antiseptic
ointments regularly.