Urogenital Conditions and Surgical Procedures in the Horse
Le Peenpeen
Review of Anatomy - Penis and prepuce
LOs
Recognise common conditions of
the male and female equine
urogenital tract and describe their
aetiopathogenesis
Demonstrate ability to differentiate
similar conditions
Formulate an appropriate diagnostic
plan
Describe the suitable surgical
options available
Examination of the penis
Need to use drugs to cause sedation (for safe examination), relaxation, and prolapse of the penis. May need to pass
a catheter or endoscope.

Use any of:

• α2 agonists
• butorphanol
• acepromazine
o Be careful with this one (explain later)

Wounds and Lacerations

• Is the urethra effected? Most important thing! – evaluate the damage
• If it’s contaminated wound
o Lavage
o Clean
• Debride and suture
• Support weight of penis, can be oedematous and heavy
o Puts traction on pudendal nerve, and can stretch and damage it
• Minimize swelling
o NSAIDs
o Cold hosing/icing
• Drains
o Increase weight, increasing traction on pudendal nerve
o Increases the chance of infection
• Dehiscence likely → infection

Haematomas
Haematomas on the penis is an emergency

Tx:

• Bandage – Esmarch bandage

o Help squeeze out haematoma
• Massage
• Cold
• Further bandages to support weight
o Preputial / sling
• Ultrasound
o Evaluate the t. albuginea – ruptured or not
o If ruptured, will need surgery to correct
• Rest
• Away from mares
o Really important they don’t get sexually aroused.

Paraphimosis – inability to retract penis

Causes:

• Trauma
• Haematoma
• castration

This is a problem because the oedema causes and increase in weight:

• muscular tone fatigues

• Pudendal nerve gets damaged
 o Leads to permanent damage

Tx:

• Bandages and massages

• Anti-inflammatories
o creams / ointments
o Systemic
• Cold therapy
• Surgery
o Phallectomy (surgical removal of the penis)
o Posthetomy (surgical removal of some prepuce skin)

Priapism – persistent erection

Corpus cavernosum is permanently filled with blood

Increased risk with phenothiazines eg acepromazine

Tx:

• Medically
o Message
o Drugs
▪ Systemically
• Benztropine mesylate
• Terbutaline
• clenbuterol
▪ Injection into corpus cavernosum → vasoconstriction
• Ephedrine
• Adrenaline
• phenylephrine
• Surgical (referral surgery)
o Irrigation of the corpus cavernosum muscle with saline and heparin (start with this)
o Shunt between corpus cavernosum and spongiosum
o Partially phallectomy – if nothing else works

Penile or preputial growths

Habronema (granulomas)
• Granulomatous reaction caused by larvae of flies
o Generally not that big of a problem in NZ
• Usually at the mucocutaneous junction

SCC
• Need a biopsy to dx
Biopsy
Punch biopsy, or cut a strip → histopathology

Based off results ie if it’s a SCC, will require surgery to remove

Penis surgery

Reefing / segmental posthetomy

Removing of a strip of skin from the penis

Sometimes, if growths are too big, may need to do a partial phallectomy

Partial phallectomy
Indiated:

• Permanent penile paralysis

• Extensive penile damage
• Extensive neoplasia – especially if invaded into tunica albuginea
• Urethral stenosis

Castration should be done 3-4 weeks prior (drop testosterone levels) to avoid haemorrhage and dehiscence
(erection = problem) – not always possible (wound or paralysis may be an emergency)

Some surgeries can be done standing, but this is not usually done well – GA is best (esp if it’s a fractious animal or
requires extensive surgery.

Different techniques, each with their own advantages and

disadvantages:

• Scotts technique
o End of penis effected is cut off
o Put catheter in to hold onto urethra
▪ Helps identify where the urethra is
▪ Need to keep a segment of it to
reflect back and suture to the skin
o Shorter penis, but roughly keeps the same
shape
o Disadvantage of stricture to urethra
▪ Decrease urine flow
 • Vinsot Technique
o Create a triangle hole, which becomes the
opening of the penis
▪ Base of triable at the base of penis
▪ Allows for flap to form
o Then cut off the tip of the penis
o Less chance of stricture
o More chance of urine scalding than Willaims
technique

• William’s technique (most common)

o Also creates a triangle (but this is towards
the end of the penis
o Less likely to stricture
▪ Big opening
o Less likely to urinate over legs (cause
scalding)
o

Basic principles

• Place urethral catheter

o Need to be able to find urethra
o Need to know how deep to cut
• Tourniquet at base of penis
• Try to reduce chance of stricture
• Hard to prevent urination over legs in future → create urine scalding
Complications of partial phallectomy

• Urethral stenosis
o Less common with Williams technique
• Oedema → due to urethral obstruction
o Can be minimal
o Can be massive and impaired urination
• Contact dermatitis / urine scalding
• Haemorrhage when urinating (weeks)
o Blood in urine for several weeks is normal
• Dehiscence
• Haematoma
o Leaking sutures over porous cavernosum
• Pain
• Infection

Testicles
Testicular Abnormalities
• Torsion of the spermatic cord
• Hydrocoele
• Haematocele
• Varicocele
• Testicular neoplasia

Testicular/spermatic cord torsion

• Not very common
• Occlusion – depends on degree of rotation
o Venous
o Venous + arterial (>180° usually)
• Signs:
o Usually unilateral
o Acute pain (>360º)
▪ Like colic signs – pawing at ground
o Inflammation of testicle, epididymis, cord, scrotum
o Cold testicle due to reduced blood flow
o Fluid accumulation in the scrotum
o Localisation of the epididymis
• Dx
o Ultrasound - differentiate from inguinal hernia (would see
intestines)
o Can palpate, but if there’s a 360° turn, it’s hard to feel!
▪ Feel where the epididymis is
• Tx:
o Unilateral castration (good prognosis)
▪ Can still breed pretty well

Hydrocoele
Accumulation of fluid within the scrotal sack

• Serous fluid or abdominal fluid

o Peritoneal layers extend around to make the vaginal tunic, so can get abdominal fluid in there.
• Idiopathic
o Neoplasia, orchitis, ascites, parasites, traumatism, heat, no exercise
 • Small ones don’t bother the horse (cosmetic)
• Large ones can be a problem – interfere with normal function
• Draining doesn’t work – just refills → need to remove the sack
• Increased temp. affects spermatogenesis

Signs:

• Acute / chronic
• Not painful on palpation
• Can have reduced reproductive success

Dx: Ultrasound examination

Tx: unilateral castration (Bilateral: poor prognosis for reproduction)

Haematocoele
Blood in the scrotal sack due to trauma or haemoperitoneaum

Tx:

• aspirate and lavage

o reduces adhesions
o have to be very sterile! Can introduce bacterial and cause infections
• If the vaginal tunic of the testis is ruptured – suture or unilateral castration (difference of temperature will
effect spermatogenesis)

Varicocoele
Distension of the pampiniform plexus – due to incompetence of valves of the testicular vein

• Uncommon
• Unsure if fertility is affected (is in humans)
o Can to semen evaluation

Dx:

• Palpate
o Fells like a bag of worms
• Doesn’t feel inflamed

Tx:

• Castration
o Only if it is affecting fertility
o Unilateral
o Probably not necessary

Neoplasia
Can be germinal (neoplasia derived from germ cells) or non germinal – but overall, uncommon

• Germinal
o Seminoma – more common
o Teratoma
o Carcinoma
• Non-germinal
o Sertoli cell
o Leydig Cells

Dx
 • History of increasing testicle size
• Firm testicle

Tx: unilateral

Surgical Conditions of the Urinary Tract

There are different pathologies depending on age

• Adults
o Urolithiasis
▪ Bladder
▪ Other localisations
o Neoplasia of bladder
▪ SCC
▪ Haematuria
o More complicated in males
• Foals
o Ruptured bladder
▪ Ruptures when pushed through birth canal
o Persistent urachus

Foal Problems
Ruptured bladder

• Rupture through the birth canal

o US black fluid
o Lethargic / colic foal
o Imbalance in electrolytes

Urachus

• Urine leaking out of umbilicus

• Can be normal in the beginning, and systemically ill later
o Urachus opens back up, and see dribbling from umbilicus

Urolithiasis
Most commonly stuck in the bladder

Excrete a lot of calcium carbonate in urine (cloudy) which sometimes can

aggregate and form stones.

• Type I (spiculated)
o More common
o Spiculated
o Irritating to mucosa of bladder
o Yellow / green
• Type II smooth (+Phosphate)
o Whitish
o Smoother

Clinical signs:

• Haematuria
• Stranguria
• Geldings more effected than mares
Dx:

• Rectal palpation
o Don’t have to go too far to feel it (elbow deep = passed it)
o Usually just into the pelvic brim – bladder is right there
• Transrectal ultrasound (confirms)
• Cystoscopy
o See the stone in the bladder
o Through penis, all the way to the bladder

Tx:

• Surgical extraction – cannot pass it if it’s bigger than the urethra

o Cystotomy – referral surgery
▪ Abdominal incision
o Laparoscopy
▪ Specialised equipment needed (not always possible)
▪ Not easy to do in horses
o Perineal urethrostomy
▪ Incision below anus to reach in and retrieve stone (or crush it)
▪ Can be temporary or permanent (temporary ones have a chance or re-block)
▪ Can do it standing
o Lithotripsy (the use of ultrasound shock waves to break up stones)
▪ Fragment
▪ Holmium laser (endoscopy)
▪ Shockwave
▪ Manual
▪ Recurrence possible - as they are broken up, not
removed

Perineal Urethrostomy (male)

Can be temporary or Permanent

• Temporary (just for surgery, then closes up)

o Access to bladder for flushing
o Access if there are obstructions by a small fragments
• Permanently in place (prolonged obstruction of the urethra for any
reason)

How it’s done:

• Do it standing (easier to do it when standing)

o but still referral surgery
• Sedation and epidural needed
o Alpha 2s and butorphanol works well for sedation Endobag
o + Buscopan ® is good (relaxation of SM)
• Lignocaine the area
• Do a surgical prep of perineal area
• Catheterise urethra
o Can palpate it easier, and feel the edges (know exactly
where to cut
• It’s distal to anus at the pelvic brim
• Incise urethra
• Lubricate urethra up
• Endoscopy or cystoscopy to get into the bladder
 • Use instrument to grasp urolith and extract via urethra
o Fragmentation may be necessary ie crush it up if it’s too big (need to be able to pull out urethra)
o Holmium laser used sometimes
• Lavage the bladder
• Leave to heal by second intention (usually about 3 weeks)
o Don’t want to cause a stricture in the urethra (wide area of the urethra too)
o Takes a while
• Vaseline will be needed to avoid urine scaling
o Going to pee out the back for 2-3 weeks
o Can get scalding down back of the legs

Cystotomy
1) Abdominal incision, caudal (midline incision,
between penis and inguinal ring.
2) Traction to exteriorize bladder
3) Stay sutures to secure bladder
4) Ventral transverse incision of the bladder
5) Extract calculus
6) Lavage bladder
7) Double layer suture (2nd inverting) to close bladder
8) Closure

Female Reproductive Tract

Common problems:

• Damage during breeding or parturition

o Cervical tears
o Rectovaginal fistula
o Perineal lacerations
• Conformation problems
o Pneumovagina

These lead to infertility, which is a problem for broodmares!

Surgical preparation for perineum

Most procedures are done standing under sedation and local anaesthesia:

Epidural - Sacro-coccigeal, between C1 – C2 (can also do before C1)

• Insertion of needle depends on the animal

• Local anaesthetics
o Lidocaine (2%, 5-7 mL, 90 min duration)
o Mepivacaine (2%, 120
o Beware ataxia/paresis!! – the mare will freak out
▪ Be careful with volumes
• α2 agonists
o Analgesia with no ataxia
o Xylazine (0.17mg/kg, 4 hour duration)
o Detomidine (30 – 60 µg/kg, 3 hour duration)
▪ Causes systemic sedation
▪ Dilute with 0.9% NaCl, up to 6-10mls
• Combination → lidocaine (0.22 mg/kg) + xylazine (0.17mg/kg)
o Using less local anaesthetic = reduce risk of ataxia or paresis
 • Strick asepsis is vital!

Additional prep:

• Evacuate rectum, and pack it up with cotton wool +/- tampon

• Bandage and tie tail out of the way
• Clean
o Soap up (mechanical scrub) first
o Iodine / Betadine (1%)
• Tetanus toxoid or antitoxin if any doubt about vaccination history
o Should do if not vaccinated within a year
• Prophylactic antibiotics
• NSAIDs

Pneumovagina
• Due to conformation defects or traumas
o Sunken anus
o Vulva above the body of the pelvis
• Leads to infertility
o Chronic inflammation or infection

Tx – Episioplasty (“Caslick procedure”)

• Local +/- sedation if necessary

• Cut into MMs (pink tissue!)
• Suture shut
• Goal is to close the vulva above the body of the pelvis
• Not the only indication for a caslick, but pneumovagina is one

Perineal Lacerations
Occur during parturition – foal hooves normally

Different types:

• 1st Degree – vestibular mucosa and skin of dorsal commissure vulva

o No treatment or caslick necessary
• nd
2 Degree – Mucosa, submucosa, and skin
o Tx = Caslick and perineal body reconstruction (dorsal muscles)
• 3rd Degree – Perineal body, rectum, and anal sphincter
o Communication between vagina and rectum
o Tx = RV shelf and perineal body reconstruction (always need surgery)
o Compatible with life (not pleasant though), but certainly not fertility
Tx – Stitch up lacerations
• Not in acute phase as tissues are very oedematous and friable after
parturition
o 4-6 weeks later (possibly even longer)
• Faecal softeners
o MgSO4 / lactulose
o Reduce mechanical load on sutures
o Can also give paraffin oil as lubricant, but MgSO4 is better
• Reconstruction – usually done in 2 phases, but can be done all at the same
time (more risk; it the more cranial section reopens, have to open it all back
up again to fix)
o 1st phase – recto-vestibular shelf
o 2nd phase (3-4 weeks later) – stitch up perineal body

Rectovaginal Fistula
Can be:

• Primary – no damage to the anal sphincter

o Usually caused by foetal foot through vagina into rectum at birth, but then pulls
foot back.
• Secondary – partial failure of a 3rd degree laceration repair.

Tx – Closure in 2 orthogonal layers

• Can be done standing

• Cut between the anus and the dorsal aspect of the vagina
o Dissect until we reach the hole
o Usually not very far in
• Suture in two layers; horizontal line, then vertical line
• Usually leave cut layer between anus and vagina open to heal by second intention
o This area is very dirty no matter how much you clean
o Need good drainage of that area (don’t want to sure in infection)

Uterus and Ovaries

• Uterine torsion
• Uterine tear
• Prolapse
• Haemorrhage
• Neoplasia
o Granulosa cell tumours

Surgery on the uterus and ovaries

• Withhold feed (if elective, not always possible)
• Antibiotics
• NSAIDs
• Can be done standing or under GA
o GA
▪ Midline celiotomy
▪ Flank laparotomy (uterine torsion, easier to do this)
o Standing
▪ Flank laparotomy
▪ Flank laparoscopy – can make diagnosis, but not actually do anything about it
Ovarian Neoplasia
Granulosa Cell Tumour – relatively quite common

Clinical Signs and diagnosis:

• Noticeable behavioural change

o See anoestrus, oestrus continual, and/or stallion-like behaviour
• Enlarged ovary / contralateral small and inactive ovaries
o Unilateral normally
o Can be palpated
• Diagnosed:
o Ultrasound
▪ Characteristic honeycomb structure and fluid filled
o Hormone tests (testosterone, inhibin, anti-mullerian hormone/AMH)

Tx – Ovariectomy

• Colpotomy – incision through the vagina

o Standing, with epidural
o Incision in the wall of the vagina (2 (left) or 4 (right) o’clock and 8 or 10 o’clock position)
o Ecraseur – basically a bicycle chain on a pole
▪ Strangulate ovary – tighten down chain
▪ Potential for serious complications!
• Fatal haemorrhage – esp if cut into major vaginal vessels
• Eventration
• Laparotomy
o Standing flank (<25 cm) or ventral midline/paramedian (GA for very large ones)
o Ligate ovarian pedicle
▪ Tension on the pedicle is painful
o Safer – potential for less complications
▪ Haemorrhage
▪ Incisional infection
▪ Adhesion to stump
▪ Intestinal trauma
• Laparoscopy – depending on size
o Pros:
▪ Better visualisation
▪ Evaluate haemorrhage
▪ Small incisions

After ovariectomy, fertility is usually ok (the other side picks up the pace) – not very malignant tumor

Uterine Torsion
Signs and Diagnosis:

• Colic signs in last two months of gestation

o Foal is really big
• Rectal palpation
o Feel broad ligament passing over top of uterus
o Don’t feel the twisted cervix like we do in cows
• Perform an ultrasound to determine foetal viability

Tx:

• Rolling (under GA)

 o Don’t really do that though
• Foetal manipulation (at term)
• Laparotomy:
o Flank (preferred correction technique)
o Ventral midline GA
▪ Damage/compromise to uterus
▪ Foal dead
▪ Caesarean section

Caesarean Section
80% are elective, the rest are emergency due to dystocia or uterine torsion

Need to resuscitate foal – they’re usually dead – NEED to be quick ie within 1.5 hrs of onset of problem

The process (full on abdominal surgery):

1) Dorsal recumbency
2) Caudal midline incision
3) Exteriorise gravid horn
4) Incise uterine wall and placenta
5) Remove foal
6) Clamp umbilical cord and section
7) Separate placenta from border
8) Suture (whip stitch then inverting)

Uterine Tears
Can occur during:

• Normal foaling
• Manipulation during dystocia
• Complication of uterine torsion
• Hydramnios (excessive amniotic fluid)

Signs and Diagnosis:

• Colicky post foaling

• Potentially signs of shock (f there’s severe blood loss)
o White MM
o Elevated HR
o Reduced PCV
• May have signs of peritonitis
• Diagnose with palpation
o Haemoperitoneum
o Need to clean perineum before hand, and use sterile rectal sleeve

Tx:

• Small tears heal spontaneously

• Large tears need to be repaired – suture
o Flank approach if one horn is effected
o GA and ventral midline if it’s unclear
o Beware of evisceration