Running head: EMPLOYEE TRAINING: UROGENITAL AND REPRODUCTIVE

Employee Training: Urogenital and Reproductive Emergencies

Sarra Borne Lord
Tarleton State University
VETE 4326: CA Emergency and Critical Care

February 24, 2015

Employee Training: Urogenital and Reproductive Emergencies
Slide 1: Title page. This PowerPoint covers three common urogenital and reproductive
emergencies that we see at our practice.
Slide 2:
Slide 3: Normal anatomy: The urogenital system. The kidneys are at the start of the
urinary tract. They are covered by a fibrous capsule and are held in place with connective tissue.
There are three major components to a kidney. The outer layer or cortex filters the blood and
begins the process of urine formation. The central layer or medulla concentrates the urine. The
inner layer or renal pelvis is where the urine collects before it exits the kidneys into the ureters
which connect the kidneys to the bladder.

The urinary bladder is located in the caudal abdomen. It is a balloon-like organ that is a
reservoir where urine is stored before it is voided through the urethra. The urethra arises from
the neck of the bladder; just beyond the neck of the bladder is the urethral sphincter which
maintains bladder control and keeps the urine inside the bladder until it is released. In the male
the urethra passes through the penis and exits the body, in the female the urethra continues
caudally until it enters the vestibule of the vulva.
We will discuss the normal reproductive system anatomy later in this presentation.
Slide 4: Feline idiopathic cystitis with obstruction. The first emergency we are going
to cover is feline idiopathic cystitis with obstruction. This disease has been called many things
over the years. Some of the common synonyms are listed, and you may know this disease by
one of its other names.
Slide 5: Clinical presentation and diagnosis. Urinary obstruction occurs when urine is
unable to be passed normally. The obstruction may be partial or complete. In dogs obstruction
is caused by organized uroliths, in cats the debris is much less organized and usually forms a
urethral plug at the tip of the penis (Battaglia, 2001). A complete urinary obstruction is a true
veterinary emergency because the inability to urinate will lead to renal failure and ultimately
death.
Depending on the owners observational skills on presentation the cat may be alert and
seemingly normal or he may be depressed and obviously painful. Owners may have observed
their cat making frequent trips to the litter box and only passing a small amount of urine each
time (pollakuria), with stranguria (straining to urinate), or the cat may be urinating in
inappropriate places. The cat may also appear restless or uncomfortable and may lick

EMPLOYEE TRAINING: UROGENITAL AND REPRODUCTIVE

continuously at their genital area. Owners will frequently mistake the multiple trips to the
litterbox and associated straining as a sign of constipation.
Fortunately diagnosis of urinary obstruction is fairly straightforward. Palpation of the
abdomen will reveal a large, firm bladder. A survey radiograph will show the engorged bladder,
and any large urinary calculi.
Biochemistry is rarely necessary for diagnosis; however azotemia, hyperkalemia,
hyperphosphatemia and metabolic acidosis are common findings that will need clinical
attention (Selected Topics, 2010). This is not to say that blood tests shouldnt be done, a
minimum database including a CBC, urinalysis, and biochemistry with a minimum of a packed
cell volume, total solids, BUN, creatinine, blood glucose, and electrolytes should be run. A lead
II ECG can show abnormalities in heart function related to electrolyte disturbances.
Slide 6: Treatment and prognosis. An intravenous catheter and isotonic intravenous
fluids should be started. If the serum potassium level exceeds 7.5 mEq/L calcium gluconate
should be added to the intravenous fluids to protect the heart. This does not reduce the level of
potassium in the serum so the patient should be unblocked as soon as he is stable.
Relieving the urinary obstruction requires sedation or general anesthesia in all but the
most moribund of patients. The obstruction is cleared as follows:
Prepare a 3.5fr open-ended Tomcat catheter attached to a syringe with sterile saline.
Gently flush the urethra with the saline as the catheter is passed to clear the obstruction. Once
the catheter is able to be passed all the way into the bladder, the bladder should be expressed and
then flushed with sterile saline. A culture should be submitted to the lab. The Tomcat catheter
should be replaced with a flexible red rubber catheter and attached to a sterile urine collection
set. This set will remain in place to quantify urinary output for the next 12 48 hours. An

EMPLOYEE TRAINING: UROGENITAL AND REPRODUCTIVE

Elizabethan collar will keep the cat from self-trauma. The patient will require standard
supportive nursing care while it is hospitalized. Blood electrolytes should be checked every 4-8
hours until they are normal. Once the urine collection set is removed urine output monitoring
should be continued for 24 hours to ensure the patient continues to urinate freely and does not reobstruct. If re-obstruction occurs a urethrostomy surgery may have to be considered. The
urethrostomy removes the narrowest, scarred portion of the urethral lumen, which usually
prevents future obstruction (Battaglia, 2001, p. 286). Even if the patient is successfully treated,
they are at risk for re-obstruction in the future.
Prognosis is good to grave; it depends on how ill the patient is when presented. Cats that
are obtunded or moribund, with a prolonged obstruction have a much graver prognosis.
Slide 7: Reproductive Emergency.
Slide 8: Normal Reproductive Anatomy of the Dog. In females the normal
reproductive system is composed of the ovaries, oviducts, uterus, cervix and vagina. The ovaries
produce unfertilized eggs and also produce hormones that are responsible for the heat cycle and
maintaining pregnancy. In the female dog, the first estrus or heat cycle normally occurs between
five and eighteen months of age, depending on the size and breed with toy dogs maturing more
quickly than larger breeds. In the intact female these cycles will occur every six to nine months
throughout her life. Estrus is broken down into four phases, proestrus, estrus, diestrus and
anestrus. Proestrus is when the reproductive system prepares itself to become fertile. The
production of estrogen increases and the lining of the uterus becomes thickened. Estrus is the
active fertility stage, and is the stage that is referred to when we say a dog is in heat.
Ovulation occurs and the dog is ready to be bred. Diestrus follows estrus, and is the phase in
which pregnancy is maintained if mating is successful, or is the phase in which the reproductive

EMPLOYEE TRAINING: UROGENITAL AND REPRODUCTIVE

system calms and begins to revert to quiescence if there was no successful mating. Estrogen
levels fall and progesterone levels increase. Fluid accumulates in the uterus due to uterine
inactivity. If there was no mating diestrus lasts about 80 days. Anestrus is the quiet period
between heat cycles in which there are no signs of sexuality.
In the male dog the normal reproductive system is composed of the testicles, vas
deferens, prostate gland, and penis. Sperm are produced and stored in the testicles. During
ejaculation, sperm is transported to the prostate gland via the vas deferens where prostatic fluids
are added to nourish the sperm and aid in its transport from the penis and through the females
uterus. A male dogs penis had two specialized structures. The glans penis which is a bulb-like
dilation that fills with blood and holds the penis inside the vagina to ensure fertilization and the
os penis which is a bone that maintains the shape and direction of the penis during mating. The
penis itself is enclosed within a pouch called the prepuce.
Slide 9: Pyometra. Pyometra is an infection of the uterus that most often occurs in
middle-aged to older female dogs and cats during diestrus, approximately 45 days after estrus
(Battaglia, 2001, p. 299). During proestrus and estrus the cervix is open which may allow
bacteria to enter the uterus. When estrus ends the cervix closes, allowing that bacteria to become
locked away inside; and with the addition of progesterone calming the uterus and reducing
uterine contractions it becomes an environment which is idea for bacterial growth and
proliferation. E. coli is the most common culprit in uterine infections in dogs. Pyometra may be
either open or closed, if the cervix remains partially open the infected fluid will drain from the
uterus and the dog will present with a purulent vaginal discharge. This is the most common
complaint of an owner bringing in a dog with an open pyometra. If the cervix is completely
closed, clinical signs of a closed pyometra are more difficult for the owner to observe. The

EMPLOYEE TRAINING: UROGENITAL AND REPRODUCTIVE

disease may be more advanced with vaguer symptoms such as lethargy, anorexia,
polyuria/polydipsia, vomiting and/or diarrhea (dogs with open pyometra may also have these
symptoms). If the disease is even more advanced the dog may be in septic shock.
Since the client may not be aware of the real issue, this is where good history and client
communication skills shine. Eliciting that the patient is an intact female who has been in heat in
the past few months gives the veterinarian a starting point; physical exam signs may also be
vague tachycardia, painful abdomen, and pale mucous membranes.
Laboratory findings may also be vague, the patient may have a neutrophilia or a
neutropenia with or without a left shift or their white blood cell count may be normal. The
biochemistry may show markers for renal disease, hepatic dysfunction and/or dehydration.
Bacterial endotoxemia and reduced liver perfusion may be responsible for the hepatic
dysfunction; and dehydration and concurrent kidney insufficiency of the older dog may be
responsible for the azotemia (Dennis & Hamm, 2012).
Abdominal radiographs may raise suspicion or be diagnostic for pyometra. The large,
distended and fluid filled uterus may be visualized filling the mid and caudal abdomen with
associated bowel displacement. An abdominal ultrasound is the preferred method to evaluate the
uterus if one is available. The operator will be able to visualize a distended uterus filled with
anechoic to hyperechoic material. Ultrasonography will also help exclude other conditions that
cause uterine enlargement with vaginal discharge such as early pregnancy (Dennis & Hamm,
2012).
Slide 10: Pyometra Treatment. Treatment for pyometra starts with stabilizing the
patient. An IV catheter and intravenous fluid therapy to restore perfusion and correct electrolyte
imbalances with antibiotic therapy to treat infection should be started immediately. Medical

EMPLOYEE TRAINING: UROGENITAL AND REPRODUCTIVE

management may be attempted if the dog is of significant genetic value to the owner; however,
ovariohysterectomy is the treatment of choice. Surgery carries significant risk in a patient with
pyometra, this is no longer a simple, routine spay. The uterine walls may be friable and there is a
risk of spilling the contents into the abdomen during removal.
Medical management consists of administration of prostaglandins to induce regression of
the corpora lutea which reduces the production of progesterone allowing the cervix to
fully open and expel the uterine contents. Prostaglandins also stimulate myometrium
contractions, promoting expulsion of uterine contents. There are significant side effects
associated with prostaglandin administration such as vomiting, abdominal discomfort,
anxiety, hypersalivation and dyspnea which may occur immediately on administration
and continue for an hour or more afterwards. Uterine rupture could theoretically occur if
contractions occurred prior to cervical relaxation. (Dennis & Hamm, 2012)
Patients undergoing medical management will need to be carefully monitored for resolution of
vaginal discharge and normalization of laboratory findings. These patients should be bred on
their next heat, and should be spayed once the owners reproductive goal has been met because
there is a high risk of recurrence. Patients undergoing ovariohysterectomy will need standard
post-operative nursing care.
Prognosis for both medical and surgical management is variable. Open pyometra caught
early carries a better prognosis than closed pyometra. Pyometra is a life threatening condition
which without treatment will be fatal.
Slide 11: Reproductive Emergency Paraphimosis. Paraphimosis is a condition in
which the penis is unable to retract into the prepuce. It is more common in dogs than in cats, and
usually occurs after erection and copulation. The penis may be unable to retract into the prepuce

EMPLOYEE TRAINING: UROGENITAL AND REPRODUCTIVE

for a number of reasons including a small preputial orifice or opening, entrapment of the penis in
the hair around the opening, a foreign object such as string, or trauma. If there is no entrapment
the patient may have a history of intermittent or persistent penile extrusion. Paraphimosis
commonly occurs in younger dogs, with small breeds being over-represented. (Norkus, 2012)
Slide 12: Paraphimosis diagnosis and treatment. While generally not a life
threatening condition, the owner may feel embarrassment and be resistant when giving a history.
Generally they will have observed their dogs penis protruding for a period of time. The dog
may be showing signs of discomfort, and obsessively licking at their genital area. They may
have noticed that the penis appears dry, or swollen or discolored.
This is not a difficult condition to diagnose as the physical signs will be obvious. On
presentation the penis will be protruding and it may be edematous or discolored. On closer
examination a band of hair or a foreign object may be visible at the base. This condition is
painful, so sedation will probably be necessary to do a complete physical examination. There are
no laboratory markers for paraphimosis, although a general pre-anesthetic panel may be done to
assess the dogs condition prior to anesthesia (Norkus, 2012). An intravenous catheter should be
placed, and intravenous fluids may be administered during the procedure.
Once the patient is sedated, the penis should be thoroughly cleaned with cool water or
saline. The urinary bladder should be palpated and if it is large and firm, a urinary catheter or
cystostomy tube will need to be placed to assist with urination until the condition is resolved.
Any foreign object impeding the return of the penis into the prepuce should be removed. The
penis should be cleansed again, well lubricated and replaced into the prepuce. A hyperosmotic
agent such as 50% dextrose may be helpful in reducing edema. If the penis is too edematous to
replace easily and there is concern of necrosis, an incision can be made in the prepuce to assist in

EMPLOYEE TRAINING: UROGENITAL AND REPRODUCTIVE

replacement. If there is an anatomical defect, such as a narrowed preputial opening a small

surgical correction can be made. In the worst case scenario where the condition has gone on
long enough for the penis to become necrotic, full or partial penile amputation will need to be
performed.
Slide 13. Paraphimosis: Home treatment. Once the patient is discharged from the
hospital after replacement or surgery, the owner will need to be instructed on proper care and
observation. An Elizabethan collar to prevent further trauma and/or self-stimulation is required.
The owner should restrict exercise to leash walking until the dog is healed, and should use the
opportunity to monitor urine production. Any straining or difficulty urinating should necessitate
an immediate return to the vets office. The hair around the prepuce should be kept clipped
short. If topical ointments are dispensed, the client will need to be instructed on how to properly
instill them into the prepuce.
In an uncomplicated paraphimosis incident prognosis for return to normal function is
good. If there was necrosis, or surgical amputation was necessary the prognosis is guarded.

EMPLOYEE TRAINING: UROGENITAL AND REPRODUCTIVE

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References
Aguirre, A., & Darling, T. (Eds.). (2012). Urinary and renal diseases. Small animal internal
medicine for veterinary technicians and nurses (pp. 289-347). Ames. IA: Wiley
Blackwell.
Battaglia, A. M. (2001). Small animal emergency and critical care: A manual for the veterinary
technician. Philadelphia, PA: W.B. Saunders.
Dennis, J., & Hamm, B. L. (2012). Canine pyometra: Early recognition and diagnosis. Retrieved
from http://veterinarymedicine.dvm360.com/canine-pyometra-early-recognition-anddiagnosis?id=&pageID=1&sk=&date=
Dennis, J., & Hamm, B. L. (2012). Surgical and medical treatment of pyometra. Retrieved from
http://veterinarymedicine.dvm360.com/surgical-and-medical-treatment-pyometra?
id=&pageID=1&sk=&date=
Norkus, C. L. (Ed.) (2012). Veterinary technicians manual for small animal emergency and
critical care. Ames, IA: Wiley-Blackwell.
Selected topics in canine and feline emergency medicine (Vol 2). (2010). Paris: Diffo Print Italia.