Cloacal Prolapse in Reptilian Patients CVMA Lectures September 2017 Krista A Keller, DVM, Dipl ACZM Assistant Professor of Zoological Medicine University of Illinois College of Veterinary Medicine Goals of Lecture Focus on common companion reptile patients Relevant anatomy Cloacal Proximal tail Which tissue is prolapsed? Stabilization Definitive All images are from me unless indicated Cloacal Anatomy Cloaca Coprodeum Rectum / Colon Urodeum Urinary bladder (if present) Ureters Genital ducts Proctodeum Musk glands (when present) Phallus (if present) Final stop for everything C U P 1
C U P Cloacal Anatomy Cloaca Coprodeum Rectum / Colon Urodeum Urinary bladder (if present) Ureters Genital ducts Proctodeum Musk glands (when present) C U P C Mader. 2 nd Ed. U P 2
Hemipene/Phallus Anatomy Hemipenes Paired organs on the base of the tail Lizards and snakes Phallus Single organ on the ventral aspect of the proctodeum Chelonians Anapsid.org C U P H P C U P 3
Cloacal Prolapses Phone Triage There is no such thing as a reptile emergency ANY prolapsed tissue is an EMERGENCY Vitalized tissue generally has good prognosis Devitalized tissue generally has poor prognosis Cloacal Prolapse Two main questions when evaluating the cloacal prolapse patient Is the tissue vital or devitalized? What tissue is prolapsed? 4
Cloacal Prolapse Two main questions when evaluating the cloacal prolapse patient Is the tissue vital or devitalized? Day 1 Day 3 Cloacal Prolapse Two main questions when evaluating the cloacal prolapse patient Is the tissue vital or devitalized? Cloacal Prolapse Two main questions when evaluating the cloacal prolapse patient Is the tissue vital or devitalized? 5
Cloacal Prolapse Two main questions when evaluating the cloacal prolapse patient What tissue is prolapsed? Phallus or hemipene(s) Oviduct Rectum Cloaca Bladder UNIDENTIFIED Cloacal Prolapse Hemipene/Phallus Signalment MUST BE A MALE! Chelonians phallus, lizards/snakes hemipenes Chelonians>lizards>snakes Commonest cause of prolapse 35.7% Cloacal Prolapse Hemipene/Phallus Gross appearance Lizards/Snakes Laterally arising Lacks a lumen Rarely pigmented Klaver & Bohme 1986 6
Cloacal Prolapse Hemipene/Phallus Gross appearance Lizards/Snakes Laterally arising Lacks a lumen Rarely pigmented Video of hemipenile plug removal. Cloacal Prolapse Hemipene/Phallus Gross appearance Lizards/Snakes Laterally arising Lacks a lumen Rarely pigmented Mans. VCNA 2016 Cloacal Prolapse Hemipene/Phallus Gross appearance Chelonians Central arising Lacks a lumen Often pigmented Video of tortoise phallus 7
Cloacal Prolapse Hemipene/Phallus Gross appearance Chelonians Central arising Lacks a lumen Often pigmented Cloacal Prolapse - Hemipene/Phallus Causes Physiologic Mating season and ready to breed! Pathologic Secondary hyperparathyroidism Infection (hemipenile plugs) Forced copulatory separation Standard causes of strianing Diarrhea Constipation Cloacal/bladder urolith Cloacitis Species Breeding Season Green Iguana Sep-Feb 18 mos Age of Maturity Leopard gecko Jan-Sep 9-10 mos Bearded dragon Mar-Jul 12-24 mos Chelonians Mar-Sep 4-7 yrs Corn snakes Year round 18-24 mos Ball python Year round (spring) 18-24 mos Cloacal Prolapse - Hemipene/Phallus Causes Physiologic Mating season and ready to breed! Pathologic Secondary hyperparathyroidism Infection (hemipenile plugs) Forced copulatory separation Standard causes of strianing Diarrhea Constipation Cloacal/bladder urolith Cloacitis Video of severe osteopenia 8
Cloacal Prolapse - Hemipene/Phallus Causes Physiologic Mating season and ready to breed! Pathologic Secondary hyperparathyroidism Infection (hemipenile plugs) Forced copulatory separation Standard causes of strianing Diarrhea Constipation Cloacal/bladder urolith Cloacitis Cloacal Prolapse - Hemipene/Phallus Medical RRR Therapy (REDUCE, REPLACE, RETAIN) Appropriate for vital tissues REDUCE Cool hypertonic solutions 50% dextrose Hypertonic saline Honey Granulated sugar REPLACE Lubrication CTAs Manual replacement (remember anatomy!) RETAIN Reduce size of the opening Strategic suture placement Often RRR Therapy May be CURATIVE! (vital tissue) Cloacal Prolapse - Hemipene/Phallus Medical RRR Therapy (REDUCE, REPLACE, RETAIN) Cant reduce? Keep moist! Mader s Reptile Medicine and Surgery 9
Cloacal Prolapse - Hemipene/Phallus Surgical (hemipenotomy/phallotomy) Pertinent anatomy/physiology No urethra (intromittent organ only) Amputation of single hemipene does not reduce fertility Anesthesia vs heavy sedation + local block Simple amputation procedure Clamp Ligate consider transfixation for larger specimens!) Cut Replace stump into normal anatomic region Consider retaining sutures for ~1wk Cloacal Prolapse 2 yr MI breeding crested gecko Hemipene would not retract after copulation! Perioperative analgesia Meloxicam 0.2mg/kg Morphine 1mg/kg Lidocaine 2mg/kg infused Sedation Midazolam 1mg/kg Dexmedetomidine 50mcg/kg CLEAN but not STERILE procedure Video of hemipenectomy Cloacal Prolapse 10 yr MI yellow foot tortoise Hemipene replaced daily for last few days Diarrhea for past 6mos Endoparasites confirmed Diffuse osteopenia Perioperative analgesia Meloxicam 0.2mg/kg Intrathecal lidocaine Sedation Midazolam 1mg/kg Dexmedetomidine 100mcg/kg CLEAN but not STERILE procedure 10
Cloacal Prolapse 10 yr MI yellow foot tortoise Hemipene replaced daily for last few days Diarrhea for past 6mos Endoparasites confirmed Diffuse osteopenia Perioperative analgesia Meloxicam 0.2mg/kg Intrathecal lidocaine Sedation Midazolam 1mg/kg Dexmedetomidine 100mcg/kg CLEAN but not STERILE procedure Cloacal Prolapse 10 yr MI yellow foot tortoise Hemipene replaced daily for last few days Diarrhea for past 6mos Endoparasites confirmed Diffuse osteopenia Perioperative analgesia Meloxicam 0.2mg/kg Intrathecal lidocaine Sedation Midazolam 1mg/kg Dexmedetomidine 100mcg/kg CLEAN but not STERILE procedure Cloacal Prolapse 10 yr MI yellow foot tortoise Hemipene replaced daily for last few days Diarrhea for past 6mos Endoparasites confirmed Diffuse osteopenia Perioperative analgesia Meloxicam 0.2mg/kg Intrathecal lidocaine Sedation Midazolam 1mg/kg Dexmedetomidine 100mcg/kg CLEAN but not STERILE procedure 11
Cloacal Prolapse 10 yr MI yellow foot tortoise Hemipene replaced daily for last few days Diarrhea for past 6mos Endoparasites confirmed Diffuse osteopenia Perioperative analgesia Meloxicam 0.2mg/kg Intrathecal lidocaine Sedation Midazolam 1mg/kg Dexmedetomidine 100mcg/kg CLEAN but not STERILE procedure Cloacal Prolapse - Cloaca Signalment Female more common than male Lizards>Chelonians>Snakes 2 nd most common form of cloacal prolapse 19.6% of cases Cloacal Prolapse - Cloaca Gross appearance Small rim of tissue (can get enlarged/edematous) Lumen present Easiest to reduce Causes Urinary straining (Urolithiasis) Fecal straining Diarrhea/constipation Cloacal irritation (cloacitis) Oxyurids in bearded dragons Intrapelvic masses (renal) Recent egg laying Systemic (hyperparathyroidism) Tegusfromaroundtheworld.com Mans VCNA 2016 12
Cloacal Prolapse Cloaca Diagnostics CBC/chem underlying disease and hypocalcemia Rads -osteopenia, GI impactions, uroliths Fecal analysis!!! Cloacal Prolapse Cloacal Medical (vital tissue) RRR Therapy Mans VCNA 2016 Cloacal Prolapse Cloacal Medical (vital tissue) RRR Therapy 13
Cloacal Prolapse Cloacal Where to put vent sutures? Cloacal Prolapse Cloacal Surgical? (nonvital tissue) Nonvitalized cloacal tissue that is PARTIAL thickness treat medically Nonvitalized cloacal tissue that is FULL thickness consider euthanasia Very difficult to resect portions of the cloaca Cloacal Prolapse - Oviduct Signalment Must be a female Chelonians/lizards Not reported in snakes 3 rd (tied) most common form of cloacal prolapse 3.5% of cases 14
Cloacal Prolapse - Oviduct Presence of a male or previous copulation NOT required to lay eggs!!!!!!!!!!! Cloacal Prolapse - Oviduct Gross appearance Long tubular organ Lumen present +/- longitudinal striations Cloacal Prolapse - Oviduct Gross appearance Long tubular organ Lumen present +/- longitudinal striations Mader s Reptile Medicine and Surgery 15
Cloacal Prolapse - Oviduct Causes Straining secondary to reproductive stasis Preovulatory stasis (large follicles on ovaries) Post ovulatory stasis ( egg bound ) Other comorbidities Hypocalcemia (acute, chronic, acute on chronic) Infection Urolithiasis Constipation Cloacal Prolapse - Oviduct Diagnostics CBC/Chem calcemia, renal values Radiographs - how many eggs, other morbidities Cloacal Prolapse - Oviduct Diagnostics CBC/Chem calcemia, renal values Radiographs - how many eggs, other morbidities 16
Cloacal Prolapse - Oviduct Medical Management RRR therapy Vital tissue Reducible tissue Video of replacing oviduct in a BEDR Cloacal Prolapse - Oviduct Medical Management RRR therapy Treat ovulatory stasis Preovulatory Ovariectomy Cloacal Prolapse - Oviduct Medical Management RRR therapy Treat ovulatory stasis Preovulatory Ovariectomy Postovulatory Spay/salpingectomy DO NOT TREAT WITH OXYTOCIN! 17
Cloacal Prolapse - Oviduct Video of collapsing eggs within the coelom of tortoise Cloacal Prolapse - Oviduct Surgical Therapy External tubular resection/anastomosis Nonvital tissue Non reducible tissue Cloacal Prolapse _ Oviduct 18
Cloacal Prolapse - Oviduct Surgical Therapy Internal tubular resection/anastomosis (salpingectomy) +/- ovariectomy Nonvital tissue Non reducible tissue Cloacal Prolapse - Oviduct Surgical Therapy Internal tubular resection/anastomosis (salpingectomy) +/- ovariectomy Nonvital tissue Non reducible tissue BETTER PROGNOSIS Cloacal Prolapse - Colon Signalment Female>Male Only lizards reported Not reported in snakes.chelonians 3 rd (tied) most common form of cloacal prolapse 3.5% of cases 19
Cloacal Prolapse - Colon Gross appearance Long tubular organ Lumen present NEVER longitudinal striations Exiting feces Cloacal Prolapse - Colon Gross appearance Long tubular organ Lumen present NEVER longitudinal striations Exiting feces Cloacal Prolapse - Colon Causes Straining secondary to GI causes Diarrhea Endoparasites Viral (adenovirus) Bacterial/fungal Constipation Foreign material Ileus Other comorbidities Hypocalcemia (acute, chronic, acute on chronic) Infection Urolithiasis Claire Grosset, DVM, Dipl ACZM 20
Cloacal Prolapse - Colon Diagnostics CBC/Chem calcemia, renal values Radiographs GI foreign material Fecal evaluation Floatation Specialized PCR tests (adenovirus) Cloacal Prolapse - Colon Medical Management RRR therapy Vital tissue Reducible tissue Cloacal Prolapse - Colon Surgical Management? Resection and anastomosis POOR PROGNOSIS Nonvital tissue Nonreducible tissue Euthanasia Mader s Reptile Medicine and Surgery 21
Cloacal Prolapse - Bladder Signalment No male or female predisposition Must be a species with a bladder! Bladder Present Chelonians (turtles, tortoises, terrapins) Rhynchocephalans (tuatara) Oophidians (snakes) Crocodilians Bladder Absent Lizards Leopard gecko (and other geckos) Green iguana Green anole Chameleons Blue tongued skink Bearded dragon Cloacal Prolapse - Bladder Uncommon form of prolapse 3.5% of cases in large retrospective (Hedley 2014) Gross appearance Thin walled/translucent Fluid filled No lumen Causes Urinary straining Cystitis Urolithiasis +/- Other causes of straining Mader s Reptile Medicine and Surgery Cloacal Prolapse - Bladder Diagnostics CBC/Chemistry (post urinary obstruction) Radiographs (urolithiasis) 22
Cloacal Prolapse - Bladder Vital tissue: RRR Non vital tissue /8 Cystotomy for urolith removal Mader s Reptile Medicine and Surgery 23