Vaginal, Cervical, and Uterine Prolapse

Chapter 43
Vaginal, Cervical, and Uterine Prolapse

Augustine T. Peter

Veterinary Clinical Sciences, College of Veterinary Medicine, Purdue University, West Lafayette, Indiana, USA

Introduction

Eversion of the vagina or both uterine horns from the vulva is commonly referred to as vaginal and uterine prolapse (from prolabi, to fall out), respectively. It is not unusual to encounter these cases in cattle practice, particularly in the developing world. Vaginal and cervical eversions usually occur before calving, and uterine eversions after calving. There is no relationship between the occurrence of these conditions. A recent review provided an excellent description of the management of these conditions from the perspective of replacing, repairing and, if need be, amputating the uterus.¹ Noteworthy is a detailed description on manual eversion of the uterus to correct a uterine tear, a technique that involves the use of different pharmaceuticals.^2,3 This chapter will address this condition from three perspectives. Primarily, it will address these maladies and provide remedies with representative images, both real and created. Secondarily, it will provide a summary of information reported in the global literature, including practical solutions provided by practitioners. Finally, a discussion will address these clinical situations from a productive, fertility and, most importantly, an animal welfare perspective.

Vaginal and cervical eversions

Eversion of the vagina (Figure 43.1) is a relatively common occurrence, particularly in cattle compared with other species.⁴ There appears to be a genetic component to its occurrence in beef cows compared with dairy cows. Among the beef breeds, Hereford,⁵ heavier breeds such as Charolais and Limousin,⁶ and Shorthorns are more affected than others. It has been known that Bos indicus breeds are predisposed to this condition, along with cervical eversion. Many factors have been suggested to contribute to this condition,^7–10 including increased intra-abdominal pressure in late pregnancy, extreme cold weather, excess perivaginal fat, prior injury to the perivaginal tissues, intake of large volumes of poorly digestible roughage, poor vaginal conformation, persistence of the medial walls of the Müllerian ducts,¹¹ and changes in hormonal secretions, particularly increased estrogen as observed in late pregnancy and in estrus. It has been suggested that the higher concentrations of estrogens found during pregnancy can contribute to excessive relaxation and edema of pelvic ligaments that support the vagina. Besides the above, incompetence of the constrictor vestibule and constrictor vulvae muscles may have a role in the etiology.⁷ The condition is observed in embryo donor cows that are exposed to hormonal stimulation of the ovaries. Imbalance in calcium and phosphorus, and hypocalcemia has been considered to be a contributing factor by some workers.¹² It should be pointed out that the association with hypocalcemia was suggested merely based on the response to calcium therapy rather than on the clinical signs of hypocalcemia. However, as eloquently suggested,¹² it can be tentatively postulated that subclinical hypocalcemia could be derogatory to the internal environment of the physiologically stressed female because of pregnancy and parturition.

c43-fig-0001 — **Figure 43.1** Grade 1 eversion: vaginal eversion occurs intermittently, particularly when the animal lies down. Reprinted from *Color Atlas of Diseases and Disorders of Cattle* by R. Blowey and A. Weaver with permission from Elsevier.

The majority of vaginal and cervical eversions occur in the last few weeks of pregnancy; however, it may occur several months before calving. In some cows, it may occur during estrus. Vaginal eversions are classified into four grades according to the severity of eversion, the extent of injury, and the exposure of cervix in such eversions.

Grade 1 eversion: a small intermittent protrusion of the vaginal mucosa through the vulval lips is noticed (Figure 43.1) when the animal lies down. Often this tissue becomes dehydrated and traumatized and leads to a grade 2. A grade 1 eversion is readily repaired by applying any one of the retention sutures described later.
Grade 2 eversion: vaginal mucosa protrudes through the vulval lips continuously (Figure 43.2) with the possibility of the urinary bladder getting trapped in the everted organ. If left untreated, grade 2 quickly progresses to a grade 3 eversion.
Grade 3 eversion: the entire vaginal mucosa and cervix protrude continuously through the vulval lips (Figure 43.3) with a trapped urinary bladder and an exposed cervical mucous plug. The cervical seal may liquefy allowing bacterial contamination of the uterus leading to placentitis and fetal death. Often these fetuses become emphysematous and cervical dilation is insufficient for a vaginal delivery. This condition is often referred to as a cervical eversion but more correctly should be referred to as a cervico-vaginal eversion. This distinguishes it from eversion of the cervix alone as sometimes observed in Bos indicus breeds. In the latter case, only the cervix everts as a pedunculated mass through the vulva.
Grade 4 eversion: an eversion of such a duration that the entire vaginal mucosa appears necrotic and fibrosed (Figure 43.4). Infection is so extensive that the urinary bladder may become involved in it and peritonitis is a possible result.

c43-fig-0002 — **Figure 43.2** Grade 2 eversion: floor of the vagina everts and stays everted. Reprinted from *Clinical Theriogenology* with permission from the Editor Dr R. Youngquist.

c43-fig-0003 — **Figure 43.3** Grade 3 eversion: floor and cervix evert and they stay everted. Reprinted from *Clinical Theriogenology* with permission from the Editor Dr R. Youngquist.

c43-fig-0004 — **Figure 43.4** Grade 4 eversion: either a grade 2 or grade 3 that has become necrotic and/or fibrotic. Reprinted from *Color Atlas of Diseases and Disorders of Cattle* by R. Blowey and A. Weaver with permission from Elsevier.

The objective of treatment in the case of pregnant animals is to replace and retain the vagina and cervix within the pelvic canal and to deliver and wean a live offspring. Many management and treatment options are described for vaginal and cervical eversions.^{1,4,7,9–11,13–33} These can be placed in two general categories: those aimed at permanent reduction and others that afford a temporary solution. It should be mentioned that one approach may not fit all grades. The severity of the eversion, the time to expected delivery, the veterinarian’s preference, and the owner’s ability or willingness to manage the patient after treatment will dictate the treatment option. The elected initial treatment option may need to be changed after the response of the patient has been assessed. This is particularly relevant if tenesmus becomes an issue. If the patient is close to parturition, induction is recommended to prevent recurrence prior to parturition.

Short-term treatment options

Caslick’s suture

This technique (Figures 43.5 and 43.6) should be reserved only for a nonirritated grade 1 vaginal eversion that occurs close to parturition and when tenesmus is not expected to be a concern. Unfortunately, a simple Caslick’s suture in many cases is insufficient. As intra-abdominal pressure increases, tenesmus begins and the suture is ripped out or the vagina begins to evert below the sutures. Further, the vulval softening and stretching that occur closer to parturition contributes to this phenomenon. Caslick’s suture may suffice in patients that are not pregnant and have a grade 1 eversion during estrus. This is often the case with embryo donor animals whose ovaries are frequently superstimulated with hormones for the sole purpose of increasing the number of ovulations.

c43-fig-0005 — **Figure 43.5** Caslick’s suture being applied to a nonpregnant cow with grade 1 vaginal eversion. Reprinted from *Clinical Theriogenology* with permission from the Editor Dr R. Youngquist.

c43-fig-0006 — **Figure 43.6** Diagrammatic representation of the Caslick’s suture procedure. Illustration by Dr T. Barkley.

Buhner stitch

This is a very effective treatment for more advanced grades and that are chronic in nature.^17,18 To have a successful outcome the stab incisions have to be placed deeply such that the retention line is as cranial to the vulval lips as possible (Figure 43.7). The disadvantage is that it is unforgiving and if assistance is not available when the patient begins to calve, severe trauma to the vulva may occur or the calf is unable to be delivered and dies in utero or the patient may die as a result of uterine rupture and fatal hemorrhage. Following epidural anesthesia, the vulva is thoroughly washed with detergent and a 1-cm stab incision is made on the midline below the vulva and as far forward as practical. A second incision is made midway between the anus and dorsal commissure of the vulva (Figure 43.7). The Buhner needle is then passed deeply from the ventral incision up one side of the vulva and out through the dorsal incision. The Buhner tape (nonwicking) is passed through the eye of the needle and the needle retracted through the ventral incision along with the tape.

c43-fig-0007 — **Figure 43.7** Diagrammatic representations of Buhner stich procedure. Note the locations of dorsal and ventral retention lines. Illustration by Dr T. Barkley.

The procedure is repeated on the opposite vulval lip and the two ends tied leaving about a two-finger opening in the ventral vulva for urination. The preference is to tie a bow knot and then tie the two loops of the bow in a single square knot. This allows the knot to be loosened but to retain the suture so that if the patient should try to evert again, it can be replaced and the knot retightened. This can also be done in the evenings, if observation of the patient for parturition is not going to occur overnight.

If the procedure is performed properly, the tape should not be visible at the dorsal incision and this helps to prevent feces tracking down the needle paths. It should be stressed to the caretakers that their presence at the onset of calving is crucial for a successful outcome. If observation is a problem, medium-sized catgut can be doubled and used as a suture material; this helps in patients that are within 10 days of calving as the gut will break during parturition.

Bootlace technique

This is not a highly preferred technique as the vulval lips are inverted and the suture placement is tedious. However, it is stronger than a Caslick’s suture. Following an epidural anesthetic procedure and disinfecting of the vulva and surrounding area, four to five small eyelets are made with umbilical tape or hog nose rings¹¹ on either side of the vulva in a dorsal to ventral line at the hair to hairless junction on the vulval lips. After placing the eyelets, umbilical or Buhner tape is then used to “lace up” the vulva much like a boot (Figure 43.8). As the pattern is tightened, the vulval lips invert. Again, the bootlace must be loosened prior to calving to avoid serious trauma to the vagina.

c43-fig-0008 — **Figure 43.8** Diagrammatic representation of a bootlace technique. Illustration by Dr T. Barkley.

Horizontal mattress (Halstead) technique

In this technique, a needle is passed through the vulval lip on the right, beginning deep at the junction of the labia with the skin of the rump. The needle is continued across the vulval opening and through the left vulval lip at the same depth as the right. The needle is then passed back from left to right at the same plane as the first passage but beginning approximately 2–3 cm ventral to the first passage. This procedure can be done using a Buhner or large cutting needle. Place as many sutures as needed to close the vulva down to about two fingers wide to allow for urination.

The disadvantage of the technique is that even if the sutures are not pulled really tight, vulval edema frequently develops and can be quite severe. This can be lessened if the suture tension is dispersed by “stents.” Polyvinyl chloride tubing (1.3 cm diameter) can be cut the length of the vulva and holes drilled 2–3 cm apart; similarly wooden dowels²⁴ or latex tubing can be utilized. A stent is placed either side of the vulva and the horizontal mattress suture passed through the holes and tied (Figure 43.9). This approach has good deep retention and more evenly disperses the pressure.

c43-fig-0009 — **Figure 43.9** An example of a horizontal mattress technique. Note the location of the stents for reduction of vulval edema and for dispersion of pressure. Illustration (b) by Dr T. Barkley.

Deep vertical mattress technique

This is similar to the horizontal mattress pattern described above. The difference is that a vertical mattress suture pattern is used and stents are recommended to disperse tension on the vulval lips (Figure 43.10). This replacement method can also have serious consequences if assistance is not available at the onset of parturition.

c43-fig-0010 — **Figure 43.10** An example of a deep vertical mattress technique applied where buttons are used as stents. Illustration by Dr T. Barkley.

Permanent treatment options

Minchev vaginopexy

There are two Minchev techniques described that differ only in location of needle insertion. In the original Minchev technique the needle is passed through the lesser sciatic foramen.

The technique is an excellent prepartum method that aims to retain the vagina in the correct pelvic location by adhesion formation between the submucosa of the vagina and surrounding fascia. An epidural is given and the gluteal area shaved and disinfected. In the original Minchev technique, a large S-shaped needle is threaded with 0.95-cm umbilical tape and a gauze bandage or large plastic or metal plate is attached at the end of the tape; the needle is then taken in vaginally and the lesser sciatic foramen is located on the dorsolateral wall of the vagina. The needle is then pushed through the dorsal area of the foramen in order to avoid the pudendal nerve. The needle is pushed through the skin in the gluteal area and the suture pulled up snug (do not tie too tightly) and another button, plate or gauze is tied into the suture. This is repeated on the other side.

Modified Minchev vaginopexy

This technique is similar except the stay sutures are placed anterior to the lesser sciatic foramen 5 cm lateral to the midline and just posterior to the shaft of the ilium, providing more cranial fixation of the vaginal wall (Figure 43.11

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