Urinary bladder eversion with hydronephrosis and renal failure in .pdf by yan198555


									  Urinary bladder eversion with hydronephrosis and
              renal failure in a beef cow
                        Cameron H. Friesen, Christine L. Theoret, Spencer M. Barber

Partial or complete eversion of the urinary bladder             96 to 110 mmol/L), hypocalcemia (1.90 mmolIL; normal,
     through the urethra into the vagina has been reported       2.11 to 2.75 mmol/L), high bicarbonate (35 mmol/L; nor-
in dairy cows (1-5) and mares (6). This condition is usu-       mal, 20 to 28 mmol/L), high creatinine (1862 pmol/L;
ally associated with severe straining, and it occurs dur-       normal, 67 to 175 pmolIL), and high urea (50.5 mmol/L;
ing late parturition or early postpartum period. Successful     normal, <7.5 mmol/L). These results were interpreted as
treatment in the cow has been reported (1-3,7). This case       inflammation, hypochloremic metabolic alkalosis, and
reports the complications that may occur when treatment         a marked azotemia. No urine could be obtained for uri-
is not initiated promptly.                                      nalysis. On paralumbar ultrasonic examination, the left
    A 640 kg, 4-year-old, Simmental cow was referred to         kidney was enlarged, displaced ventrally, and lacked a
the Western College of Veterinary Medicine with the             distinct lobular pattern, while both kidneys had a mod-
presenting complaint of a large vaginal mass. This cow          erate amount of perirenal fluid accumulation and mild
had previously been used on several occasions as an             dilations of their calices.
embryo transfer donor, and had calved without assistance           Because the bladder eversion was irreducible, and renal
2 to 3 wk earlier. One week prior to presentation, the          failure and endometritis were present, a grave progno-
referring veterinarian had diagnosed a prolapse of              sis was given and the cow was euthanized. Postmortem
perivaginal fat through a vaginal tear and had partially        examination confirmed the clinical diagnoses of complete
closed the vulva with a purse-string suture (Buhner             urinary bladder eversion and endometritis. Moderate
method).                                                        bilateral hydronephrosis and hydroureter were also pre-
   On physical examination, the cow was straining               sent. Histologically, severe diffuse cystitis with arterial
mildly and was slightly depressed and dehydrated. Her           thrombosis and multifocal interstitial nephritis and
rectal temperature and pulse rate were within normal lim-       renal cortical necrosis were present. Significant bacte-
its, but her respiratory rate was elevated to 60 breaths/       rial isolates from both kidney and uterus were Actino-
min. A serosanguinous, slightly foul, vaginal discharge         myces pyogenes and Streptococcus spp.
was observed.                                                      Although everted bladders are uncommon, a thor-
   Following a caudal epidural block with 2% lidocaine          ough manual and visual examination should provide
hydrochloride (Austin, Joliette, Quebec) and removal of         an accurate diagnosis. Delay in presentation to our
the purse-string suture, a vaginal examination was per-         clinic resulted in irreparable damage to the organ and
formed. An approximately 18 by 25 cm ovoid mass                 serious secondary complications. Possible differential
occupied the cranial two-thirds of the vaginal lumen. It        diagnoses included uterine prolapse, urinary bladder
was attached to the vaginal floor, just caudal to the           prolapse, vaginal prolapse, vaginal abscess, and vaginal
urethral fold, via a stalk that was 4 cm long and 2.5 cm        neoplasia. Although the bladder wall was markedly
wide. The mass, which could be rotated and partially            thickened, it was still oblong and had a hollow feel on
exteriorized, felt firm and edematous but somewhat              manual examination. The most helpful clinical find-
hollow on deep palpation. Its surface had a mottled             ing was the attachment of the mass by a stalk to the vagi-
dark red color, and was rough and slightly lobulated but        nal floor at the location of the urethral orifice. Inability
devoid of any defects or recognizable openings. The vagi-       to locate a urethral opening and the absence of other
nal and cervical mucosae appeared reddened, but no tears        abnormalities of the vaginal walls aided in the diagno-
could be seen or palpated, and the normal urethral              sis of urinary bladder eversion. The ureteral openings
opening could not be identified. On examination per             often can not be located, even in cases of acute ever-
rectum, the uterus was poorly involuted and contained           sion (4), because of edema and thrombosis, which can
a moderate amount of fluid, and left kidney was enlarged        occur rapidly in the bladder wall. Care must be taken not
and ventrally displaced. Based on these findings, we diag-      to confuse serosal effusion, which would accumulate in
nosed complete eversion of the urinary bladder.                 an everted bladder, with urine, which would accumulate
   On a complete blood count, there was a leukopenia            in a prolapsed bladder (4).
(1.008 X 109/L; normal, 4.0 to 12.0 X 109/L), an                   Therapeutically, an acutely everted bladder can often
increased number of band cells (0.462 X 109/L; normal,          be replaced through the urethra, but with subacute to
<0.12 X 109/L), and an elevated plasma fibrinogen               chronic eversion, edema of the wall makes this more dif-
(80 g/L; normal, <6.0 g/L). Serum biochemical abnor-            ficult. In this case, the thickness of the bladder wall
malities included hypochloremia (92 mmol/L; normal,             (3 to 5 cm) would have prevented both the reduction of
                                                                the eversion and passage of the bladder through the
Can Vet J 1995; 36: 710-711                                     urethral lumen. Replacement of the bladder following a
                                                                longitudinal incision of the urethral sphincter (4) and
Department of Veterinary Anesthesia, Radiology and Surgery, partial amputation of the bladder and its replacement
Western College of Veterinary Medicine, University of through the urethra (1) have been described. Neither of
Saskatchewan, Saskatoon, Saskatchewan S7N OWO.                  these procedures were attempted in this case because of
Address correspondence to Dr. Friesen at Sturgeon River the severe thickness of the wall, involvement of the entire
Veterinary Group, 9804 90th Ave., Morinville, Alberta T8R 1 K7. bladder, and presence of renal failure. The extensive
710                                                                                  Can Vet J Volume 36, November 1995
edema and arterial thrombosis would likely have pre-                      This case demonstrates the need for an accurate and
vented normal bladder function, even if the organ could                 timely diagnosis of complete urinary bladder eversion,
have been replaced. In some cases, loops of intestine her-              so that irreparable damage to the bladder and secondary
niate through the urethra into the everted bladder.                     complications in the urinary system can be avoided.
Correction of this condition may require both a flank                                                                                    cvi
laparotomy and a cystotomy (3).
   The chronicity of this case led to compression of the
ureters and secondary hydro-ureters and hydronephro-                    References
sis, which to our knowledge has not previously been                     1. Hentschl AF, Walton JF. Repair of an everted bladder in a cow. Vet
                                                                           Med Small Anim Clin 1966; 61: 253.
reported with this condition. These complications result                2. Jones G. Bladder eversion in dairy cows. Mod Vet Pract 1984; 65:
in a grave prognosis, regardless of the treatment proto-                   950.
col selected.                                                           3. Frazer GS. Uterine torsion followed by jejunal incarceration in
   Eversion of the urinary bladder occurs in cattle and                    a partially everted urinary bladder of a cow. Aust Vet J 1988;
horses after conditions that lead to increased intra-                      65: 24-25.
                                                                        4. Ducharme NG, Stem ES III. Eversion of the urinary bladder in the
abdominal pressure (4-7). As well, the higher incidence                    cow. J Am Vet Med Assoc 1981; 179: 996-998.
of this condition in multiparous dairy cattle (3,5) suggests            5. Peter AT, Arighi M, Gaines JD. Herniation of distal jejunum
that hypocalcemia may be important in producing                            into the partially everted urinary bladder of a cow. Can Vet J
decreased bladder tone, which, in turn, may contribute                     1989; 30: 830-831.
                                                                        6. Wegmann E. Urinary bladder eversion in a mare with colic. Mod Vet
to eversion. The animal in this report was hypocal-                        Pract 1987; 68: 174.
cemic, but this could have occurred secondary to                        7. Brunsdon JR. A case of urinary bladder prolapse in a cow. Vet Rec
anorexia.                                                                  1961; 73: 437-438.

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Can Vet J Volume 36, November 1995                                                                                                      711

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