Clinical communication — Kliniese mededeling

Surgical uterine drainage and lavage as treatment for canine pyometra

K G M De Cramera

ity. To compare the success rate of treat- ABSTRACT ment protocols for pyometra clinical Pyometra is a common post-oestral syndrome in bitches. Classical treatment consists of recovery rates, pregnancy rates, litter size, either ovariohystorectomy or medical intervention. Surgical uterine drainage and lavage recurrence rates and duration of treat- via direct trans-cervical catheterisation using a 5 % povidone-iodine in saline solution was ment should be considered. In some performed successfully in 8 bitches with pyometra. All bitches conceived and whelped cases, the duration of treatment is of con- without complications subsequent to this treatment. It is concluded that this method offers cern. In a retrospective study, some an effective alternative treatment for canine pyometra with shorter recovery times as well were treated with PG for up to 26 days as good clinical recovery and pregnancy rates in bitches destined for further breeding. and in another for over 3 weeks before 19,26 Keywords: , pyometra, uterine lavage. cure was achieved . There are cases of

canine pyometra refractory to PGF2α ther- De Cramer K G M Surgical uterine drainage and lavage as treatment for canine pyometra. 6 Journal of the South African Veterinary Association (2010) 81(3): 172–177 (En.). Rant en Dal apy and cases that recur at subsequent cy- 13,15,29 Animal Hospital, PO Box 704, Rant en Dal, Mogale City, South Africa. cles . This accentuates the importance of immediate breeding after treatment. Combination therapy using prosta- glandins with either dopamine agonists INTRODUCTION tococci, Pasteurella multocida, coagulase- or receptor antagonists By definition pyometra is a -filled positive Staphylococcus spp. and Klebsiella have been used to successfully treat spon- . Pyometra is typically a post-oestral spp. are amongst the organisms mostly taneously occurring cases of pyometra13. syndrome in adult bitches associated isolated from pyometra cases, either in In one study using cabergoline and with a variety of clinical and pathological pure culture or mixed infections6,9,10,25.As cloprostenol clinical recovery was attained manifestations of genital and multi- pyometra may have fatal complications, within 14 days in over 90 % of cases, with systemic disease2–5,7,11,20,27. Pyometra is most clients opting to retain their bitch’s repro- a pregnancy rate of 64 %13. Combination commonly associated with polydipsia, ductive capacity should be warned of therapy is probably the preferred choice polyuria, abdominal distension, vomition, potential risks of medical or surgical treat- in closed pyometra as aglepristone poor appetite, weight loss and anaemia20. ments. Pyometra cases show marked was reported to open a closed cervix in A purulent may, how- haematological and biochemical changes. approximately 48 h following the 1st ever, be the only symptom in some cases These changes include elevated total administration15. When combined with of pyometra when the cervix is open11.It white blood cell counts (WCC), marked cloprostenol the clinical recovery rate was appears that the degree of patency of the left shift, toxic degeneration of neutro- 84 % but the treatment frequently lasted cervix dictates the severity of the clinical phils, elevated serum ALP levels and up to 28 days15. Intra-uterine signs to a large extent11. Canine pyometra detection of plasma endotoxin in some and antiseptics including povidone- is a life-threatening disease28,34. It is postu- cases16. Clinical improvement of pyometra iodine have been used successfully in lated that intrauterine bacteria, which cases has been associated with reduction treating uterine infections in cows14,23,24. ascend from the during pro-oestrus in plasma progesterone concentrations, Intra-uterine infusions of saline, EDTA- and oestrus, induce the disease during increased vaginal discharges, reduction Tris, chlorhexidine gluconate and antibiot- metoestrus by acting on the progester- in diameter of the uterus as determined ics have similarly been successfully used one-primed directly via by ultrasonography and normalisa- in mares12,22,40. toxin production, or indirectly by the tion of haematological and biochemical The uterine drainage and lavage as release of inflammatory mediators33. profiles3,5,13,15,18,29. Treatment of canine illustrated in this study was performed in There is a clear association between cystic pyometra with prostaglandins (PG) is an attempt to shorten the duration of (CEH) and successful with clinical recovery rates treatment of pyometra in the bitch as well pyometra11,20,27. CEH is a progressive approaching 80 % and post-treatment as achieve both high clinical recovery and degenerative process and is generally pregnancy rates attained varying from pregnancy rates post-treatment. 19,21,29,31,37 accepted to be the initiating lesion and 40%to80% . Prostaglandin F2α contributes to failure to shed normally (PGF2α) facilitates smooth muscle contrac- MATERIALS AND METHODS transient uterine infections by compro- tion in the uterine wall leading to expul- mising the uterine environment and/or sion of uterine contents in cases of Case selection local defence mechanisms38. Parity and pyometra21. It is this expulsion of uterine The study was performed in a commer- age are significant risk factors in the contents that is suspected to be responsi- cial breeding establishment and in a development of pyometra20,32. ble in part for recovery39. The duration of private practice. Any bitch that developed Escherischia coli, beta-haemolytic strep- prostaglandin administration is thus dic- pyometra was automatically included in tated by the uterine dimension, time it the trial irrespective of age or breed until aRant en Dal Animal Hospital, PO Box 704, Rant en Dal, takes for vaginal discharges to subside 8 bitches were collected. Informed owner Mogale City, South Africa. E-mail: [email protected] and ultimately by return of the WCC to consent was obtained in all cases. The case Received: March 2010. Accepted: July 2010 normal and the patient to clinical normal- selection of the individual bitches was

172 0038-2809 Tydskr.S.Afr.vet.Ver. (2010) 81(3): 172–177 Table 1: Organisms isolated, inter-oestrus interval and litter sizes achieved.

Name of bitch Organism/s isolated Inter-oestrus interval in days Litter size

Marmelade E coli and Enterobacter agglomerans 144 1 Ansie E. coli 156 4 Callie Beta-haemolytic streptococci 168 7 Qualie E coli and beta-haemolytic streptococci 179 4 Vasta E coli & Streptococci spp. 163 5 Kanaan bitch Not done Unknown 6 Siberian husky E. coli 216 5 Greyhound Not done 252 5 based on their exhibiting some or all of the therapy and high doses of prednisolone the surgeon was able to locate its tip typical signs of pyometra characterised sodium succinate (Solu-delta Cortef, through the vaginal wall. The non-sterile by depression, anorexia, polydipsia, Upjohn) at 10 mg/kg IV. Corticosteroid assistant then removed the proctoscope polyuria, pyrexia and purulent vaginal therapy has been used in varied doses for from the vagina. The surgeon located the discharge. All showed an enlarged fluid- and related syndromes for more tip of the pipette with 1 hand and simulta- filled uterus on ultrasonography and than 50 years, but its use remains contro- neously stabilised the cervix with the typical leucogram changes. Two of the versial1. As soon as the diagnosis of other hand. The non-sterile assistant care- 8 bitches, the Kanaan and the Grey- pyometra was made, all the bitches were fully advanced the pipette cranially until hound, showed severe signs of depres- treated with 20 mg/kg clavulanate poten- the pipette was in close proximity to the sion, , severe tachycardia, tiated amoxycillin (Synulox, Beecham cervix. The surgeon then manipulated the toxic mucous membranes and anaemia. A Pharmaceuticals) twice daily and genta- cervical opening onto the tip of the vaginal discharge was noted in 5 of the mycin (Genta 20, Phenix) at 4 mg/kg (BID) pipette and slid the cervix over the pipette. bitches. Prior to antimicrobial therapy, a until the result of the antibiogram indi- The tip of the pipette was palpable in the deep vaginal guarded swab was collected cated the use of other antibiotics. Flunixin uterine body and visible when pushed and sent for bacteriological culture meglumin (Finadyne, Centaur Labora- against the uterine wall (see Fig. 3). The and sensitivity assessments tories) was also given at 2 mg/kg (SID) in non-sterile assistant then attached a 50 m (Table 1). conjunction with ringers lactate infusion syringe to the end of the pipette. De- at rates above maintenance. The surgical pending on the viscosity of the exudate, Reproductive history of the bitches flushing commenced within 48 hours of the assistant could apply suction and presented the diagnosis. aspirate content from the uterus. In most Marmalade. Beagle, 5 years multigravid cases the viscosity of the exudates pre- bitch had 3 previous litters. In her last Surgical method vented this action. The surgical assistant 2 cycles she was not bred. Pyometra The flushing medium selected was a was required to occlude the utero-tubal was diagnosed ±6 weeks post-oestrus. 50:50 mixture of ‘Betadine’ (povidone- junctions of both horns using gentle digi- Ansie. German shepherd, 4 years maiden iodine 100 mg/m , Adcock-Ingram) and tal pressure while the non-sterile assistant bitch that cycled normally. She devel- normal saline to constitute a 5 % beta- infused the flushing medium into the oped pyometra 8 weeks post-oestrus. dine- saline mixture. The 8 bitches were uterus. Considerable care was taken to Callie. German shepherd, 5 years old, premedicated with atropin sulphate 0.5 %, ensure that no pus was forced into the maiden bitch. Developed pyometra at (Centaur laboratories) and acetylproma- via the fallopian tubes. Consid- approximately 7 weeks post-oestrus. zine maleate (Aceprom 2 %, Centaur lab- erable care was also taken by the assistant Quali. German shepherd bitch, age un- oratories). Induction of anaesthesia was handling the pipette in the vagina not to known. Previous reproductive history achieved by using sodium thiopentone penetrate the uterine wall. unknown. Developed pyometra ±4 (Intraval, Maybaker) and maintenance The maximum volume infused into the weeks post-oestrus. was achieved by halothane gas inhala- uterus at any one time depended on the Vasta. German shepherd, multigravid tion. The perineal area was washed using size of the uterus and varied between 20 bitch, aged 6 years. Developed pyo- water and antiseptic soap. The bitch was and 50 m . With the surgical assistant metra 10 weeks post-oestrus. prepared surgically as for a laparotomy. occluding the utero-tubal junctions, the Kanaan bitch. Kanaan cross bitch, 6 years. In addition to a surgeon and a surgical surgeon massaged the uterine wall of the Reproductive history unknown. Pyo- assistant, the procedure required a 3rd uterus, mixing the exudate and flushing metra was diagnosed but it was not assistant to manipulate the irrigation medium. The non-sterile assistant there- recorded when she was last in oestrus. pipette and flushing medium (the ‘non- after aspirated the contents of the uterus Siberian husky, 4 years, multigravid bitch, sterile assistant’, see Fig. 1). A standard back into the syringe prior to emptying developed pyometra 5 weeks post- abdominal midline incision was made to the syringe, re-filling and injecting more oestrus. allow exteriorisation of the uterine body flushing medium into the uterus. This Greyhound, 10 years, multigravid but had (see Fig. 2) and localisation of both cervix was repeated until that part of the uterus not conceived in the last 2 years. and vagina. The non-sterile assistant was evacuated. This procedure was re- Pyometra was diagnosed 3 weeks post- introduced a sterile proctoscope into the peated progressing towards the tip of the oestrus. vagina as far cranially as possible before horn and then repeated in the other horn. removal of the introducer from the The aspirated exudate initially appeared Pre-surgical therapy proctoscope. A sterile bovine artificial purulent and viscous. It changed from a Two cases presented in severe shock insemination pipette with syringe attach- thick viscous consistency to a watery and were 1st stabilised by using shock ment was introduced via the lumen of the consistency (see Fig. 4) and resembled therapy consisting of extensive fluid proctoscope and advanced cranially until the colour of the introduced flushing

0038-2809 Jl S.Afr.vet.Ass. (2010) 81(3): 172–177 173 medium as the procedure progressed. A volume range of 300–500 ml was used to flush the entire uterus. As the viscosity of the uterine content decreased, this con- tent was observed to escape from around the catheter into the vagina. As the proce- dure progressed the uterine dimensions were observed to decrease (see Fig. 5). At the end of the procedure the remaining uterine content was milked caudally to escape from the uterus by a combination of aspiration via the pipette lumen or manually along the outer diameter of the pipette into the vagina. The pipette could then be removed from the cervix and an irrigation of the vagina was performed using the flushing medium to remove any pus that may have collected in the vagina. The surgical wound was closed using a standard method. No difficulty was en- Fig. 1: Non-sterile assistant holding syringe filled with flushing medium and bovine pipette countered in passing the pipette through in the vagina. the cervix or guiding it into the uterine horns in any of the bitches including the 3 bitches that did not show vaginal dis- charges and were considered to be closed cervix pyometra cases. The entire proce- dure was uneventful in all the bitches.

Post-surgical case management Fluid thearapy at maintenance rates was administered for the 1st day following surgery. Gentamycin and Finadyne were given for a maximum of 5 days, whereas Synulox was given till the vaginal dis- charge subsided. The results of the culture and sensitivity tests revealed that either the Synulox and/or gentamycin were effective against 6 of 8 samples tested. The results of the sensitivity tests did not warrant changing the anti- microbial therapy in at least these 6 bitches. The appetite, habitus, vital signs and volume and nature of any vaginal Fig. 2: Surgeon-exteriorised uterine horn. Note diameter of horn (yellow arrow). discharge were recorded daily for 14 days post-surgery. The colour of the vaginal discharges varied from light straw-col- oured to dark brown and appeared to be muco-purulent in nature. The volumes were scant and subsided in all but 1 bitch by day 4. The Greyhound bitch showed a vaginal discharge for 12 days. All the bitches ate normally within 2 days of surgery. A blood sample was obtained via cephalic venipuncture for haematology at 14 days post-surgery. By 14 days after the flushing, the WCC had returned to normal in all bitches.

RESULTS

The subsequent oestrus cycle At the 1st signs of pro-oestrus, the bitches were presented for routine oestrous monitoring. The bitches were all treated empirically with 20 mg/kg Synulox from Fig. 3: Surgeon holding uterine body with tip of pipette visible through uterine wall (red the time of 1st mating until 5 days into the arrow). Yellow arrow points to stretched wall of a pus-filled diseased uterus.

174 0038-2809 Tydskr.S.Afr.vet.Ver. (2010) 81(3): 172–177 the flushing procedure. It is speculated that this was achieved by both the physi- cal effect of flushing as well as manual manipulation and ‘milking’ of the uterus itself. The success of the current method described may in part be explained by the efficient expulsion of uterine contents as is the case when PG is used39. In the choice of antiseptic, its micro- bicidal properties, safety, efficacy in the presence of purulent debris and the strength of dilution at which it exhibits these properties are important consider- ations. Although povidone-iodine was found to be temporarily cytotoxic after 30 min contact with murine fibroblasts, an unexpected revitalisation was observed 24 hours later30. In one study it was demonstrated that povidone-iodine can be used safely in spinal surgeries, and Fig. 4: Non-sterile assistant suctioning uterine content, which is clearly a mixture of pus does not influence wound healing, bone and the flushing medium. union and clinical outcome at a dilution of 0.35 %8. The microbicidal action spectrum of povidone-iodine is broad even after short onset times36. Unlike local antibiotics and some other antiseptic substances, no resistance has been reported with povi- done-iodine36. With protein load (0.2 % albumin), which mimics the presence of pus, the optimum in microbicidal effec- tiveness shifts to concentrations ≥10%of povidone-iodine35. The direct antiseptic effect of the flushing medium itself may thus have contributed to its success. The fact that a residual, undetermined amount of flushing medium must have remained in the uterus might have had an osmotic effect and/or irritant post-flushing or lasting antiseptic effect. Likewise it may be assumed that an undetermined but probably small amount of pus may have remained in the uterus post-flushing. It was very clear that the mixing of the Fig. 5: Surgeon holding uterine horn, which is now emptied, with the pipette tip visible flushing medium in the uterus led to a through uterine wall at red arrow. Yellow arrow points to the uterine wall which is by now significant reduction in the viscosity of not stretched and the decrease in the uterine diameter is clearly visible. the exudate. This reduction in viscosity eased the flushing procedure as it pro- subsequent dioestrus. The bitches were lavage of the diseased (pyometra) uterus gressed but must also have aided in then monitored for vaginal discharges could be used as a safe alternative treat- improved drainage post-surgery. It is the daily until pregnancy diagnosis by ultra- ment option and also possibly shorten the author’s opinion that the removal of the sound at Day 27 of dioestrus. The duration of treatment as well as achieve exudates from the uterus, as evidenced by inter-oestrus interval appeared to be un- high clinical recovery and pregnancy reduction in uterine diameter, must have affected by the surgical intervention.The rates. The results obtained in this study been one of the main contributing factors bitches all showed a normal oestrous cy- show that the duration of treatment to successful and shorter course of treat- cle and were mated at least twice each, ev- was 12 days or shorter which compares ment achieved. ery alternate day from the 1st day of favourably with other studies and the It has been suggested that placement of standing heat until dioestrus. All the 100 % recovery and pregnancy rates intra-uterine catheters cause mechanical bitches conceived and whelped normally. achieved exceed any of those in previous drainage and reduction in uterine diameter The litter size was considered normal in studies5,6,13,15,18,19,29,31,37. These results need to as monitored by sequential hystero- all but 1 of the bitches (Table 1). be scrutinised and attempts made at possi- graphy17,25. Mechanical stimulation of the ble explanations of its success. One possi- uterine wall was supported by a case DISCUSSION ble explanation is the extent to which the which was subjected to unilateral drain- No previous reports were found on the septic exudate was efficiently removed age of the uterus for a few days25. Since use of intra-uterine antiseptics in bitches. from the uterine lumen by direct manual drainage took place along and not The purpose of this study was to evaluate manipulation and a significant reduction through the plastic catheters, it is difficult whether surgical uterine flushing and in diameter of the uterus achieved during to understand how one catheter could

0038-2809 Jl S.Afr.vet.Ass. (2010) 81(3): 172–177 175 exert its selective effect by facilitating value to both biopsy the uterine wall and metrial hyperplasia (CEH) a suitable model escape of exudate from the drained horn. monitor progesterone profiles before and for study of spontaneously occurring CEH in the uterus of the bitch? Reproduction in A more plausible explanation for the after the flushing as this may reveal Domestic Animals 37: 152–157 asymmetrical involution of the uterus whether flushing alters the extent and 5. Breitkopf M, Hoffmann B, Bostedt H 1997 could be that the catheter stimulated degree of CEH in canines suffering from Treatment of pyometra (cystic endometrial contraction of the uterine horn either pyometra or induces pathology. This hyperplasia) in bitches with an antiproges- directly or indirectly. It may be speculated study only evaluated the conception rates tin. Journal of Reproduction and Fertility. Supplement 51: 327–331 in the current study that the flushing me- of treated bitches at the 1st cycle following 6. Brown J M 1985 Use of prostaglandin F2a in dium induces increased motility in the treatment. More long-term studies are treatment of uterine diseases in the bitch. same fashion. The direct irritant proper- required to determine long-term fertility Modern Veterinary Practice 66: 381–382 ties might also have had a stimulating and in these bitches. Further studies may also 7. Chaffaux S, Thibier M 1978 Peripheral rejuvenating effect on the endometrial highlight whether uterine drainage and plasma concentrations of progesterone in the epithelium. The flushing of the uteri may lavage might be efficacious in cases refrac- bitch with pyometra. Annales de Recherches Vétérinaires 9: 587–592 also have had the effect of releasing tory to PG treatment. 8. Chang F Y, Chang M C, Wang S T, Yu W K, endogenous prostaglandins which in The direct visual examination of the Liu C L, Chen T H 2006 Can povidone- turn could have induced luteolysis, uter- uterus by laparotomy has the added iodine solution be used safely in a spinal ine motility and expulsion of septic advantage of closer examination of the surgery? European Spine Journal 15: 1005– debris, but this was not confirmed in this uterine wall for signs and severity of 1014 9. Coster R d, D’ieteren G, Josse M, Jacovljevic study. cystic endometrial hyperplasia (CEH) S, Ectors F, Derivaux J 1979 Clinical, The beneficial effects of drugs such as and other uterine/ovarian pathology histological, bacteriological and hormonal

PF2α, prolactin inhibitors and antigestagens which may have a bearing on the long- aspects of chronic metritis in the bitch. in the treatment of pyometra may be due term reproductive performance which is Annales de Médecine Vétérinaire 123: 233–247 to their effect on reducing the action of either difficult or impossible to evaluate 10. Dhaliwal G K, Wray C, Noakes D E 1998 Uterine bacterial flora and uterine lesions in progesterone on the uterus. These drugs using ultrasonography. bitches with cystic endometrial hyperplasia may, through mechanisms such as open- In conclusion, this study showed that (pyometra). Veterinary Record 143: 659–661 ing the cervix and increasing uterine con- surgical uterine drainage and lavage offers 11. Dow C 1958 The cystic hyperplasia – pyo- tractility, be beneficial adjuncts to uterine an effective alternative treatment for metra complex in the bitch. Veterinary Re- lavage. It was interesting to note that in canine pyometra with shorter recovery cord 49: 1102–1111 12. Dyk E van, Immelman A, Heerden J S 1982 the 3 cases considered to have a closed times as well as good clinical recovery and The use of in the treatment of cervix pyometra (based on absence of pregnancy rates in bitches destined for caused by Pseudomonas vaginal discharges), the cervix was easily further breeding. These results justify aeruginosa in the mare. Journal of the South passed using direct manual manipula- further studies with more cases to estab- African Veterinary Association 53: 124–126 tion. These cases had vaginal discharges lish whether this method is statistically 13. EnglandGCW,Freeman S L, Russo M 2007 Treatment of spontaneous pyometra in 22 post-flushing, indicating that the manual advantageous over current methods. It bitches with a combination of cabergoline intervention and possibly the reduction would also be of interest to establish and cloprostenol. Veterinary Record 160: in viscosity both opened or stretched the whether this method could be used in 293–296 cervical opening and allowed remaining conjunction with recognised methods in 14. Feldmann M, Tenhagen genannt Emming contents to escape from the cervix which order to optimise a treatment regimen for S, Hoedemaker M 2005 Treatment of chronic bovine endometritis and factors for was apparently closed prior to the inter- canine pyometra. treatment success. Deutsche tierärztliche vention. Wochenschrift 112: 10–16 Considering the fact that bacterial con- ACKNOWLEDGEMENTS 15. Fieni F 2006 Clinical evaluation of the use of tamination appears to occur during oestrus Sr Z van Niekerk is thanked for assis- aglepristone, with or without cloprostenol, and early dioestrus, it was logical to insti- tance in surgical procedures. Srs Mathee, to treat cystic endometrial hyperplasia- pyometra complex in bitches. 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