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Surgical Correction of Hematoma of the Penis in Bulls

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Surgical Correction of Hematoma of the Penis in Bulls Surgical Correction of Hematoma of the Penis in Bulls Robert S. Hudson, D. V.M., M.S. Department of Large Animal Surgery and Medicine School of Veterinary Medicine Auburn University Auburn, Alabama 36830 Introduction Diagnosis Rupture of the tunica albuginea of the penis of The hematoma appears as a firm, symmetrical cir­ bulls occurs at a very predictable location, i.e., on the cumscribed swelling that uniformly encases the penis dorsal aspect of the distal bend of the sigmoid flexure just cranial to the scrotum. There may be a proximal (7). The rupture probably occurs as a result of ex­ extension of the swelling along the sheaths of the treme bending of the erect penis during an inept retractor penis muscles. The swelling usually tapers copulatory thrust. The location of the rupture has distally. This description should aid in differentiation been described as the point at which a fulcrum (the from retropreputial abscess which is more distally preputial orifice) is applied to the erect penis (5). located and does not surround the penis. Collection of However, experimental rupture of 25 cadaver penises urine following rupture of the urethra presents a with hydraulic pressure at the predicted site with or large, diffuse swelling all along the sheath. The without bending indicated an intrinsic weakness at suspected hematoma should not be aspirated via nee­ the rupture site (3). The tunica albuginea has been dle puncture because of danger of inoculating the described as focally thinner at this point ( 4). The mass of blood. If the animal is seen within five to 0 angioarchitecture of the distal bend of the sigmoid seven days of the injury, the discolored preputial "'O (D flexure with its relatively large cavernous spaces (1) prolapse and purplish blotches of skin on light­ ~ may also contribute to the predisposition. The force skinned bulls will further support the diagnosis. ~ (") for the rupture comes from within the corpus caver­ (D 00 nosum penis (CCP) and may be facilitated by the Treatment 00 proposed bending. Whereas normal copulatory CCP Management of cases of hematoma of the penis 0........ 00 ,-+- pressure frequently reaches 200-400 lbs. per sq. in. requires consideration of the value of the bull and the '"i (psi) (2), the pressure required for the rupture of desires of the client in relation to general prognosis, ~ cadaver penises was ca. 1486 psi (3). At rupture a jet surgical facilities available and the length of time ex­ ~...... of blood under this pressure serves as a highly pired since the injury. Bulls of marginal value may be 0p traumatic force, which accounts for the severity of the restored by allowing sufficient time (60-90 days) for lesions encountered on surgical exposure. The blood spontaneous recovery augmented by a ten-day course tears and displaces the surrounding elastic tissue of broad spectrum antibiotics to reduce chance of layers and collects en masse along variable planes of abscessation of the clot. The clot will be resorbed the elastic tissue. The blood may invade the sheaths without other treatment or manipulation. Surgical of the retractor penis muscles. The sensory nerves correction provides an accurate closure of the rent in and vessels dorsal to the penis are vulnerable to in­ the tunica albuginea, reduces the chance of jury. The resultant hematoma formation in the ex­ cavernosal-venous shunt formation, and probably cavated surrounding tissue gives the clinical condi­ reduces convalescent time. Surgery should be tion its popular name. attempted only if aseptic technique can be ac­ The size of the hematoma is variable from case to complished, due to the susceptible nature of the area case. There is no appreciable bleeding from the flac­ if seeded with pyogenic organisms. It is preferable to cid penis and the amount of blood required to fill the perform surgery in five to seven days after injury. If CCP is ca. 100 ml (3). It is probable that a variable surgery is delayed as much as two weeks, the number of repeated attempts at copulation following procedure is quite difficult due to organization of the the rupture cause the variation in volume of extracor­ hematoma and difficulty in exposing the penis. The poreal blood. Some of the blood gravitates to the conservative approach is preferable in delays of thi s prepuce, causing it to prolapse and take on a purplish length. If the conservative approach is elected, sexual color. The surface of the prolapsus is usually glisten­ rest is indicated for 60 days but the penis may be ing due to intracutaneous lymph collection. The manually extended after thirty days to det8rmine blood may also cause blotches of discoloration of the progress. skin on the ventral aspect of the sheath and ab­ Prognosis is difficult to assess at the time of initial domen. examination. In order to return to satisfactory ser- 67 vice, the bull must present an int:act penis, capable of pattern. The immediately overlying elastic tissue, full extension and erection and with an intact sensory damaged or not, is sutured with 000 chromic gut to nerve supply. Experience indicates that most bulls provide a smooth channel for the penis. The penis is return to service. then returned to its natural position. Sterile physiological saline at 40°C is poured into the cavity Surgical Procedure to wash out bits of clot. The saline is removed. It is Inhalation general anesthesia is preferred to aid helpful at this time to have an assistant outside the maintenance of aseptic technique. A 48-hour fast aids sterile field to extend the penis. significantly in avoiding-regurgitation. The damaged superficial connective tissue cannot The patient is placed in right lateral recumbency to be reconstructed and a cavity will remain. The sub­ avoid undue pressure on the rumen. The left rear leg cutaneous tissue is sutured with O chromic gut and is flexed and raised to expose the inguinal area. the skin is sutured with non-absorbable suture. A Thorough surgical preparation of the operative field seroma will occupy the cavity but should be resorbed is mandatory. in about two weeks. The left lateral aspect of the swelling is draped for Aftercare includes prophylactic administration of an oblique cranioventral incision extending from just broad spectrum antibiotics for ten days and skin cranial to the rudimentary teats almost to the ventral suture removal in about 14 days. Manual extension of midline. As the skin and connective tissue layers the penis may be attempted at 10-14 <lays but only superficial to the clot are incised, careful hemostasis firm gentle force should be applied. If the free portion will prevent subsequent bleeding into the cavity of of the penis can be exposed, sensation should be the clot. The incised skin edges are covered by towels tested. Any demonstration of sensation is laudable; clamped in place. Since the objective is repair of the lack of sensation indicates a guarded prognosis. tunica albuginea, clot removal is incidental to ex­ Return of sensation may be delayed or may never oc­ posure of the penis. Meticulous removal of the clot in cur. The bull should have 45-60 days of sexual rest the many small irregular pockets of damaged tissue is prior to re-entry into service. A fibrotic mass may be unnecessary and will induce troublesome palpable dorsal to the penis for many months. hemorrhage. As the initial portion of the clot is removed the violent nature of the trauma will be Complications Whether the conserv(fltive approach or surgical cor­ 0 observed. This is to be expected and merely indicates "'O rection is used, the possibility of abscessation and (D rupture of the tunica albuginea has occurred rather ~ than rupture of superficial vessels under systemic subsequent fibrpsis with inability to extend the penis ~ (G). must be consid~red. Occasionally the flaccid penis (") blood pressure as has been reported elsewhere (D may be extended to its apparent full length. However, 00 The author has not experienced seeing the latter con­ 00 dition. the erect penis increases in length and circumference 0........ 00 A loop of the penis, with as much surrounding by 15% and requires less fibrotic restriction than the ,-+- flaccid penis (3). In such cases, bulls have been '"i elastic tissue as possible, is pulled through the skin ~ If incision. The confluence of the retractor penis observed to show pain at breeding. this condition ~...... persists, surgical removal of the restricting fibrotic 0 muscles with the penis is located. Occasionally the p sheaths of the muscles are filled with clot which tissue is indicated. should be carefully removed. The rupture should be Lack of sensation, whether by initial nerve injury on the dorsum directly across from the attachment of as evidenced by observing divided nerves at surgery the retractor muscles. The larger mass of clot may be or by imprudent surgical trauma, will result in the located external to several layers of elastic tissue in bull's inability to make intromission or to ejaculate. which case a relatively small hole in the elastic tissue Sometimes there is failure of sufficient erection to may be the only comm uni cation between hem a tom a allow for copulation. Previously this was thought to and the tear in the tunica albuginea. Care should be be due to occlusion of the corpus cavernosum with taken to avoid identifying the elastic tissue scar tissue. In recent years bulls with erection failure erroneously as the tunica albuginea which is dull following convalescence with conservative treatment white and-•firm collagenous tissue. The tunica have, via contrast cavernosography (8), been deter­ albuginea is exposed by careful longitudinal dis­ mined to have developed cavernosal-venous shunts at section of the elastic tissue directly on the dorsal the rupture site which preclude effective erection.
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