Case Report Inguinal Rupture with Herniation of the Urinary Bladder
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EQUINE VETERINARY EDUCATION / AE / January 2010 3 Case Report Inguinal rupture with herniation of the urinary bladder through the scrotal fascia in a Shetland pony foaleve_8195 3..6 M. Cousty*†, C. Tricaud, V. Picandet and O. Geffroy† Clinique Equine de Livet, Cour Samson, 14140 Saint Michel de Livet, France; and †École Nationale Vétérinaire de Nantes, La Chantrerie, 44307 Nantes, France. Keywords: horse; hernia; urinary bladder; inguinal rupture; surgery Summary Herniation of the urinary bladder has been reported through a congenitally enlarged inguinal canal in a cat Herniation of the urinary bladder in the inguinal region has (Zulauf et al. 2007) and in dogs (Bellenger 1996). Eversion of not previously been described in the horse. A case of the urinary bladder has been reported through the inguinal rupture with herniation of the bladder through the umbilicus in a foal (Textor et al. 2001) and the vagina in scrotal fascia in a 3-month-old Shetland pony, diagnosed mares (Squire et al. 1992). To our knowledge, herniation of by external palpation, urinary catheterisation and external the urinary bladder has not been reported in the inguinal ultrasonographic examination is reported. Surgical region in the horse. A case of inguinal rupture and management of the case was by dissection of the scrotal protrusion of the urinary bladder outside the vaginal sac in fascia, partial cystectomy and unilateral castration. During a Shetland Pony foal is described. the period of hospitalisation the only complication was a slight seroma, which resolved spontaneously. Follow-up Case history and clinical findings after 6 months did not reveal any abnormality. A 3-month-old male Shetland pony was examined for Introduction urinary incontinence, recurrent pollakuria and the presence of a scrotal mass. There was no history of dystocia. On physical examination, a fluctuant mass was Inguinal herniation (also commonly referred to as an present on the right side of the scrotum. The right inguinal indirect inguinal hernia) occurs when an abdominal ring was difficult to palpate; however, both testes were organ, usually small intestine, protrudes through the located in the scrotum. Urine was observed to drip from vaginal ring into the inguinal canal (Schneider et al. 1982; the penis each time pressure was applied to the mass. Cox 1988; Schumacher 2006). A ruptured inguinal hernia Ultrasound examination (Fig 1) revealed the presence of a occurs when an abdominal organ protrudes through the structure with a well-defined wall and anechoic contents, vaginal ring and then passes through a rent in the parietal lying in a subcutaneous position. However, it was not tunic and scrotal fascia to lie subcutaneously in the possible to determine if it was inside or outside the vaginal scrotum (van der Velden 1988; Schumacher 2006). An sac. On urinary catheterisation, the catheter was palpable inguinal rupture (also commonly referred to as a direct within the scrotal mass and after evacuation of urine the inguinal hernia) occurs when an abdominal organ passes mass was observed to decrease in size. The mass was not through a rent in the peritoneum and transverse fascia reducible by manual palpation. No abnormalities were adjacent to the vaginal ring such that the organ is found identified on routine haematology, serum biochemistry in a subcutaneous location adjacent to but outside of the and urine analysis. A diagnosis of herniation of the urinary vaginal process (Cox 1988; Schumacher 2006). Inguinal bladder was made. However, it was not possible to herniation and rupture occur more commonly in stallions determine if it was due to an inguinal herniation or an and foals and small intestine is the most commonly inguinal rupture. involved abdominal viscus (Schumacher 2006). Treatment *Author to whom correspondence should be addressed. Dr Cousty’s present address: Unité de Chirurgie, Ecole Nationale Vétérinaire, Prior to surgery the foal received ceftiofur (2.2 mg/kg bwt Atlanpôle – La Chantrerie – BP 40706, 44307 Nantes Cedex 3, France. i.v.) and flunixin meglumine (1.1 mg/kg bwt i.v.). Following © 2009 EVJ Ltd 4 EQUINE VETERINARY EDUCATION / AE / January 2010 sedation with romifidine (0.08 mg/kg bwt i.v.), anaesthesia was induced with ketamine (2.2 mg/kg bwt i.v.) and diazepam (0.2 mg/kg bwt i.v.) and maintained with isoflurane and an infusion of a romifidine-ketamine- butorphanol solution (romifidine 1 mg/kg bwt/min, ketamine 20 mg/kg bwt/min, butorphanol 0.6 mg/kg bwt/min). The foal was positioned in dorsal recumbency, the abdomen and inguinal region were clipped and a routine aseptic skin preparation was performed. A 15 cm incision was made over the right inguinal ring. The parietal layer of the vaginal tunic was carefully dissected from the surrounding fascia with Metzenbaum scissors and opened. The testis, epididymis and spermatic cord were present within the sac of the parietal layer of the vaginal tunic and no abnormality was observed. Palpation of the vaginal ring did not reveal the presence of any abdominal organ. Dissection was carefully continued outside the vaginal tunic to reveal the serosal surface of the apex of the Fig 1: Ultrasound examination of the right inguinal region showing the presence of an anechoic content with a well-defined wall. It urinary bladder between the internal spermatic fascia and was not possible to determine if it was inside or outside the vaginal the cremaster muscle. The urinary bladder was adherent to tunic. the scrotal fascia (Fig 2). The apex of the bladder was dissected free from the fascial attachments (Fig 3). However, the bladder wall was thickened and haemorrhagic, preventing replacement of the bladder into the abdominal cavity. Doyen intestinal forceps were placed across the bladder and the apex of the bladder was resected. The bladder wall was closed in 2 layers with 3 metric polydioxanone (PDS) in a simple continuous pattern oversewn by a Cushing pattern. Care was taken not to penetrate the lumen of the bladder. The bladder was then returned to the abdomen. The ipsilateral testis was resected following ligation and application of emasculators on the spermatic cord. The parietal layer of the vaginal tunic was closed with a transfixating ligature of 4 metric polyglactin 910 (Vicryl). The scrotal fascia was closed with 4 metric polyglactin 910 (Vicryl) in a cruciate pattern. The skin was closed with 3 metric PDS in a continuous pattern. Fig 2: Adhesion of the serosal surface of the apex of the urinary bladder to the scrotal fascia. Outcome Following surgery the foal received ceftiofur (2.2 mg/kg bwt i.v. s.i.d.), gentamicin (6.6 mg/kg bwt s.i.d.) and flunixin meglumine (1.1 mg/kg bwt i.v. b.i.d.) for 5 days. The foal was carefully monitored after surgery and the only complication observed was a slight seroma deep to the skin incision which resolved spontaneously. The foal was discharged 5 days after surgery. On follow-up by telephone questionnaire 6 months after surgery the foal was growing as expected without evidence of urinary dysfunction. Discussion In horses, the most common organ involved in inguinal herniation is the small intestine (Schumacher 2006). To our Fig 3: Apex of the bladder after resection of the adhesion. knowledge, herniation of the urinary bladder has not been © 2009 EVJ Ltd EQUINE VETERINARY EDUCATION / AE / January 2010 5 reported in horses, although it has been reported in cats of the vaginal ring did not reveal the presence of any (Zulauf et al. 2007), dogs (Bellenger 1996) and man (Curr abdominal organ. For these reasons, the hernia can be et al. 1988; Schewe et al. 2000; Fuerxer et al. 2006; Tubbs considered as an inguinal rupture. The precise location of et al. 2007; Bisharat et al. 2009). the hernia is shown on Figure 4 according to the findings In this case, the urinary bladder had partially passed observed during the surgical procedure. through a rent in the peritoneum and transverse fascia, Ultrasonographic examination may be used in horses and was protruding between the internal spermatic fascia to differentiate between the possible causes of inguinal and the cremaster muscle. In horses, the elastic swelling (Blackford et al. 1992) and was very useful in this abdominal tunic that covers the external abdominal case. However, ultrasonography did not allow us to muscle gives rise the superficial inguinal ring and to the determine if the herniation was due to an inguinal external spermatic fascia. The transverse fascia that lines herniation or an inguinal rupture. Urinary catheterisation the internal surface of the abdominal muscle evaginates confirmed that the mass in the inguinal region was the as the internal spermatic fascia. The cremaster muscle bladder however other diagnostic techniques have originates from the internal abdominal muscle and is proved useful in other species. Air contrast radiography located between the external spermatic fascia and the has been used to confirm bladder involvement in an internal spermatic fascia (Budras et al. 2003). The parietal inguinal hernia in a cat (Zulauf et al. 2007) but we believe layer of the vaginal tunic was intact and no abnormalities that even in a foal this technique would prove difficult. In of the spermatic cord and testis were identified. Palpation human medicine a computed tomography scan can be performed after cystography with contrast medium (Fuerxer et al. 2006). In man, as in horses, an indirect hernia follows the spermatic cord in the inguinal canal. The canal communicates with the abdominal cavity through the abdominal ring. In man, a direct inguinal hernia is located over the pelvic bone always secondary to a weakness in the pectineal ligament (Fuerxer et al. 2006). However, in horses, the intestine passes through a rent and is not surrounded by peritoneum contrary to human cases.