HISTORY
16 Jan 2021. First prolapse. Vet 1 diagnosed as rectal prolapse. X-ray available. No image. Pushed in. Purse-string suture.
26 Jan 2021. Second prolapse. Vet 1 diagnosed as rectal prolapse. Owner's images x 4. Pushed in. Purse-string suture.
7 Mar 2021. Toa Payoh Vets. Dr Daniel Sing resected a 4-inch rectal prolapse.
3 sliders lived in one big tank. Filters and basking platform. Fed one tablespoon of pellets per day in same tank. Water changed once a week. Very murky. Can't see if there were eggs laid.
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The next task, identifying the prolapsed tissue, is sometimes easier said than done. Prolapses are often chronic in nature by the time the reptile is presented for medical care.
- In a mild prolapse, only cloacal tissue may bulge through the vent or the opening through which droppings and reproductive products are expelled from the cloaca. Cloacal mucosa normally appears smooth and shiny although prolapsed tissue will become swollen over time.
- The distal gastrointestinal tract has a smooth, tubular appearance. In some instances feces are also observed.
- The hemipenes in squamates or phallus in chelonians is a relatively solid tissue that originates from the lateral portion of the cloacal wall (Fig 2)
- The lumen of the oviduct gives this tissue a “donut-like” appearance. Longitudinal folds can also be observed on the oviductal wall.
- Of course the urinary bladder is a thin walled, often fluid filled, structure.
Rectal prolapse occurs when the rectum (the last section of the large intestine) falls from its normal position within the pelvic area and sticks out through the anus. (The word "prolapse" means a falling down or slipping of a body part from its usual position.)
Complications include:
- Strangulated prolapse: This occurs when part of rectum becomes trapped and cuts off the blood supply, causing tissue to die. This can develop gangrene, and the area will turn black and drop off. It is rare and requires surgery.
- Solitary rectal ulcer syndrome: Present in mucosal prolapse, ulcers can develop on the part of the rectum sticking out. This complication often requires surgery.
- Recurring prolapse: People who have surgery for rectal prolapse may have another prolapse at some point in the future.
Prolapse occurs when the rectum becomes unattached inside the body and comes out through the anus, effectively turning itself inside out.
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ORIGINAL IMAGES
Rectal prolapse is when part of the rectum protrudes from the anus. The rectum is the last part of the large intestine and is where feces is stored before being passed.
There are two general types of surgery for rectal prolapse:
- Abdominal: Entry through the belly through a cut or several cuts in the abdominal wall. Often used for full-thickness prolapse.
- Perineal: Involves cutting out the full thickness segment of the prolapsing rectum. Suitable for people who cannot have a general anesthetic.
Complications include:
- Strangulated prolapse: This occurs when part of rectum becomes trapped and cuts off the blood supply, causing tissue to die. This can develop gangrene, and the area will turn black and drop off. It is rare and requires surgery.
- Solitary rectal ulcer syndrome: Present in mucosal prolapse, ulcers can develop on the part of the rectum sticking out. This complication often requires surgery.
- Recurring prolapse: People who have surgery for rectal prolapse may have another prolapse at some point in the future.
Prolapse occurs when the rectum becomes unattached inside the body and comes out through the anus, effectively turning itself inside out.
Complications include:
- Strangulated prolapse: This occurs when part of rectum becomes trapped and cuts off the blood supply, causing tissue to die. This can develop gangrene, and the area will turn black and drop off. It is rare and requires surgery.
- Solitary rectal ulcer syndrome: Present in mucosal prolapse, ulcers can develop on the part of the rectum sticking out. This complication often requires surgery.
- Recurring prolapse: People who have surgery for rectal prolapse may have another prolapse at some point in the future.
Prolapse occurs when the rectum becomes unattached inside the body and comes out through the anus, effectively turning itself inside out.
If you or your child has a rectal prolapse, you may be able to push the prolapse back into place as soon as it occurs.
If left untreated, possible complications of rectal prolapse include: Ulceration and bleeding. A reduction in blood supply causing strangulation of the rectum. Gangrene, resulting in death and decay of the strangulated section of the rectum.
- Sensation of heaviness or pulling in your pelvis.
- Tissue protruding from your vagina.
- Urinary problems, such as urine leakage (incontinence) or urine retention.
- Trouble having a bowel movement.
Prolapse
There are 3 common types of prolapse: rectal, penile, and intestinal. This occurs when the organs slip out of the turtle’s cloacal opening and become stuck there. This is very dangerous and requires immediate action, as the affected tissue can become traumatized, desiccated (dried out), or suffer other ill effects from compromised blood flow. Furthermore, prolapsed tissue may be attacked by tankmates, who may mistake it for something to eat.
Symptoms
- Pink/red/purple flesh hanging out of cloaca and not retracting
Reproductive
Female birds have a reproductive tract on the left side only. The oviduct is a tubular structure with longitudinal folds that are usually visible on the lumen. Prolapses are generally associated with egg laying, although rarely they may be associated with masses/tumors of the reproductive tract. When prolapsed, the tissue may become edematous, but a lumen should be clearly identifiable, and in most cases it will be possible to see the longitudinal folds. The tissue should appear on the left side of the bird, and the cloacal lining itself should also be evident and normal, with the prolapsed tissue protruding through the cloacal cavity.
Treatment of reproductive tract prolapse is always directed at identification and resolution of the primary disease process. In most cases, this will be associated with egg laying. It is essential to thoroughly evaluate for the presence of a retained egg or egg fragments. Radiographs should always be performed, but can be misleading if the egg shell is not mineralized. Ultrasound is very useful for detection of eggs, as well as follicular activity and ovarian or uterine masses. In cases where there appears to be caudodorsal enlargement or a mass effect, or the location of enlargement cannot be determined, then contrast radiographs can be useful in differentiating the intestines and the region of enlargement/mass. If there is an obvious egg within the prolapsed mass, then it can be collapsed or surgically removed. Salpingohysterectomy is recommended to prevent future episodes of egg retention and prolapse.
The cloaca, or vent, in reptiles is the slit opening under the tail. The digestive tract, the reproductive system and the bladder all empty out the same cloacal opening.
Reptiles will sometimes prolapse (slip out of place) tissues out through this opening. Cloacal prolapse refers to any condition involving tissue protruding from the reptile’s vent, where feces come out. Prolapsed tissues from the cloaca can have a variety of origins, including the gastrointestinal tract (colon, large and small intestines), urinary bladder, phallus (alligator, crocodiles, turtles, tortoises), hemipenis (snakes and lizards), and the oviduct (the organ where eggs and young are held). In rare cases the kidneys have been known to prolapse from the vent.
- Oviductal prolapses in females are usually caused by failure to give birth or lay eggs (dystocia, egg binding)
- Prolapses of the colon, large intestine and small intestines usually result from infections with parasites, bacteria or constipation
- Urinary bladder prolapses usually are caused by a bladder stone.
Cloacal prolapses occur in any age reptile of any species and of any sex. They are commonly seen in high-producing, egg-laying species. Risk factors include collections or individuals with husbandry deficiencies, especially low-calcium and low-mineral diets.
On physical examination, it is usually easy to determine that a reptile has a prolapse; there will be tissue protruding from the cloacal opening. The difficulty is determining what tissue is prolapsed and why. These are important questions that your veterinarian will try and answer so the proper treatment and prevention can be accomplished. Other abnormal findings that may be found on exam are dehydration, poor-body condition and weakness.
Diagnosis
Your veterinarian will take a detailed diet and husbandry history and perform a physical exam. In many cases, the type of tissue that is prolapsed will be identified on sight. However, your veterinarian may want to do some additional testing to determine the prolapse has occurred. The tests suggested may include a fecal exam to look for parasites; X-rays to check for metabolic bone disease, tumors or bladder stones; and a blood panel to look for sign of infection. In some cases, your veterinarian may suggest some advanced testing such as an endoscopy, during which the veterinarian puts a small camera into the cloaca to see what is going on), an MRI or CT scans.
Treatment
Prolapses are generally treated as emergencies. Treatment should begin as soon as possible. Your veterinarian will likely instruct you to “protect” the protruding tissue by wrapping it is a soft, moist cloth such as a towel while on your way into the clinic.
Once the type of tissue that is protruding is identified, your veterinarian will attempt to replace the tissue back into its normal location and position. The tissue will be cleaned and lubricated and gently massaged back into the cloaca, often using a cotton tipped applicator. If the tissue is swollen, your veterinarian may use a concentrated sugar solution or gentle pressure to help reduce the size of tissue before replacing it into the cloaca. It is common for the tissue of the phallus or hemipenes to be necrotic, and if this is the case your veterinarian may want to amputate these organs. Reptiles only use the phallus and hemipenes for reproduction, and not for urination, so you can remove it and it the animal can still live a healthy life.
To prevent the tissue from prolapsing again, the veterinarian will often suture each side of the vent to make the opening smaller. This allows the reptile to defecate but prevents the tissue from re-prolapsing. These sutures may be left in place for three to four weeks.
Depending on what your veterinarian finds might be the cause of the prolapse, a nonsteroidal anti-inflammatory drug (NSAID) may be prescribed to help with the swollen tissue. Other treatments that your veterinarian may discuss based on the type of tissue that prolapsed and the cause may include husbandry changes (diet, lighting and temperatures), surgery to prevent future prolapses (bladder stone removal, spaying mass or tumor removal), and antibiotics for infections. It is critical to give all medications just as prescribed by your veterinarian and to return for all re-check exams scheduled.
Prognosis
There is a good chance of a complete recovery if the prolapse is recent, and a cause can be identified and corrected. Phallus, hemipenis, bladder and oviduct prolapses generally are more easily corrected and treated. The chance for a cure is reduced if the prolapse has been going on for more than 24 hours and if there is damage to the prolapsed organ or tissue. The most difficult to treat, and thus the ones with the least chance for a cure, are prolapses that involve the colon or the large intestine.
Prevention
There are many reasons that cloacal prolapses can occur but the most common are from husbandry problems. A detailed review and discussion with your veterinarian is a great start. Any husbandry problems identified should be corrected so that future prolapses are minimized. Unfortunately, once a prolapse has occurred there is a greater risk for another prolapse in the future.
The next task, identifying the prolapsed tissue, is sometimes easier said than done. Prolapses are often chronic in nature by the time the reptile is presented for medical care.
- In a mild prolapse, only cloacal tissue may bulge through the vent or the opening through which droppings and reproductive products are expelled from the cloaca. Cloacal mucosa normally appears smooth and shiny although prolapsed tissue will become swollen over time.
- The distal gastrointestinal tract has a smooth, tubular appearance. In some instances feces are also observed.
- The hemipenes in squamates or phallus in chelonians is a relatively solid tissue that originates from the lateral portion of the cloacal wall (Fig 2)
- The lumen of the oviduct gives this tissue a “donut-like” appearance. Longitudinal folds can also be observed on the oviductal wall.
- Of course the urinary bladder is a thin walled, often fluid filled, structure.
Seminal or hemipenal plugs consist of keratinized material that fills one or both hemipenes. These plugs can protrude from the cloaca and can be mistaken for a prolapse in squamates. Visit Anapsid.org for a color photograph of seminal plugs.
Case management
Diagnostics
The diagnosis of prolapse relies on physical examination, however additional testing is often required to identify the underlying cause. The tests performed will vary with the tissue prolapsed but can include:
- Survey whole body or abdominal radiographs
- Fecal parasite testing
- Complete blood count/biochemistry panel
Management of the prolapse
Management of prolapsed tissue should almost always be performed under sedation or general anesthesia. Use a local anesthetic when general anesthesia s not used for reduction of a mild cloacal prolapse. Clean the exposed tissue with saline or dilute chlorhexidine solution. Removing superficial crust and debris as needed. Administer fluids and begin analgesic therapy such as an anti-inflammatory agent. Synthetic absorbable suture such as polyglyconate or polydioxanone is often selected.
Cloacal prolapse:
Once the swelling is down and the tissue is clean, carefully and gently Invert and return prolapsed tissue using a relatively large diameter, blunt instrument like a rubber catheter, syringe case, or sexing probe. NEVER simply “stuff” tissues back into the cloaca. Tissues should invert back inside in an anatomically correct orientation, like a sock being turned inside out. Devitalized tissue may require resection.
Place stay sutures after the prolapse is reduced. A purse-string suture is often placed in chelonians or larger squamates, while transverse cloacal sutures such as horizontal mattress serve well in many snakes and lizards. Stay sutures decrease the size of the opening to prevent recurrent tissue prolapse, but should remain loose enough to allow droppings to pass. Stay sutures are typically left in place for 3 to 5 days.
Visit Herp Center Network for images illustrating gastrointestinal tract reduction in a bearded dragon (Pogona vitticeps).
Oviductal prolapse:
Mild oviductal prolapses can be reduced transcloacally. More severe prolapses require a surgical approach performed by a reptile veterinarian. Traumatized tissue may need to be removed intraoperatively, however if this is necessary then ovariectomy on the same side should also be recommended to reduce to risk of yolk coelomitis.
Penile prolapse:
Prolapsed copulatory organs quickly become traumatized and swollen, making reduction near impossible in many cases. Recurrent prolapses or when prolapsed tissue is nonviable or cannot be reduced, the phallus or hemipenis can be amputated. Fortunately the urinary system is separate from phallus since the ureters empty into the cloaca so this will not compromise the reptile’s ability to urinate. Additionally, when one hemipenis is retained in squamates, future reproduction is still possible.
Make sure the prolapsed copulatory organ is fully everted. In small chelonians, place a ligature proximal to damaged tissue. Ligate tissues with transfixing, circumferential, or vertical mattress patterns. The phallus is then transected and removed (Innis 2002). In larger chelonians, the lateral vessels as well as each corpus cavernosum should be ligated separately. Transect and remove the prolapsed tissue, then replace the stump into the tail base. Afterwards a stay suture like a purse string suture is left in place for up to 2 to 3 weeks (Sykes 2010, Barten 2006, Denardo 2006).
After the prolapse has been reduced…
After the prolapse has been reduced, begin systemic antibiotics if infection is present and the keep the patient well hydrated. A stool softener can also be useful in lizards.
Prognosis and follow-up
Prognosis depends on the patient’s overall condition, viability and duration of the prolapsed tissue, as well as the cause of prolapse. If the underlying cause of prolapse has not been identified and resolved, there is a good chance that prolapse will recur. Refer “mystery” prolapse patients to a reptile veterinarian for additional diagnostics.
References
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13 Jan 2021
MY VIDEO:
Consultation and examination of the slider, before diagnosis and surgery.
9 Mar 2021. Follow up video. The slider had fully recovered and is normal. Owner sends me the video as at 9 Mar 2021.
REFERENCE:
MORE IMAGES IN THE BLOG:
https://2010vets.blogspot.com/2021/03/3563-red-eared-slider-has-oviduct.html
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Consultation and discussion about vent prolapse in a red-eared slider. The other slider had bitten the end of the vent when he saw some tissues dangling out, during egg laying.
Vent prolapse can be one of the 3 situations: Rectal prolapse, bladder prolapse and oviduct prolapse. DIFFERENTIAL DIAGNOSIS: 1. Bladder prolapse - thin walled bladder will be seen. This prolapse is thick walled. 2. Rectal prolapse. Stool pellets may be visible or absent. The lumen is present as in this case. Usually the rectal prolapse has thinner walls. 3. Oviduct prolapse. The lumen is present. Thicker muscular walls. History of egg laying recently. The red-eared slider had bitten and pulled the oviduct causing it to come out of the vent. It was traumatised and infected. SURGERY. The prolapsed oviduct mass was amputated. The red-eared slider led a normal life after surgery. VIDEO OF CONSULTATION AT:
This webpage is:
https://2010vets.blogspot.com/2021/03/3563-red-eared-slider-has-oviduct.html
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VIDEO OF CONSULTATION AT:
This video is about the consultation and discussion about vent prolapse in a red-eared slider. The other slider had bitten the end of the vent when he saw some tissues dangling out, during egg laying. Vent prolapse can be one of the 3 situations: Rectal prolapse, bladder prolapse and oviduct prolapse. DIFFERENTIAL DIAGNOSIS: 1. Bladder prolapse - thin walled bladder will be seen. This prolapse is thick walled. 2. Rectal prolapse. Stool pellets may be visible or absent. The lumen is present as in this case. Usually the rectal prolapse has thinner walls. 3. Oviduct prolapse. The lumen is present. Thicker muscular walls. History of egg laying recently. The red-eared slider had bitten and pulled the oviduct causing it to come out of the vent. It was traumatised and infected. SURGERY. The prolapsed oviduct mass was amputated. The red-eared slider led a normal life after surgery.
----------------------------------------------------------------------Owner sent a video showing RES fully recovered.
1. Had been warded 6 days.
