Cervico-vaginal prolapse (CVP) is a condition in which the cervix and vagina backtrack itself out over the caudal attachment and protrude from the vulvar opening with inner layer out (Whitter, 2007). Occurrence of vaginal prolapse in buffalo is generally reported during the last trimester of gestation
(Akhtar et al., 2012) or just after calving, if associated with dystocia. It is one of the major reproductive complaints in buffaloes that affects the productivity and future performance of herd due to decreased conception rate and prolonged inter calving period amounting to mammoth economic losses
(Akhtar et al., 2012). Duration and severity of prolapse upon presentation affect the handling and treatment of this condition. Actual etiological factor is still unknown, however increased estrogen levels has been indicated as one of the possible correlates of ante partum prolapse
(Noakes et al., 2001). Other etiologic reasons like hypocalcaemia, forced extraction
(Noakes et al., 2001) and ingestion of feedstuff rich in estrogenic compounds have also been incriminated for uterine prolapse.
Hypocalcaemia results in muscle fatigue that causes delayed involution time of uterus, thereby predisposes for prolapse (Murphy and Dobson, 2002; Roberts, 2004). Feedstuff rich in estrogenic substances such as subterranean clover, soybean meal, moldy maize and barley invariably increases the incidence of vaginal (Davis and Bennett, 1959) or uterine prolapse in other animals like sheep
(Noakes et al., 2001). The incidence of cervico-vaginal prolapse is nearly 43% in buffaloes
(Samad et al., 1987) and therefore has a huge distressing impact over dairy industry.
Our literature survey revealed no report explaining ultrasonographic evaluation (USG) of this condition along with pathological descriptions at microscopic level in the uterus or cervix during uterine or cervico vaginal prolapse in buffaloes. Hence this report records simultaneous pathological observation and ultrasonographic findings of a severe cervico vaginal prolapse in a Murrah buffalo.
Case History and Clinical Examination
An eight year old, 350 kg Murrah buffalo was presented in the Teaching Veterinary Clinical Complex, Guru Angad Dev Veterinary and Animal Sciences University, Ludhiana, Punjab with history of acute cervico-vaginal prolapse. The animal was off fed and not urinated since a day prior to its presentation. Animal was almost near completion of its gestation. Additionally, the animal was found to be primary stage of shock. There was massive excommunication of cervical tissue along with uterine mass that has led to its protrusion from the vaginal commissure, with resultant clinical development of fatigueness and contigual loss of condition (Fig 1). Due to excessive straining, the entire process of expulsion has eventually led to formation of fistula within rectum, thereby contaminated the prolapsed mass with intestinal contents. Clinical examination of buffalo revealed restlessness, tachycardia (84 beats /min) and tachypnea (46 breaths/min). The animal was uncomfortable and had sub normal rectal temperature (99.8°F) with pale, tacky mucous membranes and feeble capillary refill time of 2 s.
Ultrasonography and Pathological Observations
Ultrasonography of the protruded mass was performed using real-time, B-mode, diagnostic ultrasound (Aloka; Hitachi healthcare Americas, USA) equipped with linear array transrectal-transducer (7.5 MHz). It shows an involvement of intestine (Fig 2). Due to fistulation of dorsal vaginal wall with rectum, intestines from the dorsal wall of vagina have invaginated into the prolapse mass which further putatively resulted in serious septicemia. Intestines appeared as brief anechoic areas with few hyper echoic segments. Further there was an involvement of urinary bladder in the mass which appear as anechoic region surrounded by hyperechoic circumferential area. Due to mutilation of the prolapsed mass, 10-14 cm long tear has been formed on the dorsal surface of posterior vagina. Per vaginal examination from the tear was done to ascertain the location of fetus, but due to deep sited position, we were unable to hold any part of fetus.
The torn cervical tissue fragments were immediately taken in 10% Neutral buffered formalin (NBF) for fixation to obtain sections for further tissue alteration study, urine standard technique (Luna 1986).
On histological examination, a massive disconti- nuity in the fine and long stretches of cervical tissue muscle fibres especially of inner circular layer of
tunica muscularis was noted that has amounted to absolute disarray in their linear arrangement (Fig 3). The muscle fibres shown marked hyaline degeneration as characterized by swollen and eosinophilic, homogenous fibres with loss of striations and fewer nuclei besides early phase of necrobiotic changes characterized by few mononuclear cells (MN cells) infiltrations. The marked hyperemic blood vessels and areas of massive edematous changes noted probably had led to an inevitable bulging of muscular zone (Fig 4).
Treatment
Initially the animal was stabilized with glucocorticoid Inj. Dexamethasone 10 ml I/M (35 mg total dose; Dexona; Zydus AHL, India), antibiotic Inj. Ceftiofur 2 mg/kg b. wt. I/M (1g; Xnel; Pfizer, India); NSAID Inj. Tolfine 15 ml I/M (2mg/kg b.wt., Tolfenamic acid; Vetoquinol, India); antihistaminic Avilin 10 ml I/M (MSD Animal Health, India) haemostat Inj. Zakshot 15 ml, I/M (Tranexamic acid; Carus Laboratories Pvt. Ltd., India) and Inj. Ringer lactate (5 L, Nirlife, India) administration. Catheterization of the urinary meatus was done to evacuate the urinary bladder. The prolapsed mass was cleaned with weak potassium permanganate solution (0.1% KMnO4) to remove the debris. We applied osmotic agents like cold water and Sheather’s solution (saturated sugar’s solution) in order to effect reduction in edema of the affected organs. Additionally, a herbal POP-IN spray was also attempted to cause reduction in edema and has repeatedly been followed for three times. Due to an enormity of the prolapsed mass and involvement of visceral organs like urinary bladder and intestines, a partial reduction in size was achieved, nonetheless couldn’t d reposed it back completely. Hence an emergency caesarean section was performed to save the life of the fetus.
A caesarean section was done using left flank approach and live male calf was extracted. After cesarean section the reposition of prolapsed mass was again tried, but couldn’t succeed. Thereafter, consent from owner was sought and animal was euthanized.
Various factors like duration, severity (occurrence of traumatic laceration), bacterial contamination and involvement of other organs such as cervix, urinary bladder and intestines, determines the successful treatment of vaginal prolapse
(Beheshti et al., 2011; Yotov et al., 2013). At some situation, early determined cases of prolapse with timely presentation can be help in appropriate reduction and reposing of organ back in to system
(Ahuja et al., 2016). Since the case was presented with the highest degree of cervico vaginal prolapse (i.e. third degree) with an involvement of urinary bladder and intestines, attempted therapeutic regimen proved unsuccessful. The ultrason ographic revelations undeniably indicated extreme cervico-vaginal eversion with excommunicated placentomes eventually sharing common platform with urinary bladder and intestines. Although we found placentomes in the ultrasonographic imaging but we labeled it a cervico-vaginal prolapse of third grade due to non-involvement of uterine tissue in it. Due to this excommunication, the requisite internal milieu, essentially required for tissue homeostasis (of
tunica muscularis) was putatively disgraced (lost), which was evident from our histological findings as marked by hyaline degeneration of muscles with early necrobiotic and hyperemic changes. This hyaline changes was widely distributed with inevitable edematous changes perhaps due to constrictive effect on visceral blood vessels, during protrusion through narrow rectal openings and fistula. Such protrusion without an immediate treatment might have aggravated the loss of condition which resulted in gangrenous condition (wet gangrene) and further deteriorations in condition of animals. Cervicopexy from the flank laparotomy was additionally attempted, which normally offers best approach to provide anatomic and permanent fixation, as cervix can be more accurately anchored without the interference of urinary bladder, when excessive redundancy of the ventral vaginal wall prevailed (Newman and Anderson, 2005). Although successful surgical resection of vaginal fold prolapse has been attempted in small animal
(Ahuja et al., 2018), since here the severity and massiveness of prolapse was the major factor that hinders the reposition and resection in the given case. As mentioned in the literature, vaginal prolapse is generally classified into 4 different grades, based on severity of prolapse, that ranges from mild type to a more severe form which characterizes with trauma, infection and necrosis, as typically presented in this case and more commonly described in cattle (Wolfe and Carson, 1999). The present case has been considered to be grade III prolapse as it has been accompanied by certain clinical and physiological aberrations that can suitably be corroborated with the above classifications. Further, the clinical outcome noticed, had corresponded equitably with both ultrasonographic observations and pathological findings.
Through this study we were able to depict the probable loss of tonicity of muscle due to excessive exaggeration of prolapsed cervico vaginal mass leading to muscular degeneration as indicated in the histopathological study. Through the histopathological investigation it is clear that the changes that have occurred in the cervical tissue were irreversible. Further it was clearly appreciated through the USG observation where confluence of vaginal mucosa with intestines and urinary bladder was noted.
Hence we conclude that together with attempting the intervention to reduce and repose the prolapsed tissue we also need to ascertain whether its reposition is possible or not. We must also look for other approaches for correction or resection of the mass to minimize the suffering and to save the life of animal.
