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Proceedings of the Pre-Congress of the

16th Italian Association of Equine
Veterinarians Congress

Carrara, Italy – 2010

Next SIVE Meeting:

Feb. 4-6, 2011 – Montesilvano, Pescara, Italy

Reprinted in the IVIS website with the permission of the

Italian Association of Equine Veterinarians – SIVE

http://www.ivis.org
Published in IVIS with the permission of SIVE Close window to return to IVIS

Stallion Endoscopic Examination

Claire Card
DVM PhD diplomate ACT, Dept LACS, Western College of Veterinary Medicine,
University of Saskatchewan, Saskatoon, Sk S7N 5B4 Canada
[email protected]

INDICATIONS FOR PREPUCE

ENDOSCOPIC EXAMINATION
IN THE STALLION The penis of the stallion in the non-aroused
state is retracted and located in the sheath or
Stallions may develop ascending infections of prepuce. The prepuce of the stallion has a te-
the genitourinary tract and reproductive or- lescoping anatomic arrangement when retrac-
gans, including the urethra, accessory sex ted and its opening on the ventral abdomen is
glands, bladder, testis and epididymides. Di- called the preputial orifice. The external pre-
rect visualization of the tissues, such as the putial cavity begins on the caudal ventral ab-
urethra and bladder, help to narrow the diffe- domen near the scrotum and extends to the
rential list in cases where hematuria/hemo- preputial ring. The exterior and interior por-
spermia or pyuria/pyospermia is present. En- tion of the external preputial cavity (sheath) of
doscopy may also be used to catheterize the stallions and geldings may be visualized in si-
common duct, along with palpation/ultra- tu using an endoscope for a short distance.
sound to direct the catheter into the affected The glans penis is immediately visible in the
vesicular or ampullary gland. Urethral trauma interior.
and hemospermia are common complaints. The region from the preputial ring to the penis
The nature and extent of urethral and acces- is called the internal preputial cavity. The in-
sory sex gland problems are best explored ternal prepuce has two portions called lamina.
through a direct endoscopic approach. Unu- The internal lamina of the internal prepuce at-
sual congenital abnormalities may also be as- taches to the shaft of the penis and at the pre-
sessed using this approach.

NORMAL ANATOMIC FEATURES

The portions of the stallion’s reproductive

tract that may be visualized using endoscopy
include the sheath, urethral opening, penile
urethra, pelvic urethra, colliculus seminalis,
and bladder (Fig. 1). The two common ducts
of the ampulla and seminal vesicles open on
the colliculus seminalis (Figg. 2, 3). The pro-
minent bulbourethral gland openings, prosta-
tic ducts, and urethral glands, are visible along
the urethra (Fig. 2). The opening to the blad- Figure 1 - Endoscopic view of the glans penis and ureth-
der is also visible (Fig. 3)1. ral opening.

12
Proceedings of the Annual Meeting of the Italian Association of Equine Veterinarians, Carrara, Italy 2010
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Figure 2 - View of a dilated urethra as the junction bet-

ween the pelvic and penile urethra. Panel A shows the la-
terally located urethral gland openings, centrally placed Figure 3 - View of the dilated pelvic urethra near the ope-
bulbourethral gland openings and colliculus seminalis. ning to the bladder showing the colliculus seminalis, ope-
The colliculus seminalis has the openings of the 2 com- ning of thecommon ducts, and bladder opening.
mon ducts of the seminal vesicles and ampulla. Dorsal is
to the bottom.

putial ring it joins the external lamina of the relax the external preputial lamina, but fail to
internal prepuce. The prepuce contains glan- fully extend their penis for urination. Erro-
dular tissue that secrete smegma, a waxy sub- neously some horse owners think that they ha-
stance, which should be removed along with ve a foal with a congenital abnormality. Occa-
the exfoliated skin to visualize the surface. sionally insect bites to this region result in
If the goal is to fully assess the penis and in- swelling of the preputial tissue and a failure to
ternal and external preputial lamina, the stal- fully retract the prepuce. The attachments of
lion may be sexually aroused by teasing mares the prepuce to the penis may take a while to
in estrus and/or sedated to allow the penis to remodel in young colts and this condition re-
relax and extend from the sheath. Geldings are solves on its own without treatment.
usually sedated. Some tractable male horses Space occupying masses on the penis or the
allow the penis to be manually pulled down prepuce may prevent penile protrusion. In the-
from the internal preputial cavity. Alpha ago- se cases endoscopy of the prepuce may be
nists such as xylazine, and detomidine are used. Conditions of the prepuce include: in-
useful for the purpose of sedation, and may be fections, tumours such as squamous cell carci-
combined judiciously with acepromazine. noma, melanoma, lymphosarcoma, and sar-
Caution is advised when using acepromazine, coids. Balanoposthitis (infection or inflamma-
because it has been reported to be associated tion of the penis and prepuce) may accompany
with penile priapism (paralysis). Following coital exanthema, habronemiasis, insect
arousal from sedation with acepromazine a hypersensitivity, trauma, squamous cell carci-
reasonable precaution is to monitor the stal- noma or other bacterial infections.
lion to insure he retracts his penis, or encoura-
ge him to retract his penis by walking, appli- Smegma and exfoliated skin debris is normal
cation of cold water etc. finding in the sheath of stallions. Loose skin
Sedation results in muscular relaxation, and debris accumulates at the preputial ring, pre-
allows the penis to protrude from the sheath. puce and on the penile shaft. Discharge from
Indications for evaluating the interior of the the sheath may be noted in some stallions or
sheath of a stallion/gelding include: history of geldings and be evident on the horse’s hind
never dropping the penis, excess discharge, legs. Some discharge is attributed to normal
foul smell, trauma, palpable mass, phimosis preputial secretions, but excess secretion may
etc. Horse owners are sometimes concerned accompany overzealous cleansing, bacterial
when young colts either urinate in their sheath, overgrowth, balanitis, coital exanthema, fo-
13
Proceedings of the Annual Meeting of the Italian Association of Equine Veterinarians, Carrara, Italy 2010
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reign bodies, habronemiasis, and squamous tions for endoscopic evaluation of the urethra
cell carcinoma. Pruritis and inflammation may include: hematuria, hemospermia, abnormal
be present in some cases. Bedding, particu- urination, pyospermia, fertility problems, and
larly fine shavings, seems to be an irritant in palpable accessory gland abnormalities.
some stallions and may be associated with Urethral lacerations may occur when the tail
bacterial infections. Microbiologic culture of hairs of the mare obstruct a stallion’s bree-
the prepuce commonly yields a mixed bacte- ding attempts.
rial growth. A heavy pure culture of bacteria
may indicate an imbalance in the microflora Urethral Endoscopy
of the prepuce/penis. Treatments for bacterial Indications for urethral endoscopy include:
balantis include cleansing, antibiotics therapy, hematuria, hemospermia, pyospermia, pyuria,
NSAIDs and in resistant cases immunomodu- stranguria, pollakiuria, suspected seminal ve-
lators and smegma transplants. siculitis, or ampullary obstruction. The stal-
lion is restrained in a stocks and sedated to al-
low for examination and cleansing of his pe-
PENIS nis. The endoscopic equipment should be ste-
rilized, and any residual disinfectant removed.
The penis of a light horse stallion is approxi- Sterile lubricant is applied to the sides but not
mately 50 cm long. The penis is approxima- the front of the endoscope. Sterile water or sa-
tely 6 cm in diameter. There is a large degree line should be used to rinse the endoscope du-
of variation in penile length and diameter. The ring viewing. The opening to the urethra
examiner should note any abnormalities on should be wiped clean. The examiner passing
the penis or prepuce such as lesions associated the equipment through the urethra should
with coital exanthema, balanoposthitis, squa- wear sterile gloves.
mous cell carcinoma, melanomas, lymphosar- The urethra may be examined in its full length
coma. etc. using a flexible gastroscope or videoendosco-
pe that is at least 100 cm long. The urethra is
surrounded by the corpus spongiosum of the
PENILE HYPOPLASIA penis. The endoscope is advanced very slowly
through the urethra with intermittent or low
A history of never having seen the penis drop- airflow. The urethra should appear closed at
ped has been reported due to penile hypoplasia the end of the field of view (Fig. 4). This opti-
that accompanied Persistent Mullerian Duct mises the chance of observing the urethral le-
Syndrome in a horse. The horse had no history sions. Once the lesion has been located more
of castration and had the phenotypic appearan-
ce of a gelding. The shaft of the penis was very
short which mechanically would not allow the
penis to protrude from the sheath.

Foreign bodies include stallion rings, mi-

splaced rubber bands from malfunctioning
artificial vaginas, and organic matter such as
bedding.

URETHRA

The urethra in the stallion is long and it be-

gins at the neck of the bladder, and ends on Figure 4 - Normal healthy urethra with the preferred
the ventral portion of the glans penis. Indica- amount of insuffulation.

14
Proceedings of the Annual Meeting of the Italian Association of Equine Veterinarians, Carrara, Italy 2010
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insufflation may be used to determine the ex- be performed only after the defect has been
tent of the injury. Over-extension of the ureth- identified. Dilation of the pelvic urethra may
ra is the most common error (Fig. 5A-C). Over also assist in locating the colliculus seminalis,
extension results in a blanching of the urethra, and opening to the bladder. A uterus masculi-
and blood may be observed to rush back and nus may be visible in some stallions.
forth in response to changing insufflation pres- The extent of penile relaxation and the intrin-
sures. The odd blanched appearance of the sic length of the penis will determine the dis-
urethra may be confused with urethritis, and tance to the accessory sex gland openings and
the streak like appearance of the blood misi- the bladder. The examiner passing the endo-
dentified as hemorrhage. Full dilation of the scope should record any lesions in relationship
urethra with air to see the urethral lumen should to the insertion depth of the equipment. Almost
full insertion of the equipment is common. Al-
lowing the penis to partially retract will in-
crease the working length of the endoscope.
The region of the urethra near the junction
between the penile and pelvic injury is parti-
cularly prone to injury and should be carefully
examined. Once the full extent of the urethra
has been examined, the insufflation pressure
may be increased to allow viewing of the
structures in the pelvic urethra. In the pelvic
urethra the anatomic structures will come into
A view in sequence. The prominent openings for
the bulbourethral glands are found on the mid-
line, followed by the smaller and laterally lo-
cated urethral glands. Small pin point ope-
nings of the prostate are visible near the colli-
culus seminalis. The common ducts of the am-
pullae and seminal vesicles can be seen ope-
ning on the colliculus seminalis. The caudal
most structure is the opening to the bladder.
The colliculus is located dorsally, which is im-
portant in deciding which gland opening to
cannulate. Rectal massage of the accessory
B sex glands may move discharge out of the
glands in cases of seminal vesiculitis. This
material may be cultured.

PATHOLOGIC CONDITIONS

Urethritis
Urethritis is inflammation of the urethra. The
caudal segment of the urethra near the penis is
usually involved. Smegma may form small
concretions (beans) in the urethral fossa
C
which may mechanically impinge on the
Figure 5 - Panel A-C, Healthy urethra with progressively
urethral opening causing irritation. Bacterial
increased insufflation pressure. Panel A shows the ureth- infection of the caudal urethra may also be
ra with the maximum desired insufflation pressure. present. Bacteria such as Streptococcus equi
15
Proceedings of the Annual Meeting of the Italian Association of Equine Veterinarians, Carrara, Italy 2010
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subspecies zooepidemicus, E.coli, and Actino- Seminal Vesiculitis

bacillus have been reported in pure or mixed Seminal vesiculitis is an uncommon ascen-
cultures to cause urethritis. ding bacterial infection of stallions that affects
one or both seminal vesicles. The seminal ve-
Summer Sores - Habronemiasis siculitis may or may not be enlarged, or have
of the urethra an abnormal echotexture.
Habronemiasis is cause by the hatched larva A proportion of the mares bred to a stallion
or Drashia spp and Habronema spp. The flies with seminal vesiculitis may develop a sexually
are attracted to moist tissue such as the prepu- transmitted bacterial endometritis caused by
ce and urethral opening. The lesions are pyo- the same organism infecting the stallion.
granulomatous and may be rapidly progressi- Pyospermia, neutrophils in the semen, may be
ve. Scrapings of the affected tissue may con- identified in the semen. Mares may have shorte-
tain larvae. Biopsies have characteristic featu- ned interestrous intervals. Semen should be sent
res such as a dramatic eosinophilic infiltrate, for quantitative bacterial culture and sensitivity,
and may be used to differentiate habronemia- and typically shows mixed bacterial growth.
sis from squamous cell carcinoma. Caseous Pathogens associated with seminal vesiculi-
granules are present in the lesions. Complete tis include Klebsiella and Pseudomonas,
blood counts may show systemic eosinophi- but only a few serotypes associated with vene-
lia. Systemic and topical treatment with iver- real disease. These organisms are also found
mectin, and non-steroidal antiinflammatory commensally and in the absence of clinical
agents are used for treatment. Corticosteroids signs in a stallion, recovery of these bacteria
are used to decrease the immune response to from the semen is not a significant finding.
the larvae. Rarely have other organsims such as Actino-
bacillus, Strep and Staph been reported. Pal-
pation of the infected seminal vesicle during
endoscopy may result in expression of dis-
charge coming from the common duct on the
affected side (Figure 7).
The common duct of the seminal vesicle is
catheterized by advancing a catheter through
the biopsy port of the endoscope. Using di-
rect visualization the catheter is guided into
the common duct (Figure 8).

Figure 7 - Close - up view of brown purulent discharge

coming from the common ducts in a stallion with seminal
Figure 6 - Habronemiasis affecting the prepuce of a stallion. vesiculitis.

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Proceedings of the Annual Meeting of the Italian Association of Equine Veterinarians, Carrara, Italy 2010
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Hemospermia
Hemospermia in the stallion may vary from
microhemospermia to frank blood. Hemo-
spermia may be caused by trauma, idiopathic
urethral rents, ulcers, urethritis and granulo-
matous lesions3. Micro-hemospermia may be
caused by pin point lesions on the glands that
bleed during sexual arousal. Frank blood is of-
ten noted on the stallion’s penis at dismount or
on collection. Frank blood in the ejaculate
causes infertility. The rule outs for blood on
the stallion’s penis include breeding injuries
Figure 8 - Endoscopic view of a catheter in the common
duct. such as vaginal wall lacerations of the mare,
and in lesser amounts, rupture of hymen.
Blood may enter the ejaculate from the stal-
lion from penile/preputial injuries, or urethral
problems. There may be a history of trauma
such as breeding through a fence or unsucces-
sfully jumping over a fence with a full erec-
tion. The most common cause of hemosper-
mia is idiopathic. The urethra is very vascular.
During sexual arousal blood flow to the penis
and urethra increases and pressure rises. A
urethral lesion will communicate with the un-
derlying corpus spongiosum penis and the
pressure from sexual arousal will result in
urethral bleeding. Sexual activity or arousal
will prevent the lesion from healing. Bacterial
Figure 9 - Purulent discharge in a seminal vesicle at
infections of the urethra cause a distal primary
necropsy. urethritis, or an ulcerated area may be secon-
darily infected. Raised granulomatous lesions
are sometimes seen.
Rectal palpation and or ultrasound are used to If the chief complaint is hemospermia the stal-
confirm the location of the catheter in the se- lion should be sexually aroused to determine
minal vesicle. The ampulla is positioned late- if blood drips from the penis in association
ral to the seminal vesicle. Generally the semi- with arousal. Semen collection should be per-
nal vesicle is easiest to catheterize as it is po- formed if blood is not observed, as maximal
sitioned along the midline. Simultaneous ultra- penile and urethral pressures are achieved du-
sound of the seminal vesicle while flushing the ring the ejaculatory act (Figure 10, 11). Ureth-
catheter in the common duct to distend the roscopy is used to determine the cause, loca-
gland is another means of confirmation. Poor tion and extent of the urethral lesion. The most
penetration of antibiotics is achieved in the se- common location for urethral lesions associa-
minal vesicle through systemic administration, ted with hemospermia is at the junction of the
therefore local instillation of antibiotics is per- penile and pelvic portions of the urethra4. This
formed by injecting them through the catheter area is difficult to evaluate, hence methodical
directly into the lumen of the seminal vesicle. evaluation with low urethral insufflations
In severe cases the seminal vesicle will be pressure should be used. Over insufflation
grossly enlarged (Figure 9). Semen extenders should be avoided, because the artefacts asso-
may also be prepared with antibiotics that ha- ciated with over insufflation make the identi-
ve activity against the bacterial contaminants2. fication of urethral lesions very difficult. If a
17
Proceedings of the Annual Meeting of the Italian Association of Equine Veterinarians, Carrara, Italy 2010
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Figure 10 - Blood in a Missouri style artificial vagina

following semen collection in a stallion with a history of
hemospermia.

Figure 12 - Deep urethral rent at presentation (Panel A)

and at follow-up examination 2 months later (Panel B).

Figure 11 - Hemospermia: Frank blood in a semen sample. lows the penile urethral to be rested from uri-
ne flow which appears to prevent healing of
the urethra in some stallions. Following peri-
lesion is identified moderate insufflations neal urethrostomy the stallion may develop
pressure may be used to determine the depth urine scald that requires treatment.
and extent of the urethral lesion. Treatment in-
cludes: absolute sexual rest 3 weeks, with an- Retrograde ejaculation is an uncommon
tibiotics added based on culture and sensiti- condition where the ejaculated sperm enter
vity of the bacteria recovered from the lesion the bladder rather than being emitted from the
or urethra. The stallion is to be maintained in penis. No sperm are found in the ejaculate
a location where he will not become sexually even though it appears the stallion has ejacu-
aroused. After the 3 week rest period, a semen late. The problem arises in incomplete closure
collection is performed and the lesion is re- of the neck of the bladder, usually as a result
evaluated using endoscopy. If the bleeding of problems in the sympathetic nervous
persists generally sexual rest is continued for system. In these cases spermatozoa are reco-
another 3 months. The evaluation process is vered in the urine following ejaculation but
repeated in 3 months time. If urethral bleeding are not emitted. There are no endoscopic ab-
continues past 3 months then an endoscopi- normalities. Measurement of alkaline pho-
cally guided subischial perineal urethrostomy sphatase in the seminal fluid and catheteriza-
is performed and left to granulate in. This al- tion of the bladder will confirm the diagnosis.
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Proceedings of the Annual Meeting of the Italian Association of Equine Veterinarians, Carrara, Italy 2010
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Evaluation of the Bladder Neurogenic Bladder

If no lesions are observed in the urethra follo- Recently neurotropic strains of equine herpes
wing sexual arousal or semen collection the virus I have been associated with bladder
endoscope is advanced into the bladder. The paralysis, leading to voiding by overflow.
bladder wall, ureters, and bladder contents are Rectal examination shows a large bladder and
evaluated. a failure to regularly empty the bladder.
The mucosa of the bladder should be smooth.
Thickening or haemorrhages on the wall indi- Tumours such as squamous cell carcinoma
cate cystitis. The contents of the bladder and transitional cell carcinoma may be visua-
should include cloudy mucus and urine. The lized in the bladder.
openings to the ureters can be viewed dorsally,
and urine observed to enter the bladder. Re-
moval of the urine by aspiration may reveal CONGENITAL ANOMALIES
uroliths, or accumulation of sediment (sabbu-
lous urolithiasis). The majority of congenital anomalies in the
reproductive tract of the intersex or stallion re-
Hematuria may result from the kidney, urete- sult in changes in appearance of the external
ral, bladder, urethral problems, or trauma. genitalia. Phenotypic, gonadal and chromoso-
Chief complaint is varied and may include: mal sex are typically investigated to determi-
weight loss, colic, tenesmus, vocalization, he- ne the underlying cause.
maturia, pollakiuria, stranguria, pyuria, incon-
tinence, or obstruction. Transrectal palpation
and ultrasound usually reveals the presence of
cystic calculi.

Obstructive urolithiasis may cause complete

or partial obstruction of the urethra. Uroliths
are removed via lithotripsy, crushing, shock-
wave therapy or via surgery. Spasms of the
urethra may be palpated over the entrapped
urolith. Endoscopy is used to assist in identif-
ying the correct location of the urolith.

Cystic calculi may be identified in the blad- A

der, they may be spiculated or smooth. These
are often palpable during rectal examination
of the bladder. Cystic calculi are visualized in
the bladder using ultrasound. The dense natu-
re of the calculi results in a large ultrasound
attenuation artifact (similar to a shadow) be-
low each calculus.

Sabbulous urolithiasis is an accumulation

of crystalloid sludge from incomplete voi-
ding of the bladder as a result of bladder
paralysis. The bladder may be pulled down-
ward into the abdomen by the weight of the B
sludge. Catheterization of the bladder and
flushing will recover some of the sludged Figure 13 - Panel A shows normal bladder mucosa and
crystalline material. urine, panel B shows bilaterally dilated ureteral openings.

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Proceedings of the Annual Meeting of the Italian Association of Equine Veterinarians, Carrara, Italy 2010
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REFERENCES 3. Lloyd, K.C.K., et al., Ulceration in the proximal

portion of the urethra as a cause of hematuria in
horses: four cases (1978-1985). Journal of the
1. Gay, Y. and R. Perrin, Exploration of the genital American Veterinary Medical Association, 1989.
system in the stallion by fibroscopy. Pratique Vet- 194(9): p. 1324-1326.
erinaire Equine, 1999. 31(123): p. 189-195. 4. Whitacre, M.D. Diagnosing hemospermia in the
2. Lu, K.G. and P.R. Morresey, Reproductive tract in- breeding stallion. in Large animal proceedings of
fections in horses. Veterinary Clinics of North the North American Veterinary Conference, Orlan-
America, Equine Practice, 2006. 22(2): p. 519-552. do, Florida, USA, 17-21 January, 2009. 2009.

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Proceedings of the Annual Meeting of the Italian Association of Equine Veterinarians, Carrara, Italy 2010