Abstract
An 8-week-old domestic shorthair cat was presented with a history of pollakiuria and polydipsia. No abnormalities were detected during the clinical examination other than the penis could not be extruded from the prepuce. Urine culture demonstrated a growth of E. coli, which was treated with a prolonged course of amoxycillin. The polydipsia resolved and the pollakiuria improved but did not completely abate after antibiotic treatment and the cat had occasional bouts of haematuria. Because of the history of pollakiuria and polydipsia and the ongoing, occasional bouts of haematuria, the cat underwent surgical correction of the congenital phimosis. A small wedge of the dorsal prepuce was removed and the ipsilateral edges of the prepuce were apposed using a simple interrupted pattern. The procedure was quick, easy to perform and led to a resolution of the occasional bouts of haematuria and pollakiuria.
Introduction
Congenital phimosis, which is characterised by a narrow preputial orifice and entrapment of the penis inside the prepuce, has been reported in a small number of companion animal patients (Elkins, 1983; Kruger et al., 1996; Papazoglou and Kazakos, 2002; Proescholdt et al., 1977; Sarierler and Kara, 1998). Clinical signs of phimosis may vary from an asymptomatic narrowing of the preputial orifice, to complete occlusion of the preputial orifice and signs of urinary obstruction such as stranguria and pollakiuria (Kruger et al., 1996). A diagnosis of congenital phimosis is made by the identification of a small preputial orifice, which prevents the extrusion of the penis from the prepuce. Several methods have been described to surgically treat congenital phimosis in small animal patients (Boothe, 2003; Elkins, 1983; Hobson, 1998; Kruger et al., 1996; Papazoglou and Kazakos, 2002;Sarierler and Kara, 1998).
To the authors' knowledge this is the first case report in a cat to describe the successful correction of congenital phimosis by the resection of a small wedge of the dorsal prepuce followed by apposition of the ipsilateral edges of the prepuce.
Case report
An 8-week-old domestic shorthair cat was presented with a 2-week history of pollakiuria. The cat visited a litter tray every 10 minutes to pass a small volume of urine and then immediately licked his prepuce. The owner also reported that the cat was drinking more than its 8-week-old sibling. Clinical examination revealed that the cat was thin and that the bladder was small. The penis could not be extruded from the prepuce. A small volume of urine dribbled from the kitten's prepuce during the consultation. The cat was discharged without treatment and the owners were asked to monitor the pollakiuria and polydipsia and return if it had not resolved. The cat was re-examined on day 8 and the owner reported the pollakiuria and polydipsia was unchanged since the initial presentation. Clinical examination was unremarkable apart from the inability of the penis to be extruded from the prepuce. Routine biochemistry and haematology were unremarkable. Urinalysis revealed a trace of protein and a specific gravity of 1.033. The cat weighed 850 g and drank 130 ml of water over the following 24-hour period thereby confirming the subjective observation of polydipsia. The owner declined further evaluation at this stage and the cat was discharged.
The cat was re-examined on day 15. The owner reported that the polydipsia and pollakiuria were unchanged since the initial presentation. Again, the cat's penis could not be extruded from the prepuce. Free catch urinalysis revealed haematuria. Culture of urine collected by cystocentesis revealed a growth of Escherichia coli, which was sensitive to amoxycillin. As the owners did not want to pursue further work-up and because the polydipsia may have been caused by pyelonephritis, the cat was treated with a 10-week course of 10 mg/kg amoxycillin twice a day.
The cat was re-homed at day 70 and was re-examined on day 85, with the new owner reporting the cat was normal apart from occasional haematuria. The polydipsia had resolved and the cat's pollakiuria had improved but was still passing small volumes of urine approximately five to six times daily. However, the penis could not be extruded from the prepuce on clinical examination. Free catch urinalysis again demonstrated haematuria. The cat was re-evaluated under general anaesthesia on day 90 and the penis could not be extruded from the prepuce. No bacterial growth was cultured from a cystocentesed urine sample collected at this time. Routine open castration with autoligation was performed.
Due to continued haematuria on day 105, the cat was admitted for further work up. Premedication was with intramuscular acepromazine (ACP; C-Vet) and buprenorphine (Vetergesic; Alstoe Animal Health). Induction was with intravenous propofol (Rapinovet; Schering Plough) given to effect and anaesthesia maintained with vapourised isofluorane. Plain radiography showed poor serosal detail due to minimal abdominal fat content, however, free abdominal fluid may have contributed to this lack of detail. Urethral catheterisation was attempted but unachievable due to the small preputial orifice diameter. The cat underwent surgical correction of the congenital phimosis. The penis could not be extruded from the prepuce (Fig. 1a and b). A 3F Jackson's catheter was passed through the preputial opening but due to the decreased size of this structure catheterisation of the urethra was not possible (Fig. 2). The cat was placed in sternal recumbency and a purse string suture was placed in the anus. The perineal area was prepared for aseptic surgery. A 5-mm incision was made dorsally along the midline of the prepuce, which allowed the normal sized penis to be extruded, and catheterisation of the urethra was possible at this stage. A small wedge of prepuce was removed and the ipsilateral edges of skin and mucosa were apposed using a simple interrupted pattern with 0.7 metric monofilamentpoliglecaprone 25 (Monocryl, Ethicon). Recovery was unremarkable and postoperative analgesia was provided with buprenorphine (Vetergesic; Alstoe Animal Health) every 8 hours for the first 24 hours. The cat was discharged after 24 hours once seen to be urinating freely. A 2-day postoperative examination showed the tip of the penis could be extruded from the prepuce with minimal digital pressure. A recheck 10 days after surgery revealed and there had been no pollakiuria, polydipsia or haematuria during the postoperative period. The tip of the penis could be extruded from the prepuce with minimal digital pressure (Fig. 3). A follow-up telephone conversation revealed that the cat was free from clinical signs 6 monthspostoperatively.
(a) Appearance of prepuce on day 105. The small preputial orifice is visible and the penis cannot be extruded from the prepuce. (b) For comparison this is the appearance of a normal, 5-month-old cat's prepuce and penis. The tip of the penis can be extruded from the prepuce easily with minimal digital pressure.
Pre-operative view of the cat's prepuce showing a urinary catheter inserted into the small preputial orifice.
Appearance of prepuce and penis 10 days postoperatively.
Discussion
Congenital phimosis is a rare disorder in small animal patients and only a few case reports have described the condition. A 10-month-old domestic shorthair cat, which presented with a 3-month history of straining to urinate, was reported to have a very small preputial orifice (Elkins, 1983). A diagnosis of congenital phimosis was made which was corrected by a dorsal and ventral incision through the prepuce. The preputial mucosa was then sutured to the incised skin edges. Sarierler and Kara (1998)reported a case of congenital stenosis of the preputial orifice in a three and a half month- old mixed breed dog, which presented as pooling and dribbling of urine from the preputial orifice since birth. The dog was successfully treated by the removal of a triangular section of the prepuce. An 11-month-old dog with an infantile penis, a normal sized prepuce and a narrow preputial orifice has also been described (Proescholdt et al., 1977). To the authors' knowledge this is the first case report to describe the presentation and surgical correction of congenital phimosis in a cat by the simpleremoval of a wedge of tissue on the dorsal prepuce.
The procedure was quick, easy to perform and led to a resolution of the occasional bouts of haematuria and pollakiuria. Although no complications were seen in this patient, postoperative stenosis, due to cicatrisation of the preputial opening is possible which can be minimised by ensuring enough tissue is removed to maintain the size of the preputial orifice (Boothe, 2003). In this case the procedure was carried out when the cat was almost fully grown, however, in younger patients a second surgery may be necessary as the animal matures (Boothe, 2003).
It is unclear whether the urinary tract infection was caused by the congenital phimosis in this case. The entrapment of the penis within the prepuce was likely to cause pooling of urine in the prepuce and may have predisposed the cat to developing an ascending bladder infection. It is also difficult to assess whether the pollakiuria was caused by the urine infection or the congenital phimosis. Since the pollakiuria partially resolved on antibiotic therapy, the increased frequency of urination was most likely to have been caused by the urine infection. The cause of the polydipsia in this case is unclear. The polydipsia may have been caused by pyelonephritis, which may have developed secondary to the bladder infection. Pyelonephritis can cause polydipsia by decreasing the kidneys ability to concentrate urine because infection and inflammation damages the countercurrent mechanism in the renal medulla and therefore increases the demand for exogenous water intake (Taylor, 2000). The resolution of the polydipsia following antibiotic therapy would also be compatible with a diagnosis of pyelonephritis. As abdominal ultrasonography was not available, the possibility of pyelonephritis could not be explored further and a decision was taken to treat the cat prophylactically with a 10-week course of antibiotics. The cause of the occasional bouts of haematuria is also unclear in this case. The resolution of the clinical signs following surgical correction of the prepuce suggests that the congenital phimosis may have caused inflammation in the lower urinary tract, which resulted in occasional haematuria.
Footnotes
Acknowledgments
The authors would like to thank Tracy Hession for her assistance with the case report. Richard Mellanby would like to thank the Alice Noakes Trust for supporting his residency.