Genital Prolapse in Buffalo

In many countries, seasonality limits the reproductive performance of buffaloes [1-4] which is exacerbated by reproductive disorders. Studies analyzing data of organized buffalo farms have shown that reproductive problems accounted for a large proportion (30-40%) of buffaloes being removed (culled) from the herd [5-8]. Many reproductive problems in buffaloes occur during the periparturient period [9-12]. Clinical evaluations have shown that genital prolapse is the 3rd [13] or 4th [14,15] most common disorder affecting reproduction in the buffalo. The eversion of the genital tract (prolapse) located in the pelvis occurs as a protrusion through the external genitals (vulva) and has been reported as case reports in buffaloes as early as 1967 [16,17]. Vaginal prolapse commonly occurs during gestation [18-21] and the postpartum period [22-24], sometimes in non-pregnant buffaloes [25] and rarely during estrus [26] whereas uterine prolapse occurs during the postpartum period [27-29]. The basic cause of prolapse appears to be weakening or relaxation of the constrictor vestibuli muscle and atony of the vaginal musculature [20,30].The incidence of the problem varies widely (0.21% to 16.34%) between reports involving clinical studies and evaluations of organized buffalo farms [18,31]. In one report involving 529 calvings the problem was non-existent [32]. The etiology of the prolapse continues to be poorly understood although increasing levels of plasma estradiol during gestation [33-35] and low levels of circulating trace elements such as copper, selenium and zinc [36-39] and minerals such as calcium and phosphorous [18,40-43] are some of the postulated contributing factors. Rough and forceful manipulations of the genital tract during difficult parturition and immediate postpartum period often increase the irritability of the tract (and resultant increased contractions) predisposing it to outward protrusion because the genital tract is very relaxed during this period. The management of the outwardly projected genital organ is replacement to its original location after proper cleaning; however, the prolapse is often recurrent and in poorly managed cases, the inflammatory process continues for prolonged periods hampering fertility. In this chapter we describe the possible etiologies, risk factors, clinical findings, diagnosis and treatment for vaginal and uterine prolapse in buffaloes.

1.Vaginal Prolapse

1.1 Incidence

Analysis of reproductive records of buffaloes managed at organized farms and clinical studies have shown that the incidence of vaginal prolapse varies widely from 0.21% to 16.34% (Table 1). A few studies evaluating records involving more than 2000 Murrah and Nili Ravi buffaloes found the incidence to be 3.20% and 12.1% respectively [44,45]. Similarly, studies analyzing more than 5000 records of Murrah and Surti buffaloes recorded an incidence of 3.79% and 11.7% respectively [22,25]. In studies on Mediterranean buffaloes the incidence was shown to be as low as 2- 6% and as high as 7- 35% [46].The incidence of vaginal prolapse in one field survey involving 787 buffaloes in Iraq varied from 3.71% to 5.22% [47]. The incidence of vaginal prolapse varies according to the stage of pregnancy, breed, season and parity [18,19,48]. In Nepali Murrah buffaloes [48], 57% of buffaloes (n=26) showing vaginal prolapse were either pregnant heifers or adult buffaloes in their last lactation with different severity. The majority of the cases occurred during the seventh month of gestation and later (Table 2).

Mishra et al., [19] recorded only 3 cases of vaginal prolapse at a University buffalo farm in Jabalpur whereas many cases were recorded in their field survey and Purohit [32] found no case of vaginal prolapse for 529 calvings in Surti buffaloes at a University buffalo farm over a 10-year period.

1.2 Risk Factors

Previous prolapse, stall feeding, cemented paddocks, artificial milking and increasing parity were mentioned as significant risk factors for the occurrence of vaginal prolapse in buffaloes [18,25,38,65,66]. In one study, stall fed buffaloes had a higher incidence of vaginal prolapse (82.54%) compared to semi stall fed (17.46%) buffaloes [19] whereas in another study semi-stall fed buffaloes had a higher incidence (14.07%) compared to stall fed (12.98%) buffaloes [38]. Feeding of molded feeds or feeds high in protein were considered as a risk for the occurrence of vaginal prolapse in buffaloes [65].A higher incidence was recorded in humid summers [38,67]. Kumar and Singh [68] recorded the highest incidence of vaginal prolapse in winter and spring, however, the season of calving had non-significant effects on the incidence of utero-vaginal ante and postpartum prolapse in buffaloes. Cemented paddocks [65] and uneven floors [19,38,70] were found to be significant risks for the occurrence of vaginal prolapse in buffaloes as was close confinement [19]. Weak buffaloes staying in a crowded enclosure are more likely to develop vaginal wounds (due to attack from herd mates) and subsequent vaginal prolapse [65]. The effect of increasing number of parities on the increase in the incidence of vaginal prolapse was shown in some studies [12,53,57,59] yet other studies did not find any significant effect of the parity on the incidence of prolapse in buffaloes [56]. Pal [71] recorded the highest incidence of genital prolapse in the 2nd and 3rd calving (1.92%) compared to first (1.62%) and 4th and subsequent calvings in Murrah buffaloes and the highest incidence was reported during summer (1.80%) compared to winter (1.62%) and autumn (0.99%). Tiwana et al., however, found a significantly higher incidence of vaginal prolapse in primiparous (7.6%) compared to pluriparous (2.5%) buffaloes [23]. These authors also found that the heritability of vaginal prolapse is high (0.64) and buffaloes that have a vaginal prolapse in one parity were likely to have a vaginal prolapse in subsequent parities as well.

Low levels of circulating trace elements [37], minerals (Ca, P and Mg) [42], and altered steroid (high estrogens) concentrations [35] are some of the postulated risk factors for vaginal prolapse. Higher milk production of more than 10 liters per day was a significant risk for vaginal prolapse in buffaloes [66]. Hot humid summers were found to be a significant risk for the occurrence of vaginal prolapse in buffaloes in Pakistan [38,67]. The heritability of vaginal prolapse in buffaloes was low (0.33+0.13) [53], however, the genetic nature of the condition cannot be ruled out. Zicarelli et al., [65] in their studies on Mediterranean buffaloes found that higher numbers of primiparous daughters from the same bull were more affected with vaginal prolapse in their first calving. Two studies mentioned the shape of the back of buffaloes as a significant risk factor for the occurrence of vaginal prolapse in Mediterranean [65] and Bulgarian Murrah [72] buffaloes. The rump length (measured in cm from hook to pin bones) at 18 months of age in Bulgarian Murrah buffaloes that had prolapse was 3.1 times greater compared to those that calved normally [72]. The ideal rump length suggested was less than 40% of body length. Mediterranean buffaloes with their high placed tail, scythe shaped limbs and a short pelvis, and a sloping hind part were more at risk of vaginal prolapse [65]. Buffaloes with a lower rump width (measured from coxofemoral joints) compared to the distance between the two wings of the ileum, were more predisposed to vaginal prolapse. Such animals also had a bigger width at the ischia [65].However, in one study [73] involving prolapse affected non-pregnant (n=6), pregnant (n=45) and postpartum (n=20) Murrah buffaloes (measuring the various pelvic dimensions) found no difference in the transverse diameter of the pelvic outlet/inlet in prolapse affected and normal buffaloes. However, the vertical diameter of the pelvic outlet/inlet was significantly higher (27.90 and 28.25 cm) in pre and postpartum vaginal prolapse affected buffaloes compared to buffaloes not affected with prolapse (21.6 cm) [73].

Stress has been proposed to be one risk factor for increase in the incidence of vaginal prolapse. Galhotra et al., [74] evaluated plasma cortisol, prolactin, FSH and LH in 30 Murrah buffaloes affected with antepartum vaginal prolapse during the third trimester of gestation. Buffaloes showed three distinct levels of cortisol <10 ng/ml (low stress), >10 to <30 ng/ml (medium stress) and >30 ng/ml (high stress). The differences in FSH and prolactin in stress groups were significant (P<0.01), however, the elevated levels of estradiol in buffaloes with prolapse was unrelated to stress group and plasma cortisol. The highest risk of antepartum prolapse in buffaloes occurs between Days 271-300 of gestation.

1.3 Etiology

The basic cause of prolapse appears to be the relaxation of the constrictor vestibuli muscle and atony of the vaginal and vulvar musculature [32]. The atony of the vaginal musculature has been related to low levels of serum calcium, phosphorous and magnesium (Table 2) and low levels of plasma copper, selenium and zinc [36-39]. Postulated etiologies for relaxation of pelvic ligaments and adjoining structures during the last 2-3 months of gestation include increasing levels of plasma estradiol during this period [19,33,34,75]. The hormonal changes that occur during the last trimester of pregnancy, especially the increase of estrogen and the production of relaxin, cause relaxation of the pelvic ligaments and surrounding soft tissue structures [76,77]. The average estradiol concentration recorded were 303.5 pg/ml for 8–9 months (n=2), 352 pg/ml for 9 months (n=1), 336 pg/ml for 9.3 months (n=2) and 379.75 pg/ml of plasma for 9.5 months (n=4) of gestation in buffaloes with prepartum prolapse [34].The average plasma estradiol 17β concentrations in one buffalo with a prepartum vaginal prolapse at 10 months was 390 pg/ml of plasma that increased steadily to reach 600 pg/ml on the day of calving. In normal pregnant buffaloes the estradiol concentrations were nearly 10 times lower at all these stages [34]. Thus the role of increasing estradiol in the onset of prepartum vaginal prolapse in pregnant buffaloes cannot be ruled out.

On the other hand, the deficiency of calcium and phosphorus and higher levels of magnesium may possibly be the contributing factors in causing prepartum vaginal prolapse in buffaloes. Serum calcium was higher and phosphorus was lower (Table 3) in buffaloes with a vaginal prolapse and kept in an irrigated zone as compared to their counterparts in rain-fed zones [43]. In Iraq 6.6% -8.6% of buffaloes with a prolapse had mineral deficiencies [47]. However, in one study on 8 advanced pregnant (8 months) Murrah buffaloes, serum calcium, phosphorous, total protein and cholesterol levels did not differ from the concentrations that were obtained in the same buffaloes after parturition during the early lactation period [78]. Calcium is necessary for neuromuscular excitability, cell membrane permeability, muscle contraction and nerve impulse transmission and its deficiency can lead to reduced vaginal and uterine muscle tone which predisposes the animals to vaginal prolapse [32].Many reports have shown lower levels of circulating minerals (calcium, phosphorous and magnesium) in buffaloes with a vaginal prolapse (Table 3). Furthermore, the increased level of estrogen during the earlier part of the third trimester of pregnancy may result in greater relaxation of the pelvic structures and the situation is further accentuated by decreased levels of calcium, resulting in atony of the reproductive tract, thereby predisposing the animal to vaginal prolapse. It is possible that combinations of these two factors may initiate the vaginal prolapse [43].Difficult births account for a high proportion of vaginal prolapse in buffaloes (19.5%) during the postpartum period [79] on account of rough manipulations and excessive exertion of pressure in pulling the fetus without sufficient dilation of birth canal that pulls the vagina outwardly along with the fetus.

It has been mentioned that when the animal sits, the intra-abdominal pressure is transmitted to the flaccid pelvic structures tending to force the relaxed and loosely attached vaginal floor and walls through the loosely attached vulva [20]. Constant vaginal irritation on account of vaginitis [80], urinary infection [81] and vaginal tears or lacerations can result into vaginal prolapse. Some unusual postulated etiological factors for vaginal prolapse in buffaloes include vaginal tumors [82,83] and vaginal cysts [84]. Concurrent to vaginal prolapse, rectal prolapse has been recorded in some case reports in buffaloes [85,86]. The constant straining might be the predisposing factor for rectal prolapse. In the severest forms of vaginal prolapse, vaginal tears with protrusion of intestinal loops has been recorded in buffalo [21,87].

1.4 Critical Period

Vaginal prolapse can occur during estrus, gestation and the postpartum period in buffaloes, yet, it is common during gestation (antepartum prolapse) [18,19,22,50]. Antepartum vaginal prolapse has been recorded in Indian [18], Pakistani [43], Nepali [48], Egyptian [91], Iraqi [92] and Mediterranean [65] buffaloes. In a clinical analysis of 23 cases of vaginal prolapse in Maharashtra (India) antepartum vaginal prolapse was more common during the 3rd to 6thcalvings [93]. In Pakistani buffaloes prolapse occurred more often during the 7 to 10 month of gestation [35]. Studies comparing the relative frequency of prepartum and postpartum vaginal prolapse in buffaloes revealed that predominantly it occurs in pregnant buffaloes (Table 4). In one study, however, the incidence of antepartum and postpartum prolapse in Murrah buffaloes was 1.57% and 4.62% for 2983 different reproductive disorders (between 1992-1996) in eight villages [69]. Excessive relaxation of pelvic ligaments which support the genitalia may occur because of advancing age. Low levels of serum copper and selenium are linked to increased incidence of vaginal prolapse in buffaloes during the last trimester of gestation [39] coupled with high levels of estrogens and low levels of serum progesterone [35]. Mishra et al., [25] analyzed 63 clinical cases of vaginal prolapse in buffaloes and found that 52.4% were antepartum, 22.2% were postpartum and 11.1% were found in non-pregnant buffaloes (the rest 14.3% were uterine prolapse).

Similarly other reports have mentioned a more frequent occurrence of vaginal prolapse during gestation compared to the postpartum period (Table 4). The occurrence of vaginal prolapse in non-pregnant buffaloes is low (2.35% to 11.1% of all prolapse cases) (Table 4). Vaginal prolapse during estrus is rare in buffaloes. One report recorded a vaginal prolapse in 2 buffaloes during estrus [26]. Two reports found cervico-vaginal prolapse in 8-month pregnant buffaloes [86,94] and one report mentioned the occurrence in a full term pregnant buffalo [95]. Also, other reports have recorded postpartum cervico-vaginal prolapses in buffaloes from 3 days to 3 months postpartum [88,96-100].

1.5 Diagnosis and Clinical Findings

The outwardly projecting vagina can be easily identified and often reported by the owner [20]. The prolapse begins as an intussusception-like folding of the vaginal floor just cranial to the vestibulo-vaginal junction. The discomfort caused by the eversion, coupled with irritation and swelling of the exposed mucosa results in straining and a more extensive prolapse. With the passage of time the prolapsed tissues become edematous leading to circulatory impairment and more swelling. Eventually the entire vagina may be prolapsed with the cervix conspicuous at the most caudal part of the prolapse. It is then termed cervico-vaginal prolapse. The general condition of buffaloes with vaginal prolapse is good and unless severe infection has occurred buffaloes are seldom anorectic. The degree of tenesmus and discomfort to the animal depends upon the time and extent of the vaginal prolapse. The appearance of edema in vaginal prolapse depends upon the time since the organ has everted and the amount of straining and the degree of vaginal prolapse. The straining was weak to moderate in second and third degree vaginal prolapses and strong in fourth degree vaginal prolapses in buffaloes [48].

In cattle, vaginal prolapse has been usually graded as Grade I to Grade IV depending upon the genital and other tissue involvement and persistence of prolapse [101]. In Grade I the vagina prolapses intermittently commonly when the animal lies down. When the prolapse is continuous with or without retroflexion of the urinary bladder, it is termed Grade II, and when the cervix (external os) is also involved it is termed Grade III [101]. Grade II or Grade III prolapse along with trauma, infection or necrosis or chronic prolapse with fibrosis such that the vagina cannot be replaced is considered Grade IV [101]. The clinical classification of vaginal prolapse for buffaloes is not complete [48,102,103], however, many case reports of Grade IV [86,94,104,105], Grade III (cervico-vaginal prolapse) [93,95,98-100,106,107] (Fig. 1), Fig. 2, Fig. 3) and grade II [18,27,41,42,108] vaginal prolapse (Fig. 4, Fig. 5, Fig. 6, Fig. 7) are on record. In a clinical analysis of 35 clinical cases of vaginal prolapse in buffaloes, Jahangir et al. [103] found that 17, 8 and 10 could be classified as Grade I, Grade II and Grade III respectively. In rare cases, partial uterine prolapse can accompany a cervico-vaginal prolapse [109,110] (Fig.8). In one pregnant buffalo, the entire gravid uterus was completely torn from the cervical attachments and was found hanging out through tears in the vagina (Dr. Ravi Dutt, personal communication) (Fig.9).

Figure 20.1. Grade III vaginal prolapse (cervico-vaginal) in a buffalo with tears in the vagina.

Figure 20.2. Grade III vaginal prolapse in a buffalo (photo courtesy Dr. Anil D. Patil, College of Veterinary and Animal Sciences, Udgir, Maharashtra, India).

Figure 20.3. Grade III vaginal prolapse in a buffalo with tearing of the cervix (photo courtesy Prof. Azawi OI, Department of Surgery and Theriogenology, College of Veterinary Medicine, University of Mosul, Mosul, Iraq).

Figure 20.4. Grade II vaginal prolapse in a buffalo.

Figure 20.5. Grade II vaginal prolapse in a buffalo with concomitant rectal prolapse (photo courtesy Dr. Rajesh Kumar, Assistant Professor, Department of Veterinary Gynecology and Obstetrics, College of Veterinary Science and Animal Husbandry, NDUAT, Faizabad, Uttar Pradesh, India).

Figure 20.6. Grade II vaginal prolapse in a buffalo with concomitant prolapse of rectum and retroflexion of the urinary bladder.

Figure 20.7. Vaginal prolapse with rupture of vagina and prolapse of intestines (photo courtesy Dr. Gyan Singh, Department of Veterinary Gynecology and Obstetrics, Veterinary College, LUVAS, Hissar, India).

Figure 20.8. Cervical and uterine prolapse in a buffalo (photo courtesy Dr. NF Chaudhari, Department of Veterinary Gynecology and Obstetrics, Veterinary College, Navsari, Gujrat, India).

Figure 20.9. Uterine tear and prolapse in a pregnant Murrah buffalo and the torn gravid uterus surgically removed (photo courtesy Dr. Ravi Dutt, Department of Veterinary Gynecology and Obstetrics, Veterinary College, LUVAS, Hissar, India).

1.6 Prognosis

The prognosis of vaginal prolapse depends upon the degree of prolapse and the length of time it has existed [20]. Unattended cases of Grade I and II vaginal prolapse may progress to Grade III and IV due to constant irritation, contamination and edema of exposed tissues. Tears may occur due to compression of exposed tissues with the ground or bites by birds, and vascular insult of everted tissues may culminate in necrosis. With the passage of time the tears may harbor maggots. With prompt and appropriate therapy and sufficient after care, the prognosis in antepartum and postpartum vaginal prolapse in buffaloes is good [20,21,32]. A high proportion (88.5%) of buffaloes with a vaginal prolapse retained the prolapse subsequent to replacement and proper therapy without recurrence [48,103]. With prompt therapy and sufficient care, complete clinical recovery was achieved in 93.02% of Murrah buffaloes suffering from prolapse of genitalia in one study [27]. Buffaloes with a vaginal prolapse left untreated and without care, may develop secondary complications such as endometritis with cystitis [111], metritis, prolapse of rectum, uterine prolapse, necrosis/fibrosis of prolapsed tissue, septicemia or constant tenesmus. In unattended cases suffering from cervico-vaginal prolapse, a purulent discharge may be evident [27], the cervical seal may liquefy with subsequent death and maceration of the fetus, and rarely death of the dam. In most extreme cases complicated by the prolapse of the rectum, death of fetus, septic metritis, necrosis of prolapsed organs, septicemia or constant violent straining, the prognosis is guarded to poor [38]. The fertility of affected animals is reduced or lost and rarely buffaloes may die on account of fatal septicemia and/or peritonitis. Urinary infection was found in urine samples of 22/26 buffaloes affected with genital prolapse [112]. However, E.coli was isolated from most of these buffaloes followed by Staphylococcus aureus and Klebsiella [112]. Buffaloes with prolapse have a significantly longer service period and the numbers of services per conception are increased [113].

1.7 Treatment

Manual replacement after thorough cleaning of the prolapsed vagina is often successful in Grade I prolapse in buffalo. Lifting of the prolapsed vagina towards the tail before replacement often helps in relieving the pressure on the urinary meatus facilitating urination [114]. This helps with an easy manual replacement. In Grade II vaginal prolapse, the organ is often edematous and soiled with dirt and dung. If a vaginal prolapse has been out for several days before discovery, the tissues may be dry, damaged and more difficult to clean and replace [32]. Washing with soap and water and 1:1000 solution of potassium permanganate [108,111,115] or with 5% acriflavin [48] has been suggested. After washing the organ the edema can be reduced by application of sugar, salt or alcohol [20,32]. The organ must be sufficiently lubricated with liquid paraffin or bland oil and replaced back by slowly inverting inwards with constant pressure. This can easily be done in a standing animal rather than when the animal is sitting. Once the prolapsed part has been replaced, the operator must keep his hand inside for some time and then withdraw his hand slowly. Infusion of warm saline (2-5 litres) in the replaced organ followed by administration of 10-40 IU of oxytocin IM can help in maintaining the organ in place [109]. When animals are straining severely, often the prolapse tends to reoccur and some sedatives may initially be given. Epidural anesthesia (4-5 ml of 2% lignocaine) and pudendal nerve block were suggested previously to prevent straining in buffaloes with antepartum prolapse. The epidural anesthesia resulted in better efficiency in maintaining anesthesia for 68.3 min [116,117]. Epidural administration of xylazine (0.05 mg/kg body weight) has been suggested for prevention of straining in buffaloes with antepartum vaginal prolapse. The mean induction time was 5.3 min and analgesia persisted for 4.10±0.37 h and straining was prevented for 21.2±3.7 h [118]. Many case reports have mentioned the administration of 4-5 ml of 2% lignocaine as epidural anesthesia before prolapse replacement [97,99,115,119], however, this must be carefully done only in selected cases as the vagina becomes flaccid preventing proper repositioning and overdose can lead to loss of hind limb motility preventing standing of the animal [21]. Creation of pneumoperitoneum by insufflation of air using 3 cm 18 gauge needle in the flank region till the abdomen distends up to the level of last rib was suggested to reduce the tenesmus and prevent recurrence of vaginal prolapse in buffaloes in one study [120], however, on account of potential dangers of creating peritonitis such a technique cannot be suggested.

The vulvar truss (Fig. 10) is of practical value in retaining the prolapsed vagina in its anatomic location subsequent to replacement in pregnant dairy buffaloes and is a frequently used method (Table 5) for prevention of recurrence of cervico vaginal prolapse [22,59,78,97,121,122]. The truss made of leather, wide cloth (Fig. 10, Fig. 11) and ropes is good. The truss must be padded with small towels. A truss that is too loose may be of little value and a truss that is too tight may cause severe vulvar edema (Fig. 12) and pressure necrosis [32]. Jagatheesan, [78] treated 22 buffaloes with vaginal prolapse (both antepartum and postpartum) by replacement followed by application of a rope truss kept in place for 3-5 days and found it very useful in retaining vaginal prolapse in buffaloes without any trauma. The replacement of Grade III prolapse (cervico-vaginal prolapse) is similar to that for Grade II except that when parts of the vagina or the cervix are torn (Fig. 1, Fig. 3, Fig. 7), they need to be sutured before replacement. Application of emollient creams and local anesthetic jellies often reduce the post replacement straining. Intravenous and subcutaneous administration of calcium borogluconate and antibiotics are helpful in restoration of the motility of the vagina and prevention of infection.

Figure 20.10. The canvas and rope truss applied to a buffalo with vaginal prolapse.

Figure 20.11. The canvas and rope truss applied to a buffalo with vaginal prolapse (line diagram of the same is shown below).

Figure 20.12. Vulvar edema in a buffalo in which the rope truss was tight.

The purpose of the prolapse treatment in pregnant buffaloes is to maintain the organ in place until the completion of gestation. The truss must be removed once the signs of parturition have started and care must be exercised to prevent further prolapse during and after parturition. Pregnant buffaloes with Grade III or IV vaginal prolapse can be considered for pregnancy termination [58,123]. A combination of prostaglandin and dexamethasone is a good choice for the purpose [32]. Cesarean section has been suggested in full term pregnant buffaloes with Grade III vaginal prolapse for safe delivery of the calf [95,105].

A wide variety of sutures have been suggested for retaining the prolapsed organ in cows including the Bühner suture (purse string), the bootlace suture, and the interrupted horizontal mattress suture (Fig. 31) [20,30]. Often, when care after placement of these sutures is not good, or the straining is violent, the sutures do not hold well, resulting in tearing of tissues and/or contamination of the sutured area. Umbilical tape is useful for purse string sutures commonly used in buffalo for the prevention of vaginal prolapse [27,99,106,129,132]. The application of Bühner suture in Murrah buffaloes with a vaginal prolapse resulted in the effective retention of the prolapsed vagina in 88.9% of animals with minimum infection at suture site compared to Flessa suture (87.5% retention) and Ag Tek prefix button (66.7 % retention) [116]. A recent report in buffaloes from Malaysia mentioned the use of Bootlace suture for management of recurrent vaginal prolapse [133]. Similarly a report on Anatolian buffaloes with chronic recto-vaginal prolapse mentioned the use of suture of the vaginal wall with the pelvic wall after replacement [134]. In a comparison of the use of vaginal truss v/s vulvar sutures for retention of vaginal prolapse subsequent to manual replacement, Lakde et al., [122] treated 15 buffaloes with antepartum vaginal prolapse with a truss and 8 buffaloes with vulvar sutures. They found that vulvar sutures resulted in maggot wounds at the suture site, recurrence of prolapse in 4 buffaloes and death in 2 buffaloes whereas similar problems were not observed with the use of a rope truss.

Surgical repair to prevent the prolapse of the vagina is possible using techniques such as vaginoplasty. Yet such a technique prevents the animal from being used in natural service or normal parturition. A previous report in cows [30] mentioned repair techniques such as Caslick's operation for first degree prolapse and vaginopexy and cervicopexy for other degrees of vaginal prolapse. Two techniques for surgical repair of vaginal and cervical prolapse in buffaloes have been described. These include vaginopexy (Minchev’s method) in which the vaginal walls are tied to the croup muscles [129] and cervicopexy (Winklers operation) in which the cervix is fastened to the prepubic tendon but requires specialized needles and sufficient practice for proper placement [117,135]. These techniques are difficult to perform and thus they have not become popular [135]. Other techniques for vaginal fixation such as abdominal sacrocolpopexy and laparoscopic sacrocolpopexy described for human patients [136] have not been mentioned for domestic animals including cattle and buffalo; however, the authors feel that such techniques must be tried in recurrent cases of genital prolapse both in cattle and buffalo.

A Caslick's operation has been suggested [30] but this is often suboptimal as constant straining is common in dairy cows and buffaloes. Constant straining is also a common problem after replacement of the prolapsed organ. The use of proper lubrication, anesthetic jellies, emollient creams and mild sedatives before replacement often reduce this straining.

In the most severe type of Grade III and Grade IV vaginal prolapse per vaginum ovariohysterectomy has been suggested under epidural anesthesia in cows [137,138]. Similar descriptions for buffaloes are unavailable.

Feeding of seeds of Argyreia speciosa have been reported to be 100% curative in preventing recurrent prolapse in buffaloes [139], however, the trial was on an extremely small number of buffaloes. Seeds of Argyreia speciosa (Family Convolvulacae), locally known as "Samundar soak" (Vriddadaru in Sanskrit) (250 gm divided into 4 doses of 62.5 gm) were crushed in a pestle and mortar with some water and the resultant paste was fed orally daily with 250 gm of wheat flour for four days with claims of excellent results [139]. Dilshad et al., [140] described the use of ethno-veterinary products for therapy of genital prolapse in buffaloes in Pakistan. However; no scientific evidence of these products was mentioned in this survey. Likewise the homeopathic medicine Sepia 200 was given orally and has shown some promise in the prevention of recurrent prolapse [20] but has not yet been proven experimentally. Mata et al., [141] mentioned the use of podophyllum (a homeopathic medicine) for therapy of vaginal prolapse in buffaloes.

In spite of the many techniques described, the therapy of vaginal prolapse is sometimes imperfect. Parenteral administration of calcium (150 ml SC), phosphorous, antibiotics [27,59] and progesterone injections (500 mg IM once or twice weekly) [18,27] are often rewarding but may sometimes show sub-optimal effects and the authors feel that the more promptly the prolapse is replaced and ample care provided, the better the likelihood of therapeutic efficiency and similar views have been expressed by other workers [48]. Care of animals with prolapse include little exercise, feeding of less bulky diets, reduction in estrogenic feeds (if being fed) and frequent watch of these animals.

Figure 20.13. The three types of sutures commonly used for retaining vaginal prolapse the Purse string (1), Bootlace (2) and Horizontal mattress (3). Redrawn from Hooper et al. [30]

2. Uterine Prolapse

Spontaneous uterine prolapse is an occasionally encountered post-parturient complication requiring immediate attention [101]. It commonly occurs in buffaloes during the third stage of parturition [177 frequently during 8-48 h of calving [85,142-146]. Occasionally, it is delayed for 72 h [147]. It is one of the obstetrical emergencies which require early attention and efficient management. The inverted uterus is visible as a large mass protruding from the vulva and may extend to the hock joint (Fig. 14) [148,149]. Exposed placentomes may be visible on the prolapsed part and generally the fetal membrane might have partially separated from the caruncles. Many case reports on uterine prolapse in buffaloes have appeared in the literature (Table 6).

2.1 Incidence

Few reports are available on the incidence of uterine prolapse in buffaloes. Mishra et al., [25] found in their clinical analysis of 63 cases that the incidence of uterine prolapse was 14.28% and the rest were vaginal prolapses. Analysis of clinical records (1297 cases of reproductive disorders in buffaloes) revealed the incidence of postpartum uterine prolapse to be 6.60% [18]. Medina [44] evaluated 96 Bulgarian Murrah buffaloes and found an incidence of 14.58%. The prevalence of uterine prolapse in one study that analyzed 9745 calving records of Murrah buffaloes varied from 1.34% to 2.22% during different years with an overall incidence of 1.87% [61] and another study [68] recorded the incidence of uterine prolapse to be 4.07%. In a survey involving 815 buffaloes in Madhya Pradesh (India) uterine prolapse was the most prevalent reproductive disorder with an incidence of 8.71% [162]. In one study, the incidence of uterine prolapse was 7.7% [92]. In a study of 585 puerperal reproductive problems in Nili Ravi buffaloes in Pakistan Akhtar et al., [12] found an incidence of 3.92% for uterine prolapse.

2.2 Risk Factors

Prepartum vaginal prolapse, dystocia and low postpartum serum calcium are significant risks for the occurrence of uterine prolapse in buffaloes. Previous prolapse, difficult birth and low serum calcium were significantly associated with the occurrence of uterine prolapse in Bulgarian Murrah buffaloes [29]. Buffaloes with serum calcium below 10.42 mg/dl were 6.7 times more likely to suffer from uterine prolapse [29]. Dystocia and pre-partum vaginal prolapse were significantly associated with uterine prolapse with the odds ratio of 5.25 and 22.09, respectively [29]. Deficiency of calcium, magnesium and phosphorous during pregnancy and at parturition were significantly associated with the occurrence of postpartum uterine prolapse in Iraqi [28,163] and Indian [164,165] buffaloes. Pandey et al., [166] found that the mean values of serum calcium and inorganic phosphorus were significantly lower (p<0.01) in buffaloes with a prolapsed uterus on the day of uterine prolapse. The mean concentrations of hemoglobin and serum magnesium did not differ significantly in normal buffaloes and buffaloes with postpartum uterine prolapse [167].Reports analyzing serum biochemicals found significantly low levels of serum calcium, phosphorous and magnesium (Table 7), however, Paul et al., [168] mentioned that uterus prolapse is not due to dietary deficiency of minerals (Ca, P, Mg, Zn and Cu). Stall fed pluriparous buffaloes are more prone to uterine prolapse [169]. The lower pre and postpartum body weight of buffaloes was considered a significant risk factor for the occurrence of uterine prolapse. The mean pre (543±80.4 kg) and postpartum body weight (498.07±77.2 kg) of Bulgarian Murrah buffaloes affected with uterine prolapse was significantly lower compared to pre(596±54.5 kg) and postpartum body weight (550.61±41.4 kg) of buffaloes not affected with uterine prolapse [170]. However, Tiwana et al., [23] had previously shown that weight of dam at first calving had non-significant effects on the incidence of postpartum uterine prolapse in Murrah buffaloes.

2.3 Etiology

Decreased myometrial tone is a logical predisposing mechanism for the occurrence of uterine prolapse in cows [101]. In many case reports in buffaloes the manual extraction of the calf [106,151,157,171] probably initiated uterine eversion of the gravid uterine horn followed by a complete uterine prolapse after delivery [157] and protrusion of intestines through uterine rupture [151]. Unlike a vaginal prolapse, the heritability or additive individual susceptibility with subsequent pregnancies is not apparent in cattle with uterine prolapse [101]. In studies on buffaloes, the heritability of utero-vaginal prolapse was low. Vaginal tears or fistula can result in uterine prolapse in buffaloes as a result of strong contractions [107].

2.4 Diagnosis and Clinical Findings

The prolapse of the uterus can easily be diagnosed by visual observation of the everted reddened mass [164,169] and exposed placentomes (Fig. 8, Fig. 14) and sometimes the attached fetal membranes[158]. Rarely will a uterine prolapse show a concomitant prolapse of abdominal organs [172] such as intestines through a vaginal or uterine rupture (Fig. 15).In rare cases the gravid uterine horn may prolapse through a vaginal tear in a pregnant buffalo (Fig. 16, Fig. 17). Clinically, buffaloes with uterine prolapse may sometimes be unable to rise, have a reduced appetite and have increased temperature [27]. Subnormal body temperature probably indicates extensive blood loss.

Figure 20.14. Uterine prolapse in a buffalo (photo courtesy Dr. MV Ingawale, Department of Veterinary Gynecology and Obstetrics, PGIVAS, Akola, Maharashtra, India).

Figure 20.15. Uterine prolapse in a buffalo with prolapsed intestines through the uterine rupture.

Figure 20.16. Uterine prolapse in a pregnant buffalo (photo courtesy PM Chauhan, Dept. of Veterinary Clinics Dr. VM Jhala, Clinical Complex, College of Veterinary Science and Animal Husbandary, SD Agricultural University, SK Nagar, Deesa, Gujrat, India).

Figure 20.17. Uterine prolapse of a gravid uterine horn in a pregnant buffalo (photo courtesy PM Chauhan, Dept. of Veterinary Clinics Dr. VM Jhala, Clinical Complex, College of Veterinary Science and Animal Husbandary, SD Agricultural University, SK Nagar, Deesa, Gujrat, India).

Buffaloes with a uterine prolapse and a concomitant calcium deficiency show clinical signs of hypocalcemia. Buffaloes with a uterine prolapse may have difficulty in passing urine due to the pressure on the urinary meatus. Extensive hemorrhages may be evident if the exposed cotyledons are broken/torn during the handling of the prolapse, animal movement or transport. Clinical signs of peritonitis might be evident in buffaloes with uterine prolapse of longer duration and necrosis (Fig 18) and/or the rupture of the exposed uterus is likely.

2.5 Prognosis

Uterine prolapse is an emergency and unattended cases may turn fatal. For easy replacement, uterine prolapse cases must be attended to with priority because of rapid development of edema, contamination, mucosal trauma and cervical closure may render the replacement difficult. Moreover, severe hemorrhage may occur from the exposed placentomes which when coupled with septicemia may prove fatal. Severe hemorrhage was noticed in 21.4% buffaloes with uterine prolapse that had a dystocia [144]. The mortality rates in large studies in cows were 20-25% [173,174]. Similar reports on buffaloes are unavailable; however, the authors feel that similar rates exist in buffaloes. In cases where the animals are treated within a short time of occurrence, the prognosis is good. The effects of uterine prolapse on future fertility are negative. Data pertaining to 1055 calving records of 427 Murrah buffaloes at an organized buffalo farm (NDRI, Karnal, India) revealed that prolapse had a significant effect on the service period and the number of services per conception [113].One clinical study on uterine prolapse in buffaloes in Iraq found that the number of services per conception, pregnancy rates and days open were significantly higher in buffaloes with uterine prolapse (Table 8) compared to normal buffaloes [175]. Singh and Chandolia [176] recorded an unusual case of prolapse of non-gravid uterine horn in a pregnant buffalo that aborted one month following replacement of prolapsed horn. Complications of uterine prolapse include shock, septic metritis, peritonitis, endotoxemia and death [143,177].

Figure 20.18. Uterine prolapse in a buffalo with necrosis (photo courtesy Prof. Nitin Markandeya, Department of Animal Reproduction, Gynaecology and Obstetrics, College of Veterinary and Animal Sciences (MAFSU), Parbhani, Maharashtra, India).

2.6 Treatment

The manual replacement of the everted uterus is the preferred method for treating uterine prolapse. Therapy of uterine prolapse should be instituted immediately. It is advised to keep the organ moist and on a clean sheet of plastic or other clean material to avoid contamination by soil in a recumbent animal. The prolapsed part should be thoroughly washed with water and a hypertonic solution to remove the dirt and reduce the edema. In many case reports, the uterus was washed with 1:1000 solution of potassium permanganate [145,151]. Application of cold water and ice packs has been suggested to reduce the edema [103]. The uterus must be lifted before attempting to replace it to facilitate urination which might have been prevented due to the positioning of the urethra in an acute angle within the prolapse. A urinary catheter might be required to empty the urinary bladder in some cases of uterine prolapse of prolonged duration [153]. It should also be noted that the bladder, and even intestinal viscera, can be contained within the prolapsed uterus. Topically applying osmotic agents, such as salts or sugar, has proved effective to begin reducing and preventing the edema that rapidly accumulates within the prolapsed tissue [101]. Manual massage during replacement, using ointment with lubrication and emollient properties, is an effective alternative [101]. The surface of the uterus must be evaluated for any tears and lacerations which must be sutured. Manual replacement of the uterus with gentle eversion starting at the base and continuing up to the apex is suggested. If the animal is recumbent it is often better to raise the hind quarters or lower the fore quarters. Caudal epidural anesthetics prevent straining and facilitate replacement of the uterus and have been used during uterine prolapse replacements in many reports on buffaloes [85,143,145,148,152,157]. Handling induced trauma to the friable uterine mucosa is common in a uterine prolapse with edema. This can be minimized by previous reduction of the edema before replacement and confining the uterus in a wrapped plastic or porous fabric bag [101]. Following complete replacement, the uterus should be carefully evaluated and the handler must keep his hand inside for a few minutes followed by slow withdrawal and administration of 10-20 IU of oxytocin IM along with IV infusion of calcium borogluconate to hasten involution. Intrauterine administration of 20 IU of oxytocin in the uterine musculature has also been suggested [157]. Sufficient antibiotics and supportive therapy must be administered for 3-5 days to prevent metritis and other complications. Sometimes buffaloes die subsequent to manual replacement of uterine prolapse probably on account of unnoticed internal hemorrhages.

Techniques to suture the vulva for the retention of the uterus and vagina have been described previously [75]. Vulvar retention sutures described in case reports in buffaloes include purse string sutures [143,152,154], horizontal mattress sutures [145] and button sutures (Table 7) on the vulva [164]. In cases of uterine prolapse with concomitant uterine rupture and prolapse of intestinal loops [85,172], the suture of uterine tears subsequent to replacement of intestinal loops is suggested prior to attempting replacement. The application of a rope truss [154] is a preferred method (Table 7) to prevent recurrence of uterine prolapse.

Cervicotomy and trachelorrhaphy was described for therapy of irreducible uterine prolapse in buffalo in one report [178], however, its practical utility appears to be suboptimal. In the extreme cases of uterine prolapse of long duration (with severe necrosis, circumferential lacerations and closure of the cervix) where replacement is not possible amputation of the prolapsed uterus must be considered. Partial hysterectomy has been mentioned for chronic uterine prolapse in buffaloes [179]. In a rare case, an ovary protruded from a vaginal tear subsequent to uterine prolapse replacement in a buffalo [180].