Small Animal/Exotics 20TH ANNIVERSARY Compendium June 1999

EXOTICS ROUNDS

Urinary Bladder Eversion in Rabbit Does

ABSTRACT: During a 2-year period, two
rabbit does with a history of recent dysto-
cia were presented to the University of
Georgia College of Veterinary Medicine
Teaching Hospital for evaluation of a piri-
form mass protruding from the vulva. In
both cases, transurethral urinary bladder
eversion was diagnosed. Partial cystecto-
my and cystopexy were used to correct the
prolapse in one case, and the affected doe
remained clinically normal 1 year after
surgery.
Cheryl B. Greenacre DVM,
Diplomate ABVP (Avian)
Sheila W. Allen, DVM, MS,
Diplomate ACVS
Branson W. Ritchie, DVM, PhD,
Diplomate ABVP (Avian) and
ECAMS
University of Georgia
College of Veterinary Medicine
Athens, Georgia
local rabbit breeder for evaluation. abdominal palpation. A sterile pro-
The breeder administered intramus- bang was used to probe the margins
cular vitamin B, penicillin, and oxy- of the protruding tissue to rule out
tocin; covered the tissue with hydro- prolapse of the reproductive tract.
gen peroxide; and attempted to No attachments to the cervix or uter-
reduce the mass manually. These us could be defined. An eversion of the
treatments were unsuccessful. bladder through the urethra and cer-
The doe had kindled five previous vix was considered.
litters, the first and last
of which were still- ■ Transurethral bladder eversion has been report-
born; the last litter kin- ed in mares, cows, and women.
dled 4 days before pre- KEY POINTS
■ Bladder eversion occurs secondary to a progres-
sentation. The doe
sive loss of tone in the urethral sphincter.
would intermittently
strain to urinate but ■ An everted bladder should be repaired as soon
produced only small as possible to reduce necrosis of the bladder mu-
cosa and prevent secondary renal failure from
quantities of urine. The
ureter constriction and hydronephrosis.
perineum was wet and
smelled of urine; the
mucosa of the vulva was hyperemic, as Lateral and ventrodorsal abdomi-
frequently occurs with urine scald nal radiographs did not define the
(Figure 1). The doe weighed 1.4 kg, bladder or kidney. Abnormalities
which was considered 15% under- found on complete blood count and
weight for its body size. serum chemistry profile included a
To enable complete examination, regenerative anemia (27.1%; refer-

T
ransurethral bladder eversion
has been reported in mares,
cows, and women and most
frequently occurs within hours of
parturition. To our knowledge, this
is the first report of this condition in
rabbit does.
the rabbit was anesthetized using
isoflurane. The protruding tissue ap-
peared thickened and was covered
with a fibrinous pseudomembrane
with necrotic, hemorrhagic margins
(Figure 1). Neither the bladder nor
the kidneys could be identified by
ence interval [RI], 33% to 50%),
monocytosis (11%; RI, up to 4%),
hypokalemia (2.6 mEq/L; RI, 3.6 to
6.9 mEq/L), and hyperglycemia (273
mg/dl; RI, 75 to 155 mg/dl); in ad-
dition, the presence of numerous
schistocytes suggested that the ane-

Case 1
A 1.3-year-old female hotot rabbit
was presented with separation of the
vulvar lips caused by the protrusion
of a 5-cm piriform mass. The surface
of the exposed tissue was moist, light
yellow, and covered with strands of
hair. The client had first noticed the
abnormality the evening before pre-
sentation and had taken the doe to a
Exotics Rounds deviates a bit from the normal content of Compendium.
Because little information has been published in many areas of exotic animal
medicine, emerging disease issues are frequently as important to clinicians as are
review articles. We hope that the format of this new column will help to
disseminate needed information to practitioners who treat exotic animals.
Readers interested in submitting papers for Exotics Rounds can contact Dr.
Branson Ritchie, College of Veterinary Medicine, University of Georgia,
Athens, GA 30602; 706-542-6316; fax 706-542-6460; email britchie@
cvm.vet.uga.edu.
Compendium June 1999 20TH ANNIVERSARY Small Animal/Exotics

TABLE ONE
Results of Complete Blood Count and Selected Blood
Chemistries of the Doe in Case 11,2
Parameter Patient Finding Reference Interval
Hematocrit (%) 27.1 33–50
Erythrocytes (×106/µl) 4.1 4–12.5
Figure 1—Gentle retraction of the pir- Hemoglobin (mg/dl) 9.4 10–17.4
iform mass protruding from the vulva
Mean corpuscular volume (Fl) 66 57.8–66.5
revealed hyperemic tissue with necrotic
margins in the doe in case 1. The vul- Mean corpuscular hemoglobin (pg) 22.9 17.1–23.5
var lips are hyperemic and raised, and Platelets (×103/µl) 509 250–650
the surface of the protruding tissue is Leukocytes (×103/µl) 9.8 5.2–12.5
thickened and covered with a fibrinous Segmented leukocytes 3.137 (32%) 1–9.3 (20%–75%)
pseudomembrane. Banded neutrophils 0.0 (0%) 0 (0%)
Lymphocytes 4.99 (51%) 1.5–10.6 (30%–85%)
Monocytes 1.078 (11%) 0.05–0.5 (1%–4%)
Eosinophils 0.196 (2%) 0–0.5 (0%–4%)
Basophils 0.392 (4%) 0.5–0.9 (1%–7%)
Urea nitrogen (mg/dl) 21 13–29
Creatinine (mg/dl) 1.5 0.5–2.5
Total protein (g/dl) 5.9 5.4–8.3
Albumin (g/dl) 3.4 2.4–4.6
Alkaline phosphatase (U/L) 49 4–16
Figure 2—When performing an ex- Alanine transaminase (U/L) 44 48–80
ploratory celiotomy, care should be ex- Glucose (mg/dl) 273 75–155
ercised to avoid damaging the cecum Sodium (mEq/L) 146 131–155
(arrow), which lies in direct contact Potassium (mEq/L) 2.6 3.6–6.9
with the ventral abdominal wall. Chloride (mEq/L) 105 92–112
Bicarbonate (mEq/L) 32 16–38
Calcium (mg/dl) 11.4 5.6–12.5
Phosphorus (mg/dl) 6.1 4.0–6.9

ital thermometer placed in the rec- moistened laparotomy pads, and a

Figure 3—A mildly enlarged and hy-
peremic uterus (arrow).
mia may have been associated with
hemolysis (Table One).1,2
The rabbit was intubated and main-
tained on 1.25% to 1.75% isoflurane
with intermittent partial pressure ven-
tilation (every 2 to 3 minutes) to im-
prove oxygenation and decrease the
depressive respiratory and cardiovas-
cular effects of the anesthetic gas.
The patient was placed on a water-
circulating heating pad, and body
temperature was monitored by a dig-
tum. The doe was given an initial
dose of 240 mg of sulfadiazine–
trimethoprim orally; the dosage was
continued at 30 mg/kg every 12
hours for 14 days after surgery. Dur-
ing surgery, cardiovascular function
was evaluated using electrocardiogra-
phy and Doppler ultrasonography.
Warm lactated Ringer’s solution was
administered at a rate of 5 ml/kg/
hour through a 22-gauge polytef cath-
eter placed in the cephalic vein.
An exploratory celiotomy was initi-
ated by making a skin incision from
the midabdomen to the pubis (Figure
2). A slightly shorter incision was
made in the linea alba. The margins
of the incision were covered with
small Balfour retractor was used to fa-
cilitate exposure of the abdominal
cavity. The uterus (mildly enlarged
and hyperemic) and vagina were in
their proper anatomic positions, and
neither had prolapsed (Figure 3). The
kidneys appeared grossly normal, but
the ureters were dilated (approximate-
ly 2 mm in diameter).
The distended ureters and congest-
ed uterine vessels passed into a de-
pression in the pelvic canal, and the
bladder was not in its normal ana-
tomic location (Figure 4). When a
moistened sterile cotton applicator
was introduced into the center of this
depression, it passed inside the pro-
lapsed tissue, indicating that the
Small Animal/Exotics 20TH ANNIVERSARY Compendium June 1999

bladder had everted through the ure-

thra. The necrotic tissue protruding
from the vulva was the mucosal sur-
face of the fundus of the urinary
bladder. Several attempts to reduce
the bladder by applying external
pressure with lubricated cotton ap-
plicators caused the bladder to move
into the vagina rather than back Figure 4—Distended ureters and con- Figure 5—The bladder was reposi-
through the urethra. The bladder gested uterine vessels passing into a de- tioned in its proper anatomic location
was pulled into its proper anatomic pression in the pelvic canal (arrow). by passing forceps into the everted
location using forceps (Figure 5). bladder, grasping the inverted serosal
A partial cystectomy was per- surface of the bladder, and gently pull-
formed to remove necrotic tissue and ing it back into the abdominal cavity.
was closed using a simple continuous The depression (arrow) is caused by
the remaining everted fundus.
pattern with 4-0 polydioxanone (Fig-
ure 6). A routine ovariohysterectomy
was also performed. A cystopexy was
completed by scarifying the ventral
serosal surface of the bladder and in-
cluding it in the closure of the ab- Figure 6—The fundus and half of the
dominal incision using 3-0 polydiox- trigone (the most caudally everted tis-
anone and a simple continuous suture sue) of the bladder were necrotic and
pattern. The skin was closed using 3- were resected.
0 polydioxanone in a simple contin-
uous subcuticular suture pattern and cation but remains in its proper Figure 7—Everted bladder protruding
from the vulva of the doe in case 2.
was sealed with tissue adhesive. The anatomic orientation (i.e., the serosal
resected portion of the bladder was and mucosal surfaces do not change
characterized by diffuse transmural positions). The bladder can prolapse, der eversion in women.
necrosis microscopically, and the for example, through a rent in the In most cases, bladder eversion oc-
mucosal surface was covered with fib- vaginal wall; when this lesion occurs, curs when the urethral sphincter is
rin and degenerate neutrophils. the serosal surface of the bladder is weakened or damaged by parturition
exposed. Eversion occurs when tissue or lower motor neuron dysfunction.
Case 2
turns outward on itself; in the pa- Once the urethral tone is altered, ev-
A second doe that had recently
tients discussed in this column, the ersion becomes a progressive process
kindled four young was presented for
bladder had everted through the ure- that is precipitated by tenesmus;
evaluation following several days of
thra and the mucosal surface of the coughing; or straining caused by cys-
straining to urinate, a hunched pos-
bladder was exposed (Figure 8). titis, papilloma of the bladder, sarco-
ture, and constant restlessness. In
These are the first two reported ma of the bladder, pregnancy, a short
this case, a 4-cm piriform mass that
cases of bladder eversion in rabbits. urethra, or procidentia.3–6 Inflamma-
was light yellow, stringy, and covered
Bladder eversions have been reported tory diseases that could damage the
with dry hair was protruding from
in mares, cows, and women.3 In hu- support ligaments may also predis-
the vagina (Figure 7). Several fetuses
mans, the bladder is normally main- pose female mammals to bladder ev-
were palpable in the caudal abdo-
tained in proper anatomic position ersion.3
men. This rabbit was used for meat
by strong basal attachments and the In mares, cows, and women, ever-
production, and the client elected
urachal attachment to the umbi- sion of the bladder most frequently
euthanasia. Necropsy findings in-
licus.4 For eversion of the bladder to occurs within hours of parturition;
cluded bladder eversion through the
occur, there has to be sufficient laxity however, the eversion may occur
urethra with necrosis of the majority
in these support structures to allow months after parturition, particularly
of the exposed bladder mucosa.
caudal displacement of the apex. with perineal pathology or trau-
Discussion Vesicovaginal fistulas and ligamen- ma.3,7–9 Other abdominal organs may
A prolapse occurs when tissue tous laxity secondary to pregnancy prolapse into the everted bladder. It
“drops down” from its normal lo- are the most common causes of blad- has been suggested that bladder ever-
Compendium June 1999 20TH ANNIVERSARY
Figure 8A
Figure 8B
sion is rare because a partial eversion that may be initiated
by normal bladder movement would spontaneously reduce
when urine begins to fill the bladder.8,9 It is theorized that
multiple kindlings at a young age and recent dystocia pre-
cipitated bladder eversion in both of the does presented in
this report. It was not determined why the first and last lit-
ters produced by the doe in case 1 were stillborn. It was
also undetermined what role, if any, hypokalemia may
have played in reducing urethral sphincter tone.
In mares and cows, an everted bladder can be manually
reduced without a celiotomy by placing a hand against the
everted mucosal surface of the bladder and guiding it back
through the urethra with a large probang.10 In some cases,
the urethral sphincter has been partially incised to facilitate
replacement of the bladder.3,11,12 In other cases, a partial
cystectomy of damaged tissue coupled with repositioning
of the bladder through the urethra has been successful.3,13
The everted bladder of the doe in case 1 could not be
manually reduced through the urethra, necessitating re-
duction with forceps during laparotomy. Postsurgical uri-
nary incontinence can be a sequela to bladder eversion but
did not occur in this doe.
In most cases of bladder eversion in mares and cows, the
ureteral papillae evert with the bladder, making identifi-
cation of the protruding tissue relatively simple.10 The
ureteral papillae in these mammals are located more cra-
Small Animal/Exotics
Dilated ureter
Figure 8C
Figure 8—Artist’s rendition of bladder eversion. (A) Normal
anatomic position of the bladder. (B) Beginning of bladder ev-
ersion with (C) bladder extending through the urethra and the
mucosal surface exposed. (Courtesy of Kip Carter, Educational
Resource Center, University of Georgia.)
nially on the trigone of the bladder than they are in rab-
bits, which would favor their protrusion with the everted
bladder in the former. In both does discussed in this re-
port, urine flowed from the everted bladder when it was
manipulated. In retrospect, examination of the base of the
protruding tissue using an endoscope or small otoscope
may have facilitated identification of the ureteral papillae.
Acknowledgments
The authors thank Drs. Susan Brown and Joanne Paul-
Murphy for reviewing this manuscript prior to submission
for publication.
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Small Animal/Exotics 20TH ANNIVERSARY Compendium June 1999

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