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Urethrorectal fistula in

horse

Antonio M. Cruz, Spencer M. Barber, Sabinne B.R. Kaestner, Hugh G.G. Townsend
Abstract - Anomalies of the urethra are uncommon. Urethrorectal fistula in horses has only been
reported in foals and only in conjunction with other congenital anomalies. This report describes the diagnosis, surgical management, and possible etiologies of a unique case of urethrorectal fistula in a mature gelding.

Resume - Fistule uretrorectale chez un cheval. Les anomalies de l'uretre sont rares. Les fistules
uretrorectales chez les chevaux n'ont ete rapportees que chez les poulains et uniquement en association avec d'autres anomalies congenitales. Ce rapport decrit le diagnostic, le traitement chirurgicale et les causes possibles d'un cas unique de fistule uretrorectale chez un cheval hongre adulte.
(Traduit par docteur Andre Blouin)
Can Vet J 1999; 40: 122-124

because of depression, mild signs of colic, and hemorrhagic diarrhea. The tail and the hindquarters were wet from feces, and the temperature (38.8C), heart rate (56 beats/min), and intestinal sounds were increased. Transrectal palpation of abdominal viscera was unremarkable and the rectum contained both normal and unformed, blood-tinged feces. No rectal abnormalities were noticed. A venous blood gas analysis, blood electrolyte panel, and complete blood cell count failed to reveal any abnormalities. Abdominocentesis produced 2 mL of a serosanguineous fluid with a protein content of 33 g/L and a moderate increase in nucleated cell count (10.8 X 109/L; normal, 2-4 X 109/L), which contained 70% non-degenerate neutrophils and some degenerate neutrophils. A preliminary diagnosis of peritonitis was made at the time. A fecal and a peritoneal fluid sample were submitted for aerobic culture and sensitivity. The horse was isolated overnight and treated with gentamicin sulphate (Gentocin, Schering Canada, Point Claire, Quebec), 3 mg/kg body weight (BW), intravenously (IV), q8h, procaine penicillin G (Ethacillin, rogar/STB, Point Claire, Quebec), 22 000 IU/kg BW, intramuscularly (IM), ql2h, flunixin meglumine (Banamine, Schering Canada), 0.25 mg/kg BW, IV, q6h, and IV polyionic fluids at a maintenance rate of 50 mL/kg/d. The horse seemed to respond well to therapy, as reflected by the disappearance of the signs of colic and an improvement in his demeanor. The following day, the horse postured to urinate several times without passing urine, but the bladder was empty on transrectal palpation. Urinalysis, urethroscopy, cytoscopy, and ultrasonic
Departments of Veterinary Anaesthesiology, Radiology and Surgery (Cruz, Barber) and Veterinary Internal Medicine (Kaestner, Townsend), Western College of Veterinary Medicine, University of Saskatchewan, 52 Campus Drive, Saskatoon, Saskatchewan S7N 5B4. Address correspondence and reprint requests to Dr. Antonio M. Cruz.
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A 3-year-old, Thoroughbred gelding was presented

evaluation and palpation per rectum of the bladder revealed no abnormalities. On Day 3, the horse passed both normal and soft feces, and when straining to urinate, he passed a stream of urine from both the urethra and the rectum. On examination of the rectum by hand and with a speculum, a previously undetected 10-centimetre long, full-thickness, rectal defect of the right ventrolateral wall of the rectum was noticed. The defect was 10 cm proximal to the anus, and extended axially towards the urethra. On urethroscopy, a urethral defect could be visualized. The diagnosis was urethrorectal fistula and cellulitis of the surrounding soft tissue. Free flowing urine was collected and analyzed; the pH had increased (9.0), as had the red and white blood cell content. Urine was collected aseptically and submitted for bacteriology. Results from urine and peritoneal fluid cultures were negative. On Day 4, the horse was premedicated with xylazine (Rompun, Miles Agriculture Division, Etobicoke, Ontario) 0.5 mg/kg BW, IV, and diazepam (Valium, Sabex, Bocherville, Quebec), 0.02 mg/kg BW, IV. Intravenous ketamine (Rogarsetic, rogar/STB, Calgary, Alberta), 2.2 mg/kg BW, was administered to induce general anesthesia, which was maintained with halothane (Benson Medical Industries, Markham, Ontario) and oxygen. The horse was positioned in dorsal recumbency and a curved incision through skin and subcutaneous tissue was made in the perineum, just ventral to the anus and parallel with its horizontal axis. The dissection plane was continued craniad in the perineal body, using blunt dissection, until the defect in the rectum was located at an approximate depth of 10 to 12 cm. A full-thickness rectal defect, approximately 10 cm long, was identified ventrally. A corresponding defect in the urethra, approximately 2.5 cm x 1.5 cm, was palpable slightly axial and cranial to the rectal defect. The edges of the rectal defect were smooth but irregular and contained fibrin and fecal material. Once the edges of the rectal defect had been dissected free, they were completely debrided using a scalpel, curetted, and lavaged thoroughly with
Can Vet J Volume 40, February 1999

sterile saline. The rectal mucosa and the submucosa and muscularis were closed longitudinally in 2 separate layers with a simple continuous pattern using No. 0 polydioxanone (PDS, Ethicon, Somerville, New Jersey, USA). The urethral defect was large and partially inaccessible, and there was not sufficient tissue for closure. The urethral defect and the surgical incision were left to heal by second intention. Four stent sutures were placed in the skin to prevent excessive gaping of the wound and to achieve a more cosmetic result. Trimethoprim-sulfamethoxazole (Apo-Sulfatrim, Apotex, Winnipeg, Manitoba), 15 mg/kg BW, PO, qi 2h, replaced the systemic gentamicin 3 d after surgery and was continued until Day 14 to eliminate the need for long-term IM or IV injections. Phenylbutazone (Butezole Paste, Coopers Agriculture Division, Ajax, Ontario), 4 mg/kg BW, PO, q24h, was administered for 3 d to minimize pain and reduce inflammation. The horse was starved for 4 d following surgery. One gallon of mineral oil was administered, PO, daily during the postoperative starving period, and the surgical wound was lavaged twice a day with a dilute (0.01%) povidone iodine solution (Betadine solution, Purdue Frederick, Pickering, Ontario). Because defecation was painful, fecal material that impacted the rectal area was removed manually on a daily basis, and 30 mL of 2% lidocaine (Lidocaine, Langford, Guelph, Ontario) was applied topically to the rectal mucosa to minimize straining, until voluntary defecation occurred 3 d after surgery. Two days after surgery, the horse had signs of abdominal discomfort and an impaction in the pelvic flexure was detected by transrectal palpation. On the 4th postoperative day, a ration of bran mash and an alfalfa slurry was started and gradually modified until the horse was eating alfalfa hay and grain at Day 10. By Day 14, most of the urine was passing through the penis and all medications were terminated. The horse was discharged 3 wk after surgery. The owner reported cessation of urination from the incision site by the 4th wk after surgery, when urination and defecation were considered normal. The horse was returned for reevaluation 4 mo following surgery. A small scar was present in the skin at the surgical site and a normal stream of urine was passed through the penis without difficulty. On rectal palpation, slight scarring could be felt where the rectum had been sutured, but there was no stricture of the lumen. On endoscopic examination, the urethral lumen at the injury site was slightly narrowed, but the endoscope could be passed into the bladder without difficulty. An opening in the urethra, which was visualized at the site of the original injury, lead into a cul-de-sac, approximately 5 cm long, that extended towards the area of the original rectal defect. There was no communication with the rectum or with the exterior, and the cavity was lined with normal appearing mucosa. Anomalies of the urethra, whether congenital or traumatic, are relatively uncommon in all animal species. Urethrorectal fistula has been reported in 4 foals (1,2); each was of congenital origin and associated with other multiple congenital anomalies. Most reported cases in other species have also been congenital and usually found in association with atresia ani or other congenital
Can Vet J Volume 40, February 1999

abnormalities (3,4). Congenital urethrorectal fistulas are caused by a failure of the urorectal septum to completely separate the cloaca into a cranial urethrovesical segment and a caudal rectal segment (5). In the previously reported cases of congenital urethrorectal fistula in the horse, the associated congenital anomalies were either anal agenesis (1) or atresia ani (2). The fistula is usually recognized by 4 to 5 mo of age in other species, although in some canine and feline cases, it was not recognized until maturity (6,7). In dogs and humans, both sexes are involved, though its incidence is higher in males (6,8). All reported equine cases were male neonates. Surgical correction of the fistula and other congenital anomalies was attempted in 3 cases, with 1 animal surviving. The presence of fecal material in the urine is common in humans with a urethrorectal fistula (5), while the outstanding clinical sign in dogs is urine exiting through the anus (4). The owner of this horse had owned it for only 1 y but had reported several episodes of transitory loose feces. These problems were not treated or investigated by a veterinarian, and it is possible that they were caused by urine exiting through the anus. A small congenital defect, which became larger with time, may have been present; however, it seems unlikely that passage of urine from the anus would go undetected for 3 y. Diagnosis in this case was difficult because of the absence of obvious signs associated with the urinary system, the presence of loose feces, and the abnormal cytology of the peritoneal fluid, which, retrospectively, may have been due to the extensive pelvic cellulitis. Also, previously reported urethrorectal fistulas in horses have always been associated with other congenital anomalies, most commonly atresia ani or anal agenesis, which were not present in this case. Urethrorectal fistulas can also occur secondary to trauma, inflammation, or neoplasia (3), and in humans, they have been reported following chronic inflammation or trauma (5). The irregular surface of the edges of the rectal defect and presence of fibrin in this case would suggest an acute etiology, more consistent with trauma than with a chronic congenital defect, where smooth edges and organized tissue would be present. It is possible a urolith was lodged in the urethral mucosa, causing mucosal necrosis and fistula formation, since the proximal urethra is a common site for urethral obstruction in horses (9). In horses, urolithiasis often occurs from a single stone, but multiple stones can be formed with the smaller ones being passed via the urethra. A urolith was not found, but it may have been expelled when the fistula was formed. Also, the possibility of a traumatic incident during a transrectal palpation earlier in life can not be ruled out. However, there are no records of it. The cause of the fistula in this case remains speculative. The surgical management was successful in returning urination and defecation to normal. The surgical approach selected is commonly used for the repair of rectovaginal fistulas or third degree perineal lacerations in mares. It provides good access to defects of the caudal rectal area without causing damage to the anal sphincter. The urethral opening was easily identified but could not be entirely visualized. Closure of the urethra was not attempted because of the large defect and inaccessibility
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for surgical repair. Also, it was not considered necessary to close the urethra, as urethrotomies commonly heal uneventfully by second intention in horses (10). Leaving the surgical site open allowed urine to drain easily and prevented urine pooling in a closed incision and against the sutured rectum. In rectovaginal fistula repair, the rectum is often closed transversely, to allow more rapid passage of the fecal material over the repair site; however, in this case, the defect in the rectum was closed longitudinally, because this was the orientation of the defect and it provided apposition of the tissue edges with the least amount of tension. Modification of the diet to prevent impaction and straining is an important consideration to decrease the chance of incisional dehiscence. In retrospect, fecal output could have been greatly reduced by starving the horse for a longer period prior to surgery, thus preventing the need for daily evacuation of feces following surgery. The horse was reevaluated at 4 mo. Despite the constriction of the rectum immediately after surgery, the area was subjectively considered to be of normal size, with only slight fibrosis identified on palpation at the site of repair. This is similar to our experience following repair of rectovaginal fistulas. Perineal urethrotomies in horses usually heal by second intention without clinical signs of stricture; however, endoscopic examination of the healed urethra is usually not performed. The diverticulum formation, which was not noticed before surgery, is interesting but not surprising, considering that the granulating wound would heal gradually and eventually

close near its periphery. The significance of this is unknown, but it is possible that it may act as a nidus for urinary tract infection or urolith formation. This case is of particular interest, because the authors believe it is the first report of a urethrorectal fistula without other congenital anomalies in a mature horse and because of the presence of an urethral diverticulum, which could possibly have been the result of second cvi intention urethral healing.

References
1. Gideon L. Anal agenesis with rectourethral fistula in a colt: A case report. Vet Med 1977; 72: 238-240. 2. Kingston RS, Park RD. Atresia ani with an associated urogenital tract anomaly in foals. Equine Pract 1982; 4: 32-34. 3. Lulich JP, Osborne CA, Lawler DF, O'Brien TD, Johnston GR, O'Leary TP. Urological disorders of immature cats. Vet Clinics North Am Small Anim Pract 1987; 17: 663-696. 4. Louw JH. Congenital abnormalities of rectum and anus. Curr Probl Surg 1965; 1: 31-45. 5. Campbell MF, Harrison JH, eds. Urology, 3rd ed. Philadelphia: WB Saunders, 1970: 1611-1612. 6. Osborne CA, Engen MH, Yano BL, et al. Congenital urethrorectal fistulas in two dogs. J Am Vet Med Assoc 1975; 166: 999-1002. 7. Waknitz D, Greer DH. Urethrorectal fistula in a cat. Vet Med 1983; 78: 1551-1553. 8. Osuna DJ, Stone EA, Metcalf MR. Urethrorectal fistula with concurrent urolithiasis in a dog. J Am Anim Hosp Assoc 1989; 25: 35-39. 9. DeBowes R. Urethra. In: Auer J, ed. Equine Surgery. 1st ed. Philadelphia: WB Saunders, 1992: 790. 10. Walker DF, Vaughan JT. Bovine and Equine Urogenital Surgery. Philadelphia: Lea&Febiger, 1980: 105.

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Can Vet J Volume 40, February 1999