Prolapse Practice

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If I could be a sheep-only doc, I would be. Unfortunately (for me), veterinarians have less of a presence in the sheep industry than the various other agricultural sectors. The monetary gain from each individual sheep is just too little to rationalize the expenses incurred by having veterinary care performed by veterinarian. At least, this is what I’ve been told by sheep producers. As an industry in transition with a fragile profit margin, sheep producers have to cut costs where they can. Most veterinary care (vaccinations, deworming, wound care, breeding, reproductive management, processing etc) are performed by employees trained on-site. While this isn’t to the benefit of veterinarians, perhaps it’s one of the few reasons why large scale sheep producers are even around today.

Regardless, I am appreciative of the experience I gained on my rotation in Idaho. Every day, the tractor and “ewe” cart ventured out into the bands of sheep to pick up sick, lame, dead, laboring ewes, dystocia and ewes close to lambing. Workers would then sort the sheep by intended destination. Those with dystocias, close to parturition or in labor would go to the jugs. Ewes who were within 1 week of lambing went to the pens outside the jugs.

Sick or injured sheep were segregated into specific sick pens. One paddock had all the lame ewes and ewes with prolapses. Another, more critical pen, had the downer ewes that were most likely suffering from pregnancy toxemia. The most common conditions we saw on the ranch were dystocias and lameness (either bumble foot or footrot). The next most frequently encountered problem was vaginal prolapse. Some of these were very unsightly either due to the shear size of the prolapse, or due to the chronicity of the condition. The prolapse is basically the vagina or uterus turned inside-out, usually due to excessive straining with a predisposition of parasites, excessive tail-docking or constipatient. With prolapses left and right, my classmate and I definitely established a systematic and well-rehearsed routine.

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Our method for approaching prolapses…

Using dilute betadine and a Scrub sponge, we cleaned off debris from the exposed mucosa of the inverted vaginal as best as possible. Taking a garbage bag, we put roughly 3 cups of Epsom salt in the bag and secured it around the prolapse. The prolapses were “emersed” in Epsom salt inside the plastic bag. The difficulty in reducing the prolapse rests in the fact that the externalized tissue becomes thick and swollen due to edema and reduced venous flow. After time, the prolapsed tissue becomes a much larger “mass,” making it difficult to coax the tissue through the hole in which it came. Some of the vaginal prolapses were about 4 times the normal vaginal size. Epsom salts works to draw out edema and free fluid, creating an osmotic gradient effect.

Our rule-of-thumb for size-reduction over time using Epsom salts was:
– 30 minutes of Epsom salt contact time correlated with a reduction in the prolapse’s size by 30-40%
– 45 minutes reduced the prolapses by about 50%

The bag of salts was placed around the prolapse and umbilical tape was used to secure the bag in place. Umbilical tape was taken subcutaneously on the dorsal aspect of the sheep (to act as a sort of “stay” suture). We would then wait about 20-30 minutes while the prolapse gradually deflated.

Pain management was important to both my classmate and I, so we performed an epidural by administering 2-4 ml of Lidocaine. We would then ready our supplies in the next 10 minutes while the Lidocaine took effect. 5 mls of Flunixin, an NSAID, were given to help reduce swelling and inflammation as a supplement to our pain management strategy. If the prolapse had been present for awhile, or there was otherwise concern about the ewe systemically, we administered 8 ml of Nova lens (oxygen 300) subcutaneously.

After the Lidocaine had taken effect, the Epsom salt bag was removed and the prolapsed tissue was gently wiped with dilute betadine before trying to manually reduce it. Our first prolapse took the longest amount of time. It also happened to be the largest of the prolapses were treated. I snapped a quick picture before setting up our supplies. It took about 30 minutes to manually reduce the prolapse. It is import to reduce the externalized tissue in a way such that the tissue is returned into the body cavity in the correct order. By rolling the most caudal extent of the tissues inward, this returns the tissue to the body in the opposite order from which it prolapsed (first tissue out was the last tissue in). This process helps ensure that the vagina is patent and that the tissue is in the body cavity in its proper orientation. Having rolled, pinched or squeezed portions of tissue can results in reduced blood flow and possibly mucosal sloughing. After performing a couple of these, we realized that as soon as the prolapse was reduced, a high pressure stream of urine would quickly follow (the urethral orifice was usually blocked by the prolapse).

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After the prolapse was reduced, a prolapse “paddle” or “Prolapse Retainer” was secured in the vagina and held in place by tying two strands of umbilical tape from each retainer “wing” to a subcutaneous “stay” sture. The prolapse retainers help prevent reoccurence, while also allowing for lambs to pass under the paddle during parturition.

We became proficient at this technique, enough so that one afternoon our overseeing veterinarian confidently left us for the afternoon while he ran errands in town. It was a vote of confidence if I ever saw one. But when the ranch doesn’t have enthusiastic veterinary students roaming the premises searching for ill patients or surgical opportunities (which makes up 90% of the year), I was curious how the ranch deals with these situations. I asked about the ranch’s prolapse treatment protocol, and from what I could tell through my broken Spanish, there technique involves manually reducing the prolapse and then placing 2-3 sutures along the ventral aspect of the vulva. In other words, I doubt their correction of prolapses take 40-60 minutes. It would have been interesting to see their technique performed once, but we were so experience hungry that we didn’t pass up an opportunity to use our new-found prolapse-curing skills.

Morgan