Chronic Vaginitis Associated With Vaginal Foreign Bodies in a Cat

Introduction

Vaginitis, an inflammation of the vaginal mucosa, occurs in both sexually intact and spayed bitches of any age or breed and has also been reported in queens.^1–3 Vaginitis may occur as a primary disease process or may be secondary to vaginal trauma, neoplasia, foreign bodies, and other congenital or anatomical abnormalities of the urogenital tract.^3,4 A diagnosis of vaginitis is based primarily on the medical history and physical examination findings.¹ Vulvar discharge is a common clinical sign and may be hemorrhagic (rare), mucoid, mucopurulent, or purulent in nature.¹ Other clinical signs include dysuria, pollakiuria, frequent cleaning of the vulva, and attraction of males.^2,3 Perivulvar inflammation may also be present.^2,5

Primary vaginitis is rare in dogs and cats; therefore, when vaginitis is present, an underlying cause should be sought.^2,4 Obtaining a complete history (e.g., estrous history in intact females, administration of medications) is essential.^4,6 A thorough physical examination and a minimum data base (i.e., complete blood count, serum biochemical profile, urinalysis, urine culture) are used to detect the presence of systemic illness. In addition, perivulvar and vaginal examination is helpful in diagnosing vaginal neoplasia, foreign bodies, and conformational abnormalities. Vaginal cytology is used to determine the stage of estrus and to identify the presence of infections and neoplastic cells.^4,6 Aerobic bacterial and mycoplasmal vaginal cultures can be performed to identify potential pathogens. Radiography and ultrasonography of the lower genitourinary tract may be helpful in identifying foreign bodies, stump pyometra, and pyelonephritis. Contrast studies (e.g., vaginogram, urethrogram) may also be helpful.⁵ Vaginoscopy can be used to identify vaginal conformational abnormalities, visualize neoplasms, obtain biopsies and cultures, and retrieve foreign bodies.¹

The following case report describes a cat that developed chronic vaginitis associated with bony vaginal foreign bodies. Vaginal foreign bodies have been reported infrequently in small animals.^7–10

Case Report

An approximately 2-year-old, 5.0-kg, intact female stray cat was examined by the referring veterinarian after being hit by a car. The queen was found to have neurological deficits in the right rear leg, a deep perivulvar wound, and hematuria. A feline leukemia virus test performed on initial presentation was negative. A 1-week course of amoxicillin-clavulanic acid and prednisone was prescribed, and the queen was returned to the individuals who had initially found her. The queen recovered uneventfully from the trauma, and a routine ovariohysterectomy was performed 2 months later. No abnormalities were noted at the time of surgery.

The cat was evaluated 4 months after the ovariohysterectomy for a persistent, foul-smelling vulvar discharge. A 10- day course of amoxicillin was prescribed, and initially the signs improved; however, the discharge failed to resolve completely. Two months later, the cat was presented again to the referring veterinarian for persistence of the vulvar discharge. Examination revealed a purulent vulvar discharge and a draining tract to the left of the vulva. The referring veterinarian anesthetized the cat and surgically explored the draining tract. The tract was determined to be a blind pouch, and it did not connect with either the vagina or the rectum. Aerobic bacterial culture of the vulvar discharge revealed a light growth of hemolytic Escherichia [E.] coli. The E. coli was sensitive to amoxicillin-clavulanic acid, which was again prescribed. Because of persistent vulvar discharge and the suspicion of a stump pyometra, the referring veterinarian performed an exploratory laparotomy 1 month later. No abnormalities were found at the time of surgery. Radiographs of the abdomen and pelvis obtained postoperatively revealed two bony opacities in the pelvic area just ventral to the colon. The cat was referred to the Atlantic Veterinary College Teaching Hospital for further evaluation.

On presentation 10 months after the original trauma, the cat was bright, alert, responsive, and afebrile. A small amount of purulent discharge was observed around the vulva, but there was no evidence of a draining tract to the left of the vulva. A complete blood count was normal. A serum biochemical profile revealed mild elevations in alkaline phosphatase (50 U/L, reference range 10 to 35 U/L) and alanine aminotransferase (75 U/L, reference range 13 to 55 U/L). Mildly decreased chloride (116 mmol/L, reference range 118 to 128 mmol/L) and mildly increased amylase (1080 U/L, reference range 490 to 1000 U/L) concentrations were also present and were considered normal for this animal. An increase in total protein (85 g/L, reference range 68 to 80 g/L) from an elevated globulin concentration (55 g/L, reference range 23 to 38 g/L) was also detected and may have been secondary to a chronic infection.

Radiographs of the pelvis revealed a 1.5-cm, linear, mineral- dense opacity in the vicinity of the ischium that extended caudally from the pelvic canal [Figure 1A]. A 2.3-cm, linear, mineral-dense opacity was also seen overlying the pubis that extended out over the pelvic inlet [Figure 1B]. A chronic luxation of the right coxofemoral joint was also found.

Given the radiographic findings and the history of chronic purulent vulvar discharge, a tentative diagnosis of bony vaginal foreign bodies was made. Vaginoscopy was performed using a 5.3-mm (diameter), 127-cm (length), flexible endoscope. ^a Five bone fragments were visualized within the vaginal lumen [Figure 2]. The fragments were partially adherent to the mucosa but were easily removed using Decker alligator forceps.^b The vaginal mucosa had focal areas of erythema consistent with chronic vaginitis. No penetrating wounds or fistulous tracts were observed. Postoperatively, amoxicillin-clavulanic acid^c (12.5 mg/kg orally q 12 hours) was administered for 7 days. Within 2 weeks following discharge from the hospital, the cat was free of clinical signs.

Three bony foreign bodies removed from the vagina were identified as an intact right humerus and two intact scapulae (right and left). Two fragments were unidentifiable, but were possibly from a skull [Figure 3]. Each scapula had a suprahamate (metacromion) process. A supracondylar foramen was identified on the humerus [Figure 4]. These anatomical landmarks indicated the bones originated from a fetal kitten that was probably retained within the vaginal lumen.

Discussion

Vulvar discharge is relatively uncommon in queens.⁶ Purulent vulvar discharge may arise from the uterus, vagina, vestibule, or vulva.⁶ When vaginitis is the cause, gross evidence of inflammation (e.g., mucosal lesions, pain, edema, hyperemia) is usually present.⁶ Vaginitis in ovariohysterectomized females may be secondary to congenital abnormalities of the urogenital tract, clitoral hypertrophy, bacterial or viral infections, chemical irritation, traumatic injury to the vaginal mucosa, vaginal neoplasia, or vaginal foreign bodies. ^1,4 In addition, vaginitis may arise from direct extension of a disorder present elsewhere in the genitourinary tract.^3,4 Reported causes of vaginitis in queens include trauma, viral rhinotracheitis, and pyometra.² Primary vaginitis is rare.^2,4

In the present case, vaginal foreign bodies were suspected based on the medical history and the identification of bony opacities in the pelvic canal on survey radiographs. Possible explanations for the presence of bones in the vagina included a previous pregnancy with retention of a macerated fetus, prior ingestion of bones or a fetus with subsequent migration from the rectum into the vagina (via a rectovaginal fistula), and iatrogenic placement of bones in the vaginal canal. Given the absence of a fistulous tract or evidence supporting iatrogenic insertion, retained fetal bones were suspected. Retention of fetal bones following dystocia or fetal death in utero has been reported.^9,11

Numerous causes of pregnancy termination have been identified in queens. Infectious etiologies include panleukopenia virus, feline leukemia virus, feline immunodeficiency virus, feline herpesvirus-1, feline calicivirus, Toxoplasma gondii, and various bacteria.^12–15 Severe fetal defects may also result in early pregnancy loss.^12,13 In addition, maternal abnormalities such as trauma, nutritional deficiencies, abnormalities of the urogenital tract (e.g., cystic endometrial hyperplasia), environmental stress, and endocrinopathies (e.g., hypoluteoidism) have also been implicated.^12,13 Administration of numerous drugs (e.g., corticosteroids, chemotherapeutic agents) has also been associated with embryotoxicity and abortion.¹⁶

The cat in this report was a stray prior to initial presentation, and, with the exception of feline leukemia status, her previous history was unknown. Whether the presence of the retained fetus followed a previous dystocia or early pregnancy termination could not be determined. However, if this queen was pregnant when she was struck by a car (the reason for her initial presentation), the blunt abdominal trauma may have resulted in fetal death in utero. Alternatively, the administration of corticosteroids soon after the trauma may have induced abortion. Regardless of the cause, a fetus apparently became lodged in the cranial vagina where it underwent lysis, leaving only the bones in situ. These bony foreign bodies were likely responsible for the chronic vaginitis observed in this cat.

Conclusion

A 2-year-old cat was diagnosed with chronic vaginitis associated with bony fragments in the vagina, 10 months after being struck by a car. Some of the bones were identified as a humerus and scapulae, probably from a fetal kitten. Given the findings in this case, a thorough search for vaginal foreign bodies should be done in queens with a history of chronic, purulent vulvar discharge.

Acknowledgments

The authors thank Dr. Susan Dawson for her assistance with identification of the anatomical landmarks on the bony foreign bodies retrieved from the cat in this case report. The authors also thank Dr. Peter Foley and Dr. Rob Lofstedt for their assistance in interpreting possible causes for the presence of fetal bones within the vagina of this cat.