Phimosis in Cats: 10 Cases (2000–2008)
Medical records of 10 cats diagnosed with phimosis were reviewed. The most common clinical signs exhibited were stranguria and pollakiuria, which occurred in eight out of 10 cats. The diagnosis of phimosis was made from physical examination alone in all cats. Eight of the 10 cats had surgical widening of the preputial orifice. Seven of these eight cats had follow-up of ≥1 month, consisting of communications with the owner or referring veterinarian, who revealed resolution of preoperative clinical signs that were attributed to phimosis.
Introduction
Phimosis is a condition in which the penis cannot be extruded beyond the preputial orifice because of an absence of an opening or an abnormally small orifice.1–7 This condition can be congenital or acquired.2,5 Causes of acquired phimosis include preputial neoplasia, edema or inflammation, and scarring secondary to trauma.1,2,5,6 The cause of congenital phimosis is not known, but it has been reported in a litter of mixed-breed dogs and in multiple related golden retriever litters, suggesting that it may be heritable in some animals.8,9 Clinical signs are variable depending on the amount of narrowing of the preputial orifice. Signs can range from asymptomatic with minimal narrowing to urinary retention and death if there is atresia of the preputial orifice and it is not treated rapidly.3,9–11 Additional clinical signs include dribbling urine or a thin stream of urine, preputial swelling, inability to mate, and secondary balanoposthitis and ulceration caused by retention of urine in the preputial cavity.2,5,6,9,11 The best way to diagnose a narrowed preputial orifice is by examining the prepuce and attempting to exteriorize the penis.2,3,7–9
Phimosis has been reported in both cats and dogs.3,9,12–15 To date, to the authors’ knowledge, the condition has only been separately reported in three cats.3,12,16 Phimosis is reported in veterinary surgical textbooks with only a description of its treatment in dogs.5,6
The goals of this study were to provide information regarding the clinical presentation, surgical procedures performed, operative complications, and outcomes of the surgery in a series of cats with phimosis.
Materials and Methods
The medical records of 10 cats diagnosed with phimosis at Michigan State University Veterinary Teaching Hospital between January 2000 and May 2008 were reviewed. Information retrieved included signalment, history, clinical signs, physical examination findings, diagnostic procedures performed, prior medical treatments, surgical procedures performed, complications, and short- and long-term follow-up. Follow-up was also collected by telephone interviews with owners or referring veterinarians. Follow-up was considered short term if it occurred <1 month postoperatively and long term if it occurred ≥ 1 month postoperatively.
Results
Signalment
Ten cats were included in this study. The median age of cats was 18.6 weeks, with a mean of 30.3 weeks and a range of 8 weeks to 125.4 weeks. Nine cats were domestic shorthair, and one was a domestic longhair. No purebred cats were identified as having phimosis during the study period. Three of the cats were neutered, and seven were intact at the time of presentation [see Table].
Clinical Signs and Duration of Signs
The most common clinical sign was stranguria (n=8), followed by pollakiuria (n=7) and vocalizing when urinating (n=5). Urination in inappropriate locations and dribbling urine each occurred in three cats, and hematuria and stunted growth were each noted in two cats. Excessive licking at the prepuce and dysuria were each exhibited in one cat.
The duration of clinical signs ranged from 2 to 31.6 weeks, with a mean of 8.9 weeks and a median of 4 weeks. In three cases, the duration of clinical signs was not reported. In three cases, the clinical signs were present when the cats were adopted by the current owner, and in one case the cat started exhibiting clinical signs a few days after being adopted. In the cat that had been exhibiting clinical signs for 31.6 weeks, the onset of signs correlated with a traumatic event, which resulted in preputial myiasis.
Diagnostics and Medical Treatments
Prior to being diagnosed with phimosis, nine of 10 cats were treated medically. Medication administered included antibiotics in nine cats to treat a possible urinary tract infection, analgesics in three cats for possible lower urinary tract discomfort, and bethanechol and prazosin for possible neurological voiding phase disorder in one cat.
Diagnostic tests performed prior to diagnosis or surgery included packed cell volume and total solids (n=8), blood glucose level (n=1), complete blood count (n=3), serum biochemical profile (n=4), urinalysis (n=5), urine culture (n=4), and abdominal ultrasound, abdominal radiographs, and abdominal exploratory (n=1 cat each). All findings were unremarkable with the exception of two urinalyses, where too-numerous-to-count white blood cells and bacteria were seen; these findings were recorded as cocci in one cat. One sample was collected from voided urine, and for the other case the collection method was not recorded. Both urinalyses were performed by referring veterinarians, and no further analysis of the urine was described in the records. Urine culture was negative in all four cats.
Physical Examination Findings
On physical examination, the most common abnormalities noted were a small or absent preputial orifice and an inability of the penis to be exteriorized from the prepuce [Figure 1] in all 10 cats. In four cats, a swollen/thickened prepuce was seen. In four cats, urine leaked from the preputial orifice when the prepuce was examined, and in one cat urine dribbled from the preputial orifice throughout the examination, even without pressure being applied to the prepuce. One cat exhibited pain upon palpation of the prepuce, and one cat was cryptorchid. Bladder sizes were small in six cats, moderate in two (one which was firm), and large in two cats.
Preputial and Penile Examination Under Anesthesia
Eight of 10 cats were anesthetized for a more thorough examination of the prepuce. The penis could not be extruded through the orifice in any of the cats. In two cats, the prepuce contained what appeared grossly to be scar tissue at the preputial orifice, but histopathology was not performed to confirm this finding. Once a preputioplasty was performed to increase the orifice diameter, the penis was visualized and appeared normal in seven of eight cats. In one cat, the penis could not be visualized, and a sterile otoscope was used to examine the area. A small opening into the preputial mucosa, which was suspected to be the penile urethral opening, was identified using the otoscope. This was confirmed when the bladder was expressed and urine exited the opening.
Surgical Technique and Intraoperative Complications
Eight of 10 cats underwent a preputioplasty to increase the diameter of the preputial orifice. Seven were positioned in dorsal recumbency, one was positioned in sternal recumbency, and one was positioned in left lateral recumbency. The preputial region was clipped and prepared for aseptic surgery. In five cats, the preputial orifice was enlarged using a wedge technique. This was accomplished by making a full-thickness incision in the prepuce, starting at the preputial orifice and extending the incision ventrally. A wedge of prepuce with the base at the preputial orifice was excised, and the preputial mucosa was apposed to the ipsilateral incised skin edge using simple interrupted sutures of monofilament absorbable suture (5-0 polydioxanone,a 4-0 polydioxanone, and 5-0 poliglecaprone 25b each in one case and 6-0 polydioxanone in two cases) [Figures 2A–2D]. The preputial orifice of two cats was enlarged by making a full-thickness skin incision on the ventral aspect of the prepuce and apposing the preputial mucosa to the ipsilateral skin edge with simple interrupted sutures of 5-0 polydioxanone or 4-0 poliglecaprone 25; however, no tissue was excised. In the remaining cat, the preputial orifice was enlarged by making an incision in the prepuce from the preputial orifice ventrally. No tissue was removed, no sutures were placed, and the incision was left to heal by second intention. Three cats were also castrated under the same anesthetic episode.
No perioperative complications were reported. Three cats were discharged on the day of surgery, and five cats were discharged the day after surgery. In seven of the cats, preoperative clinical signs resolved in the early postoperative period. The one cat that continued to strain postoperatively was diagnosed with concurrent penile hypoplasia. Additional diagnostics and treatment recommendations were made, but they were declined by the owner.
The two cats that did not have surgery were discharged with no further diagnostics or treatments at the owners’ requests.
Follow-up Information
Long-term follow-up was available for seven of the cats that had preputioplasty. Follow-up ranged from 1.4 months to 76 months, with a mean of 26.7 months and a median of 4.8 months. Follow-up for six of these cats was by contact with the owner; for one cat, follow-up was with the local veterinarian. The last correspondence with the owner of the cat without long-term follow-up was on postoperative day 2. At that time, the cat was reported as doing better and only having one episode of urination outside the litter box. No follow- up was available for the two cats diagnosed with phimosis that did not have surgery.
The owners of the seven cats with long-term follow-up were satisfied with the outcomes of the procedure and reported that their cat was doing well. Of these seven cats, one was reported to have had episodes of urinating in an inappropriate location; those episodes resolved when the area was cleaned with a disinfectant. Another cat was reported to possibly “spray,” but this cat was in a multicat household, and spraying was never directly observed. Another cat had hematuria 3 months after surgery and was diagnosed with a bacterial urinary tract infection, based on urine culture results. No other clinical signs contributable to the urinary tract were reported in these seven cats.
Discussion
Phimosis occurred in young cats but was not restricted to young animals (age range of 8 weeks to 125.4 weeks, median of 18.6 weeks, and a mean of 30.3 weeks). Phimosis was only diagnosed in one cat over 9 months of age, and in this cat phimosis was secondary to a known traumatic event that had occurred when the cat was almost 2 years of age. In three cats, clinical signs were present at the time of adoption by the owner, so this number may be falsely elevated. The young age of the cats may indicate phimosis may be congenital in origin in a majority of the cats, but the phimosis could also be due to preputial trauma at an early age from the dam or littermates. It has been stated that preputial suckling by a littermate or licking by a dam may cause phimosis in dogs.2,6,11 In four of 10 cats, the owner reported the prepuce may have been suckled by a littermate. Two pairs of littermates were in this study.
Diagnosis of phimosis requires examination of the prepuce, but other causes of urinary tract obstruction should be ruled out. As reported in dogs, cats with phimosis may have other congenital abnormalities, and a complete physical examination is recommended.14,15 In this study, two out of 10 cats were noted to have concurrent congenital abnormalities; one was cryptorchid, and one had penile hypoplasia.
Based on physical examination, all cats in the study were diagnosed with phimosis, and no additional diagnostics were needed to assist in the diagnosis. In addition to a minimum database, multiple diagnostic tests were performed in five cats included in this study, because the diagnosis of phimosis was missed on the initial physical examination. Results of these further tests did not aid in the diagnosis of phimosis in any of the cats and revealed no additional conditions that required treatment, other than a suspected urinary tract infection in one cat.
All three surgical techniques used were quick and easy to perform, with no reported perioperative complications. No cats required a urethral catheter postoperatively, and follow-up revealed resolution of clinical signs in the early postoperative period for seven of eight cases.
Because the number of cases was few and long-term follow- up was via communication with the owner or referring veterinarian, determining which, if any, surgical technique might be superior is not possible. However, the authors do not recommend allowing the incision to heal by second intention. Granulation and contraction of the incision are expected to result in an increased risk of recurrence of the stenosis. Placing sutures to appose the skin and preputial mucosa should result in primary wound healing and minimize the chance of stricture.
In this study, a perineal urethrostomy was initially recommended in one of the seven cats. While perineal urethrostomy would likely resolve the problem, it is not recommended, because it has not been shown to have benefit over preputioplasty. Perineal urethrostomy is more technically demanding, more expensive, more invasive, and has more reported postoperative complications.17–19
Long-term follow-up results revealed resolution of clinical signs that were attributed to phimosis. Recurrent clinical signs resulting from excessive scarring of the preputial orifice have been reported in dogs, and such complications can lead to the animal needing a second surgery.1,15 Because none of the cats included in this study were reexamined postoperatively, no determination could be made regarding degree of scarring of the preputial orifice; however, if the cats did have scarring, it was not severe enough to lead to noticeable clinical signs.
Long-term follow-up by communication with the owner or referring veterinarian revealed that three of seven cats may have had clinical signs associated with the urinary tract; one cat had episodes of urinating in an inappropriate location, one possibly “sprayed,” and one had hematuria. This is not unexpected because of the commonality of feline lower urinary tract disease.20,21 Urinating in inappropriate locations resolved when the environment was cleaned. While “spraying” is a pattern of urination, it is most often behavioral and not a clinical sign caused by feline lower urinary tract disease.22–24 A urinary tract infection was confirmed by culture in the cat with hematuria. Because of the retrospective nature of this study and the fact that none of the cats were reexamined for long-term follow-up, it cannot be definitively determined if the cause of the clinical signs was phimosis. Any comment on the cause of these clinical signs is speculative.
Conclusion
Phimosis occurs in cats, and clinical signs can be severe and mimic other disease states, such as idiopathic lower urinary tract disease. Diagnosis is made during physical examination of the prepuce. Treatment by preputioplasty to enlarge the orifice is recommended and is associated with a good prognosis and a low potential for complications.
PDS II; Ethicon, Inc., Somerville, NJ 08876
Monocryl; Ethicon, Inc., Somerville, NJ 08876
Acknowledgments
The authors thank Dr. Reunan Guillou for providing the photographs for this paper.
Citation: Journal of the American Animal Hospital Association 45, 6; 10.5326/0450277
Citation: Journal of the American Animal Hospital Association 45, 6; 10.5326/0450277
The preputial orifice appeared stenotic or absent on gross examination of the prepuce prior to surgery.
A full-thickness incision is made in the ventral aspect of the prepuce, starting at the preputial orifice (A), and extending ventrally (B). If a wedge resection technique is performed, the additional step of excising a wedge of prepuce, with the base at the preputial orifice, is performed next. The preputial mucosa is apposed to the ipsilateral incised skin edge using simple interrupted sutures (C). The tip of the penis can easily be visualized through the widened preputial orifice (D).
