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Theriogenology 69 (2008) 360–365
www.theriojournal.com
New surgical technique to correct urovagina
improves the fertility of dairy cows
J.V. González-Martı́n a,b, S. Astiz c, L. Elvira b, F. López-Gatius d,*
a
Department of Animal Medicine and Surgery, Complutense University of Madrid, Madrid, Spain
b
Trialvet Veterinary Consultancy and Research SL, Madrid, Spain
c
Schering Plough AH, Madrid, Spain
d
Department of Animal Production, University of Lleida, E.T.S.E.A., Avda. Alcalde Rovira Roure 191, 25198 Lleida, Spain
Received 11 September 2007; received in revised form 3 October 2007; accepted 3 October 2007
Abstract
Several surgical techniques have been proposed for the treatment of urovagina as a major cause of infertility in cows. However,
so far no technique seems to be successful in all cases. Given that an incompetent or damaged constrictor vestibuli muscle is a
feature of cows with urovagina, we hypothesized that surgical correction of urovagina by cerclage of the vestibulovaginal junction
under the vaginal wall cranial to the urethral opening would prevent cranial flow of urine and improve fertility. Our study was
performed on 39 non-pregnant lactating Holstein-Friesian cows suffering urovagina, with a vaginal content of urine exceeding
100 mL and with evident incompetence of the constrictor vestibuli muscle. Cows were randomly assigned to a Control (untreated
cows, n = 20) or Experimental (n = 19) group. An encircling polydioxanone suture was placed in the vaginal wall at the
vestibulovaginal junction to create a vestibulovaginal cerclage in the Experimental cows. Surgery was observed to resolve
urovagina in 17 (89.5%) of the 19 treated cows. Pregnancy was recorded in 7/20 (35%) and 14/19 (74%) cows in the Control and
Experimental groups, respectively. Using logistic regression procedures and based on the odds ratio, we determined that cows
undergoing surgical correction of urovagina were 5.2 times more likely to become pregnant than untreated cows (P = 0.015). Our
results suggest that vestibulovaginal junction cerclage prevents the cranial flow of urine and improves the function of the constrictor
vestibuli muscle in cows suffering urovagina. They also indicate that, under these conditions, urovagina correction may
dramatically increase fertility.
# 2008 Elsevier Inc. All rights reserved.
Keywords: Vestibulovaginal cerclage; Constrictor vestibuli muscle; Urovagina; Cows
1. Introduction injury related to dystocia, with damage to the constrictor
vestibuli muscle as a common factor in most cases [1,2].
Anatomical changes in the tubular genitalia of the Damage of this muscle allows urine to backflow and pool
cow, such as the cranioventral displacement of the vagina at the cranial vagina. The presence of urine can lead to
and uterus, can cause urine to flow cranially into the further cranioventral displacement of the cranial vagina,
vagina and lead to urine pooling, a condition known as cervix and uterus, generating a vicious circle in which
urovagina. These changes are usually the result of pelvic there is an increased tendency for the vesicovaginal reflux
of more urine. The vaginal pool in some cows amounts to
as much as 3.5 L of urine [3]. Urovagina causes infertility
* Corresponding author. Tel.: +34 973 702 500;
due to chronic endometritis and the spermicidal action of
fax: +34 973 238 264. urine [2–4]. Surgical correction is recommended when
E-mail address: flopez@prodan.udl.cat (F. López-Gatius). the vaginal content of urine exceeds 100 mL [1].
0093-691X/$ – see front matter # 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.theriogenology.2007.10.002
J.V. González-Martı́n et al. / Theriogenology 69 (2008) 360–365 361
The most common techniques described for surgi- xylacin (Rompun, Bayer, Barcelona, Spain) supple-
cally correcting urovagina include modification of the mented with 4 mL 2% lidocaine (Xilocaina, Ovejero,
urethral extension, which is used in mares [5] and the Leon, Spain) into the epidural space. Once the animal
creation of a transverse fold of tissue including the was anesthetized, the tail was tied to one side by a neck
vaginal floor in cows [2,3]. Extension of the urethra rope. Pneumovagina was induced by separating the
from the urethral orifice to the vulvar labia is undertaken vulvar labia, and feces were removed from the rectum.
using vaginal wall tissue, but the formation of a fistula The rectum was then packed with a cotton tampon and
in the mucosal extension of the urethra is a common both the perineum and vaginal vault were gently
complication [2,4], and the benefits of this technique cleaned with a mild, organic iodine surgical scrub
have been recently questioned [6]. The transverse fold (Betadine, Asta Médica, Madrid, Spain).
technique builds a ‘‘dam’’ approximately 8 cm long and
5 cm high of vaginal mucosa, cranial to the urethral 2.3. Suture material
opening that forces urine to flow caudally [2,3].
However, the rate of success using the transverse fold To create the cerclage, we used an absorbable No. 2
technique has not been reported. We found a very high polydioxanone suture (PDS II 5 Metric, W9235, Johnson
incidence of failure with the transverse fold method and Johnson, UK) threaded through a 10-cm curved,
(data unpublished), and only in two out of 14 cows cutting-edge needle. Both suture and needle were
(14%) suffering chronic urovagina did urine pooling lubricated with an oil-based suspension of ceftiofur
cease following surgery. Given that a feature shared by hydrochloride (Excenel RTU; Pfizer, Madrid, Spain).
all cows with urovagina is the incompetence of, or Because the suturing process was very laborious, a
damage to, the constrictor vestibuli muscle, we modified Deschamps needle was designed by the first
hypothesized that surgical correction of urovagina by author, with the eye of the needle at the point (Fig. 1). The
cerclage of the vestibulovaginal junction to the vaginal modified needle was used in the last nine cows.
wall cranial to the urethral opening would prevent
cranial flow of urine and improve fertility. 2.4. Surgery
2. Materials and methods The lumen of the vestibule and vagina were exposed
by keeping the vulvar labia open using forceps. An
2.1. Cows incision 5–10 mm long using Metzenbaum scissors was
made at a 4 o’clock position in the caudal portion of the
Our study was performed on 39 lactating Holstein- vestibulovaginal junction. This incision was then
Friesian cows from several commercial dairy herds in extended to a depth of about 1 cm by blunt dissection.
central Spain. Animals found to suffer urovagina with a The needle was introduced through the incision and
vaginal content of urine exceeding 100 mL were passed cranially to the urethral opening between the
chronologically assigned to a Control (untreated cows, vaginal wall and the urethra along the vestibulovaginal
n = 20) or Experimental (n = 19) group. Only non- junction floor until the 8 o’clock position of the ring,
pregnant animals free of abnormalities of the uterus where the needle was exposed and withdrawn. Care was
and/or ovaries and clinical disease (mastitis, lameness taken to avoid incorporating the urethra in the suture
and digestive disorders) at the time of urovagina
diagnosis were recruited. The lack of integrity and
function of the constrictor vestibuli muscle was
assessed by visual inspection and by stimulating the
urethral orifice, to check that the vaginal opening did
not sufficiently close in response to the stimulus. All
animals were artificially inseminated and pregnancy
diagnosis was performed by palpation per rectum 40–50
days following insemination.
2.2. Preparation for surgery
Surgery was performed on standing animals under
epidural anesthesia by infusing 0.04 mg/kg of 2% Fig. 1. A Deschamps modified needle.
362 J.V. González-Martı́n et al. / Theriogenology 69 (2008) 360–365
line, by placing one finger in the urethra during this vestibulovaginal junction (Fig. 2B). It was ensured that
maneuver (Fig. 2A). The needle was then reentered at the two ends of the suture exited the incision pass at the
the 8 o’clock position and passed under the vaginal wall 4 o’clock position. Tension was applied to each end of
to the 12 o’clock position, and finally the suture was the suture to create the vestibulovaginal cerclage. The
passed from the 12 until the 4 o’clock position of the suture was tightened to permit the entry of one finger in
Fig. 2. Caudal view of the open vulva showing the approach used for the surgical correction of urovagina. (A) The needle is introduced at the 4
o’clock position and passed under the vestibulovaginal junction until the 8 o’clock position. (B) The needle is reintroduced at the 8 o’clock position,
exited at 12 o’clock and reentered at this position to exit at 4 o’clock. (C) The two ends of the suture are drawn together at the 4 o’clock exit points,
allowing the entry of one finger in the vagina, thus creating the vestibulovaginal cerclage. A surgeon’s knot was used to maintain closure and was
embedded at the incision point.
J.V. González-Martı́n et al. / Theriogenology 69 (2008) 360–365 363
the vagina and a surgeon’s knot was used to maintain days following surgery, the cows were observed for
closure (Fig. 2C). The knot was embedded at the their ability to urinate normally, presence of urovagina,
incision point so that the suture line was completely and possible secondary vaginitis. Rectal temperature
under the mucosa. Images before (A) and after (B) values were recorded daily. Urovagina was diagnosed
surgery are provided in Fig. 3. When the modified by gentle raising of the uterus by palpation per rectum.
needle was used, the needle was withdrawn and Vaginitis was detected by visual observation of the
threaded at each step. The cows received no anti- vestibule side by opening the vulvar labia. In cows that
microbial treatment. became pregnant, a further examination was performed
in late gestation and parturition was closely monitored.
2.5. Aftercare
2.6. Data collection and analysis
A gentle finger examination of the surgical site was
performed from the vestibular side on the day after The following data were recorded for each animal at
surgery to detect possible suture dehiscence or complete the time of urovagina diagnosis: lactation number, days
failure of the suture closure, and to assess the function in milk and number of prior AI received.
of the constrictor vestibuli muscle by stimulating the The effect of surgical correction of urovagina on
urethral orifice. The same examination was performed subsequent fertility was analyzed by logistic regression
20 days after surgery to assess healing. During the 5 using the SPSS package, Version 13.0 (SPSS Inc.,
Chicago, IL, USA) and adjusting for lactation number,
AI number and days in milk. The estimates and Wald
95% limits were used to calculate odd ratios and 95%
confidence intervals (CI). Explanatory variables and
possible interactions were evaluated using the backward
elimination procedure and factors that significantly
affected fertility remained in the model [7]. The level of
significance was set at P < 0.05. Values are expressed
as the mean standard deviation (S.D.).
3. Results
3.1. Surgery
No signs of discomfort were observed in any cow
during surgery. Hemorrhage was rare and hemostatic
procedures were not necessary. The time required for
surgery was approximately 15 min for both types of
needle.
The purse-string suture was insufficiently tightened
in one cow, which exhibited urovagina the day after
surgery. Complete constriction of the vestibulovaginal
junction following stimulation was observed in the
remaining cows. No fever was recorded in any cow. One
cow showing signs of purulent vaginitis, tenesmus and
dysuria on the second day after surgery received
systemic antimicrobial treatment for 5 days. This cow
started to urinate normally on the second day of
treatment. The remaining cows urinated normally
following surgery. Recurrence of urovagina occurred
in a further cow 20 days after surgery because the
Fig. 3. Caudal view of the open vulva of a cow: before (A) and after vaginal mucosa had been cut by the suture. In all
(B) surgery. Note: the running suture is placed entirely under the pregnant cows, constriction of the vestibulovaginal
mucosa. junction, absence of urovagina in late gestation, and no
364 J.V. González-Martı́n et al. / Theriogenology 69 (2008) 360–365
difficulties at parturition were observed. No cow was provided by the constrictor vestibuli muscle [2,3].
culled for reasons related to surgery. However, these techniques are known to be useful only
In Control cows, presence of urovagina was assessed in the short-term and muscle function has not been
in each AI following diagnosis and no spontaneous assessed following surgery. The long-term correction of
resolution of the condition was observed in any cow. the problem should be a major goal, and is mandatory in
the case of urovagina. In the present study, a clear
3.2. Fertility positive response of the constrictor vestibuli muscle
to cerclage of the vestibulovaginal junction was
The mean lactation number was 2.7 1.5 (1–5) and observed. In effect, the muscle was capable of
2.7 1.9 (1–9) lactations for the Control and Experi- separating the vaginal and vestibular compartments
mental cows, respectively. The mean number of even in late gestation. The use of polydioxanone, an
inseminations and days in milk at urovagina diagnosis absorbable suture of long action (60–90 days wound
were 2.8 2 (0–9) and 2.9 2.8 (0–9) inseminations support), probably contributed to the success of the
and 188 91 (58–394) and 188 98 (58–493) days for technique.
the Control and Experimental cows, respectively. The One of the primary disadvantages of the vestibu-
mean number of inseminations after urovagina diag- lovaginal cerclage procedure is that natural service is
nosis/surgery was 1.8 0.8 (0–4) and 1.7 0.9 (0–4) not possible for at least 2 or 3 months, which is the
inseminations for the Control and Experimental cows, time required for suture resorption. Artificial insemi-
respectively. The mean interval from urovagina nation proved to be successful as early as 2 days after
diagnosis/surgery to pregnancy was 89 9.4 (75–97) surgery since the vestibulovaginal junction can be
and 49 27 (2–90) days for the Control and Experi- carefully bypassed. Urovagina is an important cause
mental cows, respectively. of infertility in the cow. The strong positive effects
Pregnancy was recorded in 7/20 (35%) and 14/19 on fertility of the technique presented here support
(74%) cows in the Control and Experimental groups, the use of this repair method in cows suffering
respectively. Logistic regression procedures revealed no urovagina.
significant effects of lactation number, AI number and The use of the modified needle for surgery was less
days in milk at the time of urovagina diagnosis on laborious for the surgeon than the needle/needle holder.
subsequent fertility. Based on the odds ratio, cows Although the needle has to be recovered and re-threaded
undergoing surgical correction of urovagina were 5.2 at each step of the procedure, the time required was the
times more likely to become pregnant than cows with same for the two types of needle.
this condition not subjected to surgery (P = 0.015; 1.32– In conclusion, the present study supports the
20.5 95% confidence interval). hypothesis that surgical correction of urovagina by
cerclage of the vestibulovaginal junction helps prevents
4. Discussion cranial flow of urine by improving constrictor vestibuli
muscle function. Our results suggest that using the
The surgical correction of urovagina by cerclage of the surgical technique proposed, urovagina correction
vestibulovaginal junction proved valuable in the present could dramatically increase the fertility of cows.
study. Surgery resolved the condition of urovagina and
improved the function of the constrictor vestibuli muscle Acknowledgement
in 17 (89.5%) of the 19 treated cows, and increased their
likelihood of pregnancy by a factor of 5.2 when compared The authors thank Ana Burton for assistance with the
to Control untreated cows. Complications associated English translation.
with the surgical procedure were scarce as it showed for
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