urinary & repro exam 1

oligo anuric

• minimal to no urine output

non-oligo anuric

• some but less than normal urine output 

polyuric

•  increased urine output 

pollakiuria

•  small volume of urine 

strangnuria

•  straining to urinate

dysuria

difficulty urinating

periuria

• inappropriate urination

nocturia

•  urination at night 

incontinence

• unconscious urination 

azotemia

• increased non-protein nitrogenous compounds in the blood, increase in serum urea nitrogen and//or creatinine concentration and/or SDMA, reflective of GFR 

• Use USG to differentiate between pre/rena//post

urea nitrogen

liver, prerenal/renal/postrenal, GI bleed or high protein diet, poor sensitivity for kidney impairment, decrease from liver dysfunction, low protein diets

creatinine

from muscle (but not indicative of muscle damage), increase due to prerenal/renal/post renal, better sensitivity compared to BUN, decrease from muscle wasting

SDMA

from nucleated cells, increase due to pre-renal/renal/postrenal, most sensitive, not commonly decreased

hyperthenuria

•  highly.adequately concentrated urine

isosthenuria

• urinary osmolality=plasma osmolality

  • Tubules didn’t dilute or concentrate (USG 1.008-1.012) 

hyposthenuria

diluted urine

prerenal azotemia

• reduced renal blood flow due to hypovolemia from dehydration or shock 

• Decreased BUN and creatinine clearance 

• Increased urea production: upper GI hemorrhage. high protein diet, mildly increased UN and normal creatinine USG variable 

renal azotemia

• any renal disease that decreases GFR below 25% 

post renal azotemia

•  excretion challenge such as urinary tract blockage or rupture 

  • USG variable, hyperkalemia often present

hematuria

• intact RBCs, after centrifugation RBCs found in sediment but urine supernatant is clear  

hemoglobinuria, myoglobinuria

• after centrifugation red/brown color persists throughout, red or pink plasma if hemoglobin and clear plasma if myoglobin  

squamous epithelial cells in UA microanalysis

 contamination (urethra, vagina, skin), most common in catheterized and voided samples

transitional epithelial from UA microanalysis

 low numbers can be normal, from catheterization, UTIs and neoplasia, visible round nucleus

casts (cylindruria)

•  form in renal tubules, may not be flushed into urine, may intermittently shower, absence doesn’t rule out active tubular disease 

  • Few hyaline or granular casts can be found in healthy animals related to normal cell turnover or entrapped proteins -> more abundant in animals with glomerular proteinuria 

  • Deteriorate in urine quickly  

  • Cellular casts are abnormal

struvite crystals

 magnesium ammonium phosphate, shaped like gold bars, can be found in healthy and unhealthy dogs/cats 

calcium carbonate crystals

common finding in normal horses and rabbits, identified as spheres with radiating lines, ovals, and/or dog bone shaped 

ammonium biurate crystals

•  thorn apple shaped, often associated with liver disease, can be normal in dalmatians and english bulldogs  

bilirubin crystals

 gold needles, seen with bilirubinuria, particularly with highly concentrated dog urine

calcium oxalate monohydrate crystals

 fence pickets, associated with ethylene glycol

calcium oxalate dihyedrate crystals

can see in low numbers in health but can indicate increased calcium and/or oxalates 

urine protein:creatinine ratio

• further assess degree of proteinuria to confirm urine dipstick; clinically useful substitute for 24hr excretion study

  • Interpretation: >0.5 in dogs=overt proteinuria; > 0.4 in cats =overt proteinuria; > 2.0 suggestive for glomerular disease  

uroabdomen

• leakage of urine from the urinary tract into the peritoneal space, usually from the bladder from trauma

• CS: +/- urination, +/- abdominal swelling, +/- hematuria, vomiting, inappetance, malaise, +/- painful

• DX: blood chemistry abnormalities (BUN, creatinine, potassium), abdominal fluid (BUN, creatinine, potassium), creatinine or potassium ratio around 2:1 abdominal fluid, cytology 

  • Diagnostic imaging defines the source of the leaking: abdominal radiographs, US, urethrocystogram, intravenous pyelogram 

• TX: acute stabilization, remove urine from peritoneal space (abdominocentesis, bladder catheter, peritoneal catheter, IV fluids, correct electrolyte disturbances), then correct primary problem 

  • Primary surgical repair: advantage is rapid resolution, disadvantage is anesthesia and abdominal surgery, caudal abdominal approach debride and close bladder 

  • Long term urinary catheter: advantage is avoid general anesthesia and surgery, disadvantage is long term hospitalization, ascending infection, may still require surgery 

ureteronephrectomy

• Indications: severe infection, traumatic injury, hydronephrosis 

• Steps: ventral midline incision, free retroperitoneal attachments and flip kidney medially to expose artery, ligate artery ligate vein, ligate ureter near UVJ 

• Problems: bleeding, leakage of urine, chronic infection (remove all of ureter), renal failure 

function of kidneys

• gulation of water/electrolyte balance, extracellular fluid volume and systemic BP, acid-based balance; excretion of metabolic waste and foreign substances, regulation of RBC production, regulation of vitamin D produce and calcium and phosphate balance, gluconeogenesis  

chronic kidney disease

• abnormality of kidney structure or function that has been present for > 3m with implications for health 

  • Permanent reduction of number of functioning nephrons -> decreased glomerular filtration rate and other issues

  • Slow progression 

  • Prevalence increases with age 

  • HX/PE: polyuria/polydipsia for > 3m, weight loss for > 3m, chronic/intermittent GI signs, reduced appetite for >3m, poor haircoat, small, irregular kidneys, +/- chronic uremic breath, osteodystrophy, signs related to proteinuria/hypertension

  • CS mild relative to level of azotemia, non regenerative anemia as disease progress 

  • Fibrosis is an indicator 

  • Causes: AKI, amyloidosis, renal dysplasia, polycystic kidney disease, congenital, pyelonephritis, chronic infection with FIV/FeLV/FIP, idiopathetic, neoplasia, glomerulosclerosis, immune complex glomerulonephritis, nephro- and ureterolithiais 

  • Primary lesions within glomerulus common in dogs and within the tubulointerstitial compartment common in cats 

acute kidney injury

• an abrupt decrease in kidney function, encompassing both injury (structural damage) and impairment 

  • Sudden change in kidney structure, function, or both -> decreased GFR and other issues , may detect azotemia beforehand 

  • Potentially reversible, Predisposition to CKD  

  • HX/PE: recent change in urination, no change in weight/BCS, acute onset of GI signs, recent reduction in appetite, health hair coat, normal to enlarged kidneys 

  • More severe clinical signs for the same level of azotemia, hematocrit often normal to increased 

effects of hypertension on eye

 retinopathy, choroidopathy, optic neuropathy, retinal hemorrhage or edema, vitriol hemorrhage, partial or complete bullous detachment

effects of hypertension on heart

ventricular hypertrophy, arrhythmias, murmur vasculopathy

effects of hypertension on brain

• hypertensive encephalopathy, stroke, lethargy, seizure, altered mentation or behavior 

effects of hypertension on kidneys

•  proteinuria, progression of CKD 

pregnancy diagnosis

• Transabdominal palpation 

  • Advantages: cheap, no equipment needed, 2ccm swellings by d30 

  • disadvantages: small window accuracy (30-45 and over 45), inaccurate, iatrogenic fetal death?  

• Relaxin: can get false negatives <28d or abortion or whelping, not an assessment of fetal health or number  

• US: preferred 

  • Early diagnosis: vesicles 18-20 d, HB @25 d 

  • Late pregnancy: fetal viability and maturity 

    • Assess stress, age, placental disease, fetal maturation, puppy count (miscount, resorption)  

• Rads: mineralization >45d (>38 in the queen), assess: gestational age, fetal death, feo-maternal disproportional, best method for puppy count 

  • Tips: defecate first, ~55-60d for easier images  

• Acute phase proteins 

stage 1 labor dogs

•  6-12 h, uterine contractions, pelvic ligament and cervix relaxation, placental separation (if green to black vulvar discharge early with no puppy needs to be evaluated) 

  • Signs: obsessive nesting, anorexia, restlessness, panting, shivering 

stage 2 &3 labor dogs

fetal and placental expulsion, 30-60 min between pups, complete in 6h, fetal membranes should pass w/ pup, or within 5-15min, lochia (uterine discharge) normal up to 3w post partum, uterine involution takes up to 3m

causes of dystocia

Breed predisposition (brachycephalics), Primary uterine inertia, Feto-maternal disproportion, Singletons, Maternal abnormalities, Vaginal strictures, pelvic fractures, neoplasia , Secondary uterine inertia (large litters)

neonatal development

• Neurologic maturation 21d

• Eyes open 9-16d

• Ear canals open 10-14d

• Adult parameters 

• Thermoregulation 28d

• Solid food 

• Postural control 3-5wk

neonatal vitals

• Temp 96-97 

• HR: >200 bpm 

• RR: 15-30 bpm

• 7-10 adgar score for goof viability

reasons for no weight gain

• Inadequate lactation: domperidone, oxytocin, treat maternal health 

• Dam rejection: acepromazine, placenta, oxytocin 

• Illness: antibiotics anti parasitic 

• Large litter: supplement 240-260 kcal/kg, bottle, tube, sponge

septicemia in neonates

• failure of passive transfer of IgG +/- exposure to pathogens 

  • Risk factors: dam endometritis/agalactia, dystocia, milk replacer 

  • TX: ceftiofur, amoxiclav, trimethoprim/sulfonamides, cephalexin, penicillin, macrolides, amikacin (DONNOT give enrofloxacin or ciprofloxacin) 

proestrus dog

• ~9d,

  • increased LH pulses @ end anestrus -> follicular growth -> increased plasma estrogen 

  • Estrogen peaks at end 

  • PE: vulvar swelling seroanguinous vulvar discharge 

  • Behavior: attracts for males but wont stand for mating 

  • Cytology: starts < 10% cornified at onset, >90% cornified by end of proestrus

estrus dog

• ~9d, increasing progesterone , 2d after LH surge

  • PE: less vulvar swelling, vulvar discharge more serous

  • Behavior: attracts males and stands for mating 

  • Cytology: >90% cornified, most nuclear

diestrus

•  ~60d, 

  • Sharp decrease to <50% cornified on day 1, can use for retrospective calculation of fertile period, whelp 57 +/- 2d from d1, 

  • Cytology: some nondegenerative PMNs, no RBCs, some neutrophils 

anestrus

• 90-150d, basal progesterone and estradiol 

  • PE: no detectable changes

  • Behavior: doesn’t attract males or stand to be mater

  • Cytology: parabasal cells, some neutrophils, no RBC 

  • Most variable stage in length  

pseudopregnancy

• Behavioral changes (nesting, aggression, variable appetite), mammary gland development (lactation), weight gain 

• Non-pregnant bitches, diestrus, physiologic process, can also occur if spayed during later estrus/diestrus, withdrawal of progesterone

• Treatment: diagnosed via clinical signs, resolve with time, but if medical management is needed (megestrol acetate, mibolerone, bromocriptine, cabergoline)

megesterol acetate

• only approved progestagen

  • Estrus prevents: must start >1w prior to proestrus, treat for 32 days, 92% effective 

  • Estrus suppression: must start in first 3 days of proestrus, tx for 8 days, onset suppression in 3-8d 97% effective, will return to estrus in 4-6 months 

  • Side effects: pyometra, weight gain, lethargy, 

  • don’t use if mammary neoplasia, diabetes mellitus, liver or uterine disease

  • Not recommended if first estrus or for more than 2 consecutive estrus cycles 

mibolerone

• only approved androgen, start >30s prior to proestrus, can prevent estrus for up to 2 years, return to estrus in 70d after withdrawal, check hepatic and renal function before initiating treatment 

  • Side effects: clitoral hypertrophy, vulvar discharge, male behavior, obesity, improved hair coat 

  • Contraindications: estrus, pregnancy, renal or hepatic disease, prepuberty, uterine disease

GnRH agonists

• Leuprolide acetate: reversible azoospermia

• Suprelorin implants: used in zoo populations, not approved in domestic cat/dogs, used in Europe

• First stimulate pituitary-> then regulate FSH and LH -> decreased estradiol or testosterone 

pregnancy termination treatment

spay, prostaglandin F2a, dexamethasone, dopamine agonist, progesterone antagonist, estrogenic compounds

prostaglandin F2a

•  must have a mature responsive CL, induces luteolysis and uterine contractions

  • Dinoprost or cloprostenol

  • 90% abort in <9d, must monitor fetal heart beats and progesterone to ensure complete evacuation 

  • Side effects: vomiting, diarrhea, trembling, panting, tachycardia, rarely circulatory collapse, effects dose dependent, see within 5 min of drug admin and last up to 1 hr, shortens interstitial interval by ~70d

  • Best if combined with a dopamine agonist 

dexamethasone

• start > 35d of gestation, abortion in 7-15d in 97% of dogs

  • Side effects: PU/PD, pass fetuses 

dopamine agonist

• bromocriptine, cabergoline (fewer side effects)

  • Start >30d of gestion, abort in 4-7 days 

  • Suppresses prolactin secretion -> premature luteolysis

  • Side effects: vomit, diarrhea, anorexia, 

  • Not FDA approved usually used in combination with PGF2alpha 

progesterone antagonist

•  not available in US, synthetic steroids that bind uterine progesterone receptors and prevent progesterone’s biologic action 

  • Aglepristone 15-25 days have resorption 100%, 25-55days abortion in 7days for 96%

estrogenic compounds

• tamoxifen citrate, estradiol cypionate 

  • Speeds us oocyte transport and prevents fertilization -> only effective if given in estrus 

  • Side effects: pyometra or aplastic anemia (bone marrow suppression) never administer in diestrus 

ovarian remnant syndrome

•  recurrent estrus after OHE due to surgeon error 

  • DX: vaginal cytology, BW (estradiol, progesterone, AMH< LH), +/- US 

  • TX: surgical removal of all pedicle scar tissue and histology, hormonal therapy, 

ovariohysterectomy (OVH)

removal of ovaries and uterine horns

• increase risk or ureteral ligation, ovarian remnants, risk of hemorrhage, uterine stump complications, fistulas, granulomas, urinary incontinence 

ovariectomy

removal of ovaries

• common in rest of world, decreased surgery and anesthesia time, smaller incision, decreased abdominal trauma, no pyometras, low risk of uterine tumor, risk of ovarian remnants

ovary sparing spay (OSS)

entire uterus is removed but ovaries stay

• no pyometra, risk of mammary tumors, increased risk of pseudopregnancy, ovarian cysts, tumors or fibrosis 

castration

removal of both testes

gold standard, permanent, improves male behavior, prevent testicular, epididymal and androgen dependent diseases

epididymectomy

• bilateral removal portion of epididymis, no change in steroidogeneous//male behavior/andregen dependent disease

vasectomy

• bilateral removal or occlusion deferent ducts, prevents sperm passage, may develop sperm granulomas or spermatoceles, no change in steroidogeneous/make behavior/ androgen dependent disease  

sclerosing agents

• Zinc gluconate/arginine: FEDA approved for 3-10m of age, intratesticular, azoospermia within 90d, still some testosterone secretion and male behavior 

• Chlorahexidine 

• Formalin in pBS 

• Side effects: swelling, pain for up to 2w, ulceration, dermatitis, vomiting/diarrhea, incomplete sclerosis and infertility, 

immunocontraception

• cell mediated destruction of reproductive proteins or tissues 

  • Hard to generate antigens against many reproductive proteins, 

  • targets= GnRH, LH, FSH, oocyte zona pellucida, 

  • GnRH porcine vaccine doesn’t work well in dogs, 

  • ZP vaccines in dogs get short term infertility but also irregular estrus and ovarian cysts  

cystic endometral hyperplasia

• abnormal endometrial gland proliferation and hypersecretion, development of endometrial cysts, endometrial hyperplasia, accumulation of intraluminal fluid

  • Progressive degenerative condition 

  • Consequences: sub or infertility, predisposition to pyometra  

  • Pathogenesis: CEH allows bacteria colonize endometrium and uterus can’t clear bacteria and develop cystic changes 

    • progesterone: increases glandular secretion, decreases uterine contraction, increases cervix tone, and dampens immune response leading to a predisposition to infection

pyometra

disease of bacterial infection in uterus under the influence of progesterone, estrogen exposure also considered significant, pregnancy may be mildly protective

• CS: anorexia, depression/lethargy, vomiting, diarrhea, PU/PD, vulvar discharge, enlarged uterus, hindlimb lameness, septic shock, hx of being in heat in the past 2 months 

• Clinical pathology: leukocytosis/leukopenia, neutrophilia, azotemia, hyperproteinemia, hyperglobulinemia, progresses to endotoxemia/septicemia 

• DX: US preferred to rads 

  • US: uteromegaly, thickened uterine walls, cystic endometrial changes, anechoic to hyperechoic luminal fluid 

• Tx: ovariohysterectomy, medical management (prostaglandin F2a, broad spectrum therapy, mibolerone)

  • remove progesterone source, evacuate uterus and eliminate infection

prostaglandin F2a for pyometra

• remove progesterone and maintain cervical patency, aid with fluid evacuation; must give low frequent doses higher doses could rupture uterus; continue until progesterone and uterus is normal size with no fluid; if no improvement within 6d you must spay; better resolution combined with dopamine agonists  

vaginitis

•  vaginal inflammation (bacterial or viral infection, chemical irritation, tumors or foreign bodies, anatomical abnormalities) 

  • Juvenile vs adult is self-limiting vs chronic battle 

  • Vaginal defense mechanism: squamous epithelium, flow of fluids, normal bacterial flora, dogs with vaginitis often have atrophy of vaginal epithelium, UTIs, diabetes, or anatomical abnormalities 

  • DX: vaginal cytology +/- culture, vaginoscopy, serology (brucella and herpes), rule out pyometra and diabetes

    • Normal vaginal flora include E. coli, beta-hemolytic streptococci, staphylococcus aureus and intermedius 

  • TX: rule out brucella, eliminate underlying problems, antibiotics for 4w, vaginal douching (acetic acid or probiotic), treat potential urinary incontinence (oral estrogens if spayed, proin) 

vaginal hyperplasia

• adult intact females, estrogen mediated (vaginal edema during proestrus and estrus)

  • TX: keep moist, clean, and prevent trauma, will resolve in diestrus, will recur in future cycles; permanent treatment = OHE

  • Ddx: vaginal tumors or polyps 

causes of anestrus

silent heat, ovarian sensecence, previous OHE, ovarian aplasia, exogenous steroids, luteal cysts, diet

silent heat

• ovarian activity w/o external signs; dx: monthly serum progesterone or weekly vaginal cytologies; tx: timed artificial insemination, no estrus detect consider estrus induction GnRH implants, cabergoline  

ovarian senescence

• fertility declines starting around 5y, may stop cycling by 8 years, lower fertility/decreased litter size, longer inter-estrus interval, increase risk dystocia, higher neonatal death  

causes of persistent estrus

• follicular cyst, granulosa cell tumors, coagulopathy, pyometra, brucellosis, neoplasia

follicular cysts

• anovulatory follicle, risk in large breed and nulliparous bitches 

  • Tx: OV or OVH, often concurrent uterine disease 

indications for spay

• elective sterilization, prevention of mammary neoplasia, prevention or treatment of uterine or ovarian disease, hormone level modification 

postpartum metritis

• CS: malodorous red to brown vulvar discharge, fever, dehydration, depression, endotoxemia, can turn toxic/septic metritis, septicemia, shock 

• Cause: retained fetal membranes, macerated or decomposed pups, dystocia and uterine compromise 

• DX: CS, clinical pathology, vaginal cytology (degenerate or toxic PMNS, endometrial cells, muscle fibers), bacterial culture, US/rads (enlarged/fluid filled uterus)

• TX: stabilize with IV fluids, control bacterial growth, evacuate uterine contents 

mastitis

• usually first 2w laction, 

  • Acute: fever, depression, anorexia, can be life threatening, hot, painful mammary glands 

  • Chronic: asymptomatic, puppy failure to thrive 

  • Mammary gland secretions: macroscopic (normal, purulent, reddish brown), cytology (degenerate neutrophils, bacteria), culture (staph. strep) 

  • TX: culture and sensitivity, must penetrate milk:blood barrier, must be safe for nursing pup ( no fluoroquinolones)

subinvolution of placental sites (SIPS)

• Hemorrhagic vulvar discharge > 3 weeks post partum 

• Occurs when fetal trophoblastic cells don’t degenerate and continue to invade endometrium and myometrium (damage to blood vessels, endometrial ulceration, uterine perforation) 

• DX: rad or US, vaginal cytology (with trophoblast like cells)

• TX: spontaneous resolution, transfusions if severe, OVH, antibiotics if concurrent infection 

puerperal tetany

• eclampsia, post parturient hypocalcemia; common in small breeds first 4w lactation; decreased extracellular ionized calcium , increased membrane permeability, spontaneous muscle depolarization 

  • CS: hyperthermia, restlessness, poor mothering, panting, tremors, stiffness, seizures, death 

  • DX: CS, total blood calcium 

  • TX: 10% calcium gluconate slowly IV, may benefit from 1 dose dextrose, remove pups from nursing for at least 24 h, supplement oral calcium ( 1g TUMS tablet=400 mg , 10-30mg/kf TID) and vitamin D until weaning 

uterine torsion

• rare, often see rupture at same time, oxytocin contraindicated

  • Resolution: c-section +/- OVH, urethral obstruction rare sequelae to dystocia or torsion 

pregnancy toxemia

• rare, associated with inadequate carbohydrate intake, large litter size, and poor body condition

  • Dx: ketonuria in absence of glucosuria 

  • Life threatening 

  • TX: nutritional support as long as possible, c-section when no longer able to stabilize, best to intervene early 

orchitis

• usually ascending infection, acute or chronic 

  • DX: 

    • Enlarged, painful, hot swelling one or both tests, may be febrile/lethargic/lame if acute, preputial discharge or pyospermia

    • US: heterogenous tissue +/- obvious abscess 

    • Cytology: neutrophilic inflammation 

    • atrophy/fibrosis if chronic 

  • TX: culture and sensitivity to select antibiotic for minimum of 4 weeks, NSAIDs, cold packing, sexual rest, hemicastration or castration, poor prognosis (at least 60d to improve semen quality) 

sperm granuloma

•  chronic inflammatory condition with cysts containing sperm in duct system

  • Cause: trauma, infection and congenital abnormalities, secondary to vasectomies

  • DX: biopsy, US, castration 

  • TX: surgery, usually hemi or bilateral castration 

sertoli cell tumor

• most common testicular tumor in retained testicles, can be endocrinologically active (paraneoplastic syndrome, contralateral testis often atrophied,), scrotal or retained testis, white to pale yellow, firm mass, metastasis has be reported 

feminizing syndrome

• common with estrogenic tumors, due to increase in estrogen:

  • CS: bilateral alopecia of trunk and neck, hyperpigmentation of inguinal area and abdomen, pendulous prepuce, gynecomastia, estrogen induced bone marrow toxicity with anemia and epistaxis 

seminomas

•  tumors of germ cells within the testis, german shepherds predisposed, retained or scrotal testis, homogeneous or lobulated, pink to gray, soft, malignancy is low 

interstitial (leydig) cell tumor

•  interstitial cell adenoma or leydigoma, tumor of scrotal testes, yellow to brown, almost never malignant, usually found incidentally after castration, rarely causes paraneoplastic syndrome, either increased testosterone or estrogen  

testicular torsion

•  spermatic cord 

  • May present as acute abdomen, other CS include lameness, anorexia, vomiting, scrotal enlargement, can occur in retained or neoplastic testis due to enlargement

  • DX: US with testicular enlargement with decreased echogenicity, spermatic cord enlargement,  decrease or absent BF with color doppler; surgical explore 

  • TX: castration 

scrotal dermatitis

• Increased scrotal temperature will impair spermatogenesis

• Infectious causes: brucellosis, rocky mountain spotted fever (rickettsia rickettsi)

• Autoimmune disorders: pemphigus erythematosus, vogt-koyanagi-harada-like syndrome 

• Other: mycotoxin, frost bite, self mutilation secondary, localized erythematous drug eruptions, cell mediated hypersensitivity, irritant contact dermatitis,  

hydrocele

•  secondary to compromised lymphatic drainage= lymphosarcoma, inguinal hernia, orchitis, trauma, testicular torsion, idiopathic, ascites 

  • TX: dependent on inciting cause, may resolve following treatment of primary condition, +/- drainage via percutaneous aspiration, castration 

testicular degeneration

• decrease in size and softening of the testis, increase in abnormalities, increasing incidence with age 

  • Causes: canine brucellosis, non-inflammatory testicular disorders, testicular neoplasia, thermoregulation problems, systemic illness, trauma, idiopathic 

  • TX: fix primary problem to slow process, no reversal 

phimosis

inability to protrude penis from prepuce,

paraphimosis

• inability to retract erect or non erect protruded penis into the sheath 

  • Cause: rolling inward, edema of penis with balanitis or balanoposthitis, hair rings, IVDD, thromboembolism, trauma 

  • TX: lubrication and elevation of penis, sedation or anesthesia, wrap penis with cool flat compress, +/- temporary enlargement of preputial orifice,