Changes

=Introduction=

=Introduction=

Endometritis is the infection of the uterine endometrium [[Image:Endometritis.jpg|thumb|right|200px|Endometritis,Copyright RVC 2008]]

Endometritis is the '''infection of the uterine endometrium''' [[Image:Endometritis.jpg|thumb|right|200px|Endometritis,Copyright RVC 2008]]

=Equine Endometritis=

=Equine Endometritis=

Endometritis is a common cause of low fertility in the mare. It occurs following uterine contamination during covering, artificial insemination, reproductive examination, parturition and as a result of poor conformation.

Endometritis is a common cause of '''poor fertility''' in the mare. It occurs following '''uterine contamination''' during '''covering''', [[Artificial Insemination - Anatomy & Physiology|artificial insemination]], '''reproductive examination''', '''parturition''' and as a result of '''poor conformation'''.

==Types of Endometritis==

==Types of Endometritis==

* [[Pseudomonas aeruginosa|''Pseudomonas aeruginosa'']] - there is no available test to differentiate strains so all must be treated as pathogenic

* [[Pseudomonas aeruginosa|''Pseudomonas aeruginosa'']] - there is no available test to differentiate strains so all must be treated as pathogenic

The mare may present with vaginal discharge (ranging from scant to copious) in an acute infection. However she may also present in a carrier state, in which case there may be no outward clinical signs. Stallions are usually sub-clinical carriers of disease. All three bacteria prevent conception.

The mare may present with '''vaginal discharge''' (ranging from '''scant''' to '''copious''') in an '''acute infection'''. However she may also present in a '''carrier state''', in which case there may be '''no outward clinical signs'''. Stallions are usually '''sub-clinical''' carriers of disease. All three bacteria '''prevent conception'''.

[[Equine Viral Arteritis|Equine Viral Arteritis]] (EAV) and [[Equine Herpesvirus 3|Equine Herpes Virus 3]] (EHV-3) are also classified as venereal infections however they do not cause endometritis or prevent conception.

[[Equine Viral Arteritis|Equine Viral Arteritis]] (EAV) and [[Equine Herpesvirus 3|Equine Herpes Virus 3]] (EHV-3) are also classified as venereal infections however they do not cause endometritis or prevent conception.

===Non-venereal Infectious Endometritis===

===Non-venereal Infectious Endometritis===

This occurs following infection during covering, reproductive examination or foaling. The mare will normally present with a history of infertility or early embryonic death and short cycles. There may also be evidence of vaginal discharge. Infection may be caused by:

This occurs following infection during '''covering''', '''reproductive examination''' or '''foaling'''. The mare will normally present with a history of '''infertility''' or '''early embryonic death''' and '''short cycles'''. There may also be evidence of '''vaginal discharge'''. Infection may be caused by:

* Bacterial Infection - [[Streptococcus zooepidemicus|''Streptococcus zooepidemicus'']], [[Escherichia coli|''Escherichia coli'']] or [[Staphylococcus aureus|''Staphylococcus aureus'']]

* Bacterial Infection - [[Streptococcus zooepidemicus|''Streptococcus zooepidemicus'']], [[Escherichia coli|''Escherichia coli'']] or [[Staphylococcus aureus|''Staphylococcus aureus'']]

===Persistent Post-mating Endometritis===

===Persistent Post-mating Endometritis===

This is more common in older and multiparous mares. A transient inflammatory response is normal in the mare post-cover, however a normal immunological response is mounted and the infection cleared before the embryo exits the fallopian tube. In the cases of persistent post-mating endometritis the inflammation persists  longer than 12-24 hours so that when the embryo enters the uterus the environment is still unsuitable for embryonic development, resulting in early embryonic death.  

This is more common in '''older''' and '''multiparous mares'''. They present with a history of short cycling and often an vaginal discharge approximately two weeks post-cover.

 

A '''transient inflammatory response''' is '''normal''' in the mare post-cover, however a normal immunological response is mounted and the infection cleared before the embryo exits the fallopian tube. In the cases of persistent post-mating endometritis the '''inflammation persists  longer than 72-96 hours''' so that when the embryo enters the uterus the '''environment''' is still '''unsuitable for embryonic development''', resulting in '''early embryonic death'''.  

===Chronic Degenerative Endometritis===

===Chronic Degenerative Endometritis===

Chronic degenerative endometritis ''aka'' '''endometriosis''' is degenerative change that occurs in older mares or following repeated inflammation of the uterus. If the condition is severe it may result in delayed clearance of the uterus post-cover. Definitive diagnosis can only be achieved by biopsy, which will show degenerative change of the uterus histologically.

Chronic degenerative endometritis ''aka'' '''endometriosis''' is '''degenerative change''' that occurs in '''older mares''' or following '''repeated inflammation''' of the uterus. If the condition is severe it may result in delayed clearance of the uterus post-cover. Definitive diagnosis can only be achieved by '''biopsy''', which will show degenerative change of the uterus '''histologically'''.

===Chronic Infectious Endometritis===

===Chronic Infectious Endometritis===

Normally an underlying conformational condition such as pneumovagina predisposes the mare to chronic infectious endometritis. Infection Diagnosis is again by biopsy which should show infiltration of the endometrium with lymphocytes and plasma cells. Infection may be:

Normally an underlying '''conformational condition''' such as '''pneumovagina''' predisposes the mare to chronic infectious endometritis. Definitive diagnosis is again by '''biopsy''' which should show '''infiltration of the endometrium with lymphocytes and plasma cells'''. Infection may be:

* Bacterial - [[Streptococcus zooepidemicus|''Streptococcus zooepidemicus'']], [[Escherichia coli|''Escherichia coli'']]

* Bacterial - [[Streptococcus zooepidemicus|''Streptococcus zooepidemicus'']], [[Escherichia coli|''Escherichia coli'']]

* Fungal  - more common if there is a history of multiply intra-uterine antibiotic treaments

* Fungal  - more common if there is a history of multiply intra-uterine antibiotic treaments

Prognosis is guarded due to the chronic nature of the infection and the anatomical faults predisposing to infection. Surgical correction of the conformational abnormalities may be attempted.

Prognosis is '''guarded''' due to the chronic nature of the infection and the anatomical faults predisposing to infection. '''Surgical correction''' of the conformational abnormalities may be attempted using Caslicks procedure.

==Diagnosis==

==Diagnosis==

* Clinical examination may reveal vulval discharge or matted tail hairs.

* '''Clinical'''''' examination''' may reveal '''vulval discharge''' or '''matted tail hairs'''.

* Vaginal examination should identify any discharge and increased vascularity of the tissue. Conformational abnormalities such as pneumovagina and urovagina may be evident.

* '''Vaginal''' '''examination''' should identify any '''discharge''' and '''increased vascularity''' of the tissue. Conformational abnormalities such as pneumovagina and urovagina may be evident.

* Ultrasound examination of the uterus - more than 2 cm of fluid with abnormal character suggests endometritis.

* '''Ultrasound''' examination of the uterus - '''more than 2 cm of fluid with abnormal character''' suggests endometritis.

* Clitoral and endometrial swabs should be taken for culture and sensitivity. Clitoral swabs should be taken if a chronic venereal infection is suspected. Endometrial swabs should be taken during oestrus to identify either acute venereal infection or the causative organism of other endometrial infections.

* '''Clitoral''' and '''endometrial swabs''' should be taken for '''culture and sensitivity'''. Clitoral swabs should be taken if a chronic venereal infection is suspected. Guarded endometrial swabs should be taken during oestrus to identify either acute venereal infection or the causative organism of other endometrial infections and evidence of inflammation. A high level of neutrophils is indicative of endometritis. The mare should be confirmed as not pregnant prior to passing an endometrial swab.

* Uterine flush - the uterus should be flushed with 100mls of fluid which can then be examined cytologically.

* '''Uterine flush''' - the uterus should be flushed with 100mls of fluid which can then be examined '''cytologically'''.

* Uterine biopsy - this should be performed after all other tests have failed to reach a diagnosis or to definitively diagnose endometriosis.

* '''Endometrial endoscopy''' can be performed to visualise and assess the endometrium.

*''' Uterine biopsy''' - this should be performed after all other tests have failed to reach a diagnosis or to '''definitively diagnose''' endometriosis or chronic infectious endometritis. A single sample should be representative if the uterus feels normal on palpation. If an abnormality is detected on examination per rectum then samples should be taken from both normal and abnormal sites.

==Treatment==

==Treatment==

* Uterine lavage with copious amounts of fluid. This is beneficial because it:

 

 

'''(1) Uterine lavage''' with copious amounts of fluid. This is beneficial because it:

- removes contaminants such as bacteria and purulent material

- removes contaminants such as bacteria and purulent material

- causes mechanical irritation to the endometrium aiding healthy neutrophil recruitment

- causes mechanical irritation to the endometrium aiding healthy neutrophil recruitment

2-3 litres of saline or lactated ringers solution should be administered using a uterine flushing catheter and then drained back into the bag and inspected. Dilute Povidone iodine can also be used as a cheap alternative.

'''2-3 litres of saline or lactated ringers''' solution should be administered using a '''uterine flushing catheter''' and then '''drained''' back into the bag and '''inspected'''. Dilute Povidone iodine can also be used as a cheap alternative.

 

* Antibiotics (intrauterine or systemic) - antibiotic type should be guided by culture and sensitivity and activity of the drug in the uterus where possible. The length of the treatment should be proportional to the severity of infection.

 

* Administration of ecbolics to stimulate uterine contractility and clearance of infection - oxytocin and prostaglandin analogues

'''(2) Antibiotics (intrauterine or systemic)''' - antibiotic type should be guided by culture and sensitivity and activity of the drug in the uterus where possible. The length of the treatment should be proportional to the severity of infection.

* Hormonal therapy - Oestradiol Benzoate and PG can be used to aid the clearance of infection. They are more effective during oestrus.

 

 

'''(3) Administration of ecbolics''' to stimulate uterine contractility and clearance of infection - oxytocin and prostaglandin analogues

 

 

'''(4) Hormonal therapy''' - Oestradiol Benzoate and PG can be used to aid the clearance of infection. They are more effective during oestrus.

 

In the cases of venereal infections additional treatment may be required:

In the cases of venereal infections additional treatment may be required:

Acute infections: Repeated antibiotic clitoral irrigation and reintroduction of normal flora. A clitorectomy may be considered.

'''Acute infections''': Repeated antibiotic clitoral irrigation and reintroduction of normal flora. A clitorectomy may be considered.

Chronic/carrier infections: Repeated clorhexidine clitoral irrigation and reintroduction of normal flora.

'''Chronic/carrier infections''': Repeated clorhexidine clitoral irrigation and reintroduction of normal flora.

==Management of Susceptible Mares==

==Management of Susceptible Mares==

(1) Identify problem mare

(1) '''Identify''' problem mare

(2) Plan a single insemination using a stallion with high fertility rates approximately 1-2 days prior to ovulation. Semen extender may be delivered intra-uterine before cover.

(2) Plan a '''single insemination''' using a stallion with high fertility rates approximately '''1-2 days prior to ovulation'''. Semen extender may be delivered intra-uterine before cover.

(3) Ultrasound the uterus in the first 12 hours post-cover. The character and volume of fluid present should be assessed.

(3) '''Ultrasound the uterus''' in the first '''12 hours''' post-cover. The character and volume of fluid present should be assessed.

(4) Remove uterine contaminants via lavage and antibiotic infusion. Administer oxytocin 8 hours after treatment.

(4) '''Remove uterine contaminants via lavage and antibiotic infusion'''. Administer oxytocin 8 hours after treatment.

(5) Repeat ultrasound examination after 24 hours.

(5) '''Repeat ultrasound''' examination after '''24 hours'''.

Treatments should not be repeated if possible as this may introduce infection.

Treatments should not be repeated if possible as this may introduce infection.

==Prognosis==

==Prognosis==

The prognosis of this [[Healing and Repair - Pathology#Repair in the Genital Tract|condition]] vary according to the type, severity and chronicity of the infection and the age of the mare.

The prognosis of this [[Healing and Repair - Pathology#Repair in the Genital Tract|condition]] vary according to the '''type''', '''severity''' and '''chronicity''' of the infection and the '''age''' of the mare.

Cattle endometritis  is a '''common''' condition that is known by the layman as ''''whites''''. It occurs '''three weeks or more''' '''after calving''' and should not be confused with the more severe condition of metritis which occurs immediately post-partum. The main consequence of endometritis is '''poor fertility''' and it therefore has a '''major economic impact''' by '''increasing calving interval''', '''services per conception''' and '''cull rates''' and by '''decreasing milk yield'''. It is reported to have an incidence of between '''ten and fifteen percent''' in dairy herds (however it is very variable from herd to herd), with the total cost of '''£160 per case'''.

Cattle endometritis  is a '''common''' condition that is known by the layman as ''''whites''''. It occurs '''three weeks or more''' '''after calving''' and should not be confused with the more severe condition of metritis which occurs immediately post-partum. The main consequence of endometritis is '''poor fertility''' and it therefore has a '''major economic impact''' by '''increasing calving interval''', '''services per conception''' and '''cull rates''' and by '''decreasing milk yield'''. It is reported to have an incidence of between '''ten and fifteen percent''' in dairy herds (however it is very variable from herd to herd), with the total cost of '''£160 per case'''.

===Aetiology===

==Aetiology==

The normally '''sterile''' uterus is '''contaminated by environmental microorganisms during parturition''' or '''immediately postpartum'''. The main bacteria involved in endometritis is '''''Actinobaccillus pyogenes''''' however numerous '''gram-negative anaerobes''' may also be involved. The presence of this opportunist bacteria can '''delay return to service''' and '''cyclical activity''', '''prevent fertilisation''' and cause '''early embryonic death''' be producing a hostile uterine environment. It is also reported that it increases incidence of '''ovarian cysts'''.

The normally '''sterile''' uterus is '''contaminated by environmental microorganisms during parturition''' or '''immediately postpartum'''. The main bacteria involved in endometritis is '''''Actinobaccillus pyogenes''''' however numerous '''gram-negative anaerobes''' may also be involved. The presence of this opportunist bacteria can '''delay return to service''' and '''cyclical activity''', '''prevent fertilisation''' and cause '''early embryonic death''' be producing a hostile uterine environment. It is also reported that it increases incidence of '''ovarian cysts'''.

===Signalment===

==Signalment==

Endometritis can occur in any cow post-partum however incidence is increased by the following '''predisposing factors''':

Endometritis can occur in any cow post-partum however incidence is increased by the following '''predisposing factors''':

* Retained foetal membranes

* Retained foetal membranes

* Dystocia  

* [[Dystocia]]

* Caesarian section or assisted calving

* Caesarian section or assisted calving

* Induced parturition

* Induced parturition

* Ovarian inactivity

* Ovarian inactivity

* Parity

* Parity

* Concurrent disease and nutrition - fatty liver disease and hypocalcaemia are reported to increase endometritis rates

* Concurrent disease and nutrition - [[Fatty Liver Syndrome|fatty liver disease]] and [[Hypocalcaemia|hypocalcaemia]] are reported to increase endometritis rates

Multiple defense mechanisms exist to prevent opportunistic infection of the uterus. The '''vulva''' and '''cervix''' provide a '''physical barrier''' to opportunist bacteria; '''resident bacteria''' in the vagina '''prevents''' the '''colonisation''' of harmful bacteria; '''involution''' and '''caruncle sloughing''' expel contaminants and tissue debris; a '''higher pH''' during oestrus prevent bacterial growth and various '''immunological mechanisms''' also act to prevent infection of the uterus. Following parturition endometritis may still occur, especially is one or more of the mentioned predisposing factors is present.

Multiple defense mechanisms exist to prevent opportunistic infection of the uterus. The '''vulva''' and '''cervix''' provide a '''physical barrier''' to opportunist bacteria; '''resident bacteria''' in the vagina '''prevents''' the '''colonisation''' of harmful bacteria; '''involution''' and '''caruncle sloughing''' expel contaminants and tissue debris; a '''higher pH''' during oestrus prevent bacterial growth and various '''immunological mechanisms''' also act to prevent infection of the uterus. Following parturition endometritis may still occur, especially is one or more of the mentioned predisposing factors is present.

===Clinical Signs===

==Clinical Signs==

'''Mucopurulent vaginal discharge''' should be evident on vaginal exam '''21 days or more post-calving'''. Discharge is relatively odourless (dependant on severity) and '''white''' in colour, hence the name 'whites'. The discharge should not be confused with '''lochial discharge''' or '''vaginitis'''. Rectal palpation should reveal a '''poorly-involuted''', '''oedematous uterus'''. On a individual or herd level there may be a history of '''subfertility'''.  

'''Mucopurulent vaginal discharge''' should be evident on vaginal exam '''21 days or more post-calving'''. Discharge is relatively odourless (dependant on severity) and '''white''' in colour, hence the name 'whites'. The discharge should not be confused with '''lochial discharge''' or '''vaginitis'''. Rectal palpation should reveal a '''poorly-involuted''', '''oedematous uterus'''. On a individual or herd level there may be a history of '''subfertility'''.  

===Diagnosis===

==Diagnosis==

Diagnosis should be based on the '''calving history''' and '''clinical signs''' following '''vaginal''' and '''rectal''' exam. Vets may use a '''scoring system''' to categorise the '''colour''' and '''odour''' of the vaginal discharge which indicates how '''severe''' the infection is and whether '''treatment''' is necessary. Measurements of the '''uterine''' and '''cervical''' '''diameter''' may be included in the scoring system. Definitive diagnosis can only be achieved by '''endometrial biopsy''', however this is rarely indicated.

Diagnosis should be based on the '''calving history''' and '''clinical signs''' following '''vaginal''' and '''rectal''' exam. Vets may use a '''scoring system''' to categorise the '''colour''' and '''odour''' of the vaginal discharge which indicates how '''severe''' the infection is and whether '''treatment''' is necessary. Measurements of the '''uterine''' and '''cervical''' '''diameter''' may be included in the scoring system. Definitive diagnosis can only be achieved by '''endometrial biopsy''', however this is rarely indicated.

=== Treatment ===

== Treatment ==

'''Greater success''' is achieved with '''milder cases''' of endometritis. Treatments available include [[Antibiotics|antibiotics]], '''hormones''' and '''intrauterine antiseptics'''.

'''Greater success''' is achieved with '''milder cases''' of endometritis. Treatments available include [[Antibiotics|antibiotics]], '''hormones''' and '''intrauterine antiseptics''':

==References==

==References==

RVC staff (2009) '''Urogenital system''' RVC Intergrated BVetMed Course, ''Royal Veterinary College''

RVC staff (2009) '''Urogenital system''' RVC Intergrated BVetMed Course, ''Royal Veterinary College''

Pycock, JF (1997) '''Self-Assessment Colour Review Equine Reproduction and Stud Medicine''' ''Manson''

Ricketts, S (1987) '''Vaginal discharge in the mare''' ''In Practice 1987 9: 117-123''