Sunday, October 29, 2017

Wallace's Story; Prolapsed Rectum, Feline, Colopexy, How To Save These Cats, How Much Time It Takes, Costs, Prognosis

The cases that pull you into pieces,, return. Just to poke you at the tender marrow and remind you that you are a simply a whisper among the tsunami of burdens that another more powerful force decides. As with every hard lesson in the journey of life you will face the same challenges over and over until you learn said lesson, or, you expire. I have lost the battle of prolapses before. It is an adversary I hold personal contempt for.

Veterinarians influence, too often we don't decide. Sure, we can decide death, but that power is for the defeated and the exhausted. It isn't what happens at Jarrettsville Vet.

This is Wallace's story.

Wallace is a barn kitten. One of thousands in our community. Wallace had gone for a routine poop one day and out of his anus slipped his colon. We call it rectal prolapse. He came to us in desperate need of immediate veterinary intervention having never had even the most basic kitten stuff. He came to us too skinny, full of fleas, old cloudy injuries to both eyes, and his delicate colon swollen and protruding from his anus. It had been there long enough to become dry, distended from the tourniquet of circular sphincter anal muscle that opens when your brain tells you it is appropriate to unload, and turning tan from its normal bright happy moist pink.

Intestines are exceedingly intolerant of the outside world and respond almost immediately by drying, swelling and cascading to death. Dead intestines cost you your ability to decide when you poop, and what that poop looks like. For a barn kitten fecal incontinence is a show-stopper.

Moist tissue lives. Clean moist tissue has a chance. We immediately submerged him in a very dilute warm surgical scrub. Clean first, shrink second. As a nod to those vets before us who were still able to save little lives with little overhead nor extensive specialty training, we also had him sit in a copious handful of sugar. The sugar will "pull out" the fluid from the swollen tissue as it works like a hyperosmotic agent. It takes about 15-30 minutes to work. Although the tissue appears to be a fluid filled sac it is instead an edematous protrusion of tissue.


Practice pearl; This condition is an emergency and requires veterinary intervention immediately for the most successful prognosis.

After the tissue shrank we then applied huge amounts of lubricant. Here is where anesthesia is vital.. All of that tissue needs to go back where it belongs. This requires three people, holding the patient nose to the ground, butt to the sky, gentle traction and external palpation of the colon (located along and under the spine) to "milk" it back into it's original position, and at least four hands with fingers at 12, 3, 6, and 9 o'clock to gently push it back inside the anus. It takes time, patience, and anesthesia.

In some cases I also use a thermometer, or long cotton tipped applicator to help maintain the center of the tissue as we try to coax it back inside. It will go back inside, but you have to be gentle and patient. Once it is there it is required to place a purse string suture around the opening of the anus to hold it in place. There is an art to this. The right size of the anal opening, the correct amount of time to leave it in? It's an art I have yet to master.

Once the colon gets back into its intended place it is time to do the hard detective work. I have only had a few of these cases and they are difficult at every step and they stay that way for weeks. In theory the usual suspects are;
  1. Parasites. Intestinal parasites cause diarrhea. In kittens the diarrhea can lead to tenesmus which is the persistent urgent need to defecate. You can strain for so long that the stop check mechanism that is the anal sphincters surrender and the contents they have kept at bay fall out.
  2. Chronic diarrhea, or severe acute diarrhea. In kittens if it isn't parasites it can be a poor diet. Milk, kitten formula past nursing age, or sudden diet changes are all common historical findings.
  3. Congenital spinal deformities. The spine protects the core conductor network to talk to the muscles that allow us to function. If there is a break or disruption along the pathway things don't function normally.
  4. Trauma. Kittens in barns get hurt, intentionally or accidentally. 

What I have learned in these cases is that they are all one of two things; parasites and parasites. I do serial intestinal parasite (fecals) exams, and I treat anyway. I treat for every common intestinal parasite and keep on treating.

Wallace is like every other intelligent feline. He will forgive you once. He will tolerate you twice, and by attempt number three he will curse, bite, fight and defend his assertive ways by any means he feels necessary. He won't apologize to you afterward. (Even if you try to explain that all of it was "for his own good.") You have to be assertive, aggressive, hyper-vigilant and prepared to invest copious amounts of time into these cases. It is very unlikely it will be "fixed" at attempt number one.

Purse string Suture Technique and Plan;

I keep it in place for as long as I can each time. The literature varies on this advice. Some say 3-5 days. This is never long enough from my experience. I placed and replaced the suture. Each time I tried to leave the anal lumen opening a little larger.  The opening went from 0.5 cm to 1 cm diameter, using a thermometer, 22 gauge syringe cap, to 22 gauge syringe cover as my guide. Each time Wallace formed a fecal ball that needed to be manually broken down to pass, regardless of the food we fed, the laxatives, softeners and motility agents we tried.

Butt bath time, again, before the anesthesia and replacement of his purse string.

Once a purse string suture is in place it is time to;

  1. Submit a fecal sample to the lab for analysis (I do not recommend doing this in the clinic alone).
  2. Deworm prophylactically (for everything)
  3. Start a liquid diet to maintain a soft, easy to pass stool. The purse string requires soft stool to permit passage.
  4. Find a high quality high calorie diet and feed small amounts frequently. Dry food can be pulverized and liquefied if no other options exist. Remember adding water dilutes out calories. Feed every 2-3 hours, or whenever hungry.
  5. Get them active if they are underweight and undermuscled. 
  6. THESE CASES STAY INSIDE, UNDER HYPER-FOCUSED OBSERVATION FOR WEEKS! Wallace moved in with us. He cannot be left alone for more than a few hours. (These are not easy cases).
Wallace began straining to defecate again in about 3 days. We removed and replaced his purse string at all hours of the day and night, three times. These cases are so hard. Emotionally. Mentally. And yet that meow. Ugh, Wallace kills me with that meow.

Guide for anus opening, 22 gauge  needle cap. 

Another pursestring in place,, another waking up Wallace.

It is very important to not lose the patient in the treatment plan. Our immediate short term goal is to get him healthy and functional, but he needs to find a home, he needs to be happy, and he is a kitten who loves other cats. We kept him with others as often as we could. They helped him play and learn his social skills. Wallace also had underdeveloped rear leg muscle mass. Playing with others is the best way to build strength and stamina.

Wallace and Dory.
Sure enough, three weeks of purse string attempts failed. The last trick in the bag was a colopexy. A colopexy involves opening the abdomen to anchor the colon to the side of the internal abdominal wall. In essence you suture the straight section of the colon to the inside of the belly. It is not a difficult procedure BUT the following need to be discussed pre-op:

  • These cats are typically already too thin. Thin cats with large abdominal surgeries get cold fast. Be ready for this. Be quick with your surgery, and keep them warm before, during and after.
  • The tissue of the abdominal wall is like tissue paper. Scarify BOTH the abdominal serosa AND large intestine serosa to and including the layer of the muscularis to get adequate adhesions, take a long swath of suture (texts say 1-2 cm), I say at least a third of the descending colon. I also place a "tack" suture at the most cranial aspect of the colon. 
  • Run two parallel lines of suture (deep and superficial about 2 mm to 4 mm apart).
  • Go bigger on suture size than you think you might need. These fail. Failure and repair are less likely to be opted by a client already significantly emotionally disheartened and financially stressed. 
  • If it can hold 4 weeks you are probably out of the woods. If it fails in this time frame it was a surgical failure. Go back, try again. 

Wallace's problem hinges on his flaccid external anal sphincter.
It took me about 3 weeks to determine this.
It is hard to diagnose when it has been repeatedly stretched.

An abdominal surgery in a tiny kitten always results in  hypothermia even though we tried to do everything to avoid it. Wallace warmed up quickly with cuddles and blankets.

The last attempt at a large opening pursestring.
I also neutered him knowing that my window of restraint ability was quickly closing.

Not so fun. a colopexy in a 2 pound, underweight, undermuscled kitten. The thickness of the abdominal wall is almost transparent. These are the cases I sweat. They are also the cases with nothing left to lose and a broken heart on the line. They are the reasons I still love vet med. Don't tread lightly behind a shield of excuses as to "why you can't/shouldn't." Jump in!

It has been 8 weeks of colonic coersion. The colopexy had its own set of setbacks. The colon was anchored to the internal abdominal wall. It meant that his internal muscular squeezing tube couldn't push the feces out. It was painful to push, difficult to do, and he became constipated with diarrhea as a result. He was not happy for the first week post-op. He felt like he had to go, was punished with pain when he tried, and then started to pucker around the large pursestring as a result.

After a week of adding promotility agents, adjusting and readjusting the laxatives we had to remove the pursestring again. 

"My last hope lies on this colopexy working on it's own." My last attempt in the same situation with a different patient had failed. After two months with the previous cat I had to euthanize as he was so fractious and his colon so compromised neither of us could continue. His name was Willy. I will forever bear the pain of that case. It marks me as a cautious reminder of investing too much and treading in poorly chartered diseases.

I always talk about cost of care with my cases. This one is really hard to quantitate. 

Each purse string surgery cost about;
  • anesthesia, about $100
  • placing pursestring takes about 10 minutes $50
  • ecollar $10-25 (ask to make your own).
Monitoring is 24/7. Being prepared for it to reprolapse means keeping your cat under close supervision. These cats must be inside only. Must be checked frequently, and, must be brought to the vet as quickly as possible if they do re-prolapse. At least keep the tissue clean, moist, and away from self-traumatization until you can get to the vet. If I could grant you all one power it would be some way to be able to replace these without vet expense. I don't think there is a way to do it... (I'll keep thinking). 

The cost of the colopexy was;
  • Anesthesia $100
  • Surgery, abdominal colopexy $200 (probably should be more, find a vet who wants to try).
  • pain medication needed. Cost about $25.

Wallace's meow.. one meow and you understand why we were so determined to win this case.

Update; Wallace was humanely euthanized after he developed severe respiratory difficulties and was found to be FIV positive (he had been tested twice before and was previously negative both times). He was a kitten who was loved beyond all measure. He will be missed. 

Related blogs;

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Please note; I am not a veterinary surgeon. This case, as with all of the blogs I publish is based on my personal experience when no other options were available to the patients I treat. Please discuss your pet case with your vet. All care should be provided under the close supervision of your pets primary care veterinarian and referred to all specialists they deem appropriate.


  1. I think I understand you a little better now, Krista. All the brainsweat, all the effort and tears; it all prepares you for cases like this, where you can finally do a bit more of what you want, and get a little puece of your soul back. Bravo, and good luck to Wallace on his continued recovery.