NAVLE Reproductive

Bovine Uterine Prolapse Study Guide

📅 March 28, 2026 ⏱ 25 min read

Overview and Clinical Importance

Uterine prolapse (prolapsus uteri) is a sporadic but life-threatening postpartum emergency in cattle characterized by complete eversion of the uterus through the cervix and vagina, resulting in its protrusion outside the body. The condition occurs most commonly within hours of calving when the cervix is still dilated and the uterus lacks tone. Without prompt veterinary intervention, affected cows are at significant risk of hypovolemic shock, hemorrhage, and death. Uterine prolapse represents a true veterinary emergency with reported incidence rates of 0.002% to 1% of calvings, with higher prevalence in beef cattle (1%) compared to dairy cattle (0.6%).

Factor Category	Specific Risk Factors and Mechanisms
Metabolic	Hypocalcemia: Most significant risk factor; reduces myometrial contractility and tone. Serum calcium less than 8 mg/dL significantly associated with uterine prolapse. Multiparous dairy cows at highest risk. Hypomagnesemia: Contributes to uterine atony Negative energy balance: Compromises uterine involution
Obstetrical	Dystocia: Leads to myometrial fatigue and trauma; 57.7% of prolapse cases required calving assistance Excessive traction: Manual extraction may initiate uterine eversion Retained fetal membranes: Continued straining to expel placenta Uterine overdistension: Twin pregnancy, hydrops
Environmental	Positioning: Calving on sloped surface with hindquarters lower than forequarters Confinement: Lack of exercise during late gestation Prolonged recumbency: Gravitational effects on flaccid uterus
Patient Factors	Parity: Risk increases with age (associated with decreased calcium mobilization) Prior vaginal prolapse: Increases risk of postpartum uterine prolapse Poor body condition: Nutritional deficiencies

Etiology and Pathophysiology

Uterine prolapse occurs when the uterus undergoes complete eversion through the open cervix immediately following or within several hours of parturition. The pathophysiology involves loss of myometrial tone combined with continued straining (tenesmus), which forces the flaccid uterus through the dilated cervix. Unlike vaginal prolapse which occurs prepartum, uterine prolapse is exclusively a postpartum condition.

Predisposing Factors

High-YieldHypocalcemia is the most common underlying cause of uterine prolapse in multiparous dairy cows. Calcium is essential for smooth muscle contraction, and hypocalcemia leads to uterine atony. Studies show cows with uterine prolapse have significantly lower serum calcium concentrations (mean 8.22 mg/dL) compared to control animals.

Assessment Area	Clinical Findings
Prolapsed Organ	Large mass hanging from vulva (often to hock level) Visible caruncles on endometrial surface (pathognomonic) Progressive edema, congestion, and discoloration Possible contamination with bedding, feces, debris Placenta may or may not be attached
Systemic Status	Uncomplicated: Alert, ambulatory, normal vital signs With hypocalcemia: Weakness, depression, subnormal temperature, recumbency With shock: Tachycardia, extreme pallor, prostration, cold extremities
Complications	Uterine artery rupture (internal hemorrhage) Bladder or intestinal entrapment within prolapse Severe lacerations or necrosis of uterine tissue Hypovolemic or septic shock

Clinical Presentation

Characteristic Findings

The clinical presentation of uterine prolapse is distinctive and unmistakable. The prolapsed uterus appears as a large, heavy mass of tissue protruding from the vulva, often hanging below the level of the hocks when the cow is standing. The exposed endometrial surface displays numerous caruncles (discrete, mushroom-shaped structures that served as maternal attachment sites for the placental cotyledons). The presence of caruncles definitively distinguishes uterine prolapse from vaginal prolapse.

Clinical Signs and Assessment

Differential Diagnosis: Uterine vs. Vaginal Prolapse

NAVLE TipNAVLE loves to test the distinction between uterine and vaginal prolapse. Remember: Uterine = Postpartum with caruncles visible; Vaginal = Prepartum with smooth surface. The timing and surface characteristics are the key differentiators!

Feature	Uterine Prolapse	Vaginal Prolapse
Timing	Postpartum (within 24 hours of calving)	Prepartum (late gestation)
Size	Large mass extending to hocks	Smaller (grapefruit to soccer ball size)
Surface	Caruncles visible (bumpy, irregular)	Smooth, pink/red surface
Hereditary	Not inherited; low recurrence	Hereditary component; high recurrence
Urgency	True emergency - life-threatening	Less urgent; not immediately life-threatening
Culling	Not necessary if successful replacement	Recommended (hereditary nature)

Treatment Protocol

Treatment of uterine prolapse requires rapid assessment, appropriate restraint, and systematic replacement of the organ. The primary treatment goals are: (1) stabilize the patient, (2) clean and protect the prolapsed tissue, (3) reduce edema, (4) replace the uterus anatomically, and (5) prevent recurrence.

Pre-Treatment Assessment

Before attempting replacement, assess the viability of treatment. Consider euthanasia or emergency slaughter in cases of: severe shock with poor systemic outlook, extensive uterine necrosis, irreparable lacerations with protruding viscera, or low economic value where intensive treatment costs outweigh potential gains.

Step-by-Step Treatment Procedure

Restraint and Positioning: If standing, walk cow slowly to a crush or head gate. If recumbent, position in sternal recumbency with hindlimbs extended caudally ('frog-legged' or 'New Zealand' position). This tilts the pelvis cranially approximately 30 degrees to aid replacement.
Epidural Anesthesia: Administer caudal epidural anesthesia using 5 mL of 2% lidocaine at the sacrococcygeal or first intercoccygeal space. This prevents straining during replacement and desensitizes the perineum. Allow 5-10 minutes for full effect.
Clean the Prolapsed Uterus: Gently lavage the uterus with warm saline or warm water. Remove gross debris, bedding, and feces. If placenta is loosely attached, remove carefully; if firmly attached, leave in place and replace with placenta attached.
Reduce Edema: Apply hypertonic solutions (50% dextrose or glycerol) or granulated sugar to the uterine surface to reduce edema through osmosis. This decreases the size of the mass and facilitates replacement.
Elevate and Support: Elevate the uterus to the level of the vulva using a clean sheet, towel, or prolapse tray. This relieves vascular congestion and uses gravity to assist replacement. Ensure elevation when lifting hindquarters to prevent uterine artery stretching.
Replace the Uterus: Apply lubricant (sterile obstetrical gel). Begin replacement at the cervical portion (closest to vulva), using the palm of the hand (NOT fingertips to avoid perforation). Apply steady, gentle pressure working toward the apex. Push the uterus through the cervix and into the pelvic cavity.
Ensure Complete Replacement: After replacement, extend your arm into each uterine horn to ensure complete eversion of the tips. An invaginated horn tip will cause continued straining and re-prolapse. Infuse 8-10 liters of warm saline to help fully extend the uterine horns.
Retention (Optional): If cow remains recumbent or continues straining, place a Buhner suture or other vulvar retention suture. Many practitioners find this unnecessary if uterine horns are completely everted and oxytocin is administered.

High-YieldAlways use the palm of your hand, NOT fingertips, when replacing the uterus. Fingertips can perforate the friable uterine wall. Begin replacement at the cervical portion and work toward the apex with steady, gentle pressure.

Pharmacological Treatment

Drug Category	Drug/Dose	Purpose and Notes
Epidural Anesthesia	Lidocaine 2%: 5-10 mL at S1-C1 or C1-C2	Prevents straining during replacement; desensitizes perineum. Allow 5-10 min for effect. Can add 1 mL xylazine for prolonged anesthesia.
Uterotonic	Oxytocin: 10-40 IU IM or IV after replacement	Promotes uterine involution and increases myometrial tone. Administer AFTER replacement (not before - makes uterus rigid and difficult to replace).
Calcium Supplementation	Calcium borogluconate 23%: 450-500 mL IV slow infusion	Corrects hypocalcemia; restores myometrial contractility. Administer slowly with cardiac monitoring. Oral calcium propionate (500g) provides more sustained effect.
Antibiotics	Procaine penicillin G: 20,000 IU/kg IM for 3-5 days OR Oxytetracycline LA: 20 mg/kg IM	Prevents secondary bacterial infection due to environmental contamination. Systemic antibiotics preferred over intrauterine. Use broad-spectrum, category D antibiotics.
Anti-inflammatory	Flunixin meglumine: 2.2 mg/kg IV OR Meloxicam: 0.5 mg/kg SC	Provides analgesia and reduces inflammation. Flunixin has additional anti-endotoxic properties. Continue for 3-5 days.
Fluid Therapy	Isotonic crystalloids: 10-20 L IV as needed	For dehydrated or shocked patients. Oral pump drenching with 20L warm water also provides rehydration.

Complications and Prognosis

Potential Complications

Uterine artery rupture: Fatal internal hemorrhage can occur during or after replacement. The stretched artery may be compressed while prolapsed; bleeding occurs upon replacement.
Re-prolapse: Occurs if uterine horn tips remain invaginated or if tenesmus continues post-epidural.
Metritis and sepsis: Secondary infection from environmental contamination.
Uterine necrosis: Prolonged prolapse leads to tissue devitalization requiring amputation.
Delayed uterine involution: Affects subsequent fertility and return to cyclicity.

Prognosis and Survival Rates

NAVLE TipUnlike vaginal prolapse, uterine prolapse is NOT hereditary and does NOT require automatic culling. If successfully treated, these cows have excellent fertility and low recurrence risk (less than 1.5%). Key prognostic factors include: liveborn calf, primiparous status, and absence of Stage 3 milk fever.

Parameter	Data
Overall Survival Rate	Approximately 73-82% with prompt treatment
Subsequent Conception Rate	84-87% of surviving cows conceive
Days to Conception	Average 10 days longer than herd mates
Recurrence Rate	Less than 1.5% at subsequent calvings
Negative Prognostic Factors	Poor systemic condition at presentation Stage 3 milk fever (recumbent, comatose) Severe uterine edema or trauma Prior vaginal prolapse prepartum Replacement time greater than 20 minutes
Positive Prognostic Factors	Liveborn calf Primiparous cow Good systemic condition at treatment Prompt veterinary intervention

Prevention Strategies

Hypocalcemia prevention: Implement DCAD (dietary cation-anion difference) diets during close-up period; provide oral calcium supplementation at calving
Minimize dystocia: Use low birth weight bulls for heifers; avoid excessive traction during assisted deliveries
Appropriate body condition: Avoid over-conditioning during dry period (target BCS 3.0-3.5)
Post-calving management: Encourage cow to stand and move soon after calving; this straightens the uterine horns and promotes normal involution
Calving environment: Ensure level flooring in calving area; avoid downhill positioning of hindquarters

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