Professor Zdenek Knotek (Sid) graduated from Veterinary University Brno in 1982 (with honours). He is head of the Avian and Exotic Animal Clinic, Faculty of Veterinary Medicine, University of Veterinary and Pharmaceutical Sciences Brno, Czech Republic. Sid is a founding member and diplomate of the European College of Zoological Medicine, member of ARAV, past-president of EAZWV, president of CAZWV. Sid had teaching activities in Budapest, Copenhagen, Kosice, Ljubljana, Utrecht, Vienna, Warsaw, Purdue (USA), Denpasar (Indonesia). As a founder of reptile medicine specialty he headed the Unit for Birds and Reptiles at Vetmeduni Vienna (2010–2013). Sid supervises courses: Summer School for Exotic Medicine and Surgery (since 2004) and ESAVS courses - Exotic Pets Medicine and Surgery I, II, III (since 2005). His current focus involves medicine and surgery in reptiles, small mammals and birds.
Endoscopy is a valuable clinical technique that can be used in veterinary practice with chelonians.1-5 Performing a cloacoscopy requires an in-depth knowledge of the anatomy of chelonian cloaca. The cloaca in tortoises, terrapins and turtles has a complex structure. It is subdivided into three sections, the proximal part coprodeum, the median part urodeum and the distal part proctodeum. In coprodeum the caudal part of the colon terminates and distinct fold separates the colonic opening from the urodeum. The urodeum is the part of cloaca where the urethra and the vas deferens (in males) or oviducts (in females) open. The proctodeum represents the most caudal part of the cloaca where the reproductive organs, penis or clitoris, are presented. The proctodeum receives the outflow of the bladder, urodeum, coprodeum, genital organs and ureters. In some semi-aquatic terrapins two small accessory bladders may be also present. The chelonian cloaca is often involved in occlusions, traumas and various diseases, such as congenital anomalies, bacterial and parasitic infections, various tumours, foreign bodies, cloacolithiasis, and organ prolapses (penile prolapse, rectum prolapse, urinary bladder or oviduct prolapse, etc.). Cloacoscopy is also used for treatment and minor surgical procedures in chelonians.4,6,7
The method of cloacoscopy needs practical training and good clinical experience because any kind of technical mistake during the cloacoscopy would be very dangerous for the animal. The cloaca is examined with rigid endoscopes or flexible bronchoscopes of various diameters, depending on the size of the animal.2,6,7 In small or young chelonians the Hopkins documentation forward-oblique telescope (30°, ø 2.7 mm, 18 cm), the Hopkins slender telescope (30°, ø 1.9–2.1 mm, 18 cm), and the semi-rigid miniature straight forward telescope (0°, ø 1.0, 20 cm) are used with or without diagnostic (operating) sheaths. Rigid telescope with 4.8 mm diagnostic sheath or rigid telescope with integrated operating sheath 3.3 mm enable introduction of tools for biopsy or grasping the foreign bodies. Flexible grasping or biopsy forceps (1.7 mm) can be employed for biopsy specimen collection for laboratory tests. For large turtles the wide angle forward-oblique telescope (30°, ø 4.0 mm, 30 cm) or flexible bronchoscopes and gastroscopes are used. Endoscopic examinations of the chelonian cloacae performed by authors of this study were performed with the use of the otoscope (0°, ø 5 mm, 8.5 cm, 0°, ø 10 mm, 30 cm) connected to a camera (Telecam DX-II and TELE PACKTM, MM, SF) or with the Hopkins documentation forward-oblique telescope, 30°, ø 2.7 mm, 18 cm) with 4.8 mm diagnostic sheath, xenon lamp (Xenon Nova, 400–750 nm) and endoscopic camera (Endovision Telekam, Karl Storz, Tuttlingen).
Before the endoscopic examination it is mandatory to examine the animal clinically and to perform the haematology and plasma chemistry analyses. The chelonian is fasted for 1 day at least but has unlimited access to water. Urates and faecal material have to be flushed out. Short-time direct cloacoscopy is not painful, so the use of analgesics is not necessary and anaesthesia can be performed with propofol or alfaxalone administered intravenously.8 It is also possible to induce anaesthesia with propofol or alphaxalone intravenously, insert the tracheal tube and keep the patient under inhalation anaesthesia with isoflurane. Debilitated turtles in poor condition are restrained manually, active patients are sedated with tiletamine/zolazepam (3.5 mg/ kg, intramuscularly). The use of local anaesthesia and analgesia (e.g., 3 ml of 2% lidocaine in 1 litre of sterile 0.9% NaCl, 30°C administered through the working sheath) is also possible.3
With the animal adequately anaesthetised, the chelonian must be appropriately positioned. In clinical practice chelonians are positioned in ventral or dorsal recumbency. Small to medium size species are generally more easily examined in a dorsal position, big tortoises and sea turtles can be examined easily in ventral position.2,3 The animal head and neck are extended. Hind legs have to be fixed to the shell. The tail and cloacal opening are gently fixed with the left hand of the operator, while the endoscope is gently inserted into the cloaca. The cloacoscopy technique relies upon directing and supporting the end of the telescope with left hand while supporting the scope and camera with the right hand. Two methods should be used for distension of the cloaca and urinary bladder - insufflation with air or CO2, and irrigation with the sterile fluid solution. The later method is more feasible. Moreover, aggressive flushing the bladder and cloaca with the sterile fluid is optimal for cleaning the mucosa and removal of the small pieces of tissue, urine or faeces from the tip of endoscope.6 Continuous irrigation or single injections of sterile body-temperature saline via one of the working sheath ports is required to provide good visualisation of the cloacal cavity. Bag of sterile saline is suspended above the examination table and intravenous giving set is used to connect the bag to one of the ports of the working sheath. A second giving set is connected from the other sheath port to a collecting bowl under the examination table. By controlling both inflow and outflow, the operator can infuse and aspirate saline, thereby providing a clean view of the cloaca, colon, and bladders.2,3,7 The cloacal opening has to be held shut around the scope to keep the cloaca distended.9 The first organ likely to be encountered in the caudal portion of the proctodeum is the black coloured penis or clitoris. Fluid irrigation and gently insert the endoscope deep into the cloaca to help to dilate the urodeum of cloaca and visualise the opening of colon, the opening of urinary bladder and two accessory bladders (on the left and right side). More proximally (deeply in cloaca), the urodeum slit is present. Through the thin transparent wall of the accessory bladders some visceral organs (testicles, ovaries, loops of intestine, liver, gall bladder, fat) can be viewed. In the upper part of the urodeum a muscular ridge with horizontal fibres is observed. The opening of urethra is localized on the central part of the urogenital senum. On the left and right side laterally to the urethral opening urogenital papillae are situated. These structures are small and rod shaped in males, while in females urogenital papillae are big and have a "cauliflower" shape. The deepest organs that are possible to be examined with cloacoscopy are the urinary bladder and the colon. While the thin and transparent wall of the urinary bladder allows examine indirectly visceral organs, the wall of the colon is not transparent.
Authors did not record within years of their practice any negative health consequences associated with short term cloacoscopy in chelonians examined. However, chronic inflammation and urolithiasis can make the bladder wall weaker and more prone to rupture, especially during long term cystoscopy. Mucosal biopsy specimens should be taken with care, especially from the colon, because of its thin nature and risk of perforation (Divers 2014). Bleeding would be a complication of the cloacoscopy method if the mucosal layer of the cloaca or the penis (clitoris) is traumatised and haemorrhages would obscure the view.
The following clinical implications exist for cloacoscopy in chelonians: masses seen on radiography or ultrasonography may be visualised directly and sampled; eggs and uroliths in the cloaca may be manipulated and withdrawn; discharges from urethra or oviduct can be observed and sampled if necessary; penis and the clitoris can be examined.2,5,7,10 Sea turtles with traumatic injuries are frequently presented to the veterinary clinics, veterinary hospitals and rescue centres in Europe (FS personal observation) and Asia (ZK observation). Methods of diagnostic endoscopy would be routine parts of emergency and critical care for see turtle patients. As a part of the routine examination protocol cloacoscopy would be performed for the control of presence (and minimally invasive removal of) the foreign bodies (fish hooks, splinters, ropes and nets, plastic bags or bottles). The standard cloacoscopy is recommended for clinical practice with chelonians for visualisation of the proctodeum, urodeum and coprodeum. The method is safe and allows a detailed evaluation of the distal colon, urogenital papillae, and urinary bladder. Advanced cloacoscopy can be used to remove uroliths, shell and egg material from cloaca and urinary bladder and for neonate gender identification.
Acknowledgements
This project was partially supported by the Grant of the Faculty of Veterinary Medicine, VFU Brno (Specificky vyzkum, FVL 2014).
References
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