Part II: understanding pain in pigs—pain assessment in pigs with spontaneously occurring diseases or injuries

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Kschonek et al. Porcine Health Management (2025) 11:13 Porcine Health Management https://doi.org/10.1186/s40813-025-00420-1 REVIEW Open Access Part II: understanding pain in pigs—pain assessment in pigs with spontaneously occurring diseases or injuries Julia Kschonek1*, Kathrin Deters2, Moana Miller3, Jennifer Reinmold2, Lara Twele4, Ilka Emmerich5, Sabine Kästner6, Nicole Kemper3, Lothar Kreienbrock1, Isabel Hennig-Pauka2, Michael Wendt7 and Elisabeth grosse Beilage2 Abstract Background Pain in pigs needs to be managed and treated to the benefit of individual pigs. It is imperative for veterinarians and farmers to assure that pigs do not suffer from unnecessary pain that can be relieved. This review focusses on pain related to spontaneously occurring diseases and injuries since this topic is often neglected. The aim is to identify ways to accelerate knowledge and evidence in this area to prevent painful conditions in pigs in the future. Methods A scoping review was conducted with results from a search of the electronic databases VetSearch and CABI Rxiv. The findings of selected publications are narratively synthesized and reported orienting on the PRISMA ScR guideline. Results The results emphasize that pigs experience pain due to spontaneously occurring diseases and injuries, but systematic knowledge about this topic is scarce. More research is especially needed for rare diseases (such as UTIs). Moreover, research conducted about the topic pain in pigs should involve standardized protocols to document, analyse and share results on pain detection beyond a projects’ timeframe. The findings of this review suggest that such a protocol would comprise validated pain identification measures over time and in relation to administered pain treatment. Conclusion The results

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such a protocol would comprise validated pain identification measures over time and in relation to administered pain treatment. Conclusion The results of this study invite veterinary practitioners to reconsider in each pig patient whether pain and related indicators are present, how to handle the situation and document the process to ensure the welfare of individual compromised pigs. Keywords Pigs, Pain, Assessment, Spontaneously occurring diseases and injuries 4 *Correspondence: Clinic for Horses, University of Veterinary Medicine, Foundation, Julia Kschonek Bünteweg 9, 30559 Hannover, Germany 5 julia.dorothee.kschonek@tiho-hannover.de Institute of Pharmacology, Pharmacy and Toxicology, Faculty of 1 Institute for Biometry, Epidemiology and Information Processing (IBEI), Veterinary Medicine, University Leipzig, An Den Tierkliniken 39, University of Veterinary Medicine, Foundation, Bünteweg 2, 04103 Leipzig, Germany 6 30559 Hannover, Germany Clinic for Small Animals, University of Veterinary Medicine, Foundation, 2 Field Station for Epidemiology, University of Veterinary Medicine, Bünteweg 2, 30559 Hannover, Germany 7 Foundation, Büscheler Str. 9, 49456 Hannover, Bakum, Germany Clinic for Swine and Small Ruminants, Forensic Medicine and 3 Institute for Animal Hygiene, Animal Welfare and Farm Animal Behavior, Ambulatory Service, University of Veterinary Medicine, Foundation, University of Veterinary Medicine, Foundation, Bischofsholer Damm 15, Bischofsholer Damm 15, 30173 Hannover, Germany 30173 Hannover, Germany © The Author(s) 2025. Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit

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ational License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit ​h​t​t​p​​:​/​/​​c​r​e​a​​t​i​​v​e​c​​o​m​m​​o​n​s​.​​o​r​​g​/​l​i​c​e​n​s​e​s​/​b​y​/​4​.​0​/. The Creative Commons Public Domain Dedication waiver (​h​t​t​p​​:​/​/​​c​r​e​a​​t​i​​v​e​c​​o​m​m​​o​n​s​.​​o​r​​g​/​p​​u​b​l​​i​c​d​o​​m​a​​i​n​/​z​e​r​o​/​1​.​0​/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Kschonek et al. Porcine Health Management (2025) 11:13 Page 2 of 17 Introduction the quality and comprehensibility of the eligibility crite- Pain in pigs can be induced by spontaneously occurring ria for the selected papers, the search mode, the database diseases and injuries as well as by damaging manage- and the review documentation. ment procedures. In the literature, the focus to elaborate For the search of latest publications, the databases on signs of pain, pain

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documentation. ment procedures. In the literature, the focus to elaborate For the search of latest publications, the databases on signs of pain, pain mechanisms and therapy of pigs is VetSearch and CABI search Rxiv were used to identify often put on the latter topic and neglects common dis- papers matching the terms for animals (pigs), the focus of eases such as pain due to gastric ulcer, claw avulsion or this article (pain) and terms for specific diseases or inju- respiratory disorders. Irrespective of the reason for pain ries (topics). Many terms were defined, and specifications sensitation in pigs, pain-related conditions need to be were established during the search. To enable readers to carefully examined and treated by veterinarians and follow the process for each topic of the manuscript, the farmers. For this means, thorough knowledge is needed metrics used herein are outlined in the supplementary to examine, assess and therapize related conditions prop- material (Additional file S1). erly. In a previous article, - part I - understanding pain in Papers were included if accessible and peer reviewed pigs [1], a narrative synthesis of common and latest pub- or books (chapters) published between 2015 and end of lished literature was generated for gathering basic knowl- March 2023 besides standard literature on pig diseases edge in this respect. The former manuscript also provides and work found through snowballing technique. Included an overview of dosages and administration of analgesic languages are English and German. Concerning the topic, agents. This subsequent article - part II - focusses more papers are included if they elaborate on the search terms specifically on pain induced by spontaneously occurring in more than one sentence (buzz-words), i.e. contribute

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if they elaborate on the search terms specifically on pain induced by spontaneously occurring in more than one sentence (buzz-words), i.e. contribute diseases and injuries. This scoping review summarizes to the topic with descriptive or detailed insight. how pain in specific diseases is addressed in theory and in veterinary practice. Not anticipating the discussion of Pain induced by spontaneously occurring diseases results, it will be shown that even for common diseases or injuries in pigs like lameness in pigs, descriptions of the assessment and Locomotor diseases alleviation of pain are often indirect or vague. Hence, this Locomotor diseases include a wide range of infectious, review will help readers to learn about the current state non-infectious or degenerative diseases and injuries, of pain relief approaches and findings, and thus what is including purulent or non-purulent arthritis, osteoar- needed to accelerate evidence about pain in spontane- thritis, osteochondrosis, fractures, tenosynovitis, con- ously occurring diseases and injuries in the future. tusions, muscle tearing, dewclaw injuries or fractures, and coronary band and other foot lesions [5, 6]. Abnor- Method malities in the locomotor system often lead to lameness, The review was conducted in accordance with the which manifests as reduced weight bearing on at least PRISMA-ScR guideline [2] which is dedicated to organize one leg, an inability to stand up in the hindquarters (hind the report of scoping reviews. In contrast to systematic leg weakness) or sitting or lying posture. Lame animals reviews that answer one particular question with the help exhibit an abnormal gait, characterised by asymmetrical of specific results and evidence, a scoping review aims to weight distribution, steep walking,

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exhibit an abnormal gait, characterised by asymmetrical of specific results and evidence, a scoping review aims to weight distribution, steep walking, increased stride fre- answer generic questions and to provide an initial and quency, shortened stride lengths and/or an arching of the structured overview of findings in the field [2, 3]. The spine. Some animals also exhibit rapid changes between research question to be answered in this study is: what loading and unloading of a limb (tapping) [7, 8]. is known about the identification and evaluation of pain Lameness in pigs often manifests as changes in behav- in pigs with spontaneously occurring diseases or inju- iour. Lame pigs reduce their activity and exploratory ries? For this review, pain is defined as “[a]n unpleasant behaviour and reduce their interactions with pen mates. sensory and emotional experience associated with, or It has also been observed that lame sows lie down on resembling that associated with, actual or potential tis- walls more often than their non-lame counterparts [9– sue damage […]” ([4], Text Box 2). Depending on its neu- 11]. Sows with artificially induced arthritis showed lon- roanatomical origin, pain can result from the activation ger periods of lying down and shorter periods of standing of nociceptors (nociceptive pain), which are among the up [11–15]. Overgrowth of claws in sows leads to shorter cardinal symptoms of inflammation (inflammatory pain), stance phases and feed intake times [16]. Due to lameness lesions of neural tissue (neuropathic pain) and combina- and associated pain, behaviour changes; affected pigs eat tions of these conditions [1]. Following this definition, and drink less or not at all, as their condition does not a review protocol was predefined and discussed

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se conditions [1]. Following this definition, and drink less or not at all, as their condition does not a review protocol was predefined and discussed by the allow them to compete with non-lame pigs for feed and author group (experts in porcine health management, water [27]. Lame sows consume significantly less water pain, anaesthesia, pharmacology and research method- than healthy sows [17]. This increases the risk of lame ology in veterinary medicine). The discussion concerned animals not being able to fulfil their needs sufficiently Kschonek et al. Porcine Health Management (2025) 11:13 Page 3 of 17 and suffer from hunger and thirst [10, 18]. Therefore, Foot and joint problems were cited by farmers as the lame sows should be housed in hospital pens where they most common reason for administering NSAIDs [30]. In can recover and not have to compete with healthy sows countries where opioid analgesics are licenced, buprenor- for water and feed. A feed reward study revealed that phine can be used to reduce gait asymmetry, while the moderately to severely lame sows received fewer rewards NSAID meloxicam can be used to reduce stride fre- than mildly lame and non-lame sows [18]. quency, thus leading to better symmetry of hind leg Lameness and associated expenses have a signifi- movement in pigs with spontaneously occurring lame- cant economic impact. Lame animals require additional ness [6, 11, 14]. In non-infectious locomotor disorders labour, from identification to treatment, which implies in fattening pigs, gilts and sows, an improved lameness higher veterinary costs. Lameness in sows can also have score was observed 24 h after treatment with meloxi- a negative impact on reproductive performance [12, 19]. cam during gait and at rest [31]. After inducing lame- On average,

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fter treatment with meloxi- a negative impact on reproductive performance [12, 19]. cam during gait and at rest [31]. After inducing lame- On average, sows that leave the herd due to lameness ness, meloxicam and flunixin led to improved leg loading are younger than those that are removed for other rea- and movement in sows [32]. Moreover, the severity of sons [20]. Lame sows are less efficient at breeding and are lameness decreased, but one week after the induction more likely to be culled due to lameness [10, 21]. Muscu- of lameness, it had disappeared [33, 34]. Sows affected loskeletal problems are a leading cause of culling in pig by spontaneously occurring lameness and treated with herds [22, 23]. meloxicam had longer standing times after feeding Lameness serves as a key indicator for animal welfare than those in the control group [14]. Pain therapies are assessment in pig farming [24]. Lameness is usually easy reported to normalize the behaviour of lame sows [25]. A to recognize and is a clear sign of pain [12, 24, 25]. The survey revealed that, if lame pigs were treated, Metacam observed behavioural changes in movement disorders was usually selected as the medication, but only a quar- are most likely caused by limited mobility, pain or dis- ter of the farmers initiated treatment [26]. Meloxicam comfort and sickness behaviour [10]. Lameness is rated was named the most popular painkiller according to this as extremely painful by farmers and veterinarians, espe- survey. cially when there is minimal weight bearing [26]. In the same survey, farmers stated that recognizing pain in pigs Skin ulcers and decubitus symptoms was difficult and that they were unsure how to address it. ‘Ulcer’ refers to an external skin trauma that mainly However, the assessment of pain is

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ms was difficult and that they were unsure how to address it. ‘Ulcer’ refers to an external skin trauma that mainly However, the assessment of pain is often subjective and, develops from ‘top to bottom’ and may even affect under- therefore, difficult to quantify [10]. Lameness can cause lying bones [35–38]. In pigs, ulcers result from lying for a both pain and stress. Stress is associated with changes longer time in an unchanged posture, which compresses in the immune system and increases the susceptibility of blood vessels supplying the skin and results in insufficient animals to other diseases. If lameness persists, additional blood circulation, cell death, and necrosis [39–41]. This diseases can develop and affect animal health beyond kind of ulcer is classified as a pressure ulcer or decubitus lameness [10]. In fattening pigs, fractures, osteochondro- and mainly develops in areas of the body, where bones sis dissecans and infectious arthritis are considered par- are hardly padded by muscles or subcutaneous fat and ticularly painful [23]. thus are compressed by a hard floor. In general, ulcer- In addition to the visual observation of animals, tech- ative skin lesions can develop in many regions, such as nology such as pressure mats, force plates, motion cap- the limbs, tail, flank, udder, legs or ears [38, 42, 43]. Most ture systems and accelerometers can be used to record attention, however, is directed to shoulder ulcers located animal movement and limb loading [14, 15, 27]. The above the tuber spinae scapulae, often initiated by longer evaluation of these electronic systems enables the iden- lying during farrowing [35, 44, 45]. tification of lameness [6]. Using an accelerometer, previ- Irrespective of the location, most of the papers selected ous

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uring farrowing [35, 44, 45]. tification of lameness [6]. Using an accelerometer, previ- Irrespective of the location, most of the papers selected ous studies showed that lame sows take more steps per for this review did not focus on pain due to (shoulder) minute than healthy animals [14]. Measurements with a ulcers (for an example, see [35]). Topics address develop- force plate showed that lame sows have a lower contra- ing improved clinical detection scores [35, 46], increasing lateral hind leg load. Pressure mat analyses showed that knowledge about behavioural responses and risk fac- lame animals have an asymmetrical gait, probably due to tors [44, 47], or assessing prevention [44] and treatment the relief of the affected limb to reduce pain [11, 28]. One options [48, 49]. Moreover, a review of epidemiologic and advantage of electronic detection systems is their objec- forensic aspects [38] and knowledge about causes, pre- tivity. Visual observations are subjective and have high vention and treatment have been generated [39]. In view variability in reproducibility depending on the training of these findings, it may not be surprising that a clear and experience of the observer. However, visual obser- definition of pain and related processes [to be expected vations are inexpensive and easy to integrate into daily or assessed] is often missing. It can be inferred from work routines [29]. previous studies that tissue damage and inflammatory Kschonek et al. Porcine Health Management (2025) 11:13 Page 4 of 17 processes typical of ulcers are related to acute pain [35, in behaviour may be subtle or not obvious during 38, 50, 51]. In this respect, one previous paper elabo- examination. rated on acute phase proteins [haptoglobin and albumin, To elaborate on the age or extent

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51]. In this respect, one previous paper elabo- examination. rated on acute phase proteins [haptoglobin and albumin, To elaborate on the age or extent of chronic lesions, among others], which appear to develop in correspon- studies involving histopathological examination of skin dence with bilateral shoulder ulcers [48]. On the other ulcers can be considered [35, 38]. Concerning neural hand, chronic pain may occur given that neuromas can tissue, traumatic neuromas appear not only in shoulder develop over time [35, 51]. Moreover, many papers argue ulcers affecting deep skin layers but also in ulcers affect- that ulcers are painful for pigs because they are analogous ing only superficial layers [35]. Moreover, traumatic neu- to decubitus in humans, which can also be highly painful romas have been found in shoulders with evidence of [35, 45, 48, 52, 53]. healed ulcers [35, 51]. It is commonly accepted that nerve To assess the effect of (shoulder) ulcers on pigs, observ- damage may lead to increased activation of peripheral ers generated scores for lesions and/or for behavioural nociceptors and central neuronal excitability, including aspects. The scoring system used in these papers is not peripheral and central sensitization [56]. Moreover, neu- standardized but follows a similar pattern (for an over- roma formation is likely to initiate chronic neuropathic view see [35]). According to the tissue involved, for pain [57]. These changes contribute to post-injury hyper- example, lesions with a score of 1 affect only the epider- sensitivity, which is measured as hyperalgesia and allo- mis, while lesions with a score of 2 also affect the dermis. dynia [51, 58]. Hence, a pig that has ulcers in predisposed Lesions with a score of 3 affect all skin layers, including locations

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o affect the dermis. dynia [51, 58]. Hence, a pig that has ulcers in predisposed Lesions with a score of 3 affect all skin layers, including locations should be examined more frequently for pain- the subcutaneous tissue, and lesions with a score of 4 related behaviour and should be considered a candidate affect the entire skin and the underlying bone [35, 40]. for pain relief treatment even if no (acute) compromised Pain is likely to occur even with superficial layers, so skin is visible. findings such as size, scab, and wall alterations should be In summary, these findings reject the assumptions staged with regard to a histopathological score to avoid that nerves in damaged tissues basically cease [59] and underestimation of clinical signs [35, 40]. support that both inflammatory and neuropathic pain Further clinical signs address the adaptation of behav- can occur due to skin ulcers and cause pain in pigs. To iour [54]. Results indicate that even sows with moderately emphasize this point again, painful changes in tissue sized shoulder ulcers [3 cm in diameter] exhibit changes may occur even before they are clinically visible to the in behaviour, such as reduced lying time, increased fre- observer, and these changes may persist after clinically quency of postural changes, increased standing and visible signs have disappeared [35, 46, 51, 60]. Therefore, reduced nursing frequency [54]. This behaviour appears pigs should be carefully examined and treated for welfare to be both a response to pain and a way to protect against concerns as early as possible, as outlined below. an exacerbation of the lesion [48]. Another change in Therapy for shoulder ulcers comprises the local appli- behaviour is increased rubbing against fixtures of the cation of zinc ointment [49],

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change in Therapy for shoulder ulcers comprises the local appli- behaviour is increased rubbing against fixtures of the cation of zinc ointment [49], mãnuka honey, or local farrowing crate [54], which may even be invoked by pal- sprays [46] or the protection of the affected skin from pation of the shoulder to discriminate the reactions of soft rubber mats [44, 48, 49]. Pain alleviation via NSAIDs affected and non-affected sows [51]. Moreover, a corre- should be considered for shoulder ulcers affecting the lation between pain-associated reactions after palpation dermis and certainly for those affecting deeper skin lay- of shoulder ulcers and the depth of the lesion has been ers [61]. However, pain relief without accompanying proven [55]. treatment [effective decompression, early weaning] may Although the results speak in favour of pain sensa- have a contradictory effect [48]. If no pain alleviation is tion in pigs due to shoulder ulcers, a study has recently possible or no healing can be achieved, pigs with deep outlined the question of whether (pain in) early stages ulcers may need to be euthanized. Euthanasia should be of shoulder ulcers can be deduced from changes in rou- considered when the underlying bones are affected. To tine behaviours [47]. Indeed, behavioural changes corre- avoid reaching this stage of ulceration and secure timely sponding to early tissue changes, such as skin reddening, euthanasia in such cases, future studies should elaborate might be subtle. Detection of subtle changes requires a on the timeline of ulcer stages with regard to the appear- dedicated study design (in terms of time points in rela- ance of chronic pain on the one hand or valid healing tion to farrowing (or previous ulcers), observation time, signs on the other hand. frequency,

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a- ance of chronic pain on the one hand or valid healing tion to farrowing (or previous ulcers), observation time, signs on the other hand. frequency, sample and effect size apart from a treatment- Studies on healing published this far have shown that effect protocol). To the knowledge of the authors, no skin lesions are present in the majority of shoulder ulcers study elaborating on these points has been published in sows for at least 2 to 3 weeks and that superficial thus far. In this regard, practitioners should carefully healing usually occurs within a few weeks after wean- evaluate predisposed locations and consider providing ing. The prominent type of healing is secondary healing pain relief in cases of initial skin changes even if changes [62]. However, the chance of developing chronic pain Kschonek et al. Porcine Health Management (2025) 11:13 Page 5 of 17 initiated by traumatic neuroma [51] and an enhanced umbilical hernias were not reported, and observations risk of developing a shoulder ulcer [45] again show that were subject to variability. Therefore, findings on the will- healing is often limited by the disappearance of the vis- ingness to engage in activities as an indicator of pain due ible skin lesion. Information about the healing of ulcers to umbilical hernias needs to be interpreted with caution. in locations other than the shoulder is not available to the From the perspective of the authors, a promising behav- authors. ioural indicator for pain measurement in pigs, however, When considering the influence of treatment on the might be the time a pig is lying in sternal recumbency, as healing of shoulder ulcers, attention needs to be devoted this position is associated with maximum pressure on the to the fact that ulcers rarely develop alone. In this

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r ulcers, attention needs to be devoted this position is associated with maximum pressure on the to the fact that ulcers rarely develop alone. In this respect, hernia, particularly in hernias where the intestine cannot several studies have addressed risk factors such as lame- be repositioned into the abdomen. Painful alteration of ness, a low body condition score or the development the hernia will likely reduce the duration of lying in ster- of shoulder ulcers during previous farrowing [39, 44, nal recumbency, which is usually favoured by pigs. 63–65]. Climate conditions, such as moisture in crates Additionally, pain is very likely to compromise animal and changes in floor types before farrowing, also appear welfare when ulcerative skin lesions on the outpouch- to play a role [46]. Hence, when assessing the chance of ing are present [38]. Ulcerative skin lesions on hernias healing or generating a treatment protocol, these factors frequently start to develop from the ventral aspect and need to be considered. If underlying causes are neglected are considered painful [38]. In fact, they are the most (such as a lameness), secondary ulcers in unexpected frequent complication that lead to euthanasia of pigs regions may develop [such as over the ala of the ilium, the affected by umbilical hernia [71]. The risk for skin ulcer- head of the femur, the elbow and various locations of the ation is positively associated with the size of the hernia distal leg; see (Additional file S2 for assessment in stable and is increased in hernias where the intestine cannot be (right side) and Additional file S3 for secondary ulcers replaced into the abdomen [71]. Thus, assessing hernias (left side of the same pig)), or ulcers in typical locations and accompanying conditions is important for

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to the abdomen [71]. Thus, assessing hernias (left side of the same pig)), or ulcers in typical locations and accompanying conditions is important for determin- may develop (Additional file S4). ing further development (also in [66]). Another case in In summary, shoulder ulcers evoke several pain mecha- which pain is very likely to occur is the type of pathologi- nisms, and an appropriate treatment protocol is needed cal condition causing the hernia [70]. The typical patho- that may go beyond the consideration of pain relief or logical conditions of hernias include strangulation of the rubber mats alone. For detection, examiners need to hernia content with insufficient blood supply, obstruc- assess skin and shoulder ulcers in pigs carefully and look tion or incarceration of the intestine and adhesions to the for ulcers in unexpected regions when locomotion is intestine or omentum [72, 73]. All these complications impeded or when the body condition score is low. are associated with severe pain in humans [74], and it is reasonable to assume that this also applies to other spe- External hernia cies [72]. Hernias are protrusions of tissues or organs (or both) Surgical repair is an option for the treatment of umbili- through body walls within [internal hernia] or outside the cal hernia [75, 76], and related translational studies have body or compound (external hernia) [66]. Multiple her- been published [77]. However, as criticized in trans- nia types are defined, and they can appear due to natural lational studies, pain relief is often not reported even openings (defects), trauma or lesions of surrounding tis- though pain may be observed (also see [76, 77]). Like for sue, such as skin or muscles [66–68]. Umbilical hernias in ulcers in general, pain alleviation should be

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may be observed (also see [76, 77]). Like for sue, such as skin or muscles [66–68]. Umbilical hernias in ulcers in general, pain alleviation should be considered pigs, however, have attracted the most attention because for hernia lesions affecting the dermis, those exceeding they have consequences for transport and slaughter a medium size (e.g., a diameter of 2 cm) and, certainly, [66]. Topics about umbilical hernias in reviewed papers for deeper skin layers. When an ulcerative skin lesion address behavioural and pain indicators [66], genetic fac- on a hernia exceeds medium size or affects the subcutis tors [69] and surgical aspects [75, 76]. (Additional file S5), healing within an acceptable time is Concerning pain sensation in general, umbilical her- unlikely, particularly when the pig is kept without litter, nias with intact skin are not necessarily painful [62]. and euthanasia prevents further pain and suffering. They may cause abdominal pain or discomfort [69], but Concerning healing, the general processes of the smaller umbilical hernias without intestinal incarceration pathology of hernias have been well researched [67, 68], or ulcerative skin lesions are likely not painful for the pig. and umbilical hernias tend to maintain their basic con- As an indicator of pain, the results elaborate on reduced ditions over time [66]. For a second aspect, namely, the lying time [70] and the willingness of pigs to engage in knowledge about the genesis and healing of invagination locomotor and social activities [66]. The latter study and adhesions or incarceration and secondary injuries revealed no differences between pigs with and without of (umbilical) hernias, publications are rare. However, umbilical hernias. However, skin lesions in pigs with whether ulcerative skin

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with and without of (umbilical) hernias, publications are rare. However, umbilical hernias. However, skin lesions in pigs with whether ulcerative skin lesions on hernias result mainly Kschonek et al. Porcine Health Management (2025) 11:13 Page 6 of 17 from damaging behaviour or whether the healing of skin The histopathology of tissue injured by biting has been lesions is compromised by the pressure applied to pro- described in several studies for pigs with docked and truded organs has yet to be studied. In this review, several non-docked tails [57, 92]. papers reported on post-surgery care [75, 76]. In addi- Although undocked pigtails are likely to differ from tion, studies on other external hernias, the reporting of docked tails in neuroanatomical terms, the latter can pain and the treatment of hernia-associated skin injuries also be bitten. When discussing pain in this respect, in pigs are neglected in the literature. Moreover, studies one should consider the proliferation of neurofilaments, addressing umbilical hernias, such as the transcriptome including neuromas, in tail tips as well as (pain/inflam- analysis of Souza et al. [69], do not discuss implications matory) gene adaptation in dorsal root ganglia [92, for pain. The study suggested that gene candidates for 93]. While neuromas are not necessarily painful when umbilical hernias may also indicate expression profiles induced by tail docking [92, 94], painful conditions after where chronic pain occurs. However, it remains unclear amputation are associated with coexistent scar tissues, what conditions the pigs and hernias were in (e.g., abscesses, haematomas or osteomyelitis [95], conditions inflamed, ulcerated) and whether gene-related inferences that are likely to occur in tails with severe biting lesions.

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osteomyelitis [95], conditions inflamed, ulcerated) and whether gene-related inferences that are likely to occur in tails with severe biting lesions. about the presence of pain could be drawn. “Tail biting causes wounding of the tail, as well as amputation of part of, or the entire tail, which surely Biting lesions is painful for pigs” [89, p.144]. Pain caused by tail bit- Biting lesions caused by damaging behaviour of other ani- ing thus relates to acute pain, and the stimulus can be mals in the group occur on the tail, ear, flank and vulva. repeated when victims are bitten again [89, 91]. Inflam- Since there are various definitions for biting behaviour, mation and infections are often associated with the over- ranging from incidental chewing to forceful attacks [78], all condition of pigs with bite injuries [79, 96], as are signs biting was defined as any biting behaviour of pigs leading of chronic stress [89, p. 155]. to skin damage for this review. The tail posture has been examined for its use as an early predictor of upcoming tail biting [97–99]. How- Tail biting ever, recent studies indicate that a hanging or tucked-in Tail biting is a frequently observed abnormal behaviour tail posture does not indicate early damage [86, 100]. A in domestic pigs and is closely associated with welfare hanging tail posture is indicative of tail wounds but not and economic concerns [79–82]. Lesions can range from of minor damage, such as bite marks [86, 100]. Inflamed minor bite marks to loss of the entire tail [83]. Tail biting wounds at feeding are significantly associated with hang- and the resulting lesions are connected to increased pain ing tails [86]. Nonetheless, hanging or even tucked tails in pigs [81, 84] and are linked to local, secondary and sys- can be found

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to increased pain ing tails [86]. Nonetheless, hanging or even tucked tails in pigs [81, 84] and are linked to local, secondary and sys- can be found in pigs with no visible signs of damage [97] temic infections [79, 83]. In this regard, this topic is well and may also be related to stress [86]. In general, specific researched, especially given the questions associated with postures in animals often cannot be assessed alone but damaging management procedures such as tail docking. need to be interpreted in combination with the entire It has been suggested that tail biting is a redirected body posture or behavioural examinations [86]. behaviour with a background in unfulfilled exploratory Other studies have evaluated the feeding behaviour of behaviour [85]. Nevertheless, tail biting is multifactorial, bitten pigs under pain relief such as ketoprofen [101]. with several other factors having an impact on develop- It was found that before the onset of biting, the feeding ment [86, 87]. Despite the high research interest, neither frequency was reduced, and pain relief, as provided by standard terms for the act of biting [such as caudophagy, the applied concentration, chosen signalling pathway or chewing, fanatic attacks, cannibalism] nor final theories standalone treatment, seemed to have little effect on the explaining the motivation of pigs to engage in damag- return of feeding behaviour prior to onset [101]. More ing behaviour are commonly applied or defined [78–80, research is needed to clarify whether ketoprofen does not 88–90]. resolve stress or restlessness, a behaviour discussed ear- Tissue damage ranges from superficial bite marks to lier in this article as a sign of discomfort or pain (also see bleeding or encrusted lesions, necrosis, abscesses or even [96]).

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rficial bite marks to lier in this article as a sign of discomfort or pain (also see bleeding or encrusted lesions, necrosis, abscesses or even [96]). Another reason might be that other compromising loss of the tail body; this damage can include a loss of conditions exist that impact feeding behaviour [102]. the entire tail as well as injuries to the tail root and the In addition to behavioural indices, biomarkers can be surrounding tissue. Repeated biting results in the coinci- used to assess painful conditions in pigs [1], and several dence of acute and chronic tail lesions, as some pigs are studies have evaluated this topic with respect to tail bit- bitten multiple times [91]. According to the degree of ing. In general, studies included in this review revealed damage, (histo-)pathology reveals invasion of inflamma- that inflammatory marker levels tend to increase in bit- tory cells and development of granulation and scar tis- ten pigs [96, 103]. However, further research is neces- sue among common developmental stages [57, 88, 92]. sary to determine whether higher or more systematic Kschonek et al. Porcine Health Management (2025) 11:13 Page 7 of 17 inflammatory biomarkers are associated with tail bites or of flank biting on pigs can be described by scoring the severe damage [103, 104]. This knowledge is crucial for lesion (size, freshness, severity) and assessing behavioural discussions about healing processes as well as the exacer- indicators. Compared to tail biting, this study found bation of diseases. that the tail posture is not a reliable indicator of pain or In general, the healing of tail injuries [and pertaining distress due to flank biting. However, the occurrence of to an outbreak of biting] can be traced macroscopically. flank injury tended to be

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pertaining distress due to flank biting. However, the occurrence of to an outbreak of biting] can be traced macroscopically. flank injury tended to be associated with the severity and In acute wounds, the blood appears fresh and bright red, severity of certain tail injuries (p.11). while in older healing wounds, the blood becomes sticky, Apart from the reviewed publications, deep lesions and dry and dark [105, 106]. In the future, progressive dry tis- ulcerations of flank lesions should be considered painful, sue necrosis with eventual partial or total loss of the tail as discussed in the previous chapter. However, findings may occur within a few days [107]. While the initial leak- about pain-specific behavioural indicators for flank bit- ing secretions keep the tail constantly moist for healing, ing, treatment or healing processes have yet to be pub- they can also attract bacteria and trigger inflammatory lished and discussed in future studies. processes [108]. The risk of infection of other organs via the bloodstream, lymphatic system and cerebrospinal Ear lesions fluid is almost always present in tail wounds. In addition Ear biting refers to the oral manipulation of ear tips or to the skin, the tail muscles and tail vertebrae are often bodies and can result from damaging behaviour [115]. affected [88]. In addition to local infection, systemic An associated pathology is porcine ear necrosis (PEN), spread of bacteria may lead to arthritis or abscess forma- which can result from initial bite lesions, although other tion in the spine or lung [96, 109]. Despite these risks, aetiologies are discussed [117]. This chapter subsumes reliable conclusions about mortality rates in tail-bitten PEN and ear biting as ‘ear lesions’, as both entities repre- pigs are not easy even

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subsumes reliable conclusions about mortality rates in tail-bitten PEN and ear biting as ‘ear lesions’, as both entities repre- pigs are not easy even though it can be assumed that tail sent spontaneously occurring injuries, and the terminol- biting leads to significant losses [80, 89]. Thus, tail-bitten ogy used in related papers is often vague [117]. pigs need early and thorough examination to determine Furthermore, the [histo-]pathological characteristics which therapy and treatment are most appropriate. of ear lesions are a well-known problem in pig produc- In cases of tail injuries, local treatment, such as the tion and have long been assessed [116, 118]. In addition application of chlortetracycline (CTC) spray [110] to developing like other bite lesions [see previous chap- in combination with an analgesic, may be beneficial. ters], blood vessel occlusion induced by bacterial toxins Ketoprofen (mind the discussion above) or meloxicam is considered to be the main cause of epidermal damage (according to the experience of authors) may be assessed and necrosis [117]. Irrespective of the cause, mild and for a fit of treatment in a particular case. If signs of superficial lesions to severe necrosis and substantial loss inflammation are present (swelling, redness of the tail], of ear bodies may occur. additional systemic antibiotic treatment is indicated [107, Although tissue damage and necrosis in body parts 112] to treat the local infection and prevent secondary are likely to be accompanied by pain, none of the papers infections likely induced by bacteraemia [96, 111]. More- discusses this subject in particular. Among the papers over, pigs with severe tail injuries involving partial or total examining ear biting, however, one study developed an loss of the tail

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mong the papers over, pigs with severe tail injuries involving partial or total examining ear biting, however, one study developed an loss of the tail should be moved to a hospital pen, and ethogram for biter and bitten pigs and studied behaviours identified aggressor animals should be removed from the such as pain-related vocalization [115]. The findings from group [112]. The chances of recovery from tail biting are this study suggest that ear pulling, head shaking and, to good if the animals are treated early. In a previous study, a lesser extent, quick bites invoke greater pain, as indi- a healing rate of 89% was achieved through the provision cated by the avoidance behaviour and screaming of the of additional enrichment materials and removal of the bitten pig [115, p. 34]. Moreover, a study on behavioural perpetrators [112]. However, if an infection has occurred, and physiological responses to damaging procedures the prognosis for the animal is poor [113]. was integrated [119]. The findings from this study sug- gest that a combination of head shaking, ear scratching, Flank biting shivering and grunting indicates pain after ear tagging or Flank biting can occur due to damaging behaviour simi- notching (p.92). lar to tail and ear biting [99, 114, 115]. The pathology Apart from behavioural parameters, studies concern- of biting lesions are similar in histopathological terms. ing ear lesions often use scoring systems similar to those Hence, depending on the intensity, depth and involve- used for tail lesions. For example, clinical or histological ment of bacteria, findings range from superficial epider- examinations concerning the size, freshness, depth or mal lesions to deep ulceration [116]. loss of the ear surface have been performed (for an over- In general,

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s concerning the size, freshness, depth or mal lesions to deep ulceration [116]. loss of the ear surface have been performed (for an over- In general, studies dedicated to flank biting alone are view see [117]). Interestingly, none of the scores or stages rare [99]. Following one study in the review, the effects of severe lesions were discussed in relation to pain. Kschonek et al. Porcine Health Management (2025) 11:13 Page 8 of 17 In comparison to the treatment of such lesions, the Timely identification and removal of affected sows from healing processes and prognoses depend on the particu- the group, along with appropriate analgesic treatment, lar lesion state and are rarely discussed. In general, stages are necessary to minimize pain and further damage [122]. ranging from re-epithelization with intermediate clinical signs of crusting and leakage similar to tail bites to a final, CNS (meningitis) total loss of the ear are possible [117, 118]. Meningitis is a common disease in pigs and is considered Treatment of ear-bitten pigs depends, of course, on to cause pain [6]. Among the reviewed papers, only one the stage of the lesion. Separating pigs to a hospital pen, addressed pain in CNS-related diseases [129]. providing materials to reduce damaging behaviour and In general, Streptococcus suis is the most important mitigating risk factors are generally advised. Interestingly, pathogen that generates meningitis worldwide, and S. providing antibiotics is a discussed strategy due to the suis infections affect 5- to 10-week-old pigs in most assumed involvement of bacteria in the onset or exacer- cases. Clinical signs of this infection may include septi- bation of a lesion [117]. Although this topic has not been caemia and acute death, meningitis, polyarthritis, poly-

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this infection may include septi- bation of a lesion [117]. Although this topic has not been caemia and acute death, meningitis, polyarthritis, poly- discussed previously, pain relief for pigs with substantial serositis, and valvular endocarditis [130, 131]. Although ear lesions should also be considered. However, further most weaned piglets carry S. suis strains, few carry viru- research is needed to examine the influence of medica- lent strains capable of inducing the disease. In peracute tions such as NSAIDs on the healing process and welfare cases, pigs may die without any preceding clinical signs. of pigs with ear lesions [115, 117]. Otherwise, pigs may exhibit incoordination and adoption of unusual postures in early stages, which soon progress Vulva biting to inability to stand, paddling, opisthotonus, convulsions, Vulva biting is a behaviour observed in group-housed and nystagmus. Other clinical signs may also be observed sows and is often associated with factors such as frustra- [132], but early recognition and immediate parenteral tion, competition for food and limited access to resources treatment with an appropriate antibiotic with or without [120]. It serves as a commonly used indicator of sow an anti-inflammatory agent maximizes pig survival [133]. welfare. As S. suis is also well known as a zoonotic agent, The swelling of the vulva in late pregnancy increases assumptions about pain related to its meningitis can be vulnerability to attacks [121], leading to enhanced occur- supported by manifestations in humans. Clinically, head- rence during this period [122]. Once the vulva is bitten, ache, fever, vomiting, nervous disorders, and later hearing the increasing swelling, discolouration, and potential loss can be observed most frequently [134]. According to

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, nervous disorders, and later hearing the increasing swelling, discolouration, and potential loss can be observed most frequently [134]. According to presence of blood and pus attract further attention, different systematic reviews, fever, headache and neck thereby exacerbating pain [120]. Sows show signs of self- stiffness also appear to be the most prominent clinical protective behaviour by sitting down in feeding queues, signs [135, 136]. Headache certainly presents a sort of likely to avoid being bitten by the following sow [123] pain, but as shown in a case study of a Persian cat, severe or by keeping the time to feed at the trough particularly mid-lumbar back pain and extreme reluctance to move short [124], while bitten sows react very sensitively and were the only abnormalities on physical and neurological try to flee the situation [120]. Taken together, these find- examinations [137]. Hence, pain induced by S. suis infec- ings indicate that vulvar bites cause considerable pain to tions may be obvious not only in pigs with lameness but sows. However, in terms of pain alleviation, the signifi- also in those with meningitis [6], as described in human cance of vulva biting lesions has often been disregarded, medicine and other species. and it is not unlikely that this is caused by a misunder- In pig practice, anti-inflammatory drugs are recom- standing. An increase in the nociceptive threshold has mended for the treatment of meningitis because in been shown during late pregnancy and parturition not addition to their anti-inflammatory effects, they can only in women but also in sows [125], perhaps as an reduce pain and have antipyretic effects [138]. How- endogenous defence against the pain of parturition [126]. ever, the effects of treatment with analgesics in

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n and have antipyretic effects [138]. How- endogenous defence against the pain of parturition [126]. ever, the effects of treatment with analgesics in cases of This mechanism might facilitate pain alleviation during S. suis infection in pigs have rarely been documented. A parturition, but there is no evidence that vulvar lesions study evaluated the effect of buprenorphine treatment induced by biting are generally not painful. in an S. suis infection model in pigs [129]1. The intrave- The severity of the wounds can vary, ranging from nous administration of S. suis to 6-week-old piglets led fresh wounds to old scars, and complications such as to severe disease in approximately 50% of the animals. secondary infections can occur [127]. Skin-perforating Suppurative meningoencephalitis and arthritis as well as lesions showing signs of inflammation are likely painful fibrino-suppurative endocarditis were the main findings for affected sows. In severe cases, vulva biting can result in extensive scarring and disfigurement, possibly caus- 1 In Germany, the opioid analgesic buprenorphine is not licenced for use in ing considerable pain during subsequent farrowing [128]. pigs. Kschonek et al. Porcine Health Management (2025) 11:13 Page 9 of 17 at necropsy. For pain scoring, the following parameters dyspnoea, are associated with severe thoracic pain [141]. were assessed: feed intake, lameness, movement time, Therefore, careful monitoring and early intervention get-and-scare up, pain vocalization, and behaviour (fresh, involving euthanasia are recommended to avoid unneces- damped, listlessness, central nervous disorder [tetanic sary suffering [141]. Furthermore, Swinkels et al. showed spasm, opisthotonus, convulsion]). Additionally, special the beneficial effects of Ketoprofen in

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suffering [141]. Furthermore, Swinkels et al. showed spasm, opisthotonus, convulsion]). Additionally, special the beneficial effects of Ketoprofen in addition to antibi- signs (kyphosis, tremor) were evaluated. The adminis- otics on recovery rates and feed intake in pigs infected tration of 0.05 mg of buprenorphine/kg for 5 days i.m. with A. pleuronpneumoniae [142]. every 8 h post infection did not prevent high clinical or Despite the lack of published data on pain associated pain scores in affected animals and did not result in sub- with pulmonary diseases in pigs, pain is undoubtedly one stantially lower mean clinical or pain scores. Hence, the of the cardinal symptoms of any inflammatory response chosen protocol of buprenorphine application does not and thus also of respiratory tract infections. Therefore, it prevent severe distress or pain in this infection model can be assumed that pigs experiencing respiratory tract [129]. infections suffer pain. In addition, noxious gases released from pig faeces, Respiratory tract such as atmospheric ammonia, can irritate even healthy Infections of the respiratory tract are among the most respiratory tracts. Poor air quality increases the risk common health problems in pig husbandry. In addition of respiratory diseases by irritating the epithelium and to the general negative impact on pig health and wel- even causing cilia loss/function [143]. If given the choice, fare, respiratory tract infections can cause reduced feed young pigs would more likely choose to stay in areas con- intake, decreased daily weight gain and increased mor- taining no atmospheric ammonia than in areas with even tality. Symptoms of respiratory tract infections in pigs lower concentrations (10–20 ppm) [144]. Furthermore, include reduced general

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areas with even tality. Symptoms of respiratory tract infections in pigs lower concentrations (10–20 ppm) [144]. Furthermore, include reduced general condition, fever, dyspnoea, pain- Jones et al. found that pigs left areas where ammonia was ful breathing (sometimes in the dog sitting position), present after approximately 35 min [144]. Because of the coughing, sneezing, nasal discharge, cyanosis, reduced lack of immediate aversion, the authors concluded that feed intake [anorexia], reduced daily weight gain, and, in not the odour of ammonia caused the pigs to leave these the worst case, death [139]. areas but rather the discomfort caused by the gas. Respiratory infections not only impact the lungs but While a respiratory tract irritated by (high) levels of also affect the trachea and nasal cavities. Pneumonia and/ atmospheric ammonia is by definition not a disease, it or bronchopneumonia and pleurisy are the main find- should not be underestimated concerning the resulting ings in this context in the affected pigs at slaughterhouses discomfort and even damage and pain and the potential [140]. infections of the respiratory tract that could follow. Even though respiratory tract infections are common in pigs worldwide, there is a lack of literature concerning Gastrointestinal tract pain caused by respiratory tract infections in pigs at every Pain resulting from various gastrointestinal diseases in age. As stated by Pessoa et al., respiratory tract infec- humans is an important research field in which the spe- tions are likely to have a significant negative impact on cies pig is widely used as an animal model. Some infor- pig welfare ([140], p.1), although such an effect is rarely mation about pain in gastrointestinal diseases in pigs can considered in the literature.

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- pig welfare ([140], p.1), although such an effect is rarely mation about pain in gastrointestinal diseases in pigs can considered in the literature. Indeed, studies on indicators therefore be deduced from neuroanatomical and physi- of actual pain followed by respiratory tract infections and ological findings in these translational studies. The intes- the potential impact on pig welfare are missing. tinal nervous system in humans is mainly autonomic but This is all the more surprising because, in a survey by is in part controlled centrally by extrinsic innervation via Ison and Rutherford, farmers and veterinarians rated three pathways: parasympathetic and sympathetic effer- respiratory diseases in pigs as painful and scored the ent innervation and sympathetic afferent innervation. It expected pain with 5.1 on an 11-point scale [26]. The rec- is known that pain stimuli from the stomach and intes- ognition and management of pain was assessed as impor- tine are conducted by afferent nerves to the brain [145]. tant in this study, and many participants in the survey In contrast to studies in humans, pain assessment expressed an interest in identifying pain in pigs as well as studies of gastrointestinal disorders in pigs are rare. In the treatment options available. most studies, important animal-based indicators, such However, information on pain in relation to por- as behaviour and vocalization, are used to assess dis- cine respiratory diseases is limited to studies on por- tress without differentiating pain as a stressful condition cine pleuropneumonia caused by Actinobacillus (A.) [146]. In gastrointestinal diseases, behavioural scoring pleuropneumonia. For instance, infections induced by for pain assessment can be considered more meaning- A. pleuronpneumoniae, which

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havioural scoring pleuropneumonia. For instance, infections induced by for pain assessment can be considered more meaning- A. pleuronpneumoniae, which can cause necrotizing ful than vocalization, which has been used for acute pain pneumonia, fibrinous pleurisy, pulmonary oedema, and Kschonek et al. Porcine Health Management (2025) 11:13 Page 10 of 17 combined with extreme stress, e.g., during surgical cas- studying interventions for gastric ulcers in swine [154]. tration [147, 148]. The results obtained in this model revealed the impact Rectal prolapse is a specific disorder of the gastro- of antral ulcerations on the intramural nerves responsi- intestinal tract that can be differentiated by its length ble for the function of the pyloric sphincter. In humans, and obvious injury to the mucosa. Due to acute painful this painful disease is characterized by a malfunction of events, when the non-physiologically exposed mucosa gastric emptying [154]. In this experimental pig model is injured or destroyed, pain assessment might be easier for gastric ulcers, neuronal responses were studied. The than in other gastrointestinal diseases. Several stress bio- expression of the neuropeptide galanin, which is widely markers, including cortisol and salivary alpha-amylase, distributed in the gastrointestinal tract and modulates have been used to assess pain during rectal prolapse to the enteric nerve response, among other biological func- validate a modified pain perception protocol published tions, was also examined in inferior vagal neurons in pigs by Morton and Griffith [6, 147]. A score from 0 to 20 was [155]. Neuropeptides such as galanin are synthetized by based on the patient’s appearance and body condition primary afferent neurons and are involved in visceral pain score,

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h as galanin are synthetized by based on the patient’s appearance and body condition primary afferent neurons and are involved in visceral pain score, clinical signs and behaviour without any stimu- signalling. In swine with experimentally induced gastric lus and response to external stimuli [149]. A combined ulcers, galanin expression was significantly greater than score equal to or greater than 5 indicated not only pain that in healthy control animals, supporting the assump- but also distress and discomfort. Pain, distress and dis- tion that gastric ulcers are painful [155–158]. Abdominal comfort were recorded for pigs with a prolapse length of pain is a symptom of various anatomical and functional 6+-2.5 cm but not for pigs with smaller prolapses (3.0+- gut alterations, such as intestinal inflammation, par- 4.3 cm). The scoring outcome was related to several bio- tial blockage and gut distension. Pain is considered the markers [147]. most important symptom in 50–70% of patients with In other gastrointestinal diseases, pain assessment inflammatory bowel disease [159]. It is also known that can be biased by inappetence and other disease-related persistent changes in afferent neurons due to sensitized behaviours [6]. Gastrointestinal diseases were scored as sensory pathways and despite resolved inflammation can moderate by veterinarians and farmers, ranging from 4.5 lead to persistent pain [159]. Enteric inflammation in to 5.6 on a 10-point pain scale based on their experience swine due to various pathogens can lead to pathomor- [26]. Assessment of pain relies mainly on behavioural phological inflammatory and functional changes similar characteristics [150]. Behavioural indices for the assess- to those in humans; thus, the occurrence of abdominal ment of acute

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ctional changes similar characteristics [150]. Behavioural indices for the assess- to those in humans; thus, the occurrence of abdominal ment of acute pain have been described for piglets after pain can be hypothesized, at least in severe cases [160]. intra-abdominal injection, which can cause abdominal The ileocecal valve is innervated by dorsal root ganglia pain. Typical pain-related behaviours such as rubbing neurons, and specific bacterial lipopolysaccharides can the abdomen against the floor and huddling (i.e., tuck- influence the neurochemical reactivity to neuropeptides ing three or more legs under the body) have also been at this location [161]. It can therefore be hypothesized observed [119, p.89]. In addition, control pigs and treated that swine infectious enteric diseases impact neurophysi- pigs differed with respect to being awake without mov- ological mechanisms and therefore pain signalling. ing, as abdominal pain seems to be quite subtle, “awake inactive behaviour”, (119, p. 91). According to the experi- Urinary tract infections ence of the author team, metamizol may be assessed in Inflammatory processes in the porcine urinary tract of a given case given its spasmolytic characteristics [198, sows are mostly caused by facultative pathogens such as 199]. Escherichia coli, streptococci, staphylococci, Proteus spe- Gastric ulcers in sows and in finisher pigs are impor- cies, Klebsiella species and Trueperella (Actinomyces) tant welfare issues in swine production and occur at pyogenes [162, 163, 196]. Lesions due to nonspecific uri- varying rates among countries and studies [151]. In fin- nary tract infections [UTIs] are usually restricted to the isher pigs with gastric ulcers, behavioural changes were urinary bladder and cause only mild clinical signs.

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ions [UTIs] are usually restricted to the isher pigs with gastric ulcers, behavioural changes were urinary bladder and cause only mild clinical signs. Con- observed and interpreted as pain-related behaviour. Pigs tamination and ascent of the urethra by faecal microbiota with gastric ulcers spend significantly more time walk- is possible but more likely in females than in males. ing and standing than their pen mates and tend to rest The clinical signs in sows with cystitis include urinary less and avoid lying on the left side of the body [152]. In changes in most cases. Some pigs urinate in small quanti- contrast, behavioural observation of fattening pigs two ties with straining or be observed in a dog-sitting posi- days before slaughter and inspection of gastric lesions in tion [162, 164]. General signs of illness become apparent the respective pigs resulted in more lying in contact with if cystitis is followed by ascending infection to the kid- other pigs, more manipulation of pen mates and longer neys and the development of pyelonephritis, resulting in eating times in affected pigs [153]. In translational medi- uraemia [165–167]. cine, the “acetic acid ulcer model” is well established for Kschonek et al. Porcine Health Management (2025) 11:13 Page 11 of 17 The clinical symptoms may depend on the involved Interestingly, posterior mammary complex pairs are pathogen. For example, generalized infection of the uri- often affected, potentially due to sows injuring them- nary tract is often caused by Actinobaculum suis, which selves with hind claws [179–181] or likely to have lower is carried by boars and can be transmitted to sows dur- milk production in the caudal glands [182]. Piglets work- ing mating. Clinical signs may develop 2–3 weeks after ing harder at

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ransmitted to sows dur- milk production in the caudal glands [182]. Piglets work- ing mating. Clinical signs may develop 2–3 weeks after ing harder at the rear udder due to lower milk supply mating or may be delayed until farrowing. Affected sows might lead to more accidental biting. Additionally, the or gilts may die suddenly or be found ill, depressed, or distinct nervous supply of pair number 7 could decrease thirsty with hunched backs. Haematuria is the main sign their sensitivity to pain, resulting in slower pain reactions of the acute phase, together with frequent and pain- to injury [179]. ful voiding and dysuria. Later, the affected animals are The pathogen involved in mastitis may influence the uraemic; they pass bloodstained, purulent urine with set of clinical signs in a sow. In general, however, masti- or without vulval discharge; and they exhibit inappe- tis is considered to be a postparturient disorder complex, tence and weight loss. Typical cases exhibit the following such as postpartum dysgalactia syndrome (PPDS) (for- symptoms: hypothermia below 38 °C, a heart rate greater merly referred to as mastitis-metritis-agalactiae (MMA)), than 120, painful abdomen, polypnea, cyanosis, ataxia, rather than a distinct disease entity (cf. [183]). This and more rarely generalized tremor. Moreover, clini- approach makes it difficult to define pain-specific behav- cally affected sows frequently die from renal failure [165, iour, although mastitis in sows is generally considered 167–169]. painful by veterinarians and farmers [6, 26], similar to Regarding behavioural changes, pain due to UTI can be what is the case for cows [184, 185]. Regarding mammary expected, especially if haemorrhagic cystitis and pyelo- skin lesions, histological findings and bacterial

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case for cows [184, 185]. Regarding mammary expected, especially if haemorrhagic cystitis and pyelo- skin lesions, histological findings and bacterial identifica- nephritis are present. In the review, however, no studies tion revealed dermal and subcutaneous pyogranuloma- elaborating on pain in relation to UTI in pigs were found. tous lesions due to infection with Staphylococcus aureus This is astonishing since much about the pathophysiology and dermal abscesses associated with Trueperella pyo- of the urinary tract, including the neuronal patterns of genes. The glandular tissue of the mammary was unaf- pigs, is known and appears to perform similarly to what fected, which ruled out mastitis [179]. Another study has been done in humans [170, 171]. found an association between mammary lesions and The symptoms of acute cystitis in humans are similar Pseudomonas spp., primarily affecting the dermis with and include dysuria with or without increased frequency, potential gland involvement. Inflammation is driven by urgency, suprapubic pain, cloudy urine, or haematuria lymphocytes via the IL-1β/IL-6 pathway, partly involving [172–175]. Dysuria is defined as the sensation of pain T cells [186]. Recent evidence also links IL-1β to inflam- and/or burning, stinging, or itching of the urethra or mation and pain [187]. urethral meatus associated with urination [176]. Hence, Sows in pain may exhibit various avoidance behaviours, it must be considered that pigs with bacterial cystitis can including attempting to move away from piglets, rest- also experience some pain at least when urinating. lessness, and alterations in posture, such as dog sitting In addition to the lack of studies about pain indicators or increased ventral lying patterns [188–191, 197]. They related to UTIs,

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such as dog sitting In addition to the lack of studies about pain indicators or increased ventral lying patterns [188–191, 197]. They related to UTIs, very little is known about pain treatment may also modify their maternal behaviours, potentially for cystitis in sows. In addition to antibiotic treatment, reducing nursing frequency and increasing aggression Stirnimann et al. recommended the administration of a towards piglets [192, 193]. spasmolyticum/analgeticum [Metamizole], as the results The prevalence of teat lesions may range from 3.3 to obtained for acute UTIs in sows were better than those 19% and may not be detected by inspection alone [186]. obtained with antibiotic treatment alone [165, 166]. Summarizing, it is striking that pain due to mastitis and teat lesions in sows are (still) only marginally discussed in Mastitis and teat lesions the reviewed literature [183, 186]. Mastitis is an inflammatory process of the mammary For pain mitigation in mastitis, treatment with an gland and is caused by bacterial infections and/or trau- NSAID (flunixin, meloxicam) combined with antibiot- matic teat lesions. Acute mastitis affects sows mainly ics and oxytocin is suggested to be effective at improving within 3 days after farrowing and is accompanied by sys- clinical conditions [194]. Although farmers may tend to temic signs (fever, reduced feed intake) and local signs treat severely diseased pigs [26], another study found that of inflammation (oedema, skin congestion) [177]. Risk farmers rated mastitis to be the second most frequent factors for the occurrence of teat injuries include the reason for the administration of NSAIDs [30]. presence or absence of tooth resection in piglets, differ- NSAIDs are rather effective at mitigating inflamma- ent methods of tooth

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on of NSAIDs [30]. presence or absence of tooth resection in piglets, differ- NSAIDs are rather effective at mitigating inflamma- ent methods of tooth resection, housing systems (espe- tion than pain; however, the authors generally indicate an cially flooring), litter size, piglet-related management overall improvement in the recovery of the animals dur- strategies, milk supply and barren environments [178]. ing treatment [26, 183]. However, no further knowledge Kschonek et al. Porcine Health Management (2025) 11:13 Page 12 of 17 about the healing processes of mastitis and udder pathol- Supplementary Information ogies is available, although further study is needed to The online version contains supplementary material available at ​h​t​t​p​​s​:​/​​/​d​o​i​​.​o​​r​ g​/​​1​0​.​​1​1​8​6​​/​s​​4​0​8​1​3​-​0​2​5​-​0​0​4​2​0​-​1. avoid related pain (cf. [186). Supplementary Material 1 Discussion and conclusion Supplementary Material 2 The results of the review emphasize that pigs experi- ence pain due to spontaneously occurring diseases and Acknowledgements injuries, but systematic knowledge about this topic not applicable. is scarce. On the one hand, there is a lack of publica- tions about certain topics, such as flank biting. On the Author contributions JK designed, drafted, analysed, interpreted and revised, KD analysed, other hand, certain publications elaborate on topics interpreted and revised, MM analysed, interpreted and revised, JR analysed, that involve pain indicators, but discussions neglect the interpreted and revised, LT analysed and revised; IE analysed and revised, NK implications of results for pain identification, measure- analysed and revised, LK revised, IHP

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, LT analysed and revised; IE analysed and revised, NK implications of results for pain identification, measure- analysed and revised, LK revised, IHP analysed and revised, MW analysed and revised, SK revised, EGB designed, drafted, analysed, interpreted and revised. ment and treatment. The last point is true for research in veterinary as well as human medicine generated for Funding translational interest. Hence, one core implication of the Open Access funding enabled and organized by Projekt DEAL. This work is financially funded by the German Federal Ministry of Food and review is that more systematic research on pain in pigs is Agriculture (BMEL) based on a decision of the Parliament of the Federal needed for rare diseases (such as UTIs) and topics that Republic of Germany, granted by the Federal Office for Agriculture and Food were excluded in our reviews such farrowing in sows (BLE; grant number 28 N-2-008-01 “CARE-PIG”). (focus on reproduction management). Another implica- Data availability tion is that conducted research should involve standard- No datasets were generated or analysed during the current study. ized protocols to document, analyse and share results on pain detection beyond the project timeframe. Creating a Declarations standardized protocol is indeed another core implication Ethics approval and consent to participate of this review. The findings of this review suggest that a not applicable. standardized protocol would comprise the observation of validated pain identification measures of different kinds Consent for publication not applicable. (behavioural, biomarkers) over time and in relation to administered pain treatment. Based on a set of compa- Competing interests rable studies, it will be possible to validate these assump- The authors

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to administered pain treatment. Based on a set of compa- Competing interests rable studies, it will be possible to validate these assump- The authors declare no competing interests. tions and enhance the evidence about pain in pigs in the Received: 8 February 2024 / Accepted: 17 January 2025 future. With regard to evidence, it must be considered that the findings in this article originate from a scoping review without addressing the evidence level or risk of bias [3, References 195]. Furthermore, the search strings contained exclu- 1. Kschonek J, Twele L, Deters K, Miller M, Reinmold J, Emmerich I et al. Part I: sion criteria (such as the term “NOT”) which may have understanding pain in pigs-basic knowledge about pain assessment, mea- sures and therapy. Porc Health Manag. 2025. ​h​t​t​p​​s​:​/​​/​d​o​i​​.​o​​r​g​/​​1​0​.​​1​1​8​6​​/​s​​4​0​8​1​ excluded relevant results. 3​-​0​2​5​-​0​0​4​2​1​-​0. In the future, systematic reviews weighting results 2. Tricco AC, Lillie E, Zarin W, O’Brien KK, Colquhoun H, Levac D, et al. PRISMA based on evidence and quality of the sample size and Extension for scoping reviews (PRISMA-ScR): Checklist and Explanation. Ann Intern Med. 2018;169(7):467–73. ​h​t​t​p​​s​:​/​​/​d​o​i​​.​o​​r​g​/​​1​0​.​​7​3​2​6​​/​M​​1​8​-​0​8​5​0. statistics are needed once enough papers are available. 3. Munn Z, Peters MDJ, Stern C, Tufanaru C, McArthur A, Aromataris E. Sys- Irrespective of statistical significance, the review and tematic review or scoping review? Guidance for authors when choosing synthesis of publications show that pain in pigs due to between a systematic

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