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Perineal Hernia
These hernias differ from other hernias in that the displaced organs are not usually within a peritoneal sac. A specific cause has not yet been established for perineal hernias and multiple causative agents are most likely. It has been attributed to failure or weakening of the fascia and muscles of the perineum, permitting abdominal or pelvic organs to prolapse into the space created by atrophy or injury of the pelvic diaphragm.Although perineal hernias have been reported in the bitch, it occurs most commonly in intact male dogs over 8 years old, It does, however, occur in young animals, A structural predisposition has been suggested and dogs with rudimentary tails such as Boston Terriers would be more susceptible. Also reported is a hormonal imbalance etiology. This theory is supported by evidence that some dogs with perineal hernia are concurrently afflicted with testicular tumors, prostatic enlargement or enlargement of a cystic uterus musculinea. Constipation has been cited as a factor in perineal hernia but this has not been firmly established as a cause but more often a result of prostatic enlargement.
Clinical Signs
Most patients are presented for examination because they have been observed straining to defecate. Also, a swelling lateral to and extending from some distance ventral to the anus is a common sign. The hernial swelling is soft and fluctuate and manipulation often results in reduction of contents. If the bladder and prostate are hernial contents then the swelling may be turgid. if the bladder has become incarcerated or strangulated due to distension with urine following herniation, reduction might only be possible by withdrawing urine from the bladder. A perineal hernia may be bilateral, in which case the whole perineal region is swollen and the anus is displaced caudally.
Diagnosis
A hernia is apparent when the contents of the swelling can be pushed back into the pelvic cavity. This may be facilitated by elevating the animal's hindlimbs. Simultaneous palpation of the perineal enlargement and rectal examination aids in determining whether there is continuity between the swelling and peritoneal cavity, Digital examination of the rectum often reveals a lateral deviation or diverticulum into the hernial area. This deviation results in accumulation of feces in the rectum, and causes the animal to strain. During the course of the examination, the feces can be removed from the diverticulum, It then will be possible to pass the finger into it and observe its movement under the skin. Affected patients may only display the usual signs of discomfort, but if the bladder becomes strangulated and distended with urine following herniation, the swelling may be greatly enlarged and the overlying skin may be tense, blue-red, and exude serum. It may or may not be possible to catheterize the bladder in this case. The diagnosis of bilateral hernia sometimes is difficult because its reduction is not easy. A large unilateral hernia may migrate ventral to the anus into the opposite side and appear to be bilateral.
Treatment
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Most cases of perineal hernia are not emergency cases. However, those with acute complications, such as retroflexion of the bladder and inability to urinate, must be treated as emergencies. Relief can often be obtained by passing a catheter into the bladder. if this is not possible, urine can be removed by performing paracentesis. A 20 gauge needle or smaller is adequate. Once the bladder is emptied, an attempt can be made to reduce the hernia. When the hernial contents have been reduced, the animal should be given a narcotic to minimize straining. Such patients are suitable candidates for surgery in 24 hours. Once the diagnosis has been established surgery should not be delayed. if surgery is delayed the patient should be fed a lowresidue diet for 48 hours prior to surgery. The feces are then soft in consistency and the danger of postoperative wound disruption is reduced, Recurrence of perineal hernia is not common and has been reported to recur in two to forty percent of the cases.
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The sutures should not be tied until all have been inserted,' otherwise increasing difficulty will be encountered in placing the sutures. Following closure of the initial suture line an attempt is made to locate intact perineal fascia that may have retracted laterally. The edge of the fascia is grasped with an Allis forceps and a flap is formed by dissecting the outer surface of the fascia away from the overlying skin, The fascia flap is pulled medially and sutured to the most caudal portion of the anal sphincter. Another series of sutures is inserted in the subcutaneous tissues and excessive skin is trimmed to assure adequate and accurate closure. Possible complications following repair of a perineal hernia include fecal and urinary incontinence, wound infection from fecal contamination and lameness resulting from damage to the sciatic nerve during surgery. In severe cases, nylon mesh may be used to form a "diaphragm" that prevents the caudal displacement of the viscera.
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1/2/2012