1

Abstract

A perineal hernia may be unilateral or bilateral and results from weakening

and separation of the pelvic diaphragm muscles, favoring the abdominal viscera

herniation into the perineal subcutaneous. The factors described as possible

etiology of this affection are prostate hyperplasia, senile muscular atrophy,

myopathy, and hormonal imbalances (Sprada, 2017). Perineal hernias exhibit as a

swelling adjacent to the rectum and most commonly occur in older unneutered dogs.

A 9-year-old intact male dog weighing 14 lbs. was consulted with a presenting

complaint of urination problem. On physical examination, the perineal hernia has

been confirmed. Caudal perineal hernia type has been described in this case. The

traditional method of suture has been applied to appose weakened structures and

the skin. The patient showed uncomplicated recovery without recurrence.

Keywords: Dog, Herniorrhaphy, Pelvic floor, Perineal Hernia, Urinary Bladder

 2

Introduction

The perineum, also known as the pelvic floor in humans, is the area between

the anus and the scrotum or vulva. This area supports the organs of the pelvis. A

perineal hernia occurs when there is a weakening or traumatic tear in the muscles of

the area, resulting in the bladder, intestines, or fat pushing through the muscle to an

abnormal position just under the skin. Four types of perineal hernia have been

described: caudal, dorsal, ventral, and sciatic.

Many factors are involved, including breed predisposition, hormonal

imbalance, prostatic disease, chronic constipation, and weakness of the pelvic

diaphragm due to chronic straining. The higher incidence among sexually intact

males is evidence that hormonal influences probably play a primary role.

Prostatic hypertrophy attributed to sex hormone imbalance has been

strongly implicated. Both estrogens and androgens have been cited as causative

agents. Congenital predisposition in short/docked tail dogs because of the

underdeveloped levator ani and coccygeal muscle. It is more commonly diagnosed

in dogs than cats.

The vast majority of cases occur in intact male dogs that are middle-aged or

older. It has been hypothesized that anatomic factors, hormonal imbalances,

damage to the nerves of the pelvic diaphragm, and straining due to prostate gland

enlargement may contribute to the development of a perineal hernia. With the loss

of lateral support, there is progressive rectal deviation, which leads to enlargement.

Unilaterally, this is termed sacculation, whilst the bilateral disease is termed

dilatation. True rectal diverticula with rectal mucosa protruding through the rectal
 3

musculature are extremely rare. Hernias may be complicated by the inclusion of

pelvic and peritoneal fat, loops of the small intestine, prostate gland, paraprostatic or

prostatic cysts, and, in severe cases, by retroflexion of the bladder.

Dogs with perineal hernias often repeatedly strain as if to defecate, they may

have difficulty passing stools and may become constipated. If the bladder has

become herniated, they may also strain to urinate, have urinary incontinence, or be

unable to urinate. In severe cases, such as when the intestine has herniated or if

bladder herniation has caused a urinary obstruction, dogs will become lethargic and

have a decreased appetite. A diagnosis of perineal hernia can be made on history,

clinical signs, and visual and digital rectal examination. Several surgical methods

have been described for the reconstruction of the ruptured pelvic diaphragm. The

most important ones are the standard herniorrhaphy, the transposition of the gluteal

muscle, and the transposition of the internal obturator muscle.

 4

Description of the Case

A 9-year-old intact male, mixed breed dog weighing 14 lbs was presented to

the clinic for a clinical check-up. The presenting complaints the patient exhibits were

scanty, blood-tinged urine, sometimes anuria (complete absence of urine), and

tenesmus. On physical examination, sacculation adjacent to the rectum on one side

(right portion) had been present for several days.

Fig.1. Radiographic image showing mild sacculation of the pelvis.

After confirming the initial diagnosis, surgical correction was a primary option

to address the problem. The pre-surgical complementary tests performed were

blood count, liver profile (ALT), SGOT, BUN, and CREATININE (taken a week prior

to the case presentation) were all normal.

 5

The patient underwent surgery and was premedicated with atropine sulfate

(0.1 ml/kg, SC), followed by anesthetic induction of Tiletamine hydrochloride and

Zolazepam hydrochloride (0.15ml/kg, IV). The patient was maintained with

Isoflurane and Oxygen. Lactated Ringer's solution was administered to maintain

fluid during the procedure. The patient was positioned in sternal recumbency with

the tail retracted.

A purse-string suture pattern was placed in the anus following packing with

surgical gauze. A slightly curved skin incision extending from the base of the tail to

the lower portion of the rectum was made and deepened through the hernial sac.

The subcutaneous tissues were dissected and the hernial contents found were a

urinary bladder and an enlarged prostate gland. The urinary bladder and prostate

gland pass through the Levator ani, coccygeus, and external anal sphincter muscle.

Abdominal organs such as the urinary bladder and prostate gland were placed in

their normal anatomical position. After placing the urinary bladder and prostate

gland, the purse-string suture method was used to apposed deep areas of

sacculation. After a layer of purse string sutures, a simple interrupted suture pattern

was used to close external layers of muscle (external anal sphincter, coccygeus

muscle, and L. ani muscle) and transposition of obturator muscle into the latter

structures.
 6

Fig.2. Unilateral bulging of the right pelvic diaphragm. A curved incision was made to
open the sacculation.

Fig.3. The intra-operative image showing herniated urinary bladder and extraction of
urine content.
 7

Fig.4. Intraoperative image exposing the urinary bladder and enlarged prostate
gland.

Then, the subcutis and skin were closed routinely using 3/0 prolene. After

surgery, the purse string and the gauze were removed from the rectum. The penile

catheter was placed after the procedure to facilitate drainage of urine.

Due to various anesthetic issues that arose during the procedure, castration

was not done on this patient.

 8

Fig.5. Post-operative image of hernia of the pelvic region.

A postoperative antibiotic was applied using Cefuroxime sodium (15mg /kg

IV), Tolfenamic acid (2mg/kg), SC, and other electrolytes and supplements. After 7

days of confinement, the patient was transitioned to oral antibiotics and discharged

into his owner’s care with full care instruction on how to manage his wounds. Oral

medications were Amoxicillin + clavulanic acid (25mg/kg) as an antibiotic,

Tolfenamic acid (0.2ml/kg), Mupirocin as a topical cream, and Multivitamins. Skin

sutures were removed on the 10th day postoperative day.

 9

Discussion

Perineal hernia according to (Rohit Kumar, 2018) is a protrusion of the

abdominal organs into the peritoneal area through the weak pelvic diaphragm. It is

commonly found in uncastrated aged male dogs rare on cats and characterized by

constipation, dyschezia, perineal swelling, and urination problems. The breeds that

are most commonly affected are Boston Terriers, Boxers, Welsh Corgis, Pekingese,

and Dachshunds.

The most common perineal hernia occurs between the levator ani, internal

obturator, and external anal sphincter and is termed a caudal perineal hernia. Other

perineal hernias include the dorsolateral (between the coccygeus and levator ani),

ventral (between the ischiourethralis, bulbocavernosus, and ischiocavernosus

muscles) and sciatic perineal hernia (between the coccygeus and sacrotuberous

ligament). Combinations of these hernias can also occur on the same side or also

on the opposite (contralateral) side.

There are several techniques described to correct perineal hernias including

anatomical reposition of the pelvic diaphragm with suture (Herniorrhaphy), internal

obturator muscle transposition, superficial gluteal muscle transposition, and use of

synthetic meshes or biological membranes.

In this case, the patient was a male intact dog with a urination problem. The

patient upon physical examination, apparently has an aspect of a bag palpated on

the right, posterior area of the rectum. On radiographic findings, the presence of a

urinary bladder has been found in the latter.

 10

The type of perineal hernia occurred in this case described as caudal type

of herniation. The displaced organs (urinary bladder and prostate glands) were

displaced along the external anal sphincter muscle, coccygeal and levator ani

muscle. The organs were placed back into its normal anatomical positions during

the procedure. Purse string suture method was used to appose the deepened

structures using absorbable catgut 3/0 to prevent the contents to displaced back to

the perineum. After the deepened structures has been sutured, simple interrupted

suture pattern was used to fixed the coccygeus and levator ani muscle to external

anal sphincter. In this case, incision of internal obturator muscle which used as flap

into the posterior part of external anal sphincter, coccygeus and L. ani. muscle to

closed the opened structure using monofilament (Monosyn) 3/0. The remaining

structures like the subcutis and the skin were sutured accordingly. In here, we used

Prolene 3/0 as suture material.

The patient has a promising recovery after the procedure. Postoperative

complications were not noticed like wound infection, faecal incontinence, perineal

fistula, sciatic nerve entrapment, excessive straining due to postsurgical pain,

bladder atony due to anuria, rectal prolapse, and rectocutaneous fistula.

 11

Fig.6. Radiographic image wherein the bladder was in position after 5 post operative
days
 12

Conclusion

There are several surgical methods used to address perineal hernia in dogs

such as herniorraphy or transposition of the internal obturator muscle. Regardless of

the method used, the prime objective of the surgery is to restore displaced

structures to their normal anatomical positions. In this case report, transposition of

the internal obturator muscle of the perineal hernia was used as an applied

treatment which has a promising and good post-operative outcome with no recorded

complications and recurrence of the case after the surgery.

References
 13

Appendices

LEA JAN R. DE LA CRUZ – DIONEO, D.V.M.

Address: Brgy. Granada, Bacolod City, Negros Occidental
E-mail: leajandioneo@gmail,com
Contact Number: 09287802945

Personal Information

Birthday: June 06, 1985

Birthplace: Badbaranan, Dumarao, Capiz
Civil Status: Married
Age: 37 years old
Citizenship: Filipino
Sex: Female
Height: 5’4

Professional Summary
Veterinarian with a passion for her work who has excelled for many
years and has advanced understanding of both acute and chronic illnesses.
Committed in providing high-quality treatment to a large number of clients
while maintaining compassion.

Education
College
 Gaduated Doctor of Veterinary Medicine March 2008
Capiz State University
Dumarao, Capiz
 14

Secondary
 Our Lady of Snows Institute March 2002
Dumarao, Capiz

Elementary
 Bdbaranan Elementary School March 1998
Dumarao, Capiz

Experience
July 2008 – June 2009
Assistant Veterinarian
Banga Veterinary Clinic
Jaro, Iloilo City

June – October 2009

Instructor
College of Veterinary Medicine
Capiz State University
Dumarao, Capiz

February – November 2010

Medicator – MCF Fattener
Jaltas Hog Farm
Had. Pacita, Ma-ao
Bago City, Negros Occidental

January 2011– Present

Veterinarian
Pet House Central Veterinary Clinic

Seminars Attended
SEPTEMBER 23, 2013
Immunocomb and Immunorun Training
Glenwood Technologies International, Inc.

DECEMBER 8-9, 2014

Advancing Veterinary Dentistry and Oral Hygiene for Growing
Companion Animal Practices
Philippine Animal Hospital Association (PAHA)
 15

APRIL 21 – 24, 2015

Small Animal Veterinary Radiology Update Course
Philippine Animal Hospital Association (PAHA)

FEBRUARY 20-22, 2019

86th Philippine Veterinary Medical Association (PVMA) Scientific
Conference and Annual Convention

SEPTEMBER 27-29. 2022

27TH Annual Philippine Animal Hospital Association

JANUARY 26-27, 2023

“Revitalizing Regional Animal Industry through Resilient and
Advanced Practices”
1ST Western Visayas Companion Animal, Poultry and Livestock
Conference

Reference
DR. ELIEZER Z. DELA CRUZ
Owner
Pet House Central Veterinary Clinic
Bacolod City
Mobile no. 0933-8283555