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PATIENT. Pekinese X Pomeranian,
Male, 10-13 years old.
The dog was being cared for by the mother. The married daughter in her
late thirties did not live with her mum but took the time to bring the dog
in for a second opinion. She waited patiently and did not show an angry
face. A soft spoken and gentle serene looking woman.
I had 2 long cases. A French lady with her ear scratching Golden Retriever
needing its ear flushed. This took some time. Then another man who needed
time to decide about putting to sleep his old Cocker Spaniel with a
swollen ascites abdomen.
COMPLAINT. Constipation. The first vet treated the dog for
constipation some 19 days ago, yet the mother still complained about the
dog having constipation. This dog had a full coat and the backside
swelling was not obvious. I put the dog on the table and with my left
hand, pressed the abdomen between my thumb and fingers. This procedure is
called palpation. There was no hard stool lumps inside the abdomen. I
declared: "Your dog is not constipated."
"My mum says that the Pomeranian had great difficulty in pooping for some
time," the daughter said. "The dog eats well but he takes a long time to
pass stools."
So, something must be wrong. What could this be? A tumour inside the
rectum? Cancer of the large intestine as the dog is old? But this dog was
not losing weight and has no diarrhoea.
After palpation, I took the dog's rectal temperature. Taking the rectal
temperature must be done as a routine even though the dog had an excellent
appetite. As I inserted the rectal thermometer, the dog "yelped" as if he
had been injured by the rectal thermometer. His back end erupted with a
loud crack of gas when I expressed his anal glands to examine the glands.
Farting when the anal glands are expressed is not a normal outcome. So
there was something strange.
"Please clip the anal region," I said to my groomer. "The dog has a
luxuriant coat and clipping would permit me to check for wounds. If the
anal glands were infected or inflamed, the dog would have great pain.
Therefore, he would have difficulty pooping when pain waves came in during
defaecation.
The groomer clipped and what happened? This dog had a huge right perineal
swelling! There was also a small left perineal hernia! I palpated the
right backside swelling. Many hard faecal lumps of over 2 cm in diameter
in the rectum resisted my hand pressure. A fluid wave came from the
bladder trapped inside this hernia.
To confirm that this was a perineal hernia, I pushed the swelling inwards
while the dog was standing. The swelling disappeared and this impressed
looked like magic. One time the swelling was there. The next second, it
disappeared. Another few seconds, it appeared.
"You have the diagnosis of what's wrong with your dog," I said to the
serene lady. "The rectum has gone into this back area from inside the
abdomen. Parts of the bladder with urine and abdominal fat had also been
diverted into this big rounded swelling called a perineal hernia. So the
dog had difficulty in pooping as he had to strain hard to get the
obstructed stools out of the twisted rectum into the anus. . He probably
had some problems peeing if the full bladder got trapped inside this
perineal hernia."
The sole complaint was constipation.
"What do " the lady asked as I told her that the dog also had heart
disease and might die on the operating table as the heart failed. It would
be a long operation lasting more than 45 minutes.
"You have to take the anaesthetic risk," I said. "If the dog can't poop,
he will also die a painful death as the stools piled up inside the large
intestines and release toxins into the body."
The lady decided on surgery the next day. It would be Chinese New Year's
eve. I had asked this vet student to come in the afternoon at around 3 p.m
as I wanted to show him the real thing. The backside anatomy he would
never see in a live dog. He had a dead dog in the University shared by 4
students to study anatomy. Nothing makes veterinary anatomy as alive as
seeing the rippling muscles, the pudendal blood vessels and the nerve. On
Chinese New Year's eve of 2008, a Golden Retriever with diarrhoea came in
at 3 pm. The owner could not locate the Surgery although she was supposed
to be in before 2.30 pm as I need to start the perineal hernia operation
at 3 pm. I had the reunion dinner to attend at 6.30 pm and I did not want
to be late. The culture was such that there was the "mixing of raw fish
and vegetables" for good luck at the start of the dinner and every member
of the family must be present to do it.
The dog was operated past 4 p.m. The two sides of the skin cut were
retracted by forceps and the student saw a lot of blood tinged fluid and
gel and some pieces of yellow fat on exposure. This yellowish fluid was
drained.
I showed Daniel the backside muscles but I doubted he could see them
or name them. We had gone through the anatomy of the backside before the
surgery. He had an excellent memory. But it is difficult to motivate a 2nd
year student to appreciate the backside anatomy of the dog. Veterinary
Anatomy can be a dull subject with so many names to be memorised.
I pushed back the hernia sac into a big gap of over 10 cm long and 1.5 cm
wide. "Pelvic diaphragm" I pointed to the muscle defect. I doubted he
understood. There is a diaphragm (muscle) between the chest and abdomen.
But what is a pelvic diaphragm?
He could see the anal sphincter muscle. The coccygeal and internal
obturator muscles were atrophied unlike the beautiful illustrations in the
Vet Surgery book. I closed the muscle defect by suturing with 2 layers of
2/0 absorbable sutures.
It would be some years before he will see another perineal hernia repair
as this is not a common surgery. The dog was able to poop without problems
the next 3 days and sent home to save on veterinary boarding expenses.
I reminded the owner to keep the Elizabethan collar on as the dog was
discharged without the collar. Small omissions from my staff do make me
angry as the dog may lick and open up the big wound. Somehow my assistant
overlooked the need to apply an e-collar on discharge of the dog. I
empahsized to the lady that the dog had to be confined for at least 7
days. No jumping around.
Now, there was the left perineal hernia which seems to swell and disappear
now and then. The owner had been informed.
I advised neutering the dog some time later as the male hormone seem to be
a cause of the hernia formation according to some veterinary surgery
books. I don't know whether she would remember as she does not live with
the dog. I did not neuter the dog at the same time as I wanted to shorten
the anaesthetic time so as to be successful in bringing out a live dog at
the end of surgery. The perineal surgery took more than 45 minutes. The
dog was given 8% halothane gas and then maintained at 2%. For a short
while there was some movement and he was given 2.5%. Other than that
anaesthesia was surprising smooth flowing as if the dog had a nice nap.
Without tranquilisers given as I did not want the heart to be affected. No
pain killers were given after surgery for the same reason. This dog
recovered the next day.
It is extremely kind of the daughter to take the time to bring the dog to
the vet before it was too late. Before the dog collapsed from intestinal
blood vessel strangulation and become toxic and so sickly that the
anaesthetic risk increased from the 40% to zero percentage of survival on
the operating table! A gentle client is always much appreciated by any
veterinarian. No vet can have all gentle clients all the time! But this
case was a pleasant and happy case and the dog lived to go back to a happy
aged mother whom I will never meet! I did make it to the reunion dinner on
time.
P.S.
UPDATE: As at Jan 9, 2010, the daughter had not contacted me since
the surgery in Feb 2008. I presumed that my right perineal hernia repair
was a success and that the left perineal hernia did not expand and caused
"constipation."
Dogs are very close to aged parents as they are substitute children. I
mean, the children have had flown the coop and it will be the dogs who
keep the aged parents company at home. It will be good if the
children takes time to help their parents to get the sick dogs treated
early.
Nearly 2 years had passed. Chinese New Year's Eve of 2010 would be on Feb
14, 2010 (Valentine's Day). Another old dog, a Shetland X with a large
perineal hernia was presented. What a coincidence.
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TOA
PAYOH VETS PTE LTD