SUSPECTED ENLARGED PROSTATE GLAND CAUSING PERINEAL

HERNIA IN AN EIGHT-YEAR OLD INTACT MALE POODLE

Patricia P. Delos Santos*

Department of Veterinary Clinical Sciences, College of Veterinary Medicine

University of the Philippines Los Baños, Laguna, 4031, Philippines

*FOR CORRESPONDENCE

(e-mail: ppdelossantos@up.edu.ph)

ABSTRACT
 An eight-year old intact male Poodle weighing seven kilograms was

presented to the hospital because of a unilateral swelling on its left perineal

area. The patient underwent a complete blood count which provided the

knowledge that it is anemic. The swelling was viewed using ultrasonography

and radiography in dorsoventral and left lateral views which provided the

confirmation of the identity of the tubular organ filled with fecal material.

Contrast radiography and pneumocystography were also done in order to

visualize its direction. The barium sulfate was mainly concentrated in the

swelling and was not able to continue passing through the colon in the

abdominal area. Manual evacuation of the feces was done to also decrease

the swelling size. The patient was then prescribed with antibiotics and soft

diet. After a few days, the patient underwent perineal herniorraphy,

colopexy, open-type castration and scrotal ablation. During the confinement,

the patient was closely monitored through complete blood count which

provided the information that it was in continuous lymphocytosis and

neutrophilia. Post-operatively, the patient was prescribed with antibiotics,

supplements, DMSO, electrolytes to the diet and wound cleanser. With the

prognosis of the patient getting poorer during its follow-up, it was considered

a candidate for euthanasia.

Keywords: colopexy, contrast radiography, herniorraphy, perineal swelling

 INTRODUCTION

The incidence of perineal hernia in intact six- to eight-year old dogs is

high in Welsh Corgis, Boston Terriers, Boxers, Collies, Kelpies and its crosses,

Dachshunds and its crosses, Old English Sheepdogs and Pekingese (Rubin,

2013; Lalzawmliana et al., 2019). It is more common in male than in female

dogs (Kashyap et al., 2017). The condition occurs mainly when the pelvic

cavity muscles rupture resulting from failure of the pelvic diaphragm to give

support to the rectal wall (Lalzawmliana et al., 2019). Pelvic diaphragm

weakness may be due to tenesmus related to chronic prostatic disease or

constipation, myopathy, rectal abnormalities, and gonadal hormonal

imbalances. Unilateral or bilateral (Sprada et al., 2017) nonpainful swelling of

the perineum is the most common presenting sign of perineal hernia (Gill,

2018). The other clinical signs of the condition do not always occur which

may include dyschezia, rectal prolapse, stranguria or anuria. In this case, the

clinical signs seen in the patient were tenesmus, constipation and a

unilateral nonpainful swelling of the perineum.

CASE PRESENTATION

On January 8, 2020, an eight-year old intact male Poodle weighing

seven kilograms was presented to the hospital because of the mass on its

perineal area that has been gradually growing since February 2019. The

owner reported that the patient has been finding it hard to defecate ever

since the mass started to grow as a Ping-Pong-sized ball. As the mass

increased in size, the owners observed that the feces of the patient have
been getting smaller too. Otherwise, the patient was bright, alert and

responsive.

The solid firm and round mass found on the left side of its anus was

measured to be around 10x14x8 centimeters in diameter. Upon external

palpation of the swelling, there was no pain elicited from the patient.

However, in the digital palpation of the anus, it elicited pain from the patient.

The patient underwent complete blood count which provided a window on

the health of the patient (Table 1) which provided the information that the

patient is anemic.

Visualization of the mass using the ultrasound machine provided an

image of an encapsulated and tubular structure. On the other hand, the

lithograph x-ray film showed the dorsoventral (Figure 1) and left lateral

(Figure 2) views of the abdominal to pelvic areas of the patient provided an

image of the protruding mass that was composed of a tubular organ which

could be the colon that is full of fecal material. It was also visualized that

there is a mass at the base of the penis which could be the prostate gland

(Figure 3).

Based on the clinical presentation and diagnostic imaging done to the

patient, the working diagnosis of the veterinarian is perineal herniation and

the condition was immediately elected to be manage through perineal

herniorraphy. Manual evacuation of the feces was done to also decrease the

size of the mass. Approximately 200-300mL (50mL at each time) of water

was injected into the anus of the patient. Aside from externally massaging
the mass, a finger was also inserted in the anus to manually mash or to

soften the fecal material inside. After inserting 50mL and the fecal

manipulation through digital palpation, the patient was allowed to roam

around for it to try defecating. Fortunately, it successfully excreted some of

its feces. Lastly, 20mL of glycerine was inserted into the anus of the patient

which induced vomiting in the patient. It was prescribed with metronidazole

(20mg/kg PO BID 7 days) and soft to liquid diet.

The following day, the owners reported that the patient had defecated

four times with a watery characteristic. The skin around its mass has already

become looser compared to being very firm and tight on January 8. It

underwent contrast radiography using barium sulfate as contrast media.

Pneumocystography (Figure 4) was performed in order for the air inside the

urinary bladder to act as a radiolucent substance which contrasts with the

adjacent organs of the abdominal cavity. On the other hand, barium sulfate

was inserted through the anus to visualize the direction of the colon. It was

seen that the suspected colon remained concentrated on the area of the

mass and the barium sulfate did not continue into the abdominal cavity of

the patient (Figure 5). Manual evacuation of the feces was performed again

to decrease the perineal swelling. The attending veterinarian prescribed the

patient with Blumea balsamifera as supplement to help the patient in

urinating without straining.

The patient was then scheduled for surgery. It underwent perineal

herniorraphy, colopexy, open-type castration and scrotal ablation at the

same time (Figures 6, 7 and 8). During the procedure, it was found out that

the patient was also suffering from a possible infection in its testicles as pus

was observed upon opening the testicular sac (Figure 8). The patient was

then confined in the hospital after the surgery wherein it underwent on for

complete blood count on the following dates as seen on Table 2. On January

18, an impression smear of the surgical site was done. The results showed

that it has many Gram positive and Gram negative cocci. Post-operatively,

the patient was prescribed with clindamycin (25mg/kg PO BID for 5 days),

enrofloxacin (5mg/kg PO SID for 5 days), micronized purified flavonoid

fraction containing 90% diosmin and 10% other flavonoids (Daflon-500® - 1

tab PO SID for 5 days), dimethyl sulfoxide (topically SID for 5 days),

electrolytes (Pedialyte®) to the diet of the patient and wound cleanser. On

the 21st of January, the patient came back and was reported by the owner to

have no appetite, normal urine and its defecation usually lasts for ~45

minutes but it was reported to be formed. It also underwent post-operative

radiography which provided an image of the colon and the swelling inside

the abdominal cavity (Figure 9). The patient was then prescribed with

tramadol HCl (10mg/kg PO SID as maintenance), prednisone (10mg tab 1 tab

PO BID as maintenance), aspirin (80mg tab: Diluted in 2mL of water then

give as 5mL SID as maintenance), lactulose (3mL PO q8hr to effect; stop if

dog is already diarrheic). With the prognosis of the patient getting poorer,

the dog was considered a candidate for euthanasia.

DISCUSSION
 The pathophysiology of perineal hernia involves the weakening and

rupture of muscular layer of the rectal wall which may result to the caudal

displacement of some of the anatomical structures enclosed in the abdomen

leading to swollen perineal region and impaired defecation (Lalzawmliana et

al., 2019). These muscles are composed of the coccygeal muscle and levator

ani muscles whereas the contents may vary from the urinary bladder to the

intestines (Kashyap et al., 2017). In this case, the patient suffered from the

nonpainful swelling with tenesmus and constipation which was probably

caused by another mass inside the abdominal cavity specifically at the base

of the penis which is presumably the prostate gland. There is the probability

that this enlargement inside the abdomen is pushing out the colon that lead

to the rupture of perineal muscles resulting to the protrusion of a portion of

the colon around the anal area. Participation of the diseases of the prostate

gland may be caused by its enlargement, inflammation and pain which cause

tenesmus in the patient and more pressure on the pelvic diaphragm (Gill,

2018). It can also be visualized in Figure 9 that there is the presence of a

ribbon-shaped stool which is a clinical sign of dogs suffering from prostatic

disease as the mass compresses the rectum (Das et al., 2017).

The condition is diagnosed based on the history, clinical signs, physical

examination and diagnostic imaging (Kashyap et al., 2017). In this case, the

patient presented tenesmus and constipation as clinical signs and the

swelling was examined physically by external and rectal digital palpation.

Diagnostic imaging was also done through ultrasonography, radiography and

contrast radiography.

Recommendations for the case include doing a more thorough physical

examination in order to not miss out the swelling in the scrotal sac. Also,

postponing the surgery and making the animal more stable first by

addressing its anemic condition and possible infection as indicated by

lymphocytosis. Delaying the other procedures such as the open-type

castration and scrotal ablation can also be done. Moreover, doing an

antibiotic sensitivity testing in order to address and to provide a more

specific antibiotic for the post-operative bacterial infection in the patient.

More photos during the surgery should have been taken for better

documentation of the case.

ACKNOWLEDGEMENTS

I would like to extend my sincerest gratitude to Doctor Karla Monreal

for her valuable knowledge and help in guiding me in handling the clinical

case. I would also like to thank Miss Roxanne Elysse Bunayog for her

assistance and generosity in providing me with the information that I needed

for the completion of the case and the paper.

REFERENCES

Das MR, Patra RC, Das RK, Kath PK and Mishra BP. 2017. Hemato-
biochemical alterations and urinalysis in dogs suffering from benign
prostatic hyperplasia. Veterinary World. 10(10): 331-335.
Gill SS and Barstad R. A Review of the Surgical Management of Perineal
Hernias in Dogs. American Animal Hospital Association. 54(4): 179-187.
Kashyap DK, Giri DK and Dewangan G. 2017. Surgical correction of recurrent
perineal hernia using polypropylene mesh, synthetic collagen and
 surgical glue in rottweiler dog. Exploratory Animal And Medical
Research. 7(1): 106-109.
Lalzawmliana V, Warton Monsang S, Bhattacharya S and William JB. 2019.
Surgical correction of rectal diverticulum with perineal hernia in a
German shepherd dog: A case report. The Pharma Innovation. 8(3): 299-
302.
Sprada AG, Huppes RR, Feranti JPS, de Souza FW, Coelho LP, Moraes PC and
Minto BW. 2017. Acta Scientiae Veterinariae. 45(1): 244/1-7.

TABLES AND FIGURES

Figure 1. Dorsoventral view of the pelvic area of the patient showing the
protruding mass measuring to be 104.30 mm in diameter performed on
January 9, 2020.
Figure 2. Left lateral view of the pelvic area of the patient showing the
protruding mass measuring to be 74.45 mm in diameter performed on
January 9, 2020.

Figure 3. Mass near the base of the penis which was hypothesized to be the
prostate gland that is pushing the colon from its normal placement
performed on January 9, 2020.
Figure 4. The pneumocystogram of the patient in order to visualize the
perineal mass that was inserted with barium sulfate afterwards performed on
January 10, 2020.

Figure 5. The perineal swelling inserted with barium sulfate showing its
direction performed on January 10, 2020.
Figure 6. (A) The swelling pre-operatively that was incised on its lateral side
as seen in (B). The incision site after colopexy (C).
Figure 7. The closure of the incision site using 1-0 and 2-0 prolene for the
muscle layers, 3-0 catgut for the submucosa and 4-0 prolene for the skin.

Figure 8. The testicles of the patient that is surrounded by an inflamed

epididymis. The surgical area was closed using 1-0, 2-0 and 3-0 prolene
suture material and horizontal mattress suture pattern.
 Figure 9. Post-operative radiography of the patient on January 21, 2020.

Table 1. Complete blood count of the patient on January 8, 2020.

Normal Interpretatio
Parameter (unit) Patient
Reference Value n
Packed cell volume (%) 29.5 37 – 55 Decreased
Total White Blood Cell (x103
9.3 6.0 – 17.0 Normal
cells/uL)
 Segmented Neutrophils
6.51 3.0 – 11.5 Normal
(x103 cells/uL)
 Lymphocytes (x103
2.05 1.0 – 5.0 Normal
cells/uL)
 Eosinophils (x103
0.74 0.1 – 1.2 Normal
cells/uL)
Platelet (x103 cells/uL) 213 160 – 525 Normal
Hemoglobin (g/dL) 12.4 12.4 – 19.1 Normal
RBC (x106 cells/uL) 5.16 5.2 – 8.06 Decreased
Reference: Thrall MA., et al. 2004. Veterinary Hematology and Clinical
Chemistry.; Plumb DC. 2005. Veterinary Drug Handbook.

Table 2. Complete blood count and some biochemical tests performed on the
patient on the following dates.
Normal
January January January January January
Parameter (unit) Reference
14, 2020 15, 2020 17, 2020 18, 2020 21, 2020
Value
Packed cell volume
36.1 27.1 25.5 26.1 28.5 37 – 55
(%)
Total White Blood
24.2 15.6 41.2 32.6 25.7 6.0 – 17.0
Cell (x103 cells/uL)
 Segmented
Neutrophils
23.47 15.1 39.14 30.3 21.85 3.0 – 11.5
(x103
cells/uL)
 Lymphocyte
s (x103 0.48 0.47 0.82 1.6 2.57 1.0 – 5.0
cells/uL)
 Eosinophils
(x103 - - 0.41 0.65 0.51 0.1 – 1.2
cells/uL)
 Basophils
Rare, 0 –
(x103 0.24 - 0.82 - 0.77
0.1
cells/uL)
Platelet (x103
208 92/105 103/176 107/209 344 160 – 525
cells/uL)
Hemoglobin (g/dL) 14.4 10.6 9.8 9.8 10.9 12.4 – 19.1
RBC (x106 cells/uL) 6.0 4.56 4.26 4.64 4.87 5.2 – 8.06
GPT (U/L) 74 N/A N/A N/A N/A 4 – 91
CREA (mg/dL) 1.1 N/A N/A N/A N/A 0.6 – 1.4
Others (Incidental N/A (+) (+) (+) (+) (-)
findings) Hepatozoo Hepatozoo Hepatozoo Hepatozoo
 n n n n
Reference: Thrall MA., et al. 2004. Veterinary Hematology and Clinical
Chemistry.; Plumb DC. 2005/1999. Veterinary Drug Handbook.
*blue cells – decreased values
*orange cells – increased values