Surgical management of screw tail and vulva skin folds in dogs
MeSH keywords:dogs, intertrigo, tail, vulva
The aim of this study was to assess the effectiveness of the surgical intervention for the treatment of tail and vulvar skin-fold dermatitis in dogs. Vulvar fold dermatitis occurs in older obese female spayed dogs or in younger dogs that have juvenile vulvar conformation, while screw tail (ingrown tail or corkscrew tail) is a condition encountered frequently in brachycephalic breeds. Lesions that have become refractory to conservative management necessitate surgical treatment. Episioplasty/vulvoplasty is used to remove the excess folds that surround the vulva, while with caudectomy the skin folds are removed along with the screw tail. Data concerning canine episioplasty and caudectomy were retrieved fromthe U.S. National Library of Medicine (PubMed) and the Google Scholar and Elsevier’s Scopus databases. All data were evaluated and only studies, relevant and meeting the inclusion criteriawere included for evaluation. Only a few of the 316 articles were related to canine intertriginous dermatitis, and only 4 retrospective studies onsurgical treatment of tail and vulvar skin foldswere retrieved. Complete resolution of preoperative clinical signs with minimal complications occurred following the recommended surgical treatment. Most of the dog owners were satisfied post-operatively. However, according to this review, more specifically targeted studies with further statistical analysis are required in order to verify this conclusion.
Intertriginous or skin-fold dermatitis is an inflammatory skin condition that is caused by chronic skin apposition. This results in persistent frictional contact between two skin or mucocutaneous surfaces, minor trauma and poor air circulation (Bellah 2000). The most common locations for intertrigo include the lips, face, vulvar and tail folds (Paterson 2018). Vulvar fold dermatitis occurs in older obese spayed, female dogs or in younger dogs that have juvenile vulvar conformation (Bellah 1993). Urine and vaginal secretions that subsequently accumulate on the vulvar skin surfaces and the surrounding skin folds lead to inflammation and ulceration. In case of persistent vulvar ulceration, episioplasty/vulvoplasty can be performed to remove excessive folds of the skin (White 2006). Screw tail (ingrown tail or corkscrew tail) is a condition encountered frequently in brachycephalic breeds. This condition is characterized by the anatomic diversion of the terminal coccygeal vertebrae to adopt a spiral configuration. Abnormal tail curvature results in a redundant and intertriginous process, maceration of the skin and potential faecal contamination with bacterial overgrowth (Vasiadou & Papazoglou 2016). This condition is rarely resolved permanently by medical management, and as a result surgical intervention is necessary. Caudectomy at the level of the most cranial coccygeal vertebra is suggested (Rubin 1979). However, according to more recent papers, disarticulation of one to two vertebral articulations proximal to the affected area is the method of choice for partial caudectomy (Schoen & Sweet 2009, Simmons 2014). Medical treatment is indicated before surgery in order to decrease the bacterial number and the amount of skin inflammation at the time of the surgery. Conservative treatment is generally unrewarding since intertriginous dermatitis is secondary to a deformity, while skin fold excision resolves intertriginous dermatitis (Bellah 1993). However, this presents a challenge for the veterinarian, because deep skin folds are considered highly desirable for certain breeds, and owners and breeders may be reluctant to proceed in surgical treatment (McLoughlin 1990). Due to these concerns, it is of key importance to detect the effectiveness of surgical intervention for the treatment of excessive tail and perivulvar skin folds.
The U.S. National Library of Medicine (PubMed) and the Elsevier’s Scopus and Google Scholar databases were employed for a systematic review of all relevant publications about surgical management of canine tail and vulvar excessive skin folds. For the purposes of this research the following keywords were used: dog folds dermatitis caudectomy, dog vulvoplasty, dog episioplasty. Due to the lack of specific software knowledge, it became necessary to check the results by all the team members. The number of publications found in the above-mentioned databases are presented in Table 1. The studies included in this review had to meet certain criteria: first the included dog population had to be treated strictly surgically and secondly the encountered sites for intertriginous disease in the canine patients include exclusively vulvar and tail folds. Case reports and review articles were excluded from the present systematic review.
A total number of 316 papers was found following the databases search. Duplications and irrelevant papers were not included, and finally only four articles, that fulfilled the inclusion criteria, entered the study (Figure 1). All four studies are retrospective and have been published during the last two decades. The first one was published on December 2001 in the Journal of American Veterinary Association by Lightner et al., the second on January/February 2002 in the Journal of American Animal Hospital Association by Hammel and Bjorling, the third on July/August 2013 in the Journal of American Animal Hospital Association by Knight et al., and the last one on April 2017 in Veterinaria by Abrescia et al.
The aim of the first study (Lightner et al. 2001) was to assess the effectiveness of episioplasty as a treatment of choice for perivulvar dermatitis or chronic and recurrent urinary tract infections (UTI) that were secondary to vulvar folds in dogs. Medical records of 31 dogs with vulvar dermatitis (group 1; n=15) or UTI (group 2; n=16) that were managed with episioplasty between 1983 and 2000 were evaluated. Clinical signs failed to resolve with medical management. A purse-string suture was placed in the anus. The dogs were placed in perineal position. Two curved incisions were made in the perivulvar skin, in order to achieve elevation of the vulva out of the crevice. The skin and subcutaneous tissue directly associated with the skin were excised. Aggressive excision of local perivulvar subcutaneous fat was not deemed necessary. The amount of skin excised aimed to fixation of the dorsal vulvar commissure. The subcutaneous tissues and skin were closed in two layers, using an interrupted suture pattern. Elizabethan collars were placed on all patients after surgery until suture removal. The surgical site was evaluated, and suture removal was performed 10 to 14 days after surgery. Follow-up information were available, for at least 6 months postoperatively, from the medical records or telephone contacts with the referring veterinarians and owners. The only surgical complication observed in group 1 was incisional swelling of minor clinical importance. Complete resolution of perivulvar dermatitis was achieved in 14 of 15 dogs of group 1. One dog had recurrence of perivulvar dermatitis 2 years after the episioplasty due to excessive weight gain. No surgical complications were noticed in 15 of 16 group 2 dogs. All owners of group 2 dogs rated the surgical outcome of episioplasty as satisfactory. The authors specify that that ascending bacterial UTI appears to be a common consequence of perivulvar dermatitis. Wound dehiscence in one of the 31 dogs was the only serious complication reported in the study.
In the second study (Hummel & Bjorling 2002) medical records of 34 dogs with recessed vulva that underwent surgery at the University of Wisconsin Veterinary Medical Teaching Hospital between 1987 and 1999 were reviewed in order to evaluate the results of vulvoplasty/episioplasty. Dogs were placed in perineal position. Concentric, curved incisions whose ends were at the contralateral commissure of the vulva, were made between the vulva and the anus to remove excessive skin. Incision boundaries were planned so that if inadequate skin was removed initially, additional skin was removed to reduce tension. Tension free closure of the resultant skin defect eliminated the vulvar skin fold. Owners were asked by telephone to declare their satisfaction regarding the results of treatment. Twenty-six (76%) owners were pleased with the outcome of the surgery. Two (6%) owners rated the surgery a 3 on a four-point scale and six (18%) owners expressed their frustration concerning the surgery as persistent urinary incontinence was observed post-operatively. There was a dehiscence in a Bull Mastiff postoperatively that was managed with three additional surgeries for wound reconstruction. According to the authors vulvoplasty/episioplasty is a useful procedure for treatment of perivulvar dermatitis.
The third study (Knight et al. 2013) aimed to identify the possible complications after caudectomy in dogs with tail folds. Medical records of 17 dogs with this condition that underwent caudectomy from 2000 to 2010 at the University of Georgia Veterinary Teaching Hospital were reviewed. Physical examination findings, clinical appearance of the surgery site and complications that occurred postoperatively were recorded. Complications were identified either during the follow-up visit or via telephone communication with the referring veterinarian at suture removal. At presentation, 4 of the 17 dogs (23.5%) were receiving antibiotics. Infection occurred in 7 of the 17 dogs (41%) and was entirely resolved in 6 of the 7 cases immediately after surgery. Perioperative antimicrobial therapy was administrated to all dogs, and 13 of the 17 dogs (76%) received antibiotics for an average of 13.5 days postoperatively. Two of the 17 cases (12%) developed complications immediately after surgery, including decreased rectal sensation, behavioural abnormalities concerning defecation, and postoperative draining tracts. No treatment was given, and problems resolved approximately 3 days postoperatively. Abscessation was noticed to the other dog on the fifth day after surgery and was managed with surgical debridement, drain placement, and antibiotics administration based on culture and susceptibility. In two of 15 dogs (13%) delayed wound healing, wound inﬂammation, and behavioural disorders were observed. One dog had delayed healing at the surgical site due to tension. The sutures were retained for five more days, amoxicillin/clavulanate acid (14 mg kg-1 per os twice a day) was given for 2 weeks and the inflammation resolved. Inﬂammation at the surgical site, and abnormal behaviour regarding defecation and tail chasing activity occurred in another dog for the ﬁrst 3 days after discharge. Removal of the sutures and administration of enrofloxacin (10 mg kg-1 per os once daily) for 10 days led to complete resolution of the clinical signs. From the thirteen owners that were available for the follow up, ten (77%) were extremely satisfied with the surgical outcome while one owner was frustrated with the surgical outcome due to permanent cosmetic changes in the dog’s appearance. Authors pointed out that complete or partial caudectomy is the treatment of choice for dogs with tail folds with no lifelong complications.
The fourth retrospective study (Abrescia et al. 2017) was about evaluating caudectomy for treatment of intertriginous dermatitis of the tail in brachycephalic dogs. Case records of eleven brachycephalic dogs (10 English bulldogs and 1 Boston terrier) that were treated surgically, from 2007 to 2016 were reviewed. All dogs were presented for severe anatomical malformations of the tail and intertriginous dermatitis at the level of the tail base. Patients underwent preoperative antibiotic therapy intravenously. Surgery was performed by disarticulation of the coccygeal vertebrae associated with excision of the skin folds. Three complications (27%) were observed in the first week post-operatively. In two cases a subcutaneous abscess was treated with passive drainage, lavage, and antibiotic therapy for seven days. In one case, despite the application of a passive drainage in the operative site, wound dehiscence was noticed due to the formation of an abscess. The wound was covered with a tie-over bandage, and complete healing by second intention within 18 days was achieved. The minimum post-operative follow-up was two months for all patients. The authors believed that surgery was curative in all dogs despite the presence of postoperative complications.
Major limitations of the studies entered this systematic analysis include their retrospective nature and the small size of treated dogs. According to the first two retrospective studies, episioplasty/vulvoplasty is an effective low morbidity treatment for perivulvar dermatitis and chronic UTI associated with excessive vulvar skin folds. Wound dehiscence was the only serious complication reported in both studies. Furthermore, in both studies most of the owners claimed to be satisfied with the surgical outcome. Obesity, a condition, which may create extra folds around the vulva, is twice as likely to occur in spayed females compared to intact female dogs. One limitation is that it was difficult to standardize the body weights for dogs in both studies because of the number of breeds and conformations represented. As a result, insufficient information was available to assess the occurrence and severity of obesity in the cases included in the current report. Due to the retrospective nature of this study, it was impossible to evaluate the amount of skin removed during surgery and to determine why clinical signs did not resolve in every case. Moreover, although in Lightner’s study instructions for post-operative management were given to the owners, in Hammel’s study were not described, and therefore there are difficulties to observe possible interactions between the post-operative instructions and complications or to standardize a post-operative treatment of choice. Another major limitation is that although the population size taken into consideration was big (31 and 34 dogs respectively) only descriptive statistics were used, thus the importance of the results cannot be verified.
Based on the findings of the other two retrospective studies (Knight et al. 2013, Abrescia et al. 2017) complications occurred in 4/17 (23.5%) and in 3/11 (27%) of the patients including abscess formation, change in defecation behaviour and delayed healing, minor complications that were reported in 1 out of 4 dogs. Closer examination of these two studies, shows that surgery resulted in resolve of the clinical signs of the ingrown tail in all dogs. One issue associated with the validity of the studies in these reviews is that they include a small population size, which may underestimate the reported complications and exclude other complications that may had been seen with a larger sample. Another major inconsistency between the two studies, is that although in Knight’s study, owners were available for follow-up interviews, in Abrescia’s study, owner’s satisfaction over the surgical management was not taken into consideration. Another limitation in the latter study is that it was written and published in Italian, so reading is quite challenging for those that are not familiar with this language.
Antibiotic therapy was used in some cases before and after surgery to limit the potential bacterial contamination in all four studies. However, no conclusions can be drawn between preoperative infection or antibiotic use and postoperative infection since every patient had different prescriptions to follow. Moreover, sufﬁcient long-term follow up was reported in all studies to evaluate complications associated with the surgical procedure.
It is accepted that episioplasty and caudectomy are the recommended treatment for screw tail and vulva skin fold intertriginous dermatitis. All the animals in the studies included here had complete resolution of preoperative clinical signs with minimal complications. Complications resolved following appropriate medical or surgical treatment. Clinicians should continue to inform owners regarding the potential complications and the fact that dogs no longer conform to breed standards due to the cosmetic changes in dogs’ appearance. Finally, little information is available regarding the outcome of surgical management of excessive tail and vulvar folds in dogs, so larger studies should be performed and take into consideration other body locations of skin folds, make comparisons between different locations, and statistically analyse the results.
Conflict of interest
The authors declare no conflicts of interest.
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