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9:01 AM   April 20, 2014
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Common Cause of Chronic UTI Has a Surgical Solution

By Phil Zeltzman, DVM, Dipl. ACVS

Redundant vulvar fold in an 18-month-old Labrador. (Courtesy of Dr. Zelztman)

The solution to some chronic urinary tract infections is not always antibiotics. When female dogs present excessive or redundant skin folds dorsally and laterally to the vulva, a cascade of events often follows.

Common complaints from the owner include excessive licking of the vulvar area, scooting, malodor, hematuria and sometimes urinary incontinence. How can a simple skin fold cause urinary incontinence?

The redundant skin fold acts like a dam and enables urine retention. Moisture, body heat, darkness and accumulation of skin debris create an ideal environment within the skin folds for bacteria to proliferate and cause local infection.


The two main challenges are assessing precisely how much skin to remove, and closing the surgical site in a cosmetic manner.



Friction between the two skin surfaces causes microtrauma, which adds to self-trauma via licking and scooting. This leads to skin fold dermatitis or pyoderma. In turn, secondary vestibulitis, vaginitis or ascending UTIs have been reported. At worst, urinary incontinence can occur.

The poster child for this condition is an overweight female dog with a hypoplastic or recessed vulva. The mean weight was 71 pounds in a fairly recent study.1 Another study reports the condition in medium to giant breeds, except for one bichon frise.2 The mean age is approximately 3.5 years in both studies.

Intradermal Suture Pattern

The intradermal, or subcuticular, suture is a simple continuous pattern and may be used instead of or in addition to skin sutures or staples. It is a modified horizontal mattress suture pattern.

The suture starts and ends with a buried knot, which improves the cosmetic appearance of the resulting suture. My favorite at the end of the suture is the wonderful Aberdeen knot, although any buried knot will do the trick. Multiple short bites, within the dermis, parallel to the long axis of the incision, are placed from one end of the incision to the other, with 3-0 or 4-0 absorbable suture material.

This suture pattern can be used in elective cases, such as spays and neuters, as well as after more complex procedures. It can be used with fractious or aggressive patients, to avoid the need for suture removal: a suture recheck will be sufficient. Technicians will love you for saving them from an unnecessary struggle!

After vulvoplasty, the vulva becomes visible.(Courtesy of Dr. Zelztman)
The diagnosis is confirmed by careful observation of the redundant skin folds and the dermatitis. A speculum may be helpful. 

Medical management entails using systemic antibiotics and topical treatments, as well as weight loss. The results are “generally palliative and unrewarding.”1 

The definitive treatment is episioplasty or vulvoplasty, which is the surgical excision of the redundant perivulvar skin folds. This reconstructive procedure provides better ventilation of the perivulvar area.

A purse string suture is placed in the anus to avoid fecal contamination of the surgical site. Two concentric crescent-shaped incisions are made laterally and dorsally to the vulva.  The skin and the subcutaneous tissue are excised. The skin is sutured in a standard fashion, which eliminates the skin fold.

What Is a Surgical Skin Marker?

Ever watch “Extreme Makeover”?  The purple markings all over the human patients are made with a single-use surgical skin marker.

We can use the same trick in cats and dogs for skin surgery, cosmetic or not. A skin marker allows the surgeon to diagram incisions. The ink is gentian violet, which is scrub-resistant, non-toxic and non-irritating. The sterile pens are provided in peel pouches, just like suture material.

Such markers can be used to plan the excision of a vulvar fold, as well as removal of a large skin mass, in order to decide precisely how much skin can be sacrificed.
My personal favorite is the intradermal suture pattern, which avoids the need for an uncomfortable suture removal session. A simple suture recheck is performed 14 days after surgery. Self trauma is avoided by using an Elizabethan collar. Confinement is recommended for two weeks.

Analgesics and a short course of antibiotics are prescribed.

If the fold is not eliminated appropriately after suturing the skin, then too little skin was removed and a wider excision is performed.  If too much skin is excised, tension will ensue. This caused wound dehiscence in one case.2  The treatment would be difficult, to say the least, in this area with little loose skin. This complication can be avoided by thoughtful surgical planning, which may include the use of a surgical marker.

Two studies—the only recent ones to my knowledge—reviewed the results of the procedure. In one report of 34 cases, more than 80 percent of owners were satisfied with the results.2 The other study followed 31 cases: “Owner satisfaction was extremely high” as complete resolution was achieved in 100 percent of cases with minor complications.1

Top 10 Causes of Female Urinary Incontinence
  1. An ectopic ureter is seen on this IVP study in the pelvis of a 2-year-old incontinent female Yorkshire terrier.
    Spinal disease
  2. Pelvic bladder
  3. Ectopic ureter(s)
  4. Urinary tract infection
  5. Patent urachal remnant
  6. Detrusor muscle instability
  7. Infiltrative bladder neoplasia
  8. Redundant perivulvar skin fold
  9. Chronic inflammatory bladder diseases
  10. Urethral sphincter mechanism incompetence

Here are a few more conclusions from the studies:

Chronic UTIs were diagnosed in about half of the patients.

If urinary incontinence persists despite corrective surgery, another etiology should be investigated for the signs: pelvic bladder, hormonal deficiency, ectopic ureter, etc.

Bacterial culture most commonly reveals E. coli, but multiple other bacteria can be found.

Mean duration of symptoms was over one year in both studies, which confirms that this condition is easy to overlook. It is important to include it in the differential diagnosis of chronic UTIs. Interestingly, the only recurrence was in a dog that gained 20 pounds. Weight loss solved the problem in that dog.

Overall, the prognosis of an episioplasty is excellent. The two main challenges are assessing precisely how much skin to remove, and closing the surgical site in a cosmetic manner. Recognizing this fairly common problem in our ever-fattening canine population is the first step. <HOME>

Keep In Mind

The vulvoplasty addresses only one cause of urinary incontinence: external conformation. Many other etiologies exist. The episioplasty should resolve chronic UTIs, perivulvar dermatitis, and urinary incontinence. If it doesn’t resolve the incontinence, another cause should be investigated. Additional surgery (e.g. for ectopic ureters) or medical management may be necessary to solve the problem.

Dr. Zeltzman is a small animal board-certified surgeon at Valley Central Veterinary Referral Center in Whitehall, Pa. His website is www.DrPhilZeltzman.com.

REFERENCES:
1. BA Lightner et al. “Episioplasty for the treatment of perivulvar dermatitis or recurrent urinary tract infections in dogs with excessive perivulvar skin folds: 31 cases (1983-2000).” JAVMA 2001, Vol. 219, N. 11, p. 1577-1581.

2. AP Hammel and DE Bjorling. “Results of Vulvoplasty for Treatment of Recessed Vulva in Dogs.” JAAHA 2002, Vol. 38, N.1, p. 79-83.

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Common Cause of Chronic UTI Has a Surgical Solution

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Reader Comments
Our Greyhound adoption group got a returned Greyhound who had an extra fold of skin at the top of her vulva which covered almost 50% of her opening. This skin and the surrounding skin (even the underside of her tail in the area) was discolored and had urine scald. This greyhound had her vulvoplasty surgery on 11/11/13 and is doing very well. She can now easily pee and is healing up quickly. The vet had us give her antibiotics the week before her surgery and she
will continue these and also Tramadol for pain for the week after surgery. Glad we had the surgery done.
Marne, Denver, CO
Posted: 11/15/2013 7:09:31 AM
My Vet and I talked about this yesterday and she sent me the link for this article. Very informative and my 5 yr. old Yellow Lab is a prime candidate. She's 70 lbs., and licks the vulva constantly and scoots as well. I'm strongly thinking that this is the way to go, before things get worse. I also want my dog to be healthy and comfortable. Thank you!
Nancy, San Antonio, TX
Posted: 11/12/2013 8:31:02 AM
Informative and helpful article. Daisy had her episioplasty 4 days ago at NorthFork Veterinary Hospital in Auburn, CA, due to UTI's from a recessed vulva. She is a 5 year old Smooth Collie. We were hesitant at first to put her through this, but it was truly the best decision. She is healing nicely, was never in severe pain, and now urinates in the proper female position. Right decision for our angel and great veterinary care. :)
Geri, Santa Rosa, CA
Posted: 2/11/2012 2:09:19 PM
my english bulldog has been having chronic uti's for the past year and a half. she is 4-1/2 years old, the vet recommended having this surgery done saying that it is purely her anatomy (she is very similar to the picture shown). I appreciate this article, I have not been able to find anything about this since the vet first told us about it about a year ago. We've tried to avoid it..always wiping her with baby wipes after she urinates, and having clean water available at all times. My main concern is that we put her through this and then maybe it is something more causing this other than her anatomy but I am very grateful to see that other people know about this!
sara, buffalo, NY
Posted: 10/31/2011 7:47:37 AM
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