I strategically placed Marshmallow as the first image, because she is a little bit more attractive than a perineal hernia, which often appears as a bulge of tissue lateral to the anus/rectum (see below).
Perineal hernias often occur in middle-aged to older entire male dogs and have a complex aetiology. Clinical signs can include straining to defecate or feces accumulating in a dilated rectum, constipation, a soft fluctuant mass that can usually be reduced back into the abdomen, and urinary signs may be present if the bladder has also retroflexed via the hernia. Diagnosis can be made via rectal exam - your finger can be palpated via the skin (ie. via the dilatation). Ultrasound, radiographs and contrast cystography can help aid diagnosis. The most frustrating complication associated with perineal hernias is the recurrence rate after surgery. This used to be high, prompting surgeons to combine the traditional techniques with intra-abdominal techniques designed to pull the bladder and colon cranially thereby reducing the pressure on the pelvic musculature. But are these additional procedures required? They add cost and morbidity. Recent papers have suggested that by including the sacrotuberous ligament in the repair, this may be enough to reduce the recurrence rate (in the below paper, it was zero). As is common when analysing the veterinary literature, we often rely on retrospective case series to guide our decisions, however inclusion of the sacrotuberous ligament seems promising. The key thing about the addition of this technique is to be aware of the close approximation of the sciatic nerve to the sacrotuberous ligament. A good paper describing the technique and the anatomy is; "A novel technique to incorporate the sacrotuberous ligament in perineal herniorrhaphy in 47 dogs" Cinti et al. Veterinary Surgery 2021.
Thank you for this excellent paper.
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