Surgery of the vagina and vulva Flashcards
Why is vaginoscopy most useful for diagnostics?
- Direct visualization of stenosis
- Can evaluate repro and urinary tract together
- Can rule out ureteral abnormalities (e.g. ectopic ureter)
Anatomy
Is a bacterial culture of the lower reproductive tract helpful? Why/why not?
Rarely
- Limited value
- Caudal repro tract not sterile
- Indicated for resistant infection
- May detect specific pathogens (Brucella)
What are the anatomical indications for an episiotomy approach?
- Used for vestibular and vaginal lesions
- Access up to just cranial to urethral opening
What is the proper positioning for an episiotomy approach?
- Position for perineal sx
- Tail looped up and over
- Be sure to provide padding to prevent sores on the ventrum
- Incise on midline from vulvar opening
What are the anatomical indications for a ventral approach to the lower repro tract?
For intrapelvic and abdominal lesions
What are the differences between a caudal approach and transpelvic approach?
- Ventral midline abdominal incision
- Limited access to lesions caudal to cervix
- Rarely sufficient exposure by itself
- Transpelvic
- Req. muscle elevation, osteotomy
- Significant morbidity
- Risks
- Obturator nerve
- Complex blood supply to intrapelvic viscera
- Avoid damaging urethra
What is the etiology of vestibulovaginal stenosis?
- Developmental anomalies
- No basis for genetic transmission
What are the various forms vestibulovaginal stenosis can take?
- Retained embryonic epithelial tissue–3 types of lesions
- Vertical septum–generally have vertical band in the center dividing vagina
- Annular fibrotic stenosis–ring lesion; usually toward cranial aspect
- Hypoplastic region–narrow area that resembles stricture
What clinical signs are associated with stenosis?
- Recurrent vaginitis
- Recurrent UTI
- Difficulty or pain with breeding
- Urinary incontinence often reported due to ectopic ureters
- Usually due to other causes
What is the significance of urinary incontinence related to stenosis?
Repair of stenosis will NOT fix incontinence
How can a contrast vaginourethrogram be used to diagnose stenosis?
- Iodinated contrast
- Measure max and min diameter
- Calculate ratio B:A
- < 0.2 indicates severe stenosis
What are the indications for treatment of stenosis?
Breeding dogs
Spayed dogs with clinical signs
What criteria is used to determine stenosis treatment decisions?
- Lesion type: septum vs. annulus vs. hypoplasia
- Location: caudal vs. cranial
What are the two treatment options for a simple septal lesion?
Episiotomy or endoscopic treatment
How is an episiotomy used to treat a simple septal lesion?
- Limited access cranial to urethral opening
- Mucosal resection at lesion attachments–cut out the band
- Appose mucosa
- Some lesions retracted caudally to expose
Explain endoscopic treatment of a simple septal lesion
- Laser ablation
- Endoscopic scissor resection
T/F: Mucosal resection for an annular lesion is prone to stricture
TRUE
What does the technique for resection of mucosa for an annular lesion depend on?
Location
Explain the caudal to pelvis technique for an annular lesion resection
- Vaginal resection and anastamosis
- Dorsal approach–similar to episiotomy but you don’t go into the lumen of the vestibule; doesn’t enter lumen of vaginal vault
- Incise skin over vestibule, incise stenotic area and then anastamose
Explain the intrapelvic technique for resection of mucosa of an annular lesion
- Vaginectomy–cervix to urethral opening
- Ventral abdominal + transpelvic approach
- Include OHE if not already spayed
What is the etiology of a recessed vulva?
- Conformational abnormality
- Medium to large breed dogs
- AKA “hooded vulva”
T/F: There is no relationship between age at OHE and incidence of recessed vulva
TRUE
Does obesity have an impact on incidence of recessed vulvas?
Nope–no data to support it
What are the clinical signs associated with a recessed vulva?
- Skin fold dermatitis or vaginitis
- Urine pooling
- Recurrent UTI
- Apparent incontinence
- Urine is trapped and can be dribbling
What are the indications for surgical treatment of a recessed vulva?
- Recurrent UTI
- Significant skin fold dermatitis
- Urine pooling/leakage
What is the recommended procedure for recessed vulva?
- Episioplasty–vulvar reconstruction to remove the skin fold
- Straightforward
- Outline area, resect to expose vulva
Are complications of episioplasty for treatment of recessed vulva common?
No–rare
Recurrent signs almost always resolve
What is the prognosis for treatment of a recessed vulva?
Good prognosis
When does vaginal edema resolve?
End of cycle
What is the history/signalment of vaginal edema?
- Young dogs
- One of the first proestrus/estrus cycles
- Mucosa becomes edematous
- Edematous mucosa protrudes from vulva
- Tissue subject to drying/trauma
What is the etiology of vaginal edema?
We don’t really know why, but the tissue becomes edematous
How is vaginal edema usually treated?
- Manual reduction of tissue
- If significant will likely recur
- OHE is recommended to prevent recurrence and injury to everted mucosa
- Episiotomy likely required
When treating vaginal edema, why is resecting the protruding tissue without an OHE not recommended?
The procedure is associated with significant hemorrhage and does not prevent recurrence during subsequent estrus cycles
How do you differentiate vaginal prolapse from vaginal edema and neoplasia?
- Vaginal prolapse–entire circumference of vagina prolapses and creates a ‘doughnut-shaped’ prolapse
- Edema/neoplasia–only part of the vagina prolapses and it looks like a lump of tissue instead of a doughnut shape
What are the etiologies of vaginal prolapse?
Secondary to dystocia, constipation, or forced separation
How is vaginal prolapse typically treated?
- Manual reduction + OHE
- Bladder, colon may herniate as well (possible referral)
- Hysteropexy (tack uterus to rim of pelvis to keep it from collapsing)
- Breeding animals
What is the typical signalment associated with reproductive neoplasia?
Older, intact female dogs > 10yrs old
(Suggests hormonal influence)
What is the relative likelihood of benign vs. malignant neoplasia?
- Most masses (80%) are benign
- Leiomyoma most common
- Fibroma, polyp, cyst
What staging workup is necessary for reproductive neoplasia?
- Pre-op staging workup
- CBC/chem/UA
- Thoracic rads
- Abdominal U/S
How is benign disease typically treated?
- Excisional biopsy via episiotomy
- Full-thickness resection at base
- If only resect to the mucosa, probably won’t get entire mass (often come from the smooth muscle wall of vagina)
- Electrocautery highly recommended
What is the most common malignancy?
Leiomyosarcoma
What are the characteristics of leiomyosarcomas?
- Relatively low risk of metastasis
- Locally invasive
- Survival can be good with local control of tumor
What is involved in the surgical treatment of malignant reproductive tumors?
- Aggressive resection is necessary!
- Transpelvic approach likely necessary
- Remove entire repro tract + opening of urethra
- Vulvovaginectomy
- Also requires perineal urethrostomy
