Author

Stephen J. Birchard DVM, MS, Diplomate ACVS

Sunday, December 4, 2016

Episioplasty for Perivulvular Dermatitis in Dogs

Intertriginous dermatoses, or skin fold pyoderma, is a well recognized disorder caused by excessive skin folds in various regions in dogs, such as nasal, lip, and perivulvular skin folds.(Fig. 1a,b)
Fig. 1a: Excessive skin fold in perivulvular area of a  spayed mixed breed dog.

Fig. 1b: Same dog as Fig. 1a; the chronically inflamed vulva is exposed by
pushing the skin fold dorsally.
Redundant skin in these areas leads to skin friction, excessive moisture, and poor air circulation.(1a-b) Trapped skin secretions are fertile ground for surface bacteria and yeast to establish infection. Chronic skin infection in the perivulvular region can also lead to ascending urinary tract infection(UTI). 

Medical treatment consisting of hair clipping, medicated soaps and shampoos, and topical and systemic antibiotics may improve the condition, but surgical resection of the excessive skin is necessary to achieve successful long-term resolution.(1) Episioplasty is a skin reconstructive surgical procedure to correct excessive perivulvular skin folds and is well described in standard surgical textbooks.(Fig.2)
Fig. 2: Schematic representation of episioplasty in dogs. A: initial incision of skin to be resected;
B: beginning skin closure; C: completed closure.
From: Bellah JR. Surgery of intertriginous dermatoses. In: Saunders Manual of Small Animal Practice. 3rd edition, 
Birchard and Sherding, eds., Elsevier, St. Louis, 2006. Pg. 537
Episioplasty has been used for many years to treat perivululvar dermatitis in dogs that did not respond to more conservative treatment but has also been shown to be an effective treatment for the chronic urinary tract infection associated with perivulvular dermatitis.(2) In this blog we will describe the surgical technique and postoperative care for episioplasty in dogs. 

Surgery 
After placing the dog under general anesthesia, it is positioned in ventral recumbency and the perivulvular region clipped and prepared for aseptic surgery. Administer prophylactic intravenous antibiotics, such as cefazolin, to establish blood levels prior to the surgical procedure. Empty the anal sacs and place a purse string suture in the anus to prevent fecal contamination during the perioperative period. Pull the tail dorsally and cranially and secure with tape. 

The redundant perivulvular skin is carefully examined to determine how much will require resection. The proposed area of skin to be removed is marked to aid in excision.(Fig.3) 
Fig. 3: The proposed area of perivulvular skin to be resected is marked with a sterile marking pen.
The skin incisions are made with a scalpel and the skin removed with blunt and sharp dissection using Metzenbaum scissors.(Fig.4) 
Fig 4: Appearance of the surgical site after resection of the perivulvular skin fold..
Electrocautery is used for hemostasis. Only the skin is removed; subcutaneous fat is left in tact in order not to create excessive dead space under the reconstructed skin. The deep fascia and subcutaneous tissues are closed first with absorbable suture in a simple interrupted pattern. The first sutures are placed at the 10, 12 and 2 o’clock positions, then the remainder placed as needed to provide accurate apposition of the skin.(Fig.1) Skin closure can be with skin sutures, intradermal sutures, or continuous absorbable skin suture (e.g. 4-0 Monocryl).(Fig.5)
Fig. 5: Appearance of the surgical site after completion of  the skin closeure.
Remove the pursestring suture in the anus after completion of the procedure. 

Postoperative Care 
Postoperative care consists of analgesic therapy such as tramadol and a NSAID (if not contraindicated), ice packs on the incision for the first 24 hours followed by warm compresses, and exercise restriction until the incision is healed and skin sutures removed.(Fig.6) 
Fig 6: Appearance of the surgical site 3 weeks postoperatively.
Keep the incision clean and free of urine and fecal soiling. If episioplasty was performed for chronic UTI, maintain antibiotic therapy for 2-3 weeks followed by repeat urine culture and sensitivity. Continue antibiotics until the urine culture is negative. 

Prognosis 
Complete resolution of the skin fold pyoderma should occur after resection of the excessive skin. Episioplasty is effective in treating perivulvar dermatitis.and in treating chronic urinary tract infection that is secondary to ascending infection from excessive skin folds around the vulva.(2) 

References 
1. Bellah JR. Surgery of intertriginous dermatoses. In: Saunders Manual of Small Animal Practice. 3rd edition, Birchard and Sherding, eds., Elsevier, St. Louis, 2006. Pg. 537. 
2. Lightner BA, McLoughlin MA, Chew DJ, Beardsley SM, Matthews HK. Episioplasty for the treatment of perivulvar dermatitis or recurrent urinary tract infections in dogs with excessive perivulvular skin folds: 31 cases (1983-2000). J Am Vet Med Assoc 219: 1577-1581, 2001