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Basics ⬇

Basics

Definition

Altered anatomic architecture due to congenital anomalies (imperforate hymen, dorsoventral septum, hymenal constriction, rectovaginal fistula, segmental aplasia, cysts, conformational defects of the vulva) and acquired conditions (vaginal hyperplasia, foreign bodies, strictures, adhesions, fistulas, and neoplasia).

Pathophysiology

Congenital

  • Normal embryologic development-the paired paramesonephric (Müllerian) ducts fuse to form the uterine body, cervix, and vagina; urogenital sinus forms the vestibule, urethra, and urinary bladder; hymen (composed of the epithelial linings of the paramesonephric ducts and urogenital sinus and an interposed layer of mesoderm) normally disappears by birth.
  • Errors during embryonic development-imperforate hymens; dorsoventral septae; hymenal constrictions (including vestibulovaginal stenoses); vaginal diverticulum (double vagina, vaginal pouch); cysts.

Acquired

  • Vaginal scarring-response to trauma (mating, dystocia, sexual abuse) or inflammation; with mature scarring, may note adhesions or strictures, which narrow the diameter of the vagina.
  • Vaginal hyperplasia (dogs)-result of an exaggerated response of the vaginal mucosa to estrogen; effect produced is edema rather than hyperplasia or hypertrophy.
  • Neoplastic processes-extraluminal leiomyoma most common; usually old patients; no effect of ovarian status on occurrence.

Systems Affected

  • Reproductive-principal effect: interference with natural mating and whelping; frequent concurrent problem: vaginitis.
  • Renal/Urologic-ascending urinary tract infections not uncommon; may note urinary incontinence in conjunction with congenital malformations of the hymenal area; interrelationship not understood and is not universally accepted.
  • Skin/Exocrine-usually see perivulvar dermatitis secondary to vaginitis, recessed vulva (redundant perivulvar folds or hypoplastic vulva), or urinary incontinence.

Genetics

Congenital-heritable component may be suspected; no direct evidence.

Incidence/Prevalence

  • Incidence (congenital)-unknown; conditions may be asymptomatic, especially if the female is never used for breeding.
  • Prevalence (vaginal septa)-in one study, reported as 0.03% of all cases seen.

Signalment

Species

Dog and cat

Breed Predilections

  • Congenital-none identified.
  • Vaginal hyperplasia-breeds more prone: large and brachycephalic breeds (boxer, mastiff, English bulldog, Saint Bernard); Labrador and Chesapeake Bay retrievers; German shepherd; springer spaniel; walker hound; Airedale terrier; American pit bull terrier.

Mean Age and Range

  • Congenital lesion (e.g., imperforate hymen, stenosis, septa)-young (<2 years of age) intact or spayed females.
  • Vaginal hyperplasia-young (<2 years of age) intact females.
  • Acquired lesion (adhesions and strictures)-post-pubertal females of any age.
  • Neoplasia-mean age, 10 years; ovarian status has no effect.

Signs

Historical Findings

  • Vulvar discharge
  • Excessive licking of vulva
  • Frequent or inappropriate urination
  • Stranguria or dyschezia
  • Urinary incontinence
  • Attractive to males
  • Refuses mating
  • Mass at vulvar labia

Physical Examination Findings

  • Usually normal.
  • Evidence of vaginal discharge or perivulvar dermatitis common.
  • Recessed or hypoplastic vulva occasionally seen.

Causes

  • Congenital
  • Inflammatory
  • Hormonal
  • Traumatic
  • Neoplastic

Diagnosis ⬆ ⬇

Diagnosis

Differential Diagnosis

  • Vaginitis-concurrent with many malformations; differentiated by vaginoscopy and positive contrast vaginography.
  • Urinary tract infection-differentiated by vaginal cytology and concurrent urinalysis on a sample collected by cystocentesis.
  • Pyometra-differentiated by CBC, biochemistry profiles, and abdominal ultrasonography.

CBC/Biochemistry/Urinalysis

  • CBC and biochemistry-usually normal.
  • Urinalysis-may show evidence of a secondary ascending urinary tract infection.

Imaging

Positive-Contrast Vaginography

  • Defines vaginal vault to the cervix, urethra, cranial vestibule, and urinary bladder.
  • Defines the cervical canal and uterine lumen in intact patient during estrus.
  • Identifies strictures, septae, persistent hymens, masses, rectovaginal fistulas, urethrovaginal fistulas, vaginal rupture, and diverticulae.
  • Patients should be fasted for 24 hours; give enema 2 hours before the procedure.
  • Place patient under sedation or general anesthesia.
  • Pass a balloon-tipped Foley catheter in the vestibule; inflate balloon; infuse aqueous iodinated contrast media (1 mL/kg); avoid overdistension and underdistension.
  • Vestibulovaginal stenoses: ratio of the maximal height of the vagina to the smallest height of the vestibulovaginal junction-normal >0.35, mild 0.26–0.35, moderate 0.20–0.25, severe <0.20.
  • Urinary incontinence-may require excretory urography to rule-out ectopic ureters or an intrapelvically positioned bladder neck; urethrocystoscopy.

Abdominal Ultrasonography

  • Much of the vagina is not accessible owing to the bony pelvis.
  • Cranial vaginal masses-may occasionally be imaged.
  • Aid visualization by infusing saline into the vagina before examination; helps differentiate luminal from transmural or extraluminal lesions.

Diagnostic Procedures

  • Order in which procedures are performed is important; they are listed here in the recommended order.
  • Vaginal culture-identify secondary infections; guarded culturette recommended to avoid contamination from the vestibule and caudal vagina (see Vaginal Discharge; Vaginitis).
  • Vaginal cytology-identifies stage of the estrous cycle; reveal inflammatory or neoplastic cells (see Breeding, Timing).
  • Digital examination of the vestibule and caudal vagina-measure the diameter; identify caudal strictures or masses; note the size and conformation of the vulva; patient standing with abdomen supported (sedation) or in recumbency (anesthesia).
  • Vaginoscopy-identify strictures, adhesions, septa, diverticula, masses, and foreign bodies; may use a variety of specula; a long (16–20 cm), hollow, rigid-type (e.g., infant proctoscope) with either a fiber-optic or halogen light source recommended; match the speculum's diameter to size of the patient; post-cervical fold (normal) obscures visualization of the external os of the cervix; rigid cystoscopes (used for transcervical insemination) adequate for many anomalies, need vaginal distension (under general anesthesia) with saline or air to visualize some anomalies or lesions.
  • Imaging-when results of previous procedures suggest an anatomic abnormality; vaginography and/or ultrasonography.

Pathologic Findings

Congenital

  • Imperforate hymen-thin fenestrated membrane, dorsoventral band(s), or a thick membrane at the vestibulovaginal junction; simplest, most common defect; remainder of the genital tract normal.
  • Dorsoventral septum-oriented dorsoventrally in the vagina, cranial to the vestibulovaginal junction; may note a double cervix (most common variant); double vagina, or divided uterine fundus (rare).
  • Hymenal constriction or vestibulovaginal stenosis-moderate to severe constriction at the vestibulovaginal junction.
  • Vaginal hypoplasia, or vaginal aplasia-vagina, cervix, uterus, vulva may be absent or hypoplastic.

Acquired

  • Strictures and adhesions-may be identified anywhere in the vagina or vestibule; result of prior trauma and/or inflammation; persistent vaginitis, refusal to mate, dystocia, or problems with micturition are common sequelae.
  • Vaginal hyperplasia and prolapse.
  • Vaginal neoplasia-usually leiomyoma, usually extraluminal in the wall of the vestibule; leiomyosarcomas; transmissible venereal tumors; lipomas; mast cell tumors; epidermoid carcinomas; squamous cell carcinomas; fibromas; fibrosarcomas; and invasive urinary tract carcinomas reported.
  • Foreign bodies-plant material, sticks, and swabs occasionally found.

Treatment ⬆ ⬇

Treatment

Appropriate Health Care

  • Usually outpatient, until nature of the defect is ascertained.
  • Inpatient-for positive contrast vaginography.

Nursing Care

Manual dilation (bougienage)-digitally or with a smooth rigid object; may attempt in patients that have an imperforate hymen or mild vestibulovaginal stenosis; may be performed in a sedated patient gradually over a course of several treatments; may be performed in an anesthetized patient at one time to maximal dilation; variable success; typically leads to reduction, but not complete resolution, of clinical signs; unlikely to resolve moderate or severe stenoses.

Surgical Considerations

  • Resection, transection, excision-many minor congenital (e.g., imperforate hymen, small dorsoventral septa) and acquired lesions (small strictures or adhesions in the caudal portion of the vagina or masses).
  • Episiotomy-usually required for adequate surgical access.
  • T-shaped vaginoplasty-described for vestibulovaginal stenoses; resection appears to provide the best odds of resolution, although results are variable.
  • Complete ring resection-vaginal stenosis.
  • Vulvoplasty-excessive vulvar fold (redundant perivulvar skin fold) with or without increased perivulvar fat deposition; recessed vulva; reserved for patients with concurrent chronic vaginitis, vaginovulvar discharge, perivulvar dermatitis.
  • Transendoscopic laser ablation-one report for correcting a dorsoventral septum in an English bulldog that subsequently bred and delivered four pups vaginally.
  • Ovariohysterectomy-patient has no breeding value; exhibits signs only during estrus.
  • Vaginal ablation (vaginectomy cranial to the external urethral orifice) and ovariohysterectomy-patient has no breeding value; concurrent severe, refractory vaginitis at all stages of the estrous cycle; severe vaginal stenosis; broad-based vaginal tumors.

Medications ⬆ ⬇

Medications

Drug(s) Of Choice

  • Concurrent vaginitis-common; usually resolves with correction of the anatomic defect; for severe condition, hasten resolution with appropriate local and antibiotic therapy (see Vaginitis).
  • Stenotic lesions-corticosteroids (prednisone: 1 mg/kg PO q 24h) used in conjunction with manual dilation in an attempt to prevent recurrence; high recurrence rates with or without steroids.

Follow-Up ⬆ ⬇

Follow-Up

Prevention/Avoidance

Congenital lesions-possibly inherited, but not confirmed; for a familial line with a high number of affected individuals, recommend sterilization of affected individuals and their sire and dam.

Possible Complications

  • Dystocia, urinary tract infections, incontinence, and vaginitis-with vaginal malformations; with patients that fail to respond to treatment.
  • Strictures and adhesions-may be postoperative complications of surgical procedures aimed at correcting abnormalities.

Expected Course and Prognosis

  • Depends on the severity of the lesion and the degree of inflammation after treatment.
  • Prognosis after treatment for imperforate hymens, short dorsoventral bands, or caudal strictures or adhesions-fair to good for improvement of clinical signs; fair to guarded for complete resolution of signs and normal fertility.
  • Prognosis for hymenal constrictions, vaginal hypoplasia or severe cranial strictures or adhesions-guarded to poor for complete resolution of signs and normal fertility; with concurrent severe vaginitis, the best recommendation is vaginal ablation.

Miscellaneous ⬆

Miscellaneous

Associated Conditions

  • Urinary tract infections
  • Vaginitis
  • Urinary incontinence

Age-Related Factors

  • Congenital-more likely in young bitches of any ovarian status.
  • Vaginal hyperplasia-more likely in young intact bitches.
  • Neoplasia of the vagina or vestibule-more likely in old bitches of any ovarian status.

Pregnancy/Fertility/Breeding

  • Some patients may be bred by artificial insemination; the possibility for a vaginal delivery is unlikely without correction of the anomaly.
  • Warn owner that an elective cesarean section may be required.

Internet Resources

Seim HB. Surgeon's Corner: Vulvoplasty. Clinician's Brief. http://www.cliniciansbrief.com/article/surgeon-s-corner-vulvoplasty

Author Sara K. Lyle

Consulting Editor Sara K. Lyle

Suggested Reading

Crawford JT, Adams WM. Influence of vestibulovaginal stenosis, pelvic bladder, and recessed vulva on response to treatment for clinical signs of lower urinary tract disease in dogs: 38 cases (1990–1999). J Am Vet Med Assoc 2002, 221(7):995–999.

Johnston SD, Root Kustritz MV, Olson PNS. Disorders of the canine vagina, vestibule, and vulva. In: Canine and Feline Theriogenology. Philadelphia: Saunders, 2001, pp. 225–242.

Johnston SD, Root Kustritz MV, Olson PNS. Disorders of the feline vagina, vestibule, and vulva. In: Canine and Feline Theriogenology. Philadelphia: Saunders, 2001, pp. 472–473.

Kyles AE, Vaden S, Hardie EM, Stone EA. Vestibulovaginal stenosis in dogs: 18 cases (1987–1995). J Am Vet Med Assoc 1996, 209:1889–1893.

Lulich JP. Endoscopic vaginoscopy in the dog. Theriogenology 2006, 66(3):588–591.

Mathews KG. Surgery of the canine vagina and vulva. Vet Clin North Am Small Anim Pract 2001, 31(2):271–290.