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SMALL ANIMALS
Combined preputial advancement and phallopexy as a revision technique for treating paraphimosis in a dog SM Wasik* and AM Wallace
A 7-year-old neutered male Jack Russell terrier-cross was presented for signs of recurrent paraphimosis, despite previous surgical enlargement of the preputial ostium. Revision surgery was performed using a combination of preputial advancement and phallopexy, which resulted in complete and permanent coverage of the glans penis by the prepuce, and at 1 year postoperatively, no recurrence of paraphimosis had been observed. The combined techniques allow preservation of the normal penile anatomy, are relatively simple to perform and provide a cosmetic result. We recommend this combination for the treatment of paraphimosis in the dog, particularly when other techniques have failed. Keywords dogs; advancement
paraphimosis;
Aust Vet J 2014;92:433–436
phallopexy;
preputial
doi: 10.1111/avj.12252
P
araphimosis is defined as the inability to retract the penis into the normal position within the preputial sheath.1,2 It may occur subsequent to sexual excitement or mating,2 an aetiology that is frequently observed in the equine patient.3 Paraphimosis affecting dogs has been described in the veterinary literature, with several case reports4–6 and case series.7–9 Surgical intervention is indicated in the event of recurrence, when the penis cannot be replaced into the preputial sheath or if penile necrosis occurs. Multiple surgical techniques have been described for this condition; in the intact male dog, castration is always advocated as part of the treatment protocol.8 In dogs with a shortened, congenitally hypoplastic prepuce or ineffectual preputial muscles, preputial lengthening via advancement of the prepuce has been described with or without myorrhaphy of the preputial musculature.2,7,10 The creation of a permanent surgical scar between the mucosa of the dorsal aspect of the penile shaft and the skin of the dorsolateral prepuce via phallopexy has also been reported.8 When necrosis and strangulation of the penis and compromise of the urethral lumen occurs, partial penile amputation is indicated as a salvage procedure.8,10 Despite the description of multiple techniques to address an initial episode of paraphimosis, there is no specific treatment algorithm regarding recurrent episodes subsequent to a failed corrective technique. In this case report we describe preputial advancement combined with phallopexy as a single-stage revision technique for recurrent paraphimosis. Recommendations are also provided to assist *Corresponding author: Adelaide Animal Emergency & Referral Centre, 119 Anzac Highway, Kurralta Park, South Australia 5037, Australia; [email protected] University of Melbourne Veterinary Clinic and Hospital, Werribee, Victoria, Australia
© 2014 Australian Veterinary Association
SMALL ANIMALS
CASE REPORT AND CLINICAL REVIEW
with decision making regarding the most appropriate surgical management of these challenging cases. Case report A 7-year-old, 7.4-kg neutered male Jack Russell terrier-cross was referred for evaluation of persistent paraphimosis of approximately 6 months’ duration. Initial attempts to manage the paraphimosis conservatively via lubrication and manual reduction of the exposed penis were successful for only a few days. At 3 months prior to referral, the dog had undergone surgical enlargement of the preputial ostium, which was initially successful, but episodes of paraphimosis recurred after a few weeks. Physical examination findings at the time of the referral consultation showed that the penis was flaccid, but protruded 2 cm beyond the preputial orifice. The exposed tissue was pale pink in colour and dry to the touch. The surface was normal. The distal-most aspect of the preputial ostium was inverted, exposing the glans penis (Figure 1). However, with lubrication, the prepuce could easily be drawn cranially to cover the penis. The preputial ostium was an appropriate size. No other penile or preputial abnormalities were identified. Rectal examination revealed that the prostate was non-painful, symmetrical and of an appropriate size for a neutered dog. Surgical correction was recommended to the owner and a combined preputial advancement and phallopexy was performed 3 weeks later. The preputial advancement was performed as described by Leighton11 and adapted by Papazoglou.7 During both procedures, the patient was positioned in dorsal recumbency with the forelimbs extended and secured with restraints to prevent deviation during the procedure. The hindlimbs were secured in a loose frog-leg position to prevent excessive tension on the skin of the caudal abdomen. Because the prepuce was included within the surgical field, it was liberally flushed with sterile saline in addition to standard skin preparation techniques. A large surgical field, extending from the xiphisternum to the level of the pelvic brim, was established. A U-shaped incision was created 2 cm cranial the preputial orifice, continuing laterally on either side, to the caudal extremity of the preputial cavity. The paired preputialis muscles were transected and the preputial arteries and veins on either side of the prepuce were coagulated then transected with monopolar electrosurgery. The prepuce was then undermined from the body wall. A crescent of residual skin and subcutaneous tissue was excised between the new preputial location (just caudal to the umbilicus) and the original incision. At the cranial aspect of the U, five simple interrupted sutures were placed (2/0 polydioxanone) in order to appose the deep dermal border of the prepuce to the fascia of the abdominal wall
Australian Veterinary Journal Volume 92, No 11, November 2014
433
SMALL ANIMALS
SMALL ANIMALS
Figure 3. Intraoperative appearance of the completed phallopexy in a 7-year-old neutered male Jack Russell terrier-cross, demonstrating the junction of the pars longa glandis (PLG) and the preputial mucosa (PM).
Figure 1. Prolapse of the glans penis with inversion of the preputial ostium in a 7-year-old neutered male Jack Russell terrier-cross.
Figure 4. Immediate postoperative appearance of the completed preputial advancement and phallopexy in a 7-year-old neutered male Jack Russell terrier-cross.
Figure 2. Intraoperative appearance of the apposition of the cranial dermal layer of the prepuce to the external rectus sheath of the body wall with interrupted sutures (2/0 polydioxanone) during preputial advancement in a 7-year-old neutered male Jack Russell terrier-cross.
(Figure 2). The preputialis muscles were not specifically re-apposed. Simple interrupted sutures were then used to appose the superficial subcutaneous tissues of the prepuce to the subcutaneous tissues of the abdominal wall (3/0 polydioxanone). The skin was closed with simple interrupted sutures (3/0 nylon). The phallopexy procedure was then performed according to the methods described by Somerville and Anderson8 extrapolated from
434
Australian Veterinary Journal Volume 92, No 11, November 2014
the equine technique originally described by Bolz.12 The approach was commenced on the right side of the prepuce via a 3.5-cm incision extending from the skin into the preputial cavity, approximately 3 cm caudal to the preputial ostium. The penis was exteriorised via this incision and a 2.5 × 0.5 cm strip of penile mucosa was excised from the dorsal midline of the pars longa glandis, commencing approximately 2 cm caudal to the tip of the penis. The borders of this defect were then directly re-apposed to the adjacent borders of the incised preputial mucosa in paired simple continuous patterns (3/0 polydioxanone) (Figure 3). The subcutaneous layer was closed in a simple continuous suture pattern (3/0 polydioxanone) and the skin was closed with simple interrupted sutures (3/0 nylon). At the completion of both procedures, the penis could not be manually extruded from the preputial sheath (Figure 4). The dog was discharged from hospital 2 days later with an Elizabethan collar in place and a 7-day course of cephalexin (22 mg/kg PO twice daily), carprofen (2 mg/kg PO twice daily) and tramadol (2 mg/kg PO twice daily). The owner was instructed to restrict the dog’s activity and keep him confined to a small playpen for the next 2–3 weeks. The owner was also instructed to keep the Elizabethan collar in place at all times to prevent licking or chewing at the wound sites. A recheck at 14 days after surgery for skin suture removal revealed a normal appearance to the wound. According to owner observations, the dog was able
© 2014 Australian Veterinary Association
this technique;7 however, more recent information questions the significance of the role of ineffectual preputial muscles in the development of paraphimosis and thus the benefit and need for this additional technique.10 In the absence of electromyographic or histopathological evaluation of the preputial muscles, their true effect cannot be known. In this instance, the paired preputialis muscles were transected in order to allow the cranial preputial advancement, but myorrhaphy was not performed. The absence of this step did not have a negative effect on the postoperative outcome in this dog.
Figure 5. Appearance of the surgical site at 1 year postoperatively in a 7-year-old neutered male Jack Russell terrier-cross. The dog is positioned in right lateral recumbency with the head orientated to the left. The preputial ostium is identified by an arrow.
to urinate normally. The tip of the glans penis was palpable within the preputial sheath, approximately 3 cm caudal to the preputial ostium. The penis could not be manually extruded. A follow-up telephone conversation with the owner 1 year after surgery relayed no observation by the owner of recurrent paraphimosis (Figure 5). Discussion This case report describes combined preputial advancement and phallopexy as a surgical treatment for unresolved paraphimosis. Given that a procedure to enlarge the preputial ostium had already failed, careful consideration was given to the most appropriate surgical treatment method(s) for this dog. Our aim was to perform a definitive, single-stage procedure to prevent recurrence while preserving the dog’s normal penile anatomy. Because of the absence of penile necrosis or any other abnormalities associated with the penis, urogenital system or prepuce, a salvage procedure such as partial penile amputation was not considered appropriate. Preputial advancement alone was considered inappropriate because of the exposure of the glans penis by 2 cm. A previous study reported good success utilising this technique alone when 1.5 cm of the glans penis was initially exposed, recurrence of paraphimosis occurred within 12 days of surgery.7 In addition, preputial advancement does not completely eliminate the risk of recurrent paraphimosis, because erection, balanoposthitis and ongoing selftrauma are all still possible.8 Incorporation of the external rectus sheath into the sutures of the cranial dermal border of the prepuce has been proposed to reduce tension across the surgical wound and reduce the risk of dehiscence7 or loss of advancement secondary to elastic retraction of the prepuce.13 Myorrhaphy of the paired cranial preputial muscles has been advocated as an important component related to the success of
© 2014 Australian Veterinary Association
SMALL ANIMALS
SMALL ANIMALS
Phallopexy has also been described as a stand-alone procedure for the prevention of recurrent paraphimosis. Somerville and Anderson8 have documented resolution of repeat episodes of paraphimosis in three dogs of different breeds. This suggests that their technique as described is appropriate for dogs of various size and body weight. The authors stated that no penile or preputial abnormalities were observed in any of the affected dogs; presumably the preputial ostia were of appropriate size. However, the exposed glans penis length was not documented for any of the dogs within that study. Pavletic10 stated that there are insufficient numbers of reported cases to determine whether preputial advancement or phallopexy is the superior technique for recurrent paraphimosis. He has also stated that these two techniques may be combined ‘in more challenging cases’. We could not find a report describing using these techniques in combination. Similarly, there have been no reports of currently stand-alone techniques such as phallopexy or preputial advancement being utilised successfully in a revision setting, following a previous surgical failure. Therefore, because of the small number of documented cases previously treated successfully with either preputial advancement or phallopexy, we elected to perform the techniques in combination. The relative length of exposed glans penis in this particular case, and the owner’s desire to minimise the risk of recurrence, were also important considerations. Preputial advancement was performed prior to phallopexy, in order to allow mobilisation of the prepuce to its new location along the body wall prior to anchorage of the penis. Although it would have been technically easier to perform the phallopexy during the elevation of the prepuce from the body wall, particularly if a ventral phallopexy was chosen, we wanted to ensure that the penis would be immobilised in the most appropriate anatomical position. Recurrence of paraphimosis may occur with phallopexy if the penis is inadequately retracted within the preputial sheath prior to its immobilisation. Likewise, fixation of the penis in an excessively caudal location within the preputial sheath raises concerns about possible retention of urine within the preputial cavity, leading to urine scalding and balanoposthitis. This is of particular concern in the equine patient,14 but has not been observed in dogs.8 Although more technically challenging, a dorsal phallopexy was preferred in our case, as previous reports have described reduced mobility relative to the body wall in this location.8,10 Additionally, the penile urethra is located more superficially on the ventral aspect, placing it at risk of iatrogenic injury during the procedure.10 In this case report, combined preputial advancement and phallopexy is described as a successful surgical treatment option for recurrent paraphimosis in a dog. We have provided guidelines regarding when this combined technique should be chosen over others, including
Australian Veterinary Journal Volume 92, No 11, November 2014
435
SMALL ANIMALS
SMALL ANIMALS preputial advancement or phallopexy in isolation, particularly in cases of revision. This technique allows preservation of the normal penile anatomy and is simple compared with other more radical techniques such partial penile amputation. No peri- or postoperative complications were observed and no further episodes of paraphimosis have occurred. The result was cosmetic and the owner was satisfied with the outcome. In summary, we recommend this technique for the treatment of recurrent paraphimosis without penile necrosis in the dog, particularly when other techniques have failed. Acknowledgments The authors thank Dr Sarah Hall at Eaglehawk Veterinary Clinic for referral of the case. References 1. Root Kustritz MV. Disorders of the canine penis. Vet Clin North Am Small Anim Pract 2001;31:247–258. 2. Papazoglou LG, Kazakos GM. Surgical conditions of the canine penis and prepuce. Compend Contin Educ Vet 2002;24:204–218.
436
Australian Veterinary Journal Volume 92, No 11, November 2014
3. Hayden SS. Treating equine paraphimosis. Compend Contin Educ Vet 2012;34:E1–E5. 4. Chaffee VW, Knecht CD. Canine paraphimosis: sequel to ineffectual preputial muscles. Vet Med Small Anim Clin 1975;70:1418–1420. 5. Lee J. Paraphimosis in a pseudohermaphrodite dog. Vet Med Small Anim Clin 1976;71:1076–1077. 6. Rezaie A, Kazemi D. Paraphimosis in a mixed breed sheepdog following copulation and sexual activity. Adv Environ Biol 2011;5:2459–2461. 7. Papazoglou LG. Idiopathic chronic penile protrusion in the dog: a report of six cases. J Small Anim Pract 2001;42:510–513. 8. Somerville ME, Anderson SM. Phallopexy for the treatment of paraphimosis in the dog. J Am Anim Hosp Assoc 2001;37:397–400. 9. Kumar A, Sangwan V, Mahajan SK et al. Transmissible venereal tumor induced paraphimosis in dogs. J Adv Vet Res 2012;2:48–49. 10. Pavletic MM. Preputial reconstructive surgery. In: Pavletic MM, editor. Atlas of small animal wound management and reconstructive surgery. 3rd edn. WileyBlackwell, Iowa, 2010;615–645. 11. Leighton RL. A simple surgical correction for chronic penile protrusion. J Am Anim Hosp Assoc 1976;12:667. 12. Bolz W. The prophylaxis and therapy of prolapse and paralysis of the penis occurring in the horse after the administration of neuroleptics. Vet Med Rev Leverkusen 1970;4:255. 13. Pavletic MM. Management of canine paraphimosis. 2005. http:// www.hungarovet.com/wp-content/uploads/2008/07/management-of-canine -paraphimosis-2005.pdf. Accessed April 2014. 14. Schumacher J. The penis and prepuce. In: Auer JA, Stick JA, editors. Equine surgery. WB Saunders, Philadelphia, 1999;546–547. (Accepted for publication 3 June 2014)
© 2014 Australian Veterinary Association
SMALL ANIMALS
Combined preputial advancement and phallopexy as a revision technique for treating paraphimosis in a dog SM Wasik* and AM Wallace
A 7-year-old neutered male Jack Russell terrier-cross was presented for signs of recurrent paraphimosis, despite previous surgical enlargement of the preputial ostium. Revision surgery was performed using a combination of preputial advancement and phallopexy, which resulted in complete and permanent coverage of the glans penis by the prepuce, and at 1 year postoperatively, no recurrence of paraphimosis had been observed. The combined techniques allow preservation of the normal penile anatomy, are relatively simple to perform and provide a cosmetic result. We recommend this combination for the treatment of paraphimosis in the dog, particularly when other techniques have failed. Keywords dogs; advancement
paraphimosis;
Aust Vet J 2014;92:433–436
phallopexy;
preputial
doi: 10.1111/avj.12252
P
araphimosis is defined as the inability to retract the penis into the normal position within the preputial sheath.1,2 It may occur subsequent to sexual excitement or mating,2 an aetiology that is frequently observed in the equine patient.3 Paraphimosis affecting dogs has been described in the veterinary literature, with several case reports4–6 and case series.7–9 Surgical intervention is indicated in the event of recurrence, when the penis cannot be replaced into the preputial sheath or if penile necrosis occurs. Multiple surgical techniques have been described for this condition; in the intact male dog, castration is always advocated as part of the treatment protocol.8 In dogs with a shortened, congenitally hypoplastic prepuce or ineffectual preputial muscles, preputial lengthening via advancement of the prepuce has been described with or without myorrhaphy of the preputial musculature.2,7,10 The creation of a permanent surgical scar between the mucosa of the dorsal aspect of the penile shaft and the skin of the dorsolateral prepuce via phallopexy has also been reported.8 When necrosis and strangulation of the penis and compromise of the urethral lumen occurs, partial penile amputation is indicated as a salvage procedure.8,10 Despite the description of multiple techniques to address an initial episode of paraphimosis, there is no specific treatment algorithm regarding recurrent episodes subsequent to a failed corrective technique. In this case report we describe preputial advancement combined with phallopexy as a single-stage revision technique for recurrent paraphimosis. Recommendations are also provided to assist *Corresponding author: Adelaide Animal Emergency & Referral Centre, 119 Anzac Highway, Kurralta Park, South Australia 5037, Australia; [email protected] University of Melbourne Veterinary Clinic and Hospital, Werribee, Victoria, Australia
© 2014 Australian Veterinary Association
SMALL ANIMALS
CASE REPORT AND CLINICAL REVIEW
with decision making regarding the most appropriate surgical management of these challenging cases. Case report A 7-year-old, 7.4-kg neutered male Jack Russell terrier-cross was referred for evaluation of persistent paraphimosis of approximately 6 months’ duration. Initial attempts to manage the paraphimosis conservatively via lubrication and manual reduction of the exposed penis were successful for only a few days. At 3 months prior to referral, the dog had undergone surgical enlargement of the preputial ostium, which was initially successful, but episodes of paraphimosis recurred after a few weeks. Physical examination findings at the time of the referral consultation showed that the penis was flaccid, but protruded 2 cm beyond the preputial orifice. The exposed tissue was pale pink in colour and dry to the touch. The surface was normal. The distal-most aspect of the preputial ostium was inverted, exposing the glans penis (Figure 1). However, with lubrication, the prepuce could easily be drawn cranially to cover the penis. The preputial ostium was an appropriate size. No other penile or preputial abnormalities were identified. Rectal examination revealed that the prostate was non-painful, symmetrical and of an appropriate size for a neutered dog. Surgical correction was recommended to the owner and a combined preputial advancement and phallopexy was performed 3 weeks later. The preputial advancement was performed as described by Leighton11 and adapted by Papazoglou.7 During both procedures, the patient was positioned in dorsal recumbency with the forelimbs extended and secured with restraints to prevent deviation during the procedure. The hindlimbs were secured in a loose frog-leg position to prevent excessive tension on the skin of the caudal abdomen. Because the prepuce was included within the surgical field, it was liberally flushed with sterile saline in addition to standard skin preparation techniques. A large surgical field, extending from the xiphisternum to the level of the pelvic brim, was established. A U-shaped incision was created 2 cm cranial the preputial orifice, continuing laterally on either side, to the caudal extremity of the preputial cavity. The paired preputialis muscles were transected and the preputial arteries and veins on either side of the prepuce were coagulated then transected with monopolar electrosurgery. The prepuce was then undermined from the body wall. A crescent of residual skin and subcutaneous tissue was excised between the new preputial location (just caudal to the umbilicus) and the original incision. At the cranial aspect of the U, five simple interrupted sutures were placed (2/0 polydioxanone) in order to appose the deep dermal border of the prepuce to the fascia of the abdominal wall
Australian Veterinary Journal Volume 92, No 11, November 2014
433
SMALL ANIMALS
SMALL ANIMALS
Figure 3. Intraoperative appearance of the completed phallopexy in a 7-year-old neutered male Jack Russell terrier-cross, demonstrating the junction of the pars longa glandis (PLG) and the preputial mucosa (PM).
Figure 1. Prolapse of the glans penis with inversion of the preputial ostium in a 7-year-old neutered male Jack Russell terrier-cross.
Figure 4. Immediate postoperative appearance of the completed preputial advancement and phallopexy in a 7-year-old neutered male Jack Russell terrier-cross.
Figure 2. Intraoperative appearance of the apposition of the cranial dermal layer of the prepuce to the external rectus sheath of the body wall with interrupted sutures (2/0 polydioxanone) during preputial advancement in a 7-year-old neutered male Jack Russell terrier-cross.
(Figure 2). The preputialis muscles were not specifically re-apposed. Simple interrupted sutures were then used to appose the superficial subcutaneous tissues of the prepuce to the subcutaneous tissues of the abdominal wall (3/0 polydioxanone). The skin was closed with simple interrupted sutures (3/0 nylon). The phallopexy procedure was then performed according to the methods described by Somerville and Anderson8 extrapolated from
434
Australian Veterinary Journal Volume 92, No 11, November 2014
the equine technique originally described by Bolz.12 The approach was commenced on the right side of the prepuce via a 3.5-cm incision extending from the skin into the preputial cavity, approximately 3 cm caudal to the preputial ostium. The penis was exteriorised via this incision and a 2.5 × 0.5 cm strip of penile mucosa was excised from the dorsal midline of the pars longa glandis, commencing approximately 2 cm caudal to the tip of the penis. The borders of this defect were then directly re-apposed to the adjacent borders of the incised preputial mucosa in paired simple continuous patterns (3/0 polydioxanone) (Figure 3). The subcutaneous layer was closed in a simple continuous suture pattern (3/0 polydioxanone) and the skin was closed with simple interrupted sutures (3/0 nylon). At the completion of both procedures, the penis could not be manually extruded from the preputial sheath (Figure 4). The dog was discharged from hospital 2 days later with an Elizabethan collar in place and a 7-day course of cephalexin (22 mg/kg PO twice daily), carprofen (2 mg/kg PO twice daily) and tramadol (2 mg/kg PO twice daily). The owner was instructed to restrict the dog’s activity and keep him confined to a small playpen for the next 2–3 weeks. The owner was also instructed to keep the Elizabethan collar in place at all times to prevent licking or chewing at the wound sites. A recheck at 14 days after surgery for skin suture removal revealed a normal appearance to the wound. According to owner observations, the dog was able
© 2014 Australian Veterinary Association
this technique;7 however, more recent information questions the significance of the role of ineffectual preputial muscles in the development of paraphimosis and thus the benefit and need for this additional technique.10 In the absence of electromyographic or histopathological evaluation of the preputial muscles, their true effect cannot be known. In this instance, the paired preputialis muscles were transected in order to allow the cranial preputial advancement, but myorrhaphy was not performed. The absence of this step did not have a negative effect on the postoperative outcome in this dog.
Figure 5. Appearance of the surgical site at 1 year postoperatively in a 7-year-old neutered male Jack Russell terrier-cross. The dog is positioned in right lateral recumbency with the head orientated to the left. The preputial ostium is identified by an arrow.
to urinate normally. The tip of the glans penis was palpable within the preputial sheath, approximately 3 cm caudal to the preputial ostium. The penis could not be manually extruded. A follow-up telephone conversation with the owner 1 year after surgery relayed no observation by the owner of recurrent paraphimosis (Figure 5). Discussion This case report describes combined preputial advancement and phallopexy as a surgical treatment for unresolved paraphimosis. Given that a procedure to enlarge the preputial ostium had already failed, careful consideration was given to the most appropriate surgical treatment method(s) for this dog. Our aim was to perform a definitive, single-stage procedure to prevent recurrence while preserving the dog’s normal penile anatomy. Because of the absence of penile necrosis or any other abnormalities associated with the penis, urogenital system or prepuce, a salvage procedure such as partial penile amputation was not considered appropriate. Preputial advancement alone was considered inappropriate because of the exposure of the glans penis by 2 cm. A previous study reported good success utilising this technique alone when 1.5 cm of the glans penis was initially exposed, recurrence of paraphimosis occurred within 12 days of surgery.7 In addition, preputial advancement does not completely eliminate the risk of recurrent paraphimosis, because erection, balanoposthitis and ongoing selftrauma are all still possible.8 Incorporation of the external rectus sheath into the sutures of the cranial dermal border of the prepuce has been proposed to reduce tension across the surgical wound and reduce the risk of dehiscence7 or loss of advancement secondary to elastic retraction of the prepuce.13 Myorrhaphy of the paired cranial preputial muscles has been advocated as an important component related to the success of
© 2014 Australian Veterinary Association
SMALL ANIMALS
SMALL ANIMALS
Phallopexy has also been described as a stand-alone procedure for the prevention of recurrent paraphimosis. Somerville and Anderson8 have documented resolution of repeat episodes of paraphimosis in three dogs of different breeds. This suggests that their technique as described is appropriate for dogs of various size and body weight. The authors stated that no penile or preputial abnormalities were observed in any of the affected dogs; presumably the preputial ostia were of appropriate size. However, the exposed glans penis length was not documented for any of the dogs within that study. Pavletic10 stated that there are insufficient numbers of reported cases to determine whether preputial advancement or phallopexy is the superior technique for recurrent paraphimosis. He has also stated that these two techniques may be combined ‘in more challenging cases’. We could not find a report describing using these techniques in combination. Similarly, there have been no reports of currently stand-alone techniques such as phallopexy or preputial advancement being utilised successfully in a revision setting, following a previous surgical failure. Therefore, because of the small number of documented cases previously treated successfully with either preputial advancement or phallopexy, we elected to perform the techniques in combination. The relative length of exposed glans penis in this particular case, and the owner’s desire to minimise the risk of recurrence, were also important considerations. Preputial advancement was performed prior to phallopexy, in order to allow mobilisation of the prepuce to its new location along the body wall prior to anchorage of the penis. Although it would have been technically easier to perform the phallopexy during the elevation of the prepuce from the body wall, particularly if a ventral phallopexy was chosen, we wanted to ensure that the penis would be immobilised in the most appropriate anatomical position. Recurrence of paraphimosis may occur with phallopexy if the penis is inadequately retracted within the preputial sheath prior to its immobilisation. Likewise, fixation of the penis in an excessively caudal location within the preputial sheath raises concerns about possible retention of urine within the preputial cavity, leading to urine scalding and balanoposthitis. This is of particular concern in the equine patient,14 but has not been observed in dogs.8 Although more technically challenging, a dorsal phallopexy was preferred in our case, as previous reports have described reduced mobility relative to the body wall in this location.8,10 Additionally, the penile urethra is located more superficially on the ventral aspect, placing it at risk of iatrogenic injury during the procedure.10 In this case report, combined preputial advancement and phallopexy is described as a successful surgical treatment option for recurrent paraphimosis in a dog. We have provided guidelines regarding when this combined technique should be chosen over others, including
Australian Veterinary Journal Volume 92, No 11, November 2014
435
SMALL ANIMALS
SMALL ANIMALS preputial advancement or phallopexy in isolation, particularly in cases of revision. This technique allows preservation of the normal penile anatomy and is simple compared with other more radical techniques such partial penile amputation. No peri- or postoperative complications were observed and no further episodes of paraphimosis have occurred. The result was cosmetic and the owner was satisfied with the outcome. In summary, we recommend this technique for the treatment of recurrent paraphimosis without penile necrosis in the dog, particularly when other techniques have failed. Acknowledgments The authors thank Dr Sarah Hall at Eaglehawk Veterinary Clinic for referral of the case. References 1. Root Kustritz MV. Disorders of the canine penis. Vet Clin North Am Small Anim Pract 2001;31:247–258. 2. Papazoglou LG, Kazakos GM. Surgical conditions of the canine penis and prepuce. Compend Contin Educ Vet 2002;24:204–218.
436
Australian Veterinary Journal Volume 92, No 11, November 2014
3. Hayden SS. Treating equine paraphimosis. Compend Contin Educ Vet 2012;34:E1–E5. 4. Chaffee VW, Knecht CD. Canine paraphimosis: sequel to ineffectual preputial muscles. Vet Med Small Anim Clin 1975;70:1418–1420. 5. Lee J. Paraphimosis in a pseudohermaphrodite dog. Vet Med Small Anim Clin 1976;71:1076–1077. 6. Rezaie A, Kazemi D. Paraphimosis in a mixed breed sheepdog following copulation and sexual activity. Adv Environ Biol 2011;5:2459–2461. 7. Papazoglou LG. Idiopathic chronic penile protrusion in the dog: a report of six cases. J Small Anim Pract 2001;42:510–513. 8. Somerville ME, Anderson SM. Phallopexy for the treatment of paraphimosis in the dog. J Am Anim Hosp Assoc 2001;37:397–400. 9. Kumar A, Sangwan V, Mahajan SK et al. Transmissible venereal tumor induced paraphimosis in dogs. J Adv Vet Res 2012;2:48–49. 10. Pavletic MM. Preputial reconstructive surgery. In: Pavletic MM, editor. Atlas of small animal wound management and reconstructive surgery. 3rd edn. WileyBlackwell, Iowa, 2010;615–645. 11. Leighton RL. A simple surgical correction for chronic penile protrusion. J Am Anim Hosp Assoc 1976;12:667. 12. Bolz W. The prophylaxis and therapy of prolapse and paralysis of the penis occurring in the horse after the administration of neuroleptics. Vet Med Rev Leverkusen 1970;4:255. 13. Pavletic MM. Management of canine paraphimosis. 2005. http:// www.hungarovet.com/wp-content/uploads/2008/07/management-of-canine -paraphimosis-2005.pdf. Accessed April 2014. 14. Schumacher J. The penis and prepuce. In: Auer JA, Stick JA, editors. Equine surgery. WB Saunders, Philadelphia, 1999;546–547. (Accepted for publication 3 June 2014)
© 2014 Australian Veterinary Association
