Thursday, September 27, 2012

Perianal what???

Sometimes there are topics that, as a dog owner you have to learn about...things you find yourself talking about at the dog park you never thought you would discuss with strangers.   This is one of those things that as a German Shepherd dog parent and or lover, you should know about.  (I do draw the line at pictures, though.  Sorry)

Perianal fistula

Perianal fistula is characterized by multiple chronic fistulous tracts or ulcerating sinuses involving the perianal region. The cause is not known, but apocrine gland inflammation (hidradenitis suppurativa), impaction and infection of the anal sinuses and crypts, infection of the circumanal glands and hair follicles, and anal sacculitis have all been proposed. The gastrointestinal system becomes involved because of excessive scar tissue formation around the anus. Self-mutilation can also be a major problem associated with this disorder.


Dogs German shepherd dog and Irish setter most commonly affected breeds Mean age, 7 years (range, 7 months-12 years) No gender predisposition reported, but sexually intact dogs have a higher prevalence A genetic basis has been proposed, but not proven


Vary with the severity and extent of involvement : Dyschezia, tenesmus, hematochezia, constipation, diarrhea, malodorous mucopurulent anal discharge, fecal incontinence, painful tail movements, licking and self-mutilation, anorexia, weight loss, reluctance to sit, posturing difficulties, and personality changes

causes and risk factors

Proposed causes involve an inflammatory component Low tail carriage and a broad tail base are risk factors predisposing the dog to inflammation and infection because of poor ventilation, accumulation of feces, moisture, and secretions High density of apocrine sweat glands in the cutaneous zone of the anal canal of German shepherd dogs Hidradenitis suppurativa may be associated with immune or endocrine dysfunction, genetic factors, and poor hygiene

diagnosis: differential diagnosis

Chronic anal sac abscess Perianal adenocarcinoma that is ulcerated and draining Rectal fistula


Results usually normal. Patients with inflammation may have an inflammatory leukogram.

other diagnostic procedures

Presumptive diagnosis is based on clinical signs and results of physical examination. Definitive diagnosis is made by biopsy of the affected area.


Surgery is considered the most effective treatment. However, a tremendous amount of controversy exists as to which surgical method should be used, and none of those currently employed result in consistent resolution of the problem. Surgical options include electrosurgery, cryosurgery, surgical debridement with fulguration by chemical cautery, exteriorization and fulguration by electrocautery, surgical resection, radical excision of the rectal ring, tail setting, tail amputation, and laser surgery. Each technique has advantages and disadvantages that must be weighed when making a choice. The primary objective of surgery is the complete removal or destruction of diseased tissue while preserving normal tissue and function. Multiple procedures may be necessary for complete resolution.


Medical treatment of perianal fistulas is usually unrewarding and can be detrimental by delaying more definitive treatment and allowing progression. Medical palliation involves clipping hair from the affected area, daily antiseptic lavage, systemic and topical antibiotics, hydrotherapy, elevation of the tail, and systemic corticosteroids.

contraindications/possible interactions

Corticosteroids are contraindicated when infection is possible.


After surgery for appropriate healing, signs of recurrence, and associated complications

Complications associated with the various surgical procedures include recurrence, failure to heal, dehiscence, tenesmus, fecal incontinence, anal stricture, and flatulence. The incidence of postoperative complications is directly related to severity of disease.

Prognosis is guarded for complete resolution except in mildly affected patients. Clients often become frustrated with the difficulty of attaining definitive resolution of this disorder.


Matthiesen DT, Marretta SM. Diseases of the anus and rectum. In: Slatter D, ed. Textbook of small animal surgery. 2nd ed. Philadelphia: WB Saunders, 1993;627-644. van Ee RT. Perianal fistulas. In: Bojrab MJ, ed. Disease mechanisms in small animal surgery. 2nd ed. Philadelphia: Lea & Febiger, 1993;285-286. Author James L. Cook

Consulting Editor Brent D. Jones

Current Recommendations for the Treatment of Perianal Fistula

Author Kyle Mathews, DVM, MS, DACVS


The surgical treatment of perianal fistula has been fraught with complications and a high recurrence rate (generally, 40% to 50%). Recommended treatments have included cryosurgical destruction of diseased perianal tissues, electrofulguration, rectal pull-through, and caudectomy (tail amputation). Complications have included rectal stricture, recurrence, and fecal incontinence. Medical treatment with cyclosporine may be effective in some cases.


The underlying cause of perianal fistula is not known. It is thought to be the extension of infection or inflammation of superficial tissues (hydradenitis) or of the anal sacs. Conformation has also been thought to play a role in the formation of a fistula, such as a tight tail base or a sunken or recessed anus. These anatomic peculiarities may result in a persistent fecal film in the perineal region, predisposing to infection. Reports of clinical response to immunosuppressive drugs suggest that perianal fistula may be a primary immune-mediated disease or have an immune-mediated component.

In one canine study, 9 of 27 (33%) German shepherd dogs with a fistula and histologically confirmed colitis had resolution of their fistula after being placed on a high dosage of corticosteroids and a hypoallergenic diet.1

An important change in the treatment of canine perianal disease occurred recently with the report that the immunosuppressive drug cyclosporine results in marked improvement or resolution of perianal fistula in many patients.2 After 16 weeks of treatment, the fistula healed in 17 of 20 dogs (85%). Humans with a form of chronic inflammatory bowel disease (Crohn's disease) may also develop perianal fistulation that often responds to cyclosporine.3

I typically start treatment of perianal fistula with administration of microemulsified cyclosporine (Neoral, Sandoz Pharmaceuticals, East Hanover, New Jersey) at 3 mg/kg PO q12h. Neoral comes in 50-ml vials (approximately $300 per vial) and the proper dose can be aspirated in a syringe and then added to an empty gelatin capsule. The drug is also available in 100-mg gelcaps, which is often close to the proper dose for the typical German shepherd with this disease.

I check the patient's trough plasma concentration of cyclosporine 2 weeks after beginning the medication and make appropriate dosage adjustments based on the results. The target concentration is 300 to 500 ng/ml (using an HPLC assay) or 500 to 750 ng/ml (using the TdX assay at North Carolina State University). Make sure you know which assay your laboratory is using. Most laboratories associated with human hospitals run this assay, but they may not for veterinary patients or it may be expensive.

Cyclosporine should be kept in a dark cupboard at room temperature. Blood samples should be drawn in the morning, 12 hours after the last evening dose was given, and before giving the dog his or her morning medications. The blood should be mailed in an EDTA (purple-topped) blood tube in a crush proof container to the laboratory by next-day delivery. Samples should not be sent on a Friday or before a holiday because they may not be delivered promptly. The sample does not have to be frozen for shipment.

The cyclosporine dosage is increased if the trough concentration is low, particularly if the response is minimal or absent after 1 month of drug administration. Trough concentrations as low as 75 ng/ml (HPLC) may be effective in some dogs.4

A decrease in fistula size is not usually seen for the first 2 weeks. However, many clients report an improvement in their dog's energy level, decreased licking at the area, and diminished tenesmus within the first 2 weeks.

Unanswered questions regarding cyclosporine and perianal fistulas include these:

What is the proper duration of treatment? I administer the drug to fistula patients for at least 2 weeks after complete resolution based on visual examination. It is unclear if these dogs should be treated longer in order to keep the disease in remission or if it is better to treat only during recurrent episodes. Small fistulas recurred in 7 of 17 dogs 2 to 24 weeks after discontinuing treatment.5 What is the underlying cause and reason that cyclosporine works? What is occurring at a cellular level before, during, and after treatment with cyclosporine?

Why do some dogs respond and others do not? One study showed no difference in the mean blood or intestinal tissue concentration of cyclosporine in human responders and non-responders with Crohn's disease.6

What ancillary treatments are appropriate (e.g., dietary modification and antibiotics)?

Should other medications be given to inhibit cyclosporine metabolism and thereby decrease the cost of treatment (e.g., ketoconazole)?

I currently recommend cyclosporine administration for the treatment of perianal fistula; however, medication costs and the surgical options and their potential complications need to be discussed so that the guardian can come to an informed decision. In addition, excision of persistent or recurrent fistulas may be required.


The cause of perianal fistula and why many dogs respond to treatment with cyclosporine is poorly understood. The cost of cyclosporine is prohibitive for some clients. However, the cost and risk of multiple potential surgeries must be considered as well. Cyclosporine has greatly simplified the treatment of perianal fistula in many animal patient. Questions regarding recurrence rate and long-term therapy will likely be answered within the next few years.


1. Harkin KR, Walshaw R, Reimann KA, et al. Association of perianal fistula and colitis in the German Shepherd Dog: response to high-dose prednisone and dietary therapy. J Am Anim Hosp Assoc 1996;32:515.

2. Mathews Karol A, Sukhiani HF. Randomized controlled trial of cyclosporine for treatment of perianal fistulas in dogs. J Am Vet Med Assoc 1997;211:1249.

3. Present DH, Lichtiger S. Efficacy of cyclosporine in treatment of fistula of Crohn's disease. Digest Dis Sci 1994;39:374.

4. Wooldridge JD, Gregory CR, Mathews KG, et al. Clinical evaluation of leflunomide alone, leflunomide and cyclosporine, and cyclosporine at varying dosages in the treatment of perianal fistulas in dogs. Submitted, J Am Vet Med Assoc, 1999.

5. Mathews KA, ibid.

6. Sandborn WJ, Tremaine WJ, Lawson GM. Clinical response does not correlate with intestinal or blood cyclosporine concentrations in patients with Crohn's disease treated with high-dose oral cyclosporine. Am J Gastroent 1996;91:37.

Thursday, September 6, 2012

Attacked by....Golden Retrievers???

Yesterday, I packed up my daughter and leashed up my two dogs and headed down to our local park.   We walk down there several times a week just before lunch to get everyone some exercise.   It is a nice walk down a big hill, and there is a great playground and usually lots of kids E's age.   It is also nice for Violet the Pom and Odie the Shepherd to get in an extra walk.   
We meandered down, checking out every snail and roly poly on the path.   Between Violet and Ella...I don't think we missed one.    As expected, once we got to the park lots of the regulars were there and Ella joined in the fun swinging, sliding and playing in the sand.   Odie, Violet and I sat on the bench chatting with some of the moms and nannies.   After a while, Ella came over for a snack.   We sat on the bench sharing an apple.    Violet was patiently waiting for the Goldfish crackers to come out and Odie was just hanging...
All of a sudden, Odie stood up and growled.  Oddly enough-Violet the yappy little watch dog was SILENT.   I turned and saw two large Golden Retrievers barreling down the hill at us.   Two young boys were chasing behind them screaming.   Trouble.   
I grabbed Ella and threw her up on the bench.   Have you seen the signs around trails telling you if you see a Mountain Lion to put your kids on your shoulders and keep them high??  That flashed through my mind.   I used my serious mommy voice telling her to STAY and scooped up Violet and put her over my shoulder.   Odie was already in front of us-directly in front of us and he took a big hit as the first retriever slammed into him.   It really was like Clash of the Titans.  It was so loud. Then the dog grabbed Odie by the neck.   Odie was bucking and twisting but the dog would not let go.   Ella was screaming now, as were lots of the others parents.   Violet, over my shoulder was still SILENT.   
I started kicking the retriever... he was at least 80 pounds...a big thick male.   I was so afraid he was ripping Odie's throat open.  I kicked him twice in the ribs.  Nothing.   So with my flip flops I started kicking him in the face.  After 4 solid kicks to his face and shoulder he let go.   Odie went crazy and the dog backed off to stand with the other dog.   One of the young boys, who I later learned was 14, grabbed the attacking dog and dragged him off.   There was blood all over Odie's shoulder so I frantically checked him with my free hand while I told everyone it was ok.  It is ok Ella.   It is ok Odie.   It is ok Violet.   That is not how I felt inside though.   I couldn't find any real wounds in Odie's thick fur.   His ear was bleeding but not badly.    I screamed over at the remaining kid that I needed his mom's number now.   He was reluctant to give out personal information so I gave him an option-give me the name, number and address of your parents now or sit there while I call the police.    He gave me the info which I entered into my phone.   This was a small miracle because my hands were now shaking.   Really shaking.   I dialed the number to make sure it was good, and left a message.  "Hi, my name is Liz.  Your dogs just attacked my 100 lb German Shepherd and he is bleeding.  Call me."   Click.  
I grabbed my three babies and headed up the hill.   I just wanted to get Odie home so I could treat his wounds which I was sure were bad.  It was so violent.  I had never seen a dog fight like that.    The hill seemed really long and really steep today.   I stopped about halfway and just took inventory and gave every one hugs.   I still couldn't find the source of the blood.   As I walked, I called my friend Maria to make sure I was doing everything right, as my brain was now pure adrenaline.   She agreed.   Just get home.   Check your boy.   
Just as I rounded the corner to my house the mom of the dogs called.   She was very apologetic and had already talked to her boys.   I told her I was going to have to call her back.  I had to get home.   
Once I got home, I spent a long time going over Odie.   I wet his neck so I could see better.    No wounds other then a small one of the tip of his ear.   The blood must be from the other dogs mouth.   I gave Odie some Metacam because I was sure he was going to be sore.   It was hitting me that he had absolutely protected us.   If the dogs had gotten Violet she would be dead.   Now the tears started and all I wanted to do was hug my big boy and thank him.   I had always known he was amazing, and that he would protect us, but now I had witnessed it and it was so powerful...he is such a sweet, gentle soul...but his German Shepherd blood kicked in and he absolutely was not going to let anyone hurt us.   Do you know what that feels like?   It began to dawn on me that all this talk about how a dog would die for you... it is true.   This may have not been a life threatening situation for us, but Odie didn't know that when he stood out in front of us.   I looked over at my two little girls... Ella and Violet.   Wow.   How do you thank a dog for that?    I am not 100% sure, but I will spend the rest of this magnificent creatures life trying...

Stay tuned for more on the Golden Retrievers and two little boys very important life lesson.   

Wednesday, September 5, 2012

A guest post from a Volunteer about....volunteering!

Here is another way you can help at the German Shepherd Rescue of OC-contribute to our blog.    

The below blog is from MaryBeth.   She is part of the walking team.   Her and the other walking team members go out every week and make sure our dogs who are being cared for in kennels, get out for a walk.   This is very good for the dogs, and is also very helpful in us learning more about the dogs so we place them in the home that will be a perfect fit...after all, we are looking for forever homes.   

From MaryBeth O-

Often times when I tell someone that I volunteer with the German Shepherd Rescue of OC I get the following response or variations of: "I don't know how you do it, it would break my heart" or "I could never do that, I would want to take them all home!"
To be honest, both of those statements ring true when I am spending time with our dogs that are waiting for a home.  As part of one of our walking teams, I spend time Sunday mornings taking some of our dogs out for a walk, roll in the grass and some well deserved belly rubs.  There is nothing like the excitement they have when they come barreling out into the sun!  Yes, it is hard to take them back knowing they are going back to kennel run, but I know that they have had a blast being out for even just an hour.
However, if the other volunteers or myself were not there for our dogs, who would be?  It is because of the 150 plus volunteers at GSROC that thousands of dogs have been spared their lives and have found wonderful loving homes and many more dogs in the future will as well.
Do you have a special talent, time to donate or resources to lend and love German Shepherd Dogs? We would love to have you as part of our volunteer team!  Check out to fill out the volunteer application....

I promise you that you won't regret having your heart strings tugged at when one of the GSROC dogs past or present recognize you with a tail wag followed by a big wet kiss!