Page 1008 - Small Animal Internal Medicine, 6th Edition

980 PART VIII Reproductive System Disorders

CHRONIC VESTIBULOVAGINITIS IN THE Vaginal strictures are commonly identified and impli-
OVARIOHYSTERECTOMIZED OR cated but are rarely causal in this author’s opinion. Most are
VetBooks.ir These bitches present with variable vulvar discharge that is cranial to the urethral papilla, and the pathology caudal. A
OVARIECTOMIZED BITCH
minimum database should be performed on these chroni-
mucoid to hemorrhagic or purulent, and usually accompa-
(CBC) and serum chemistries, including a urinalysis (pref-
nied by signs of discomfort (licking, scooting, pollakiuria). cally affected bitches, involving a complete blood count
Perivulvar and vulvar dermatitis are also frequently present. erably acquired by cystocentesis), and culture or culture
The condition is invariably seen in ovariectomized bitches of “if indicated.” A careful vulvovaginal examination under
any age, and at variable times from the spay procedure. The adequate (heavy) sedation or anesthesia, with endoscopic
history usually includes multiple therapeutic efforts without equipment allowing evaluation of the entire vaginal vault,
resolution, although transient improvement can occur. The should be performed. This usually means a rigid cystoure-
duration is generally chronic, from weeks to months, some- throscope with saline insufflation is a necessity. Otoscopes
times lasting years. and vaginal speculums do not permit adequate evalua-
The etiology of chronic vestibulovaginitis is usually tion of the entire vaginal vault. Pediatric proctoscopes lack
multifactorial, and the primary cause is often masked and the sensitive optics of cystourethroscopes. It is important
exacerbated by previous therapies, including long-term anti- to observe the undisturbed perivulvar anatomy and then
microbial use, self-mutilation, and topical irrigations. The retract surrounding skin to expose the perivulvar region to
vaginal mucosa is erythemic and nodular showing lymphoid evaluate for significant dermatitis (Fig. 55.35, A, 55.35, B).
follicles; biopsy frequently shows nonspecific lymphoplas- Vaginoscopy permits localization of pathology and identi-
macytic inflammation, but sometimes suppurative (neutro- fication of foreign bodies, masses, or anatomic anomalies.
philic) or eosinophilic inflammation is predominant (Fig. Contrast radiography (vaginogram, urethrogram, cysto-
55.34). Vaginal cultures can show overgrowth of an atypi- gram, IV pyelogram) and/or ultrasound of the entire geni-
cal bacterial species (pure gram-negative cultures, resistant tourinary tract can be helpful in localizing the problem and
organisms, Pseudomonas spp.) or pure culture of Mycoplasma eliminating differential diagnoses. Ultrasound is preferable
spp. if antibiotics have been used extensively. Occasionally because it does not require anesthesia and is the best method
a yeast overgrowth is identified. Primary bacterial vaginitis to noninvasively evaluate the uterine stump, bladder, and
is rare. urethra (Fig. 55.36, A, 55.36, B). Ideally ultrasound should
The most common documented etiologies of chronic ves- be performed before vaginoscopy; saline insufflation can iat-
tibulovaginitis include: rogenically introduce fluid into the uterine stump, making
its appearance suspect.
1. Extensive perivulvar dermatitis associated with redun- Vaginal cytology, cytologic evaluation of vulvar discharge,
dant dorsal and lateral vulvar folds guarded vaginal swabs for aerobic bacterial and Mycoplasma
2. Granulomatous uterine stump (rule out stump pyometra) cultures, and pinch biopsy of affected vaginal mucosa may
3. Vaginal foreign bodies (foxtails, bone fragments) be helpful in better defining the problem. If estrogen influ-
4. Chronic urinary tract infection with urethritis/vestibulitis/ ence is detected with vaginal cytology (superficial cells),
vulvitis evaluation for an ovarian remnant is indicated (see later).
5. Cystic, urethral, vaginal, or vestibular neoplasia If vulvar discharge is purulent and the ultrasonographic
appearance of the uterine stump suggests abscessation, eval-
uation for stump pyometra with serum progesterone and
close inspection for ovarian structures with abdominal ultra-
sound is indicated (see later). Identification of any contribu-
tory anatomic abnormalities is important (e.g., significant
caudal vaginal strictures causing urine pooling or accumula-
tion of secretions, masses, redundant dorsal or lateral vulvar
folds, anomalous ureteral anatomy). It is helpful to evaluate
the bitch in a normal standing position to accurately assess
external anatomy, followed by another examination after she
has urinated, and again after recumbency for urine pooling
and scalding. The presence of urine pooling in the vaginal
vault, noted only when the bitch is under anesthesia, can be
misleading. The presence of redundant vulvar folds is also
difficult to ascertain when the bitch is anesthetized and posi-
tioned for vaginoscopy, but the presence of perivulvar der-
matitis implicates external anatomic contribution to chronic
FIG 55.34
Vaginoscopic image of lymphoid follicles in the cranial vestibulovaginitis.
vagina in an ovariohysterectomized bitch with chronic General therapeutic guidelines apply to most cases. Discon-
vestibulovaginitis. tinuation of topical irrigations, prevention of self-mutilation