Changes

=Introduction=

==Introduction==

Perineal lacerations are the result of foaling injuries.

Perineal lacerations in horses are the result of foaling injuries.

There are three levels of perineal laceration:

There are three levels of perineal laceration:

* '''First Degree''' Perineal Laceration = damage to '''skin''' and '''mucous membrane''' only - vulval lacerations should be repaired immediately

* '''First Degree''' = damage to '''skin''' and '''mucous membrane''' only  

* '''Second Degree''' Perineal Laceration = damage to '''skin''', '''mucous membrane''' and '''musculature''' - the wound should be repaired after the formation of granulation tissue

* '''Second Degree''' = damage to '''skin''', '''mucous membrane''' and '''musculature'''  

* '''Third Degree''' Perineal Laceration = '''complete perforation''' of the vaginal wall and rectum producing a single opening to the rectum and vagina

* '''Third Degree''' = '''complete perforation''' of the vaginal wall and rectum producing a single opening to the rectum and vagina

 

==Initial Assessment and Stabilisation==

==Initial Assessment and Stabilisation==

(1) Assess '''vital parameters''' for evidence of internal haemorrhage. This should including '''heart rate''' and '''mucous membrane colour'''.

# Assess '''vital parameters''' for evidence of internal haemorrhage. This should including '''heart rate''' and '''mucous membrane colour'''.

# '''Prevent or treat injury to other pelvic organs'''. Such injuries include uterine haemorrhage, tearing of the middle uterine artery, prolapse of the bladder, and injury to the small or large colon. They tend to be caused by the foal’s hind legs.

(2) '''Palpate''' the '''anterior vagina''' and '''rectum''', examining for evidence of possible tears in the abdominal cavity or peri-rectal space.

All cases should receive anti-inflammatories, antibiotics and tetanus antitoxin.

(4) '''Prevent or treat injury to other pelvic organs'''. Such injuries include uterine haemorrhage, tearing of the middle uterine artery, prolapse of the bladder, and injury to the small or large colon by the foal’s hind legs).

The wound should be surgically repaired after the formation of granulation tissue.

==Treatment==

===Third Degree===

Treatment of third degree perineal laceration is always '''surgical''' and the aim is to '''restore normal anatomy'''. If the foaling injury is '''less than 3 hours old''', '''immediate repair''' can be considered but is '''rarely performed'''. There is usually extensive '''bruising''' and '''laceration''' therefore repair should be delayed until bruising has subsided and '''granulation tissue''' has formed, usually a minimum of '''6–8 weeks''' after foaling.

Treatment of third degree perineal laceration is always '''surgical''' and the aim is to '''restore normal anatomy'''. If the foaling injury is '''less than 3 hours old''', '''immediate repair''' can be considered but is '''rarely performed'''. There is usually extensive '''bruising''' and '''laceration''' therefore repair should be delayed until bruising has subsided and '''granulation tissue''' has formed, usually a minimum of '''6–8 weeks''' after foaling.

Preparation for surgery:

'''Preparation for surgery''':

* A laxative diet should be fed.

:A laxative diet should be fed. The horse should be placed in stocks and sedated and restrained appropriately. The tail should be wrapped and tied, an epidural administered and the rectum emptied and packed to prevent contamination. The area should be clipped and scrubbed and dorsolateral and ventrolateral retention sutures placed.

* The horse should be placed in stocks and sedated and restrained appropriately.

* The tail should be wrapped and tied.

* An epidural should be administered.

* The rectum should be emptied and packed to prevent contamination.

* The area should be clipped and scrubbed.

* Dorsolateral and ventrolateral retention sutures should be placed.

   

   

There are two techniques for repair of a third degree perineal laceration:

There are two techniques for repair of a third degree perineal laceration:

'''(1) The Aanes technique is a two-stage repair technique''':  

:'''The Aanes technique''' is a two-stage repair technique:  

 

::'''Stage 1''' is the '''reconstruction of the recto-vestibular shelf''' (the perineal body is left open). The wound is dissected to 2-3cm past the defect and then the shelf is closed in two layers - a simple continuous pattern is used in the tissue beneath the rectal mucosa to invert it and a six-bite interrupted purse-string suture is used to close the perineal shelf and vaginal mucosa.

* '''stage 1''' is the '''reconstruction the recto-vestibular shelf''' (the perineal body is left open). The wound is dissected to 2-3cm past the defect and then the shelf is closed in two layers - a simple continuous pattern is used in the tissue beneath the rectal mucosa to invert it and a six-bite interrupted purse-string suture is used to close the perineal shelf and vaginal mucosa.

::'''Stage 2''' involves the '''closure of the perineal body''' 3–4 weeks later. The site should be infiltrated with local anaesthetic prior to surgery. Excess tissue is removed and the edges of skin are sutured from the anal sphincter to the most ventral point of the incision. To eliminate dead space additional sutures may be placed deep to the perineal body. It is important that '''no sutures''' are placed in the '''anal sphincter'''. Sutures should be removed after 7-10 days.

 

* '''stage 2''' involves the '''closure of the perineal body''' 3–4 weeks later. The site should be infiltrated with local anaesthetic prior to surgery. Excess tissue is removed and the edges of skin are sutured from the anal sphincter to the most ventral point of the incision. To eliminate dead space additional sutures may be placed deep to the perineal body. It is important that '''no sutures''' are placed in the '''anal sphincter'''. Sutures should be removed after 7-10 days.

'''(2) The Goetze technique is a one-stage operation''' that involves everting the rectal mucosa into the rectum and vaginal mucosa into the vagina using a '''purse string suture'''

:'''The Goetze technique '''is a one-stage operation that involves everting the rectal mucosa into the rectum and vaginal mucosa into the vagina using a '''purse string suture'''

Endometrial swabs should be taken once the wound has healed to check for the presence of '''endometritis'''.

Endometrial swabs should be taken once the wound has healed to check for the presence of '''[[endometritis]]'''.

==Prognosis==

==Prognosis==

The outcome is usually good if normal anatomy is restored, allowing normal function.

The outcome is usually good if normal anatomy is restored, allowing normal function.

==Reference==

==Reference==

RVC staff (2009) '''Urogenital system''' RVC Intergrated BVetMed Course, ''Royal Veterinary College''

RVC staff (2009) '''Urogenital system''' RVC Intergrated BVetMed Course, ''Royal Veterinary College''

[[Category:To Do - Siobhan Brade]]

 

[[Category:To Do - Manson review]]

[[Category:Reproductive Diseases - Horse]]

[[Category:Expert Review - Horse]]