(also called “perineal fistulae,” “anorectal abscesses,”
Most people are not in the habit of inspecting the area under their dog’s tail unless the dog seems to be doing something that indicates a problem. Signs of a problem might include licking under the tail, scooting the rear end on the ground, or seeming to be in pain when sitting or raising the tail. When the tail is lifted and the anus inspected, a dog with perianal fistulae will show deep open crevices, some oozing pus, all around the anal sphincter. Odor may be noted, and the dog might be straining to defecate. There is also an association of perianal fistulae with the mucous diarrhea of colitis so that might be seen as well. Perinanal fistulae wax and wane but ultimately over time the condition is progressive, ulcerating the surface of the anus and its surroundings.
WHAT CAUSES THIS CONDITION?
At the present time, no one knows but recent information suggests an immune-mediated basis. There seems to be some genetic basis as the German shepherd dog seems predisposed to development of this condition, though this phenomenon may be more about conformation than about a specific genetic factor for the disease. The German shepherd dog also has an increased number of apocrine sweat glands, the type of sweat glands that produce stinky oily sweat (as opposed to watery sweat), in the anal area relative to other breeds. The average age of onset is 5 years and approximately twice as many males are affected as females. The anal glands may or may not be involved in the fistulation, but there seems to be a clear association with concurrent colitis (inflammation of the colon, as mentioned).
Approximately 80% of affected dogs are German shepherd dogs.
This condition is an immune-mediated disease and treatment centers on suppressing the immune reaction that is causing the problem and this means immunosuppressive drugs as the centerpiece of therapy. It should be realized from the beginning that it will take 2-5 months to get the lesions under control and that maintenance therapy may be needed for the remainder of the animal’s life. The good news is that control can usually be achieved and there are many dogs who do not require on-going therapy after the condition has cleared up.
In older times, an assortment of surgical procedures were used to trim the diseased tissues of the perineal fistulae but immunomodulating drugs have largely supplanted surgery. In particular two medications have emerged: cyclosporine (an oral drug) and tacrolimus (a topical drug). Many dogs will need both to control their disease at least at first but often eventually the topical product can be used alone.
Cyclosporine tissue levels can be boosted (and expense mitigated) with the concurrent use of ketoconazole, an antifungal drug. This "trick" can be used to cut the dose of cyclosporine and save money. There is controversy regarding whether blood levels of cyclosporine area helpful in determining dose and what the relationship actually is between tissue levels and blood levels. Because of the long term use needed to control perianal fistulae, it is best to monitor liver enzymes or liver function tests in the patient; cyclosporine blood levels may or may not be recommended by your doctor.
Improvement is typically obvious within the first two weeks. Several months are needed for resolution of lesions after which cyclosporine may be tapered off over another 3-5 months. Approximately 50% of dogs will recur within 2-12 months if a maintenance schedule is not implemented. This could involve tacrolimus (see below) or cyclosporine or both.
Cyclosporine currently dominates treatment for this condition but it is an expensive drug and it may not be feasible to use it for months on end in a large breed dog. In this event, prednisolone has been used but there are undesirable side effects with high dose steroid use (extreme thirst, increased appetite, weight gain, panting, muscle loss) and approximately 30% of dogs will not respond.
Azathioprine is a stronger immune-suppressive drug. The above side effects are not associated with its use though bone marrow suppression is possible and some monitoring tests are generally recommended. Because it takes some time to exert its effects it is commonly combined with prednisolone at least at first. Approximately 50% of dogs were able to achieve remission with azathioprine in combination with a limited ingredient diet (see below).
SUPPORTIVE THERAPY BEYOND IMMUNE SUPPRESSION
NOVEL PROTEIN/LIMITED INGREDIENT DIET
SURGERY - IF IMMUNE SUPPRESSION FAILS
Before the advent of cyclosporine, perianal fistulae were treated surgically with mixed results. Presently, surgery is only recommended for patients for whom immunosuppression has failed or where the anal glands are involved. The goal of surgery is to remove the proliferative or dead tissue, prevent or treat any anal or rectal strictures (narrowed areas caused by scarring), and change the “environment” of the perineal region. Tail amputation may be required; in fact, in one study, tail amputation alone was 80% successful in preventing recurrence of the fistulae.
If the anal glands are involved in the fistulae, they will have to be removed. In milder cases, chemical cauterization of fistulae (which destroys abnormal tissue and allows normal tissue to heal in) may be helpful. Cryotherapy, where a freezing agent is used instead of a chemical one, has been less effective (more scarring, less control over the area treated etc.) Laser therapy, on the other hand, has been 95% successful in preventing recurrence and controlling pain (20% of patients developed fecal incontinence but most of these cases were controlled with diet).
The more extensive the surgery, the more the potential for complications. Stool softeners are typically needed for a month after surgery and the owner should be comfortable cleaning the anal area. Fecal incontinence, narrowed anus, and inability to control the fistulation are the chief complications with surgery.
Perianal fistulae have become vastly more treatable with the advent of newer medications but, while excellent results are now within reach of many dogs, long term management is necessary and the best treatments involve some expense and effort. It is important to periodically recheck with your veterinarian with regard to progress of the lesions so that treatment can be appropriately modified.
For more information, visit the American College of Veterinary Surgeons page at:
Page posted: 5/13/09