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"She's got peri WHAT?" With heart and stomach suddenly in my throat and choking me. "She has perianal fistulas." "WHAT'S THAT!?"
This is what I learned from Mr. Webster - Webster's Ninth New Collegiate Dictionary:
Perianal fistulas, also known as Anal Furunculosis in the United Kingdom, are ulcerated tracts that
develop in the area surrounding the anus. The tracts spread out similar to the root system of a
plant, eating out the flesh around the anus and often into the intestinal track itself. Some of the
clinical signs that a problem exists are constipation, painful defecation, weight loss, lethargy, and
open "sore(s)" often with a malodorous discharge, which reminded me of the odor when having
the anal sacs expressed. You will also most likely notice the dog licking itself more than is normal,
a sure sign that something is amiss.
At this point in time, I still did not know that I was dealing with something that was life threatening and that the long-term prognosis was, at best, guarded. Friends who owned German Shepherd Dogs who knew [or made inquiries] about this disease either didn't have the nerve, or the heart, to tell me, because they knew how much my lovely German Shepherd Lady meant to me. My knowledge of this problem has evolved slowly and continues to grow.
I have also learned the following:
Etiology: Unknown. There are many theories as to the cause of this insidious disease. Included in the various hypotheses are: genetics, many feeling that we have done so much line breeding and inbreeding that we have turned our beautiful breed into a genetic nightmare; problems with immune system (genetic?); possible relationship to problems with the anal glands/sacs; still others feel they may be related to the basic conformation of the German Shepherd Dog, i.e., broad based tail which hangs down and does not allow much air circulation in the anal area, keeping it warm and moist and a breeding ground for bacteria. It is known that German Shepherd Dogs do have an increased density of perianal apocrine sweat glands. However, it is not known if this makes our breed more prone to fistulas. The bottom line is, no one knows what causes perianal fistulas. Is it any of the above? Or perhaps a combination of several and/or all of the above? We just don't know. Research has not given us a yes or no answer to any of these questions but more and more, it seems that the immune system is involved.
Since we began our battle with perianal fistulas in 1993, I have talked with many people who have in the past or are currently going through the heartache of dealing with this disease. Each individual case is different and yet many of the dogs will show the same classic symptoms. For instance, many of the dogs, though not all, suffer from autoimmune problems and many of them, though again not all, have recurring problems with the anal glands needing to be expressed on a frequent basis and often becoming infected. Not all dog owners have had a thyroid screening done but in most of those that were done, the T3/T4 levels were usually in the low to low normal range.
German Shepherd Dogs are most likely to be affected by perianal fistulas. Approximately 70 percent of known cases are German Shepherd Dogs. Other breeds affected are Setters, Retrievers, Sheepdogs, Bouvier des Flanders, Spaniels, Collies, Bulldogs, and Dachshunds. I even know of a toy poodle that suffered from this disease and was successfully treated. The theory of the tail set would certainly not be a consideration in the cases of the Bouviers, Bulldogs, Dachshunds and Poodles which have been diagnosed with this disease. Both dogs and bitches are afflicted and perianal fistulas can and do strike at any age, though in most cases I've been connected with, they have been most often diagnosed in younger dogs between two and five years of age, but as old as 10 years of age.
This is not a problem in the United States alone. Canadian and German lines suffer from perianal fistulas and as noted above, the United Kingdom also sees the problem in their German Shepherd Dogs. I do not know about other countries in the world, but have to assume that the problem is world-wide.
Perianal fistulas do not respond satisfactorily to antibiotics though they are helpful in dealing with secondary infections. There are several methods of surgery used, with varying degrees of success and post-surgical problems.
A very brief description of some of the more common surgeries are:
Chemical cauterization - Excision of superficial fistulas with a chemical solution inserted into the deeper tracts. The wound is allowed to heal by second intention. Claimed success is in excess of 80% with fecal incontinence occurring in about 20 percent of the cases.
Heat cauterization - Excision of diseased tissue from the fistulous tracts followed by heat cauterization. (My personal choice because, in combination with Prednisone treatment, it was successful for us and for a number of other survivors.)
Deroofing and fulguration - All chronic tissue and scar tissue is excised, lining is electrofulgurated. This method spares the sphincter muscle, however, the fistulas do return in a high percentage of the cases and is not as successful if more than half of the anal circumference is involved.
Cryosurgery - Application of nitrous oxide or liquid nitrogen into the fistulous tracts with second intention healing. Claimed success rates run from approximately 50 to 95 percent. Post- operative fecal incontinence and stenosis is low compared to some of the other surgical options.
Surgical excision - A complicated surgery involving removal of all diseased tissue and much of the surrounding healthy tissue and all fibrosis causing rectal or anal stricture are also removed.. The sphincter muscle is often damaged and post-operative fecal incontinence runs 13-29 percent.
Laser - A synthetic sapphire tip and continuous impulse of 13 to 15 watts is used to excise the fistulas. Claimed success rate of near 95 percent. Fecal tone is reduced; flatulence increases in many of the dogs, and about 20 percent develop fecal incontinence.
Tail amputation - Must include the lateral skin folds of the tail up to the second or third cocygeal vertebra. Superficial lesions may heal but surgery is still required on the deeper fistulas as they rarely heal. It appears that people owned by German Shepherd Dogs are the least likely to agree to this particular surgical procedure.
Prednisone - Experimental treatment at Michigan State University with Prednisone has had limited success. Approximately one-third of the dogs respond quite well to the therapy with another one-third showing a reduction in the inflammation and one-third not responding. Treatment begins with high dosages which are reduced in increments of one-half the prescribed dosage over a period of time; i.e., 1 mg per pound of weight for four weeks; 1/2 mg per pound of weight for the second four week period; 1/4 mg. For the third 4-week period. (Many people that I've talked with refused to use Prednisone because of the side effects of the drug. Considering the alternative of losing the battle with perianal fistulas, I consider it a moot argument.)
Cyclosporin - In 1996, Guelph Veterinarian College, University of Guelph, Ontario, Canada did experimental work using Cyclosporin, an anti-rejection drug used in humans who have undergone organ transplant surgery, the theory being that perianal fistulas are related to autoimmune problems. The initial research claimed 100 percent success but the fistulas do return in about one- third of the cases. The drug is also very expensive and cost prohibitive for most dog owners. At this point in time, I think it is too soon to make a judgment on the long-term effects of this treatment, and, as with Prednisone, does have its side effects since it also suppresses the immune system.
As stated above, some of the surgical methods are more radical than others, and some more likely to cause serious side effects like fecal incontinence and stenosis. Surgical treatment seems to be the only method of successfully dealing with perianal fistulas, and even then, they often recur. The method of treatment must be judged on each individual case, how invasive the fistulas are, age of the dog involved, and monetary considerations.
Prognosis, at best, should be considered guarded.
Back to my original question. Is there hope after a diagnosis of perianal fistulas? Yes, I believe there is hope, guarded though it may be. But, believe it or not, there are veterinarians who seemingly do not recognize this condition and are still making incorrect diagnoses. Others do not believe in the aggressive surgery "because it doesn't do any good." Knowledge by dog owners that perianal fistulas exist and frequent checking for them, along with early and correct diagnosis, are essential if there is to be hope of successful treatment of this disease.
Treatment in each case must be judged on an individual basis taking into consideration how early the diagnosis is made, how invasive and the amount of damage already done by the fistulas, the age of the dog and its overall general health. Cost is also a factor that must be taken into consideration and the availability of a qualified surgeon who has expertise in this field.
One of my greatest frustrations in dealing with the perianal fistulas was, like Kay Goolsby (Perianal Fistulas - A Silent Killer, The German Shepherd Dog REVIEW, January 1995, and The German Shepherd Quarterly, Summer 1995), not being able to find anyone to talk with who had been through this problem. I had a lot of caring concern, but no one who "had been there."
I did have wonderful veterinarians, and Scootie Sherlock, to offer me suggestions and support. There is no way I can give adequate thanks to Michael Gentry and Todd Marcum, D.V.M. (who made the original diagnosis), for their early and correct diagnosis, and wonderful support through this trying time, and to Dr. Elkins, for the successful surgery. I also thank them for taking the time to review the original article to make sure the clinical information I imparted was correct.
Kay Goolsby and I started a support network of people whose dogs have suffered from, or are currently going through, this horrible disease. We may not be able to help the dogs, but we can at least offer moral support to pet owners and give them someone to talk with who knows what they are feeling. And, the exchange of ideas and treatments can only benefit all of us and our dogs. We currently have 38 people across the country and in Canada who will make themselves available and help in any way they can. We have talked with many more people whose dogs have suffered or are suffering from perianal fistulas.
One of the projects we are currently working on is gathering pedigrees and building a database of German Shepherd Dogs who have suffered from perianal fistulas. In most of the American bred dogs, common lineage is not difficult to trace. However, we do need more European pedigrees. I don't think the disease is genetic insofar as there being a specific gene involved but if we can trace the lines of the affected dogs from different countries back to one early German Shepherd Dog who is a common ancestor of all of them, we may get some clues as to what is involved and see if there are other health problems common to the same descendants of that dog. We are also starting a second database of GSDs known to have never suffered from this disease for a comparison.
If you or a friend find yourself in need of help or just moral support because of perianal fistulas, we will help in any way we can and also put you in contact with others who know what you are going through.