Introduction
In dogs, the prepubic tendon attaches the ventral abdominal muscles to the cranial border of the pubis.1 It is comprised of the muscle fibers from the internal and external abdominal oblique as well as the rectus abdominis. In cats, there is no true prepubic tendon and it is suggested that the crura of the superficial inguinal ring and external abdominal oblique muscle aponeurosis carry out the same purpose as the prepubic tendon in canines.1,2 Prepubic tendon rupture is also referred to as prepubic hernia (PPH), which may be more accurate when referring to both dogs and cats.1 Prepubic hernia is most commonly associated with high-impact trauma.3 This injury can lead to herniation of various abdominal organs, resulting in a PPH that may require surgical intervention.4 However, in less severe cases in which no organs are herniated, the injury may heal conservatively.
Diagnosis has been described on the basis of ultrasound, radiographic findings, surgical findings, and contrast cystourethrogram.1,3,5,6 However, studies describing diagnostic imaging findings in small animals with PPH are lacking, particularly in the absence of organ herniation. Previously documented herniated organs include the urinary bladder and the intestines.1,5 As most of these hernias result from vehicular trauma, concurrent injuries can be severe and may include multiple pelvic fractures, long bone fractures, and soft tissue injuries.1 Reported concurrent injuries have included coxofemoral luxation, sacroiliac (SI) luxation, femur fracture, ilial fracture, urinary bladder rupture, and urethral rupture.7
Typically, the tendon is avulsed from the pubis, so little to no soft tissue remains attached to the pubis for surgical reattachment. Therefore, a common method to reattach the prepubic tendon or aponeurosis involves drilling small holes into the pubis itself.1 Suture is passed through the pubic bone tunnels and through the avulsed tendon to secure it back into place. Alternatively, suture may be passed through both obturator foramina rather than predrilled holes.1 While there is some tension inherent in the repair of a PPH, for cases in which tension is excessive, reconstruction can be augmented with the use of mesh or porcine submucosa between the pubis and body wall. Reports of 2 different muscle flaps to bridge the gap have been documented: the rectus abdominis muscle flap and the cranial sartorius flap.1,3 In some cases, the pelvis may be too fractured to be securely attached to the prepubic tendon or aponeurosis. In these cases, fascia from the caudal abdominal musculature may be sutured to the adductor muscles, with or without incorporation of the periosteum of the underlying pubis.1
There is little published research regarding PPH and its various clinical outcomes in small animals. The first aim of this report was to describe common imaging findings and concurrent injuries found in conjunction with PPH. The second aim was to describe common treatment strategies and short-term clinical outcomes for cases in which surgical reconstruction was attempted.
Methods
The electronic medical records at the Texas A&M Veterinary Teaching Hospital and the University of Georgia Veterinary Teaching Hospital were searched from August 1, 2008, through August 31, 2023, using the search term prepubic tendon. All cats and dogs diagnosed with suspected or confirmed prepubic tendon (complete or partial) rupture/PPH were included in the study, including those that were euthanized or lost to follow-up, to fulfill the first aim of the study to describe imaging findings and concurrent injuries. Medical records were reviewed, and data collection included signalment, date and etiology of trauma, presenting physical examination abnormalities and vital signs, what organs were herniated, imaging results, concurrent injuries, method of diagnosing the rupture, surgeries performed, method of PPH repair, whether pelvic fractures were repaired before or after the rupture, and days until discharge. The imaging studies used to diagnose the PPH (abdominal radiographs, pelvic radiographs, abdominal ultrasonography, and/or abdominal CT) were reviewed by a board-certified radiologist to confirm the radiographic description and diagnoses. If, after radiologist review, the diagnosis of a PPH was not conclusive, the animal was excluded. Postoperative complications were recorded as mild, moderate, severe, or death as described in the revised Accordion Classification System.8
Statistical analysis
Data were collected in a spreadsheet (Excel, version 16.88; Microsoft Corp) and summarized in Prism (version 9.0.0; GraphPad Software LLC). Data are described as percentages or median (range) with 95% CI of the median reported (calculated in GraphPad). The 95% CI for percentages (where reported) was determined with the use of an online CI for a proportion calculator (www.sample-size.net).
Results
Dogs
Presentation
Seventy-one dogs with PPH were identified. Median age was 5 years (range, 0.5 to 18 years). Median weight was 10.7 kg (range, 3.0 to 53.4 kg; 95% CI, 8.1 to 16.2 kg). Sex distribution included 24 castrated males (33.8%), 20 spayed females (28.2%), 17 intact males (23.9%), and 10 intact females (14.1%). Mixed-breed dogs were most common (n = 15), followed by Dachshund (10), Shih Tzu (5), Border Collie (4), Yorkshire Terrier (4), Labrador Retriever (3), Cocker Spaniel (3), Jack Russell Terrier (3), and 2 each of Maltese, Australian Shepherd, Springer Spaniel, and Chihuahua; there were 16 additional breeds with 1 dog each.
Dogs were presented to the hospital within 24 hours (55 of 71 [77.5%]), 2 to 7 days (12 of 71 [16.9%]), 8 to 14 days (2 of 71 [2.8%]), and 21 days (1 of 71 [1.4%]) after trauma. One dog (1.4%) had no known trauma, and the PPH was suspected to be chronic in nature. Prepubic hernia occurred following vehicular trauma in 62 of 71 dogs (87.3%), unknown trauma in 6 of 71 dogs (8.5%), and a dog attack in 3 of 71 dogs (4.2%). Vital parameters and ambulation status on presentation to the hospital are presented in Table 1. Select blood values at the time of presentation to the hospital are available in Table 2. In dogs with available values, 38 of 67 (56.7%) were hyperglycemic, 28 of 66 (42.4%) were hyperlactatemic, 20 of 60 (33.3%) had low total solids, 16 of 67 (23.9%) were anemic, 16 of 35 (45.7%) had elevated ALT, and 3 of 57 (5.4%) were azotemic. Four of 56 dogs (7.1%) with both values available had elevated BUN but normal creatinine.
Summary of vital parameters, mentation, and ambulation status at the time of hospital presentation in 71 dogs and 16 cats diagnosed with a prepubic hernia (PPH) between August 2008 and August 2023 at 2 academic referral institutions.
| Vital parameters | Dogs | Cats |
|---|---|---|
| Body temperature | Median, 37.9 °C (range, 35.1–39.1; 95% CI, 37.7–38.2) | Median, 37.4 °C (range, 33.8–38.8; 95% CI, 36.1–38.1) |
| Heart rate | Median, 132 bpm (range, 80–230; 95% CI, 120–140) | Median, 208 bpm (range, 100–250; 95% CI, 180–240) |
| Respiratory rate | Median, 38 brpm (range, 18–120; 95% CI, 32–40) | Median, 60 brpm (range, 28–140; 95% CI, 40–60) |
| Systolic arterial pressure* | Median, 120 mm Hg (range, 46–200; 95% CI, 113–139) | Median, 92 mm Hg (range, 70–136; 95% CI, 76–130) |
| Mentation | ||
|   Bright and alert | 57/71 (80.3%) | 11/16 (68.8%) |
|   Dull | 9/71 (12.7%) | 3/16 (18.8%) |
|   Obtunded | 2/71 (2.8%) | 2/16 (12.45%) |
|   Stuporous | 2/71 (2.8%) | 0 |
|   Mentation not recorded | 1/71 (1.4%) | 0 |
| Ambulation | ||
|   Nonambulatory | 45/71 (63.4%) | 8/16 (50.0%) |
|   Ambulatory all limbs | 11/71 (15.5%) | 8/16 (50.0%) |
|   Ambulatory with lameness of 1 pelvic limb | 10/71 (14.1%) | 0 |
|   Ambulatory paraparesis | 4/71 (5.6%) | 0 |
|   Ambulation status not recorded | 1/71 (1.4%) | 0 |
bpm= Beats per minute. brpm= Breaths per minute.
*Available in 50 dogs and 11 cats.
Select point-of-care blood values at the time of hospital presentation in 67 dogs and 15 cats diagnosed with PPH as described in Table 1.
| Hct (%) | Total protein (g/dL) | Blood glucose (mg/dL) | BUN (mg/dL) | Creatinine (mg/dL) | Lactate (mmol/L) | ALT (U/L) | |
|---|---|---|---|---|---|---|---|
| Dogs | |||||||
|   No. of dogs | 67 | 60 | 67 | 56 | 66 | 66 | 35 |
|   Median | 41 | 5.8 | 119 | 18 | 0.9 | 2.6 | 118 |
|   Range | 22–68 | 3.0–8.4 | 54–500 | 7–75 | 0.4–6.1 | 0.5–14.7 | 48–2,676 |
|   95% CI | 37–44 | 5.3–6.4 | 105–139 | 15–21 | 0.8–1.0 | 1.9–3.2 | 84–198 |
|   Reference range | 35–51 | 5.7–7.8 | 83–112 | 7–32 | 0.2–2.5 | < 2.5 | 10–130 |
| Cats | |||||||
|   No. of cats | 15 | 14 | 14 | 15 | 14 | 14 | 8 |
|   Median | 33 | 6.2 | 153 | 31 | 1.6 | 2.1 | 103 |
|   Range | 20–48 | 2.8–7.8 | 82–272 | 23–137 | 0.8–6.0 | 0.8–8.9 | 46–404 |
|   95% CI | 25–41 | 5.0–7.4 | 114–227 | 27–55 | 1.0–2.7 | 1.2–5.1 | 45–404 |
|   Reference range | 35–51 | 5.7–7.8 | 83–112 | 7–32 | 0.2–2.5 | < 2.5 | 10–130 |
Excluding mentation changes (described in Table 1), 36 dogs (50.7%) had neurologic deficits recorded, including absent proprioception in the pelvic limbs (n = 8), lumbosacral spinal pain (6), absent patellar reflex in 1 limb (5), absent anal tone (4), decreased anal tone (3), paraplegia with sensation (2), paraplegia without sensation (2), monoplegia with absent sensation in a pelvic limb (2), and urinary and fecal incontinence, absent pupillary light reflexes, and a head tilt (1 dog each). Pain was noted on palpation of orthopedic injuries in all dogs (Table 3) and abdominal pain was noted in 19 dogs (26.8%).
Summary of traumatic injuries diagnosed via imaging in 71 dogs and 16 cats with concurrent PPH as described in Table 1.
| Imaging finding | Dogs | Cats |
|---|---|---|
| PPH diagnosis | ||
|   Ventral body wall swelling | 64 (90.1%; 95% CI, 80.7–96.0) | 16 (100%; 95% CI, 79.4–100.0) |
|   Ventral body wall retraction | ||
|     Lateral view | 51 (71.8%; 95% CI, 59.9–81.9) | 16 (100%; 95% CI, 79.4–100.0) |
|     VD view | 35 (49.3%; 95% CI, 37.2–61.4) | 10 (62.5%; 95% CI, 35.4–84.8) |
|   Herniated viscera | 27 (38.0%; 95% CI, 26.8–50.3) | 6 (37.5%; 95% CI, 15.2–64.6) |
|   Inguinal streaking | 63 (88.7%; 95% CI, 79.0–95.0) | 15 (93.8%; 95% CI, 70.0–99.8) |
| Orthopedic injuries | ||
|   Pubic fracture | 54 (76.1%; 95% CI, 64.5–85.4) | 10 (62.5%; 95% CI, 35.4–84.8) |
|     Avulsion | 45 (63.4%; 95% CI, 51.1–74.5) | 5 (31.3%; 95% CI, 11.0–58.7) |
|     Symphysis | 35 (49.3%; 95% CI, 37.2–61.4) | 5 (31.3%; 95% CI, 11.0–58.7) |
|   Sacral fracture | ||
|     Wing | 16 (22.5%; 95% CI, 13.5–34.0) | 2 (12.5%; 95% CI, 1.6–38.4) |
|     Body | 12 (16.9%; 95% CI, 9.1–27.7) | 0 |
|   Ilial fracture | ||
|     Wing | 13 (18.3%; 95% CI, 10.1–29.3) | 0 |
|     Body | 22 (31.0%; 95% CI, 20.5–43.1) | 1 (6.3%; 95% CI, 0.2–30.2) |
|   Acetabular fracture | 15 (21.1%; 95% CI, 12.3–32.4) | 0 |
|   Ischiatic fracture | ||
|     Body | 26 (36.6%; 95% CI, 25.5–48.9) | 3 (18.8%; 95% CI, 4.1–45.7) |
|     Table | 44 (62.0%; 95% CI, 50.0–73.2) | 3 (18.8%; 95% CI, 4.1–45.7) |
|   SI luxation | 40 (56.3%; 95% CI, 44.1–68.1) | 11 (68.8%; 95% CI, 41.3–89.0) |
|   Vertebral fracture or luxation | 7 (9.9%; 95% CI, 4.1–19.3) | 0 |
|   Hip luxation | 8 (11.3%; 95% CI, 5.0–21.0) | 0 |
|   Femur fracture | 4 (5.6%; 95% CI, 1.6–13.8) | 0 |
|   Tibial fracture | 3 (4.2%; 95% CI, 0.9–11.9) | 0 |
|   Pelvic limb digit fractures | 3 (4.2%; 95% CI, 0.9–11.9) | 0 |
|   Tail luxation or fracture | 4 (5.6%; 95% CI, 1.6–13.8) | 2 (12.5%; 95% CI, 1.6–38.4) |
|   Patella fracture | 1 (1.4%; 95% CI, 0–7.6) | 0 |
|   Os penis fracture | 1 (1.4%; 95% CI, 0–7.6) | 0 |
|   Facial bone fractures | 1 (1.4%; 95% CI 0–7.6) | 0 |
SI = Sacroiliac. VD = Ventrodorsal.
Fifty-one of 71 dogs (71.8%) had moderate to severe subcutaneous bruising or swelling, involving the caudal abdomen in 32 dogs, inguinal region(s) in 22 dogs, a pelvic limb in 8 dogs, the preputial region in 3 dogs, flank in 2 dogs, perineal region in 2 dogs, scrotum in 1 dog, and chest in 1 dog. Fifteen of 71 dogs (21.1%) had full-thickness lacerations reported. In 2 dogs, the laceration was a large caudal abdominal wound with evisceration of herniated contents from the PPH.
Additional abnormal findings noted during physical examination included pale mucous membranes (13 of 71 [18.3%]), palpable pelvic fractures on rectal examination (9 of 71 [12.7%]), decreased lung sounds (8 of 71 [11.3%]), palpable herniated organs (6 of 71 [8.5%]), hematochezia (6 of 71 [8.5%]), increased respiratory effort (4 of 71 [5.6%]), heart murmur (4 of 71 [5.6%]), frank blood from the vulva (2 of 71 [2.8%]), harsh lung sounds (2 of 71 [2.8%]), and epistaxis, a suspected rectal tear, hematuria, and evisceration through the PPH (1 dog each). Suspicion for a PPH specifically was not documented in the physical examination findings for any dog.
Diagnostic imaging
Forty-seven of 71 dogs (66.2%) underwent a point-of-care abdominal ultrasound, with absence of peritoneal effusion in 34 of 47 dogs (72.3%), scant peritoneal effusion in 6 of 47 dogs (12.8%), moderate peritoneal effusion in 2 of 47 dogs (4.3%), and severe peritoneal effusion in 1 dog. Abdominocentesis was recorded in 6 dogs and was consistent with a uroabdomen in 5 dogs and hemorrhage in 1 dog. On the basis of point-of-care ultrasound results alone, 10 dogs were suspected to have abdominal organ herniation, including both urinary bladder and intestines in 4 dogs, intestines alone in 4 dogs, and urinary bladder alone in 2 dogs. Thirty-seven of 71 dogs (52.1%) underwent a point-of-care thoracic ultrasound with absence of pleural effusion in 35 of 37 dogs (94.6%), B-lines in 9 of 37 dogs (24.3%), and scant pleural effusion in 2 of 37 dogs (5.4%). In 1 dog, the liver was suspected to be in the thoracic cavity on point-of-care thoracic ultrasound.
Fourteen of 71 dogs (19.7%) had a diagnostic abdominal ultrasound performed by a board-certified radiologist. A PPH was confirmed via ultrasound in 4 of 14 dogs with incarceration of both urinary bladder and intestines in 1 dog, urinary bladder in 1 dog, jejunum (with mechanical obstruction) in 1 dog, and no organs in 1 dog. Additional findings on ultrasound included peritoneal effusion (n = 6), retroperitoneal hemorrhage (4), abdominal lymphadenomegaly (3), bilateral adrenomegaly (2), urinary bladder rupture (1), seromas within the inguinal canals (1), seroma of the lateral abdominal body wall (1), and a splenic infarct (1).
Fifty-two of 71 dogs (73.2%) had thoracic radiographs performed at presentation and 4 of 71 dogs (5.6%) had thoracic CT performed, with no significant findings in 31 dogs, pulmonary contusions in 8 dogs, rib fractures in 7 dogs, pneumothorax in 7 dogs, definitive diaphragmatic hernia in 2 dogs, possible diaphragmatic hernia in 2 dogs, a bronchial pulmonary pattern in 2 dogs, and pneumonia, pneumomediastinum, xiphoid fracture, subluxation of T11-T12 vertebrae, and mild left atrial enlargement in 1 dog each. Two dogs had repeat thoracic radiographs 3 and 7 days after presentation and did not have developed pleural effusion noted on intake radiographs. One dog had a CT of the skull that confirmed multiple skull fractures.
Findings of abdominal/pelvic diagnostic imaging related to PPH diagnosis and orthopedic trauma are summarized in Table 3. Imaging modalities included pelvic radiographs in 61 dogs (85.9%), abdominal radiographs in 44 dogs (62.0%), and abdominal CT in 43 dogs (60.6%). The diagnosis of a PPH was confirmed with radiographs in 43 of 71 dogs (60.5%), CT in 22 of 71 dogs (31.0%), surgery in 4 of 71 dogs (5.6%), and both radiographs and CT in 2 of 71 dogs (2.8%). Retraction of the body wall, inguinal streaking, and ventral body wall swelling were the most common findings leading to a diagnosis of PPH (Figure 1; Supplementary Figure S1). Pneumoperitoneum was identified in 4 dogs. Additional abdominal injuries included urinary bladder rupture (n = 3), urethral tear (2), splenic laceration (2), and complete urethral transection, jejunal perforation, single kidney rupture, single small kidney laceration, and proximal ureteral rupture (1 dog each). Herniated abdominal contents were confirmed in 35 of 71 dogs (49.3%), including both urinary bladder and intestine (n = 12), urinary bladder alone (9), intestine alone (7), peritoneal fat with no organs (6), and the uterus (1).
Ventrodorsal (A) and left lateral (B) radiographic images of a dog that presented after being hit by a car. Cranial is to the top of panel A and left of panel B, and the right side is to the left of the image (identified by the letter R on the image). The urinary bladder is absent from its normal location, with ventral displacement of the colon within and cranial to the pelvic canal (asterisk), and a rounded soft tissue structure (displaced bladder) is visualized ventral to the body wall and dorsal to the os penis (white arrow). Disruption of the caudal abdominal body wall is present, with thickening of the body wall and retraction from the pubis (black arrowhead). The body wall thickening is bilateral on the ventrodorsal view (black arrows), with indistinct margins on the left. Fluid streaking is noted within the inguinal fat (white star). Orthopedic injuries include the following: right sacroiliac luxation (white oval), pubic symphyseal separation (yellow oval), right pubic (yellow arrow) and ischial (red arrow) fractures, and left coxofemoral luxation (blue arrow). Fluid streaking is also present in the peritoneal and retroperitoneal cavities.
Citation: Journal of the American Veterinary Medical Association 2025; 10.2460/javma.24.09.0593
Treatment
Four dogs were transferred to the primary veterinarian for continued care on the day of presentation and lost to follow-up, 4 dogs were euthanized without treatment, and 1 dog was euthanized on the day of presentation after receiving a blood transfusion. Information on treatment was thus available in 62 of 71 dogs (87.3%).
The PPH was surgically repaired in 35 of 62 dogs (56.5%). The method of PPH repair is summarized in Table 4. In 2 dogs with pubic bone tunnel closures, a 1- to 2-cm defect remained in the body wall and was filled with a polyester mesh patch in 1 dog and an omental patch in 1 dog. Orthopedic surgical procedures in dogs that had surgical repair of the PPH included the following: SI luxation repair (n = 9), ilial fracture repair (4), combined acetabular and ilial fracture repair (3), femoral head and neck ostectomy (3), sacral fracture repair (2), and tibial fracture repair, pubic fracture repair, and metatarsal fracture repair (1 dog each). The timing of pelvic fracture repair in relation to PPH repair is summarized in Table 4. Additional soft tissue surgical procedures in dogs that had surgical repair of the PPH included the following: inguinal herniorrhaphy (n = 6), castration (5), urinary bladder repair (3), diaphragmatic herniorrhaphy (2), cystotomy (2), jejunal resection and anastomosis (2), gastropexy (2), and ovariohysterectomy, tail amputation, wound vacuum-assisted closure placement, and repair of a ureteral tear with ureteral stent placement (1 dog each). All soft tissue procedures were performed at the same time as PPH repair.
Method of surgical PPH repair and order of procedures when both PPH repair and pelvic fracture repair were undertaken in dogs and cats diagnosed with PPH, as described in Table 1.
| Dogs | Cats | |
|---|---|---|
| Method of surgical repair of PPH | ||
|   Muscle closure only with polypropylene suture | 11/35 (31.4%) | 2/7 (28.6%) |
|   Pubic bone tunnels with polypropylene suture (repair augmented with graft material in 2 dogs) | 10/35 (28.6%) | 4/7 (57.1%) |
|   Muscle closure only with polydioxanone suture | 9/35 (25.7%) | 0 |
|   Pubic bone tunnels with polydioxanone suture | 1/35 (2.9%) | 0 |
|   Repaired with unspecified method | 4/35 (11.4%) | 1/7 (14.3%) |
| Order of procedures when pelvic fracture repaired | ||
|   Same anesthetic event, PPH first | 3/16 (18.8%) | 2/3 (66.6%) |
|   Same anesthetic event, pelvic fracture first | 4/16 (25.0%) | 0 |
|   Same anesthetic event, unclear order | 1/16 (6.3%) | 0 |
|   Separate anesthetic event, PPH first | 5/16 (31.3%) | 0 |
|   Separate anesthetic event, pelvic fracture first | 3/16 (18.8%) | 1/3 (33.3%) |
Twenty-two of 62 dogs (35.5%) had a surgical procedure but no repair of the PPH. Nineteen of 22 dogs had orthopedic procedures, and 3 of 22 dogs had soft tissue procedures. Orthopedic procedures included ilial fracture repair (n = 9), SI luxation repair (5), femur fracture repair (4), femoral head and neck ostectomy (3), and acetabular fracture repair, tibial fracture repair, tarsal fracture repair, premaxillary bone reduction with nasal stent placement, and sacral fracture repair with lumbosacral stabilization (1 dog each). For the 3 dogs with soft tissue procedures, 1 dog had urinary bladder rupture repair and a prophylactic gastropexy; 1 dog had a jejunal resection and anastomosis (due to trauma), splenectomy, and repair of a lateralized midabdominal body wall hernia; and 1 dog had an exploratory laparotomy for septic peritonitis, and no source was identified. In all 3 dogs, though PPH was diagnosed, no mention of repair was noted in the surgery report.
The remaining 5 of 62 dogs (8.1%) received medical treatment but no surgery. Two dogs were treated with pain medication and IV fluids for 3 days, then transferred to the primary veterinarian for further care; one of these dogs received a packed RBC transfusion to treat anemia. Both dogs were lost to follow-up. One dog was transferred to the primary veterinarian 2 days after presentation for euthanasia. One dog was euthanized 3 days after presentation due to progressive neurologic signs, azotemia, and oliguria. One dog with multiple pelvic fractures was hospitalized for 25 days. This dog developed a uroabdomen 4 days after presentation; a urethral catheter was already in place. Cystourethrogram was normal; thus, a healed traumatic urethral tear was suspected. This dog also developed aspiration pneumonia during hospitalization.
Complications in surgical patients
Overall, 24 complications were reported in 19 of 35 dogs (54.3%) that underwent PPH repair. Complications were categorized as follows: 4 minor (level 1) complications (self-resolving anemia in 2 dogs, and 1 dog each with regurgitation and failure of sacral fracture implant treated conservatively); 6 moderate (level 2) complications (hypoalbuminemia causing generalized edema and requiring albumin transfusion in 3 dogs, and 1 dog each with aspiration pneumonia, incisional infection requiring antibiotics, and anemia requiring blood transfusion); 4 severe (level 3) complications (incisional dehiscence requiring sedated wound care in 4 dogs); 7 severe (level 4) complications (1 dog with acute kidney injury, thrombocytopenia, and anemia requiring prolonged ICU care; 1 dog with pelvic fracture implant failure requiring surgical revision; 1 dog with failure of the initial PPH repair [polypropylene suture with bone tunnels in addition to repair of a urinary bladder rupture] and surgical site infection [SSI] requiring addition of more bone tunnels and suture to bolster the PPH repair, castration, and scrotal ablation 2 days postoperatively; 1 dog that had undergone PPH reconstruction with a polyester mesh graft developed an SSI with a draining tract, requiring implant removal 2 months after surgery; 1 dog that underwent ureteral repair and stenting required nephrectomy due to persistent uroabdomen; 1 dog that developed a septic uroabdomen with a urethral tear identified requiring surgery for urethral repair 4 days postoperatively; and 1 dog with severe skin necrosis along the ventral abdomen requiring anesthetized debridement); and 3 deaths (level 6; 2 dogs were euthanized 4 and 7 days postoperatively due to lack of improvement in severe physiologic degloving, and 1 dog died 3 days postoperatively after receiving 5 fresh frozen plasma transfusions and 1 packed RBC transfusion due to acute respiratory distress of unknown etiology).
Seven complications were reported in 6 of 22 dogs (27.3%) that underwent a surgical procedure but no PPH repair. These complications were categorized as follows: 2 mild (level 1) complications (1 dog with a ventricular tachyarrhythmia that responded to sotalol, 1 dog with femoral nerve neuropraxia that did not require treatment), 3 moderate (level 2) complications (2 dogs with dehiscence requiring antibiotic therapy and nonsedated wound care and 1 dog with anemia requiring blood transfusion), 1 severe (level 4) complication (skin necrosis requiring sedated wound care and several days of hospitalization), and 1 death (level 6; failure of SI and acetabular implants leading to euthanasia 8 days postoperatively).
Outcome
For the 62 dogs for which treatment information was available, median duration of hospitalization was 7 days (range, 2 to 33 days; 95% CI, 5 to 8 days). Six of 62 dogs (9.7%) died or were euthanized prior to hospital discharge. The remaining 56 dogs were lost to follow-up a median of 58 days (range, 2 to 3,543 days; 95% CI, 32 to 87 days) after discharge. One dog treated medically was euthanized 8 days after discharge for seizures; this dog had a history of epilepsy. One dog died spontaneously 68 days after discharge; a necropsy was not performed. One dog that had no sensation in the right pelvic limb secondary to the original injury remained sensation-negative in the limb 4 months later and underwent a pelvic limb amputation. One dog was evaluated 6 months after discharge for acute monoparesis of the right pelvic limb; this was suspected to be due to unrelated intervertebral disc disease and was treated conservatively. The owner of 1 dog with a tail avulsion injury reported that the tail fell off 1 month after discharge. No additional complications related to PPH injury or repair were reported.
Cats
Sixteen cats with PPH injuries were identified over the study period. Median age was 7 years (range, 0.6 to 15 years; 95% CI, 1 to 10 years), and median weight was 4.8 kg (3.4 to 8.5 kg; 95% CI, 3.7 to 6.1 kg). Breeds included 12 domestic shorthair cats, 2 domestic medium hair cats, 1 domestic longhair, and 1 Ragdoll. There were 9 castrated males (56.3%), 6 spayed females (37.5%), and 1 intact female. Fourteen of 16 cats (87.5%) were presented to the hospital within 24 hours of reported trauma, and 2 of 16 cats (12.5%) presented within 2 to 7 days. Injury was a result of vehicular trauma in 6 of 16 cats (37.5%), unknown trauma in 6 of 16 cats (37.5%), and animal attack in 4 of 16 cats (25.0%). Vital parameters and ambulation status on presentation to the hospital are presented in Table 1. Select blood values, available in 15 cats at the time of presentation, are available in Table 2. For cats with available values, 12 of 14 (85.7%) were hyperglycemic, 8 of 15 (53.3%) were anemic on presentation, 4 of 14 (28.6%) had low total solids, 4 of 14 (28.6%) were hyperlactatemic, 4 of 15 (26.7%) were azotemic, and 3 of 8 (37.5%) had elevated ALT. Two of 15 cats (13.3%) had elevated BUN but normal creatinine.
All cats were painful upon palpation of the abdomen and pelvic limbs. A palpable PPH was noted on the intake examination of 2 of 16 cats (12.5%). Moderate to severe bruising was reported along the abdomen in 4 cats and inguinal region in 1 cat. Puncture wounds were reported in 4 cats and full-thickness lacerations in 2 cats. One cat had subcutaneous emphysema associated with the pelvic limbs and multiple puncture wounds over the ventrum. Neurologic deficits aside from mentation changes noted in Table 1 included decreased anal tone, absent anal and tail tone, paraplegia, and historical blindness in 1 cat each. Other physical examination findings included a heart murmur in 2 cats and historical right pelvic limb amputation in 1 cat.
Diagnostic imaging
Point-of-care ultrasound was performed of the abdomen in 11 of 16 cats (68.8%) and thoracic cavity in 8 of 16 cats (50.0%). No significant findings were reported in the abdomen of 9 cats, peritoneal fluid was identified in 1 cat, and 1 cat was confirmed to have herniation of intestines and the urinary bladder. Pleural effusion was not identified in any cat; however, scant B-lines were identified unilaterally in 2 cats and bilaterally in 1 cat. Diagnostic abdominal ultrasound by a board-certified radiologist was performed in 1 cat and revealed a suspected urethral tear. Thoracic radiographs were performed in 12 of 16 cats, with no significant findings in 8 cats, and 1 cat each with pulmonary contusions, a suspected traumatic bulla, diffuse subcutaneous emphysema and pneumomediastinum, a mild diffuse interstitial pattern, and a scapular fracture.
Findings of abdominal/pelvic diagnostic imaging related to PPH diagnosis and orthopedic trauma are summarized in Table 2. Imaging modality included radiographs in 14 cats and CT in 4 cats. Retraction of the body wall, inguinal streaking, and ventral body wall swelling were the most common findings used to diagnose PPH (Table 3; Figure 2). Herniation of abdominal organs was confirmed in 6 cats (37.5%), including the urinary bladder only in 4 cats and the urinary bladder plus small intestine in 2 cats. The diagnosis of PPH was confirmed on radiographs in 10 of 16 cats (62.5%), both radiographs and CT in 4 of 16 cats (25.0%), CT in 1 cat (6.3%), and surgery in 1 cat (6.3%).
Left lateral (A) and ventrodorsal (C) radiographs and sagittal (B) and dorsal (D) reconstructed CT images in soft tissue window at the level of the urinary bladder of a cat that presented following unknown trauma (window level, 40 HU, and window width, 300 HU, for all images; thickness, 0.6 mm). Cranial is to the top of panels C and D and to the left of panels A and B, and the right side is to the left of the image (identified by the letter R on the image). There is disruption of the ventral abdominal body wall with retraction from the pubis (blue arrows), thickening of the body wall (white asterisk), and mild fluid streaking of the inguinal fat and ventral displacement of the urinary bladder beyond the body wall into the inguinal tissues (yellow star). Orthopedic injuries in this cat include bilateral sacroiliac luxation (white ovals), left pubic fracture (white arrow), and right femoral head luxation and femoral neck fracture (red asterisk).
Citation: Journal of the American Veterinary Medical Association 2025; 10.2460/javma.24.09.0593
Treatment
Five of 16 cats (31.3%) were euthanized on the day of presentation with no treatment. The owners of 1 cat with bilateral SI luxation and PPH without organ herniation elected transfer to the primary veterinarian for further care on the day of presentation; this cat was lost to follow-up. Information on treatment was therefore available for 10 cats. Seven of 16 cats (43.8%) underwent surgical repair of the PPH. The method of PPH repair and timing in relation to pelvic fracture repair is summarized in Table 4. Procedural images in a cat that underwent repair via pubic bone tunnels are available in Supplementary Figure S2. Additional procedures in cats that underwent PPH repair included fixation of an SI luxation in 3 cats and repair of a diaphragmatic hernia, repair of an inguinal hernia, and ilial fracture repair in 1 cat each. One cat required prolonged open wound management for a large caudal abdominal laceration. One cat with a urethral tear had a closed suction drain placed in the abdomen at the time of PPH repair, and a urethral catheter was left in place to attempt conservative management of the urethral tear. One cat had bilateral SI luxation stabilization surgery but no surgical treatment of the PPH.
Outcome
Median duration of hospitalization for the 10 treated cats was 6.5 days (range, 3 to 14 days; 95% CI, 4 to 13 days). No deaths occurred during hospitalization, and a median of 33 days (range, 1 to 3,530 days; 95% CI, 4 to 1,251 days) of follow-up was available. Five complications were reported in 4 of 10 cats (40.0%), including 2 mild (level 1) complications (fluid overload that responded to discontinuing fluids and transient postoperative hypothermia and hypotension that improved with time), 1 moderate (level 2) complication (hypotension requiring blood product administration), 1 severe (level 3) complication (1 cat developed worsening azotemia and a uroabdomen 3 days after presentation; a urethral tear was confirmed via cystourethrogram and was treated conservatively with an indwelling urethral catheter for 7 days), and 1 severe (level 4) complication (the cat with a closed suction drain and urethral catheter in place at the initial surgery developed a septic uroabdomen; reoperation for a urethral anastomosis was required). All cats with complications reported had undergone surgery for PPH repair; however, complications specifically related to PPH repair or injury were not reported.
Discussion
Prepubic hernia was sustained after vehicular trauma in the majority of cats and dogs in the present study. Diagnosis was made with radiographic images in most cases, though some required CT or surgery for definitive diagnosis. Concurrent injuries were common, with pubic fractures and SI luxation being the most common orthopedic injuries sustained. Urinary tract trauma leading to urine leakage was noted in several cases. Duration of hospitalization was prolonged in many cases, with a median duration of approximately 1 week in both cats and dogs. In dogs, PPH reconstruction was most commonly achieved with muscle closure only, whereas use of pubic bone tunnels was more commonly employed in cats. Long-term complications related to the PPH injury or repair were not reported in cases with follow-up available.
While it may be possible to diagnose a PPH on physical examination, our current findings indicate that this is a rare occurrence and should not be relied upon. The presence of traumatic pelvic fractures, particularly pubic fractures or SI luxation, should prompt the clinician to evaluate the patient for a PPH even if no herniation is palpated. Radiographs were sufficient for diagnosis of the PPH in most cases, particularly the lateral projection that best highlighted body wall retraction, streaking of the soft tissues in the inguinal region, and swelling of the ventral body wall. None of the PPH diagnosed via CT alone (not apparent on radiographs) had herniated abdominal contents; therefore, it is possible that a PPH not visible on radiographs alone may not be clinically significant.
Previous reports document that the most common surgical repair method for PPH involves the use of bone tunnels drilled into the pubis for reattachment of the prepubic tendon.1 However, most dogs in our study had PPH repair with muscle closure only, whereas use of bone tunnels was more common in cats. It was unclear in most surgical reports whether this choice was based on surgeon preference or degree of trauma; however, some reports noted that the severity of pubic bone fractures made creation of bone tunnels impossible. Complications related to the PPH repair were uncommon; however, it was not possible to determine with this retrospective study whether use of muscle closure alone is inferior to the stability provided by bone tunnels. The only repair failure was reported 2 days postoperatively in a dog with bone tunnels used during the first surgery; use of additional bone tunnels was employed at the revision surgery. Infection and cutaneous ischemic damage secondary to trauma are suspected to have played a role in this surgical failure.
Anecdotally, some surgeons worry about tension on the pubis during PPH repair interfering with the integrity of pelvic fracture repairs and thus recommend that PPH repair be done prior to orthopedic procedures for cases in which both are indicated. Order of orthopedic procedures in relation to PPH repair in the present study was diverse, with about half of cases undergoing orthopedic surgery first and half undergoing PPH repair first. There were insufficient data in the present study to make meaningful comparisons regarding patient outcome based on order of repair.
Concurrent injuries were numerous and often severe. Of note, approximately 12.5% of both canine (8 of 71) and feline (2 of 16) patients in this study were diagnosed with urinary tract rupture that was occasionally not recognized until several days after hospital admission. Uroabdomen following pelvic fractures has been previously described, with a 3.6% (3 of 83) incidence in 1 study.9 All but 1 dog with urinary tract rupture in this study had concurrent pelvic fractures. Given the potentially detrimental consequences associated with urinary tract injury, clinicians should closely evaluate any patient with a PPH to ensure an intact urinary tract.
Conservative management may be a reasonable approach for patients that have no herniated abdominal organs. Particularly in light of increasing financial impact of surgical procedures in veterinary medicine, it may be possible to conservatively manage PPH without organ herniation in lieu of allocating funds toward orthopedic or other injuries. Complications related to the PPH injury were not reported in any dog or cat that did not undergo repair in this study. Complications were typically related to surgery and anesthesia in general (SSI, dehiscence, aspiration pneumonia) or as a consequence of implant failure. The need to repair a PPH when no abdominal organs are herniated is questionable and warrants further investigation.
As this was a retrospective study, there were inherent limitations. The sample size was relatively small. Some information was not readily apparent in the medical record, such as the surgeons’ preference to use muscle closure over bone tunnel placement. Factors weighing into the decision to repair the PPH or manage it conservatively could not be deduced. Additionally, a number of cases were lost to follow-up, decreasing the amount of data available regarding outcome and prognosis.
In conclusion, PPH should be considered in any patient that has sustained significant trauma, particularly when pelvic fractures are present. This injury can usually be diagnosed or highly suspected on lateral view radiographs. For cases in which no abdominal organs are herniated, medical management may be considered, though further research is needed to investigate this. Common concurrent injuries include SI luxation and urinary tract trauma including urinary bladder tear or rupture. Complications directly associated with PPH repair are rare, and the prognosis is good. However, the severity of the concurrent injuries is an important factor in determining individual patient prognosis.
Supplementary Materials
Supplementary materials are posted online at the journal website: avmajournals.avma.org.
Acknowledgments
The authors would like to acknowledge Paulina Sanchez Fernandez for her assistance with data collection.
Disclosures
The authors have nothing to disclose. No AI-assisted technologies were used in the generation of this manuscript.
Funding
The authors have nothing to disclose.
ORCID
M. S. Sombrio https://orcid.org/0000-0001-8540-9347
V. Dickerson https://orcid.org/0009-0008-0096-9942
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