When I was in college, I got a dog. (Note to college students: Don’t do this. You’re busy enough. Your parents are happy they finally have only themselves to feed. They really don’t want to take your dog next semester when you realize you don’t have time.) Where was I? Oh, right. I got a dog. My childhood dogs were all little females, so of course I got a big male Irish setter-husky cross. One day, I noticed two lumps in his groin. Not testicles. I knew about testicles. These were bumps never seen before. I rushed to the veterinarian, panicked, sure it was cancer. The doctor laughed. “Those are bulbourethral glands. Perfectly normal male dog. They swell when he’s aroused.” I left the office, embarrassed, but reassured.
Forty years later, a client called. Her Labrador retriever, Poutine, had swelling in his groin. Another case of misunderstood anatomy? Maybe not. Poutine was also dripping blood. Bloody penile discharge in intact male dogs often just means benign prostate enlargement, but Poutine was neutered. I suggested they come in. On examination, Poutine had a high fever. His prepuce (the skin covering the penis) was so swollen I could not retract it to see what was happening underneath. Thin bloody fluid dripped from the opening. Otherwise, he seemed alert and happy. “He must have injured himself,” I speculated. “There’s probably a cut or tear inside I can’t see because of the swelling.”
During veterinary school, I looked after a malamute who had jumped a barbed wire fence while he was … um … what’s the appropriate euphemism? Let’s just say that if you are a romantically excited male dog leaping over barbed wire, you should jump extra high. The wire had snagged him, lacerating his penis and damaging the urethra (the tube that carries urine from the bladder). His owner didn’t notice at first, but the injury impeded the dog’s urination. He could only dribble. His bladder became so distended it eventually lost the ability to contract at all. Once the owner realized and sought medical care, veterinarians used catheters of gradually increasing diameters to stretch the scar tissue and slowly widen the urethra back to normal. My job was expressing his bladder every six hours, keeping it small, so the muscles would regain contractility.
Perhaps Poutine had jumped a fence? Or sustained some other penile injury. Once the swelling lessened, I could get a better look. He had urinated normally earlier. His bladder wasn’t enlarged. Good. Blood work was normal. Good. We sent him home on antinflammatory pain medication and antibiotics with instructions to observe urination, and return the next day for a recheck. But the following morning, his owner called early. “The swelling has doubled,” she said. “One eye is bulging, and now he’s dripping blood from his nose, too.” A thousand red flags waved. Bleeding from multiple orifices often indicates coagulopathy — i.e., a clotting disorder. Seriously bad news. The bulging eye? Probably hemorrhage behind the eyeball. Dogs with coagulopathies do best if immediately transferred to specialty facilities with ICUs and blood banks for transfusions. We sent Poutine straight to the ferry.
Over the next two days at the specialists, things rapidly went from bad to worse. His head swelled. His prepuce sloughed. He had trouble breathing. Was he hemorrhaging into his lungs? No. Chest x-rays were surprisingly normal. We wracked our brains for explanations. Brown recluse spider bite? They started antihistamines. Unidentified tickborne disease? They started doxycycline. The genital swelling became so severe Poutine could no longer urinate. Even using an endoscope, it took an hour to place a urinary catheter. Because his head was too swollen for an Elizabethan collar, Poutine soon pulled out his urinary catheter. Now what? The respiratory distress eventually passed, but his inability to urinate combined with inability to catheterize him created an untenable situation. He wasn’t eating. He was deteriorating fast. Financial realities and the poor prognosis had to be factored in. Euthanasia seemed the only realistic choice. The family brought him back for one final night at home … where Poutine surprised everyone by eating and urinating on his own.
I wish this story had a happy ending. It doesn’t. Poutine’s owner nursed him heroically as we continued to hope for recovery. The bleeding, fever, and head swelling resolved. But then his legs became swollen, the skin cracking and sloughing in large swathes.
I believe Poutine may have had necrotizing fasciitis (NF) — a rare, life-threatening bacterial skin infection sometimes called “flesh-eating bacteria.” “Necrotizing” means “causing death of tissues.” The bacteria enter the body through a break in the skin, such as a puncture, scratch, or insect bite. Infection then spreads rapidly through connective tissue layers called fascia. Toxins are released, causing surrounding flesh to die. In humans, NF is most commonly caused by Group A streptococcus. In dogs, Groups G and C strep have been implicated in causing symptoms similar to Poutine’s, like hemorrhagic pneumonia, skin sloughing, sepsis, and bloody nasal discharge. These bacteria may be normal microflora on canine skin or genitals (just as some humans carry strep A without being clinically ill). But when they get into places they shouldn’t, in rare instances, these horrific infections may result. Immunocompromised individuals or those with other underlying illnesses are most susceptible, but often cases just occur randomly. NF is rarely contagious, but good hygiene is recommended, including wearing gloves when in contact with patients, and frequent hand washing. The only effective treatment is intravenous antibiotics and rapid surgical removal of all dead tissue, often including amputation. Even then, one-quarter of human cases are fatal.
Ten days after returning home, Poutine was still eating, urinating, and wagging his tail … but the massive infection in three of his legs was getting progressively worse. He could no longer walk or even stand up. We let him go on a beautiful late summer morning, on the front porch of his house, where he could look out over his domain once more before he closed his eyes.