October 2025
In this VETgirl online veterinary continuing education blog, Dr. Amy Kaplan, cVMA, DACVECC, MRCVS discusses a case of vaginal prolapse with bladder entrapment in an older female dog. When a female intact dog comes in with something dangling like this below, it’s an emergency and needs to be addressed right away! What causes this dramatic-looking condition, and what other anatomy can get pulled with it along the way? Read on to find out!

Canine Vaginal Prolapse with a Twist!

Dr. Amy Kaplan, cVMA, DACVECC, MRCVS, CE Program Manager, VETgirl

The Case That Walked In

Photo courtesy of Dr. Amy Kaplan, cVMA, DACVECC, MRCVS

As an ER vet, I’ve seen some things. But when a large, pink mass is protruding from a dog’s back end, it’ll stop me in my tracks. This case was a 10-year-old, intact female, mixed-breed dog who presented for, quite literally, “something hanging out” of her back end. The owner had spotted the tissue that morning, and after watching it balloon for a few hours, rushed her into the ER.

On exam, this patient was bright, active, and overall unfazed. She had whelped just a few weeks earlier. The circumferential tissue protruding from her vulva was pink to red, mostly smooth with some patches of dryness and cracking, and a few shallow ulcerations. Generally, cases of mild vaginal prolapse don’t hurt the patient unless the tissue gets dry, cracked, or traumatized. However, this case was much more severe, and sadly, this girl was definitely uncomfortable even with gentle palpation of the tissue.

Diagnosis and Differentials

Vaginal prolapse is generally a “look and diagnose” condition. So, what exactly is happening here? In most cases, this estrogen-driven drama strikes young, intact bitches during their first or second heat cycles in the proestrus or estrus stages. Rising estrogen levels cause vaginal tissue to swell and engorge (to prepare for breeding), which can rarely lead to eversion of the vagina—which looks like a sock turning inside out. Even accidental ingestion of topical human estrogen creams (Yes, we’ve seen this from the dog licking the pet parent chronically!) can cause tissue engorgement and potential prolapse. While the average age for vaginal prolapse is <2 years, you’ll still see it crop up in periparturient bitches of any age. Don’t forget other causes for vaginal prolapse which may occur without elevated estrogen levels – tenesmus, dystocia, vaginal masses, or trauma (it’s another reason not to break up “tied” dogs, since they naturally are “stuck” post-breeding for around 5-20 minutes on average – but can be longer!). Cats rarely can get vaginal prolapse, but they don’t get a free pass! In cats, the vaginal and uterine prolapse appear to be more often related to periparturient causes.

Photo courtesy of Dr. Amy Kaplan, cVMA, DACVECC, MRCVS

There are three types of vaginal prolapse categorized by the extent of protrusion:

  • Type I: swelling, no real protrusion
  • Type II: circumferential protrusion through the vulva
  • Type III (also called “true prolapse”): the entire vaginal circumference + cervix protrudes, often with dystocia or trauma

Type I and II are often managed conservatively and will regress on their own with time. Type III is where things can get… complicated and emergent. Type III vaginal prolapse, also termed a “true prolapse,” typically arises from non-estrogen-dependent causes and represents the most severe manifestation, based on the extent of protruding tissue. This form is often compounded by displacement of adjacent structures, such as the cervix, bladder, or even invagination of the descending colon.

Normally, the bladder is supported by a median (ventral) ligament and two lateral ligaments. The median ligament secures the ventral surface of the bladder to the linea alba and pelvic symphysis, while the lateral ligaments — which also enclose the ureters — anchor the bladder to the pelvic sidewalls. Laxity or disruption of these fascial supports predisposes to cystocele formation. A cystocele is defined as herniation of the bladder into the vaginal wall due to attenuation or failure of these supporting ligaments. In humans, this condition is commonly termed a “dropped bladder.” In the dog, it may manifest clinically as a subtle, pink bulge at the vulvar commissure with little to no overt protrusion, as the bladder displaces against the vaginal wall rather than prolapsing externally.

Bladder incarceration can be associated with a true vaginal prolapse and represents a more advanced stage beyond cystocele, characterized by extrusion and entrapment of the bladder within the everted vaginal tissue protruding from the vulva – it’s pulled externally along with the prolapsing tissue because it’s trapped! Once incarcerated, the bladder becomes mechanically constrained, predisposing to urinary outflow obstruction (Hello, emergency!), vascular compromise, and, in severe cases, ischemic necrosis. If manual reduction into the abdominal cavity cannot be achieved, the condition is considered a surgical emergency requiring immediate intervention.

Conservative Management for Type I and II: Keep It Clean, Keep It Moist

For most Type I and II prolapses, the tissue regresses within 7-14 days after the end of the estrus stage as estrogen levels fall. During that time, the mantra is: keep it clean, keep it moist, and protect it. Lubricants, barrier creams, E-collars, and topical antibiotics for ulcers all help prevent tissue trauma. If the tissue becomes necrotic, severely ulcerated, or traumatized, surgical excision with ovariohysterectomy (OVH) or ovariectomy may be recommended.

Don’t Forget to Check Anatomy!

Here’s where this case got interesting. After peripheral intravenous (IV) catheter placement, methadone bolus for her discomfort, and propofol induction for intubation followed by gas anesthesia, we were able to better examine the tissue. On palpation, the tissue wasn’t just the soft edema we were expecting—it had something firm inside. And our patient had been seen in hospital squatting as if to urinate repeatedly with only a drop or two produced.

Photo courtesy of Dr. Amy Kaplan, cVMA, DACVECC, MRCVS

To our surprise, on ultrasound through the prolapsed vaginal tissue, we found a very large, fluid-filled, hypoechoic bladder!

Given the marked bladder distension secondary to urinary retention and the inability to visualize or navigate a catheter through the distorted anatomy, urinary catheterization was not feasible. Instead, bladder decompression was achieved via cystocentesis using a 21-gauge needle connected to sterile IV extension tubing and syringes.

Photo courtesy of Dr. Amy Kaplan, cVMA, DACVECC, MRCVS

Next, hyperosmotic therapy with topical sugar was applied to the prolapsed tissue in an effort to reduce edema and facilitate manual reduction, as surgical intervention was initially declined by the clients. Despite these measures, manual replacement of the bladder and prolapsed vaginal tissue was unsuccessful. Ultimately, the owners consented to surgical management, and an OVH was performed via an open abdominal approach to achieve reduction of the incarcerated structures and to prevent recurrence of prolapse.

Photo courtesy of Dr. Amy Kaplan, cVMA, DACVECC, MRCVS

Surgery

Surgery was… a team sport to say the least. It took multiple people compressing and pushing the externalized tissues towards the vulva while the surgeon worked internally to retract the uterine body until she was able to grab the cervix and continue retracting structures inwardly. (Ouch, post-op pain meds are a must!)

Photo courtesy of Dr. Amy Kaplan, cVMA, DACVECC, MRCVS

Fortunately, both the bladder and the reproductive tract were viable, with no evidence of necrosis or vascular compromise. Preservation of a healthy uterine body was particularly important to allow secure placement of ligatures during the OVH. The dog underwent successful ovariohysterectomy and recovered without complication. In similar cases, surgeons may also elect to perform a cystopexy to stabilize the bladder following incarceration, and/or a cervicopexy to address attenuation of the natural ligamentous supports.

Photo courtesy of Dr. Amy Kaplan, cVMA, DACVECC, MRCVS

Photo courtesy of Dr. Amy Kaplan, cVMA, DACVECC, MRCVS

So, what are the takeaways?

Vaginal prolapse is usually an estrogen-fueled spectacle more common in the young intact females, but older dogs can surprise you! Most of the time it looks worse than it is, and with clean, moist tissue care, the prolapse will regress once estrogen levels out. But if the tissue is necrotic, ulcerated, or hiding stowaways like a retroflexed bladder, you’re likely headed to surgery. Remember that recurrence is common, so spaying is the best bet to prevent recurrence. And don’t forget – don’t just treat the tissue you see… check your anatomy twice, because the real problem might be tucked inside.

Abbreviations:

IV: intravenous

21G: 21 gauge

References:

  1. Johnson CA. Estrogen- and Androgen-Related Disorders. Clinical Endocrinology of Companion Animals. Wiley, 2013.
  2. Horwood C, Wan J, Zur Linden A, et al. Treatment of a cystocele in a female dog 3 days after whelping. Can Vet J 2022;63:1203–1207.
  3. Vigneswari M. Surgical management of cervicovaginal prolapse in a bitch. New Era Agriculture Magazine 2023;2(4):35–37.
  4. Alan M, Cetin Y, Sendag S, et al. True vaginal prolapse in a bitch. Anim Reprod Sci 2006.
  5. Concannon PW. Endocrinologic control of normal canine ovarian function. Reprod Domest Anim.2009;44(S2):3-15.

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