Thursday, October 21, 2010

8-year-old neutered male cat can't pee

"I know my cats well," the lady said when I asked whether 8-year-old her male neutered cat was having constipation instead of having difficulty in urination. "I have 5 of them. I can differentiate constipation from urination difficulty."

She had consulted Vet 1 twice on Monday and Wednesday but the cat still had dysuria (difficulty in passing urine). She said: "I find that the vet is not sure of what's happening to my cat." When the cat does not get well, many Singapore owners will lose confidence and seek another opinion. Diseases take time to resolve with antibiotics and the second vet usually benefits from the passage of time to deliver an excellent outcome.

Vet 1 had told her that there was no major problem after palpation of the bladder. She said that her maid had kept a close eye on this cat and was sure that the cat had not peed a drop of urine for the past 2 days.

I said: "I have the same finding as Vet 1 in that the bladder is not full at all. So there is no urethral obstruction. If there is urinary sand obstructing the urethra, the bladder should be as big as a mango. If the cat had not peed for 2 days, the bladder should be swollen and can be felt easily."

The maid was holding the cat upside down for me to examine his private parts. There was a purplish red tip of the penis which was otherwise not swollen and normal in size and colour. The cat had medications from Vet 1 and the "normal finding" of the penis must be taken into account.

The lady was in the subway train on the way to the surgery after work. Her mum and maid had brought the cat in first. The cat had lost appetite today and had dysuria. She was insistent that the cat had a problem with urination.

PHYSICAL EXAMINATION
1. Cat standing on the examination table. Palpation of the bladder. Not swollen at all. Slight pain around the bladder area but not

2. Cat turned upside down. The penile length was extruded. Except for a purplish red tip due to traumatic licking, there was nothing abnormal. I asked the maid: "Is it possible that the cat peed when every family member including you were asleep? The bladder pain may have gone for a while and the cat pees most of the urine." The maid did not object to this comment. "Did you see blood in the cat's urine earlier?" I asked the maid. "No," she said.

WHAT TO DO NOW?
There was no doubt that the owner knows best. The cat does not have constipation as the palpation does not reveal hard faecal stools. Yet the cat does not have a full bladder or blood in the urine history.

WHAT THE OWNER WANTS
An accurate diagnosis on what's wrong with her cat. In the male dog, it is much easier to catheterise the dog's bladder and get the urine out for examination of blood and bacteria.

RE-EXAMINE THE CAT'S PENILE AREA AGAIN
I asked the maid to bring the cat to the operating room for a re-examination of the penile area again under the bright operating lights. My assistant pushed the penis out from the prepuce. The prepuce and penile body were normal pink. Only the penile tip was purplish red in colour as seen in traumatic licking.

The cat was now getting angry with all these manipulations. Suddenly the maid pointed to her right side of her T-shirt and shouted: "The cat peed onto me!" She managed a twist and turn. Much of the pee bombed onto the floor. There was a big drop of blood-stained urine remaining on the preputial area.

"Get a one-ml syringe," I shouted to my assistant. "Suck out the urine for examination." In the meantime, I took out my digital camera to take evidence for the owner who was rushing to the surgery.

"You need a 2-ml syringe," my assistant went to the chest of drawers to get one. That drop of urine would fill the 1-ml syringe. While my assistant was looking for the syringe, the cat gave a turn to be upright. So, there was no more bloody urine evidence. The maid was the witness. The bloody urine on the floor was of no use as the floor tiles were greyish in colour and anyway, the amount was not that much. It was around 20 ml spread out on the tiles.

The owner arrived. "The cat had blood in the urine," I said. She looked at me for proof. I took out the digital camera and got the image for her to see. Dark red blood at the penile tip. She seemed satisfied. Nothing can convince the doubting owner than real physical evidence of bloody urine.

TREATMENT
The owner reluctantly agreed to the cat being warded one day. Blood test would be done. The urine would be collected the next day while the cat had a IV saline to produce urine. I will then catheterise the cat and collect the urine. After that, the bladder would be flushed well with saline to get all urinary sand out.

DIAGNOSIS
In dysuria and haematuria in an 8-year-old cat of recent onset, the possible causes are:
1. FIC (feline idiopathic cystitis). This is the most common cause.
2. Urolithiasis (stone or sand in the bladder). Usually in cats over 10 years old.
3. Urethral plugs.

In this case, the tentative diagnosis is FIC but it may be a combination of 3 causes. After manipulation of the penile tip, the urethral plug was loosened and the cat peed onto the maid.

TESTS
1. Blood test
2. Urine test - cystocentosis, catheterisation or voiding. I prefer catherisation although some vets advocate cystocentosis is said to prevent introduction of bacteria into the bladder.
3. Urolith analysis (struvite & calcium oxalate usually).

ADVICE
"Stop feeding dry cat food," I said to the owner firmly. "If you feed dry food, the cat may suffer from the same lower urinary tract disease again and you will have to spend money for treatmen. Don't say I did not tell you."

The lady said: "My cat loves dry food. The other 4 cats are also eating dry food. One of them is older than him and has no such problem."

I said: "Not every person or cat will suffer from the same disease or condition. This is the diversity of life."

CONCLUSION
This is one of those cases where the cat is presented with no swollen bladder. So any vet will say that there is no urethral obstruction. So the owner will lose confidence in the vet and seek a second opinion. The second opinion was no better than the first opinion till the cat delivered the blood urine as evidence of a lower urinary tract disease! Luck does play an important part in living and in veterinary diagnosis sometimes.

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