INTERESTING CASES ON WEDNESDAY JAN 26, 2011
I asked intern, Michelle to write down the following rather than being an observer. She has just completed her A levels and is waiting for the A-level results and wants to study vet medicine. So, I spent some time on this case with her to make vet medicine alive for her when I am free as she does not really benefit from case studies as she is not in Vet course yet.
The Pug had a complaint as follows:
Not able to pee normally for past 2 days. "But he pees normally at one big lot yesterday," the lady who loves pugs wanted to consult me as she had a black pug seen by me some 18 years ago. The black pug had passed away from old age and she never had such problems for the 3 pugs she had. Now, this pug that does not look like a "pug" because he had a longer body and not broad chested had dysuria (difficulty in urination). He had been operated on by an expensive vet one year ago ($2,000 for the whole urinary stone surgery case etc).
"The vet removed the kidney stones," the lady told me but had no medical records from the vet.
"Are you sure it is kidney stones?" I asked her as she was satisfied that the dog had recovered and that was what mattered. The dog had been on S/D diet for one month and C/D diet for 3 months. Then only home-cooked food for the last 8 months. Dysuria occurred 2 days ago. So she consulted me as she surfed the internet.
I was in charge of this case working closely with my associate Dr Vanessa Lin.
PALPATION OF BLADDER, URINE TEST AND BLOOD TEST
1. Empty bladder. So, I asked the owner to let me keep the dog till his bladder is full and I can collect urine for analysis of urinary stones and crystals as well as other tests. There is no point catheterisation at this stage to collect urine as the bladder was emptied recently. Blood was taken. An IV drip was given to get some urine produced.
2. URETHRAL OBSTRUCTION
Dr Vanessa told me that the catheter could not be passed through for more than 10 cm, i.e.. beyond the os penis. I advised X-ray and a spasmogesic injection to be given to relax the bladder muscles. She gave the spasmogesic injection and did the X-ray before 5 pm. She used a smaller hard-catheter and could get the urine out (around 20 ml in a collection bottle) for laboratory analysis.
I checked the pug at 6 pm with the owner who came to visit. The pug was put on the floor. He was very happy. He lifted his leg and peed around 20 ml of dark brown urine. The nurse matron apologised but I said it was OK and a common incident. The intern mopped away the urine.
The following is Michelle's case report is as follows:
3) Pug with difficulty urinating
Catheter could not go through; obstruction in the urinary tract; small bladder stone detected using x-ray
Urinated at 6.30pm; dipstick test:
Colour of urine: orange-yellow
Specific gravity: 1.015
"The dipstick results are not as accurate as urine analysis," I told Michelle. "The urine test report will be in tomorrow and compare the results."
ADVICE FROM DR SING
Each vet has his or her own method of treatment. For me, the diagnosis is urethral obstruction behind the os penis (based on catherisation mainly). "The X-ray showed some opaque sand behind the os penis," I said to the owner. "What happens is that it causes pain and so the dog has dysuria. After the pain subsided, the sand particles go back to the bladder and so the dog could pee a large amount of urine at one go. Till the next episode."
"What is the treatment?" the lady asked me. "The dog can't be peeing with difficulty now and then."
"Be patient," I said. I advised a low dose of prednisolone and let Dr Vanessa Lin know about this approach. Pred brings down inflammation and let the sand particles be passed out. This is my rationale for the treatment but each vet will have his or her own approach.
Antibiotics for the next 2 days. The dog would drink water and urohydropropulsion can be used to flush out the sand particles. This would be tried first before another bladder surgery which the owner was not keen to do. This case may not need the bladder surgery but the owner must be patient for dietary and medical treatment. This is where many owners want fast results. Bladder surgery would resolve the problem fast but there is the owner's wish not to have it. It would not cost her $2,000 but economics do play a great part for the owner.
This is Day 1. The pug had passed urine at 6.30 pm with some difficulty (leg held up for more than 60 seconds). Will wait and see.
Dr Vanessa phoned the previous vet and was told that the urinary stone removed was 95% struvite. As every urinary case is different and every vet has his or her approach, my management of this case may differ from that of my associate vet. The urinary pH on dipstick is 7.0. So, a vet could argue that the urine is not alkaline. Struvites stone form in alkaline ph but a pH 7.0 on urine dipstick shows neutral pH.
Dietary and medical management, instead of surgery may be possible. Will update when urine test pH and crystal results come in today.