Tuesday, May 3, 2011

426. Two cases of a cat having difficulty in peeing

NO NEWS IS GOOD NEWS
"The owner's previous male cat had the same problem of dysuria (difficulty in passing urine)," I said as I presented a 3-year-old male cat to the Senior Veterinarian, Dr Foo for radiography which is an X-ray of the bladder and kidneys. "He died a few weeks later." 

Dr Foo frowned. He had performed at least a thousand cases in forty years of small animal practice and had a solid surgical reputation in my opinion. Deaths from urinary bladder obstruction would occur as no veterinarian could save every case and many owners had not complied with instructions to take medication, change to a calculolytic diet or go for a follow up. In most cases, the cat refused to take medication or accept a new diet and the owner could not do much.

I elaborated, "The owner did say that she had left the post-operative care of her first case to her mother as she was overseas. The cat would not take the medication and her mother had not consulted any veterinarian. The cat then died. Probably due to urinary bladder rupture and or kidney failure."

"No point taking X-rays," Dr Foo said. "Nothing will be seen as the cat with urolithiasis do not have solid stones."  

"There may be obstruction by stones further up the bladder, in the ureter or in the kidneys," I said. "Although urethral obstruction in the cat is usually caused by an organic matrix which would not be seen clearly on X-rays, sometimes there may be crystals." 


No urinary stones seen on X-rays
X-rays add to the veterinary costs and in the dog-eat-dog veterinary practices of Singapore, it was the least cost that attract the average pet owner. Overheads are high and if there are no clients, there will be no revenue and the practice will have to close within a year or two.

Dr Foo had been long in practice to understand that Singaporeans want cheap and good services. The competitor was nearby. Younger veterinarians in new practices underprice their services, a common situation in the private sector.

He was experienced but he could not command higher fees because the pet owners were not sophisticated enough yet to pay a premium for veterans. In fact, his fees were in some cases lower than the competition!




The mean age (50% of the cases) for urolithiasis in cats is 7 years old and the range 1 - 22 years old, but this cat was only 3 years old. He was a gentle slim cat with a "M" in his forehead, nervous about going outdoors and much loved by the equally trim and fit lady owner, a career lady who worked long hours into the night. She had said, "I hope you don't need to neuter him during treatment as I wanted him to be a father."

The cat was tranquilised and treated. It was difficult to dislodge the organic plug inside the urethra. After some five minutes, the urine shot out onto his hands. 

The obstruction was cleared and the bladder was pressed to allow more urine to flow out. It was a relief as if we had urinary bladder obstruction. Nurse Ann's joy was short-lived. The urine flow stopped suddenly. The male cat urethra is very narrow and it was blocked again.  

More work at dislodging the urethral plug. Dr Foo inserted a catheter into the urethra to let the urine flow out. Strong ammonia smell mixed with blood. Infected smelly urine. The urine had a strong ammonia smell as if it was kept for several days inside the bladder. 




A neck collar was worn to prevent the cat from biting off the catheter which was sutured to the skin. Dr Foo said that the cat could go home with medication and that would mean least cost. But would that be in the interest of the cat? It was not easy for most Singapore owners to medicate a cat.   

It would have been better to keep the cat for the next 3 days to observe and checked that his urinary obstruction and bleeding in the bladder had stopped. But the practice would be known as "expensive" and that would out price the competitors. 

I had given him antibiotic and dextrose saline injections to flush out any "sand" inside his bladder. Two hours after surgery, he passed a large amount of smelly blood-stained urine. Seventeen hours later, his urine passed the smell test. It was not smelly and that was good. 

Would his catheter get blocked? The owner brought the cat back the next day as I did not want her to incur more boarding costs. 

The owner, being a doctor, would know what to do with medication and a change from dry cat feed to a low magnesium diet. The urine and the uroliths inside the urine were not sent for laboratory examination or bacterial culture because that would increase the cost of treatment.

In private practice all over the world, the average pet owner usually goes for the cheapest doctor.

Well, telephone consultations are free. I phoned the doctor five days later to enquire about this gentle cat. I left a message on her busy mobile phone for her to call me back. No call. I got her on her phone but she was busy at consultation.

"I can't talk now," she said.

"Is your cat OK?" I had to ask as this was the only chance since I did not expect her to return calls.

"Yes," she said and that was all. There were no return calls from her despite leaving messages on her mobile phone. Singaporeans seldom return phone calls unless they need to as they usually lead a hectic life.

It was best not to persist. No news is good news, that is the saying. I hope the cat had recovered well.
A Cat Can't Pee On Labour Day
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Date: 04 May, 2011
toapayohvets.com
Be Kind To Pets
Veterinary Education
Project 2010-0129
The above-mentioned case, probably recorded in 2000, was fished out from my archives as I am keeping all my cat's urinary tract problem cases under
http://www.sinpets.com/cats/20110433cats-urinary-tract-urethra-obstruction-infections-toapayohvets-singapore.htm for ease of reviews and for clinical research.

On Sunday, May 1, 2011 (Labour Day in Singapore), I was manning the front desk while Dr Vanessa Lin was doing the consultation. A man in his early 50s phoned me as his cat could not urinate normally for the past two days. I had a discussion with Dr Vanessa Lin on the management of this case as I would be having the afternoon off as each vet handles a case of urethral obstruction differently. When the patient recovers, everybody is happy. But should the patient gets worse or dies, litigation and complaints may occur and I don't want that to happen to Toa Payoh Vets.

There are certain standard operating procedures I will want to advise the owner and be recorded in case of medical negligence litigation and I had to inform my associate vets as I was taking the afternoon off. These are:

1. urine collection for analysis of crystals, bacteria and blood - mandatory. Some vets do not do this and may be sued for possessing a lower standard of care if the cat dies since the vet has no defence of urine or blood tests.

2. blood collection for health screening is strongly advised esp. to check whether the kidney is affected and whether there is a severe bacterial infection. Fever may or may not be an indicative sign of this infection. If the owner does not want to pay for this test, this objection must be recorded in the case sheets.
 
3. As to whether the urinary catheter should stay in this cat for 2 days, I left that option to her. However, I said: "Usually I don't stitch the catheter after thoroughly irrigating the bladder if the urethra obstruction is a recent event as in this case".

For long-standing cases, I do stitch the catheter for 2 days and may irrigate the bladder again. See my procedures at: The hissing cat has difficulty peeing again  

CAUSE OF THE URETHRAL OBSTRUCTION/URINARY TRACT INFECTION?
In this cat, there was no urethral obstruction as the catheter passed into the bladder easily. I spoke to the owner the next day as he came for the cat. Monday, May 2, 2011 was a public holiday as May 1 (Labour Day) happened on a Sunday.

What was the cause of this cat's dysuria problem?

"FLUTD (Feline Lower Urinary Tract Disease) usually occurs in a male neutered cat over 5 years of age," I was thinking that this cat could have some injury or infection.

"My cat is only one and a half years old and he is not neutered!" the IT man said to me.

"5-years is the average age," I said. "Some cases happen in younger cats. Is your cat busy mating with other cats and thereby suffering from traumatic injury?"

"Well, my other cat keeps humping him every month. But this has been going on for several months and there has been no problem with urination."

I try not to be antagonistic and impatient. I said: "Many events don't happen until they are performed often enough. For example, people don't get prawn allergies till they are eat prawns for many times. It is possible that your cat has traumatic injury to the penile area."

I don't want to appear soliciting for business by advising neutering of the humping cats and therefore let sleeping dogs lie. This cat's dysuria is likely to be a case of traumatic injury. The cat owner will give canned food instead of dry food. I will follow up on the cat's urine and blood test results.


TOA PAYOH VETS' URL
http://www.asiahomes.com/singaporetpvet/0707cat_urolithiasis.htm

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