Sunday, September 30, 2012

1126. Audit - intestinal surgery - removal of foreign body

Every vet at Toa Payoh Vets is required to maintain a proper record of anaesthesia and surgery in a book dedicated to each vet. I audit some cases now and then.  This case is interesting as it has been performed in a short time, using only domitor and ketamine, without isoflurane gas.

AUDIT OF ANAESTHESIA & SURGERY BY ASSOCIATE VET
Bichon, Male, 3 months
Vomiting over 5 days
Ate prayer food

Hard lump 3x2x2 cm in large intestine. Painful

ANAESTHESIA
Sep 30, 2012 (Sunday) 1.8 kg 3 months

Dom/Ket  0.07/0.09
50% given  0.04/0.05 IV

A: Injection D+K IV   3.47 pm
D: First skin incision   3.56 pm
E: Completion of skin stitching  4.11 pm
No isoflurane gas used for enterotomy

E-A  = 24 min
E-D  = 5 min

SURGERY
Around 3 cm incision. Big greenish hairy hard lump taken out.
"Apricot seed," my vet said.
3/0 monosyn appositional stitches.
I saw the intestinal wall as over 4 mm in width. Blackish edge over red inflamed patch where hard Foreign Body was lodged. Gangrene had set in. That was why dog was vomiting.
Vet has 3 years of experience. A good surgery done.

No blood test and no x-ray due to financial reasons. The owner decided on surgery on Friday evening but I advised the associate vet to wait 2 more days to strengthen the health (vomiting for past 5 days due to financial reasons, not seeking vet treatment). On Sunday afternoon, this dog was operated and today, he looks as good as gold.
Day 2  Oct 1, 2012  11.32 am, I checked the dog and took some pictures. Active. Disliked e-collar.

1125. Sunday's interesting cases - Sep 30, 2012

Sep 30, 2012

Bright sunny day
Case 1. Red-eared slider with "smaller and sunken" left eye. The husband and wife came for a review. "How many turtles have you treated?" she asked me.

"Around seven cases last year," I said. "Singaporeans seldom keep turtles to an older age like yours and there are not many."  Maybe Toa Payoh Vets get less turtle cases. Who knows?

"They release the turtles to the reservoirs," the slim wife with dark rimmed glasses said. "What type of cases you see?"

"Mostly eye problems like closed eyes. Rectal prolapse, cracked shells and not eating."

2 days ago, the husband brought the turtle for consultation as he observed the left eye sunken and smaller than the right eye. He is an observant man as his wife did not know any eye change.

I could see the haziness in the upper part of the cornea of the smaller left eye and took some images to document corneal ulceration (green flurosecein stain). Dr Daniel gave an IM injection in the back thigh muscle of an anti-inflam and antibiotics.

I advised cleaning up the turtle as it smelled fishy, giving eyedrops 3x/day and not letting the eye get wet unless eating time. After eating, wash the eye with boiled water. "Or tap water left overnight as there is chlorine in the water and that will evaporate overnight," I said.
However the husband said: "The tap water has only fluoride, not chlorine." I can't substantiate this and so said nothing.

Today, the husband was to bring the turtle for review and he did so. The turtle's left eye looked so much clearer. It is still sunken but lesser. How to prove it? It was difficult as the turtle did not permit me to take image head-on of both eyes on the reception counter. He was restless and moving. "Do it inside the consultation room after switching off the lights, as before," the husband advised. "Use ISO 3200."

"The images are not so good compared to natural light in the waiting room," I said. "I used ISO 6400 the last time." As I did not want to upset the owner, I took images inside the darkened consultation room. The turtle was calmer. The cornea looked much more transparent esp. in the 11 to 2 o'clock area where there was cloudiness 2 days ago.
Case 2.
 Shih Tzu, 1 year old, with red ear lumps in both ears but the lady in her 40s said that there was no scratching. The right ear was more painful when I palpated the vertical canal and the dog cried.
She had seen my associate vet for the past 3 times with the same problems. Antibiotics, injection and ear flushing again.
"I had spent much money in the eye ulceration treatment last time," she said to me when I advised lateral ear resection surgery. Now she trimmed the hairs around the eyes and put eye drops daily. No more eye ulcerations but this ear inflammation and pus could not be resolved since Jan 2012.
"It is usually the money matters," I said. "Ear surgery is the solution to open up the vertical canal to enable the horizontal canal to be ventilated and drained as the shih tzu's floppy ears covered up the canals 24 hours/day. But most owners will not accept the surgery due to its costs."

"How much?" she asked.
"I estimate $500 for one ear, including nursing care for around 7 days post surgery. It is just an estimate."
Now she had seen my associate vet 4 times and tried to clean the ears and give medication. The total costs and her time would be $600.
"It is just the luck of the owner," I said. "Some families have children with health problems and incur lots of medical expenses. I just have a case of a Shih Tzu dog owner who spent over $8,000 just for 5 bladder stones removal in the dog. Other Shih Tzu owners have no need to spend a cent."

Case 3.
An apricot seed inside the large intestine of the Maltese. I came back to the surgery at 3.30 pm to check whether my associate vet had operated on this Maltese. The owner had delayed operation but the dog kept vomiting and she decided on the operation on Friday. I advised against immediate operation for expediency as Saturday was the day off for my associate vet. The dog needed the IV drip and antibiotics to recover. Today, Sunday, the dog was in much better health but still vomited. My associate vet took out the apricot seed, put in interrupted appositional stitches to close up the wound. The large intestines were inflamed to 6 mm in depth of mucosa and serosa. The dog was alert and well after surgery. That was good.  
Case 4
The old Minature Schnauzer with the bloated stomach of closed pyometra came back for stitch removal as required by Dr Vanessaa. I asked Dr Daniel to remove the stitches. The pyometra surgery was done on 31 August. None of the nylon stitches were present now as it is past one month since surgery. This dog had pus in the hairy ears and dry skin problems in the forearm and body. At least she did survive the surgery as I thought the pyometra would burst if you see the images in my case studies.  



"Today, there is a white spot in the left eye," the wife said.

1124. Cost, Duration & Complications of spaying a 3-year-old jack russell query

 
 
On Sun, Sep 30, 2012 at 2:39 PM, ...1989@hotmail.com> wrote:
Hi,

I have a female jack russell coming 36 months but has yet to be spay.. Can i knw if there're any complications doing this procedure at this age? And roughly the duration and cost of it? Kindly advise, thank you.

Cheers,
J Y
 
 
 
EMAIL REPLY FROM DR SING DATED SEP 30, 2012 
 
Thank you for your email. I am Dr Sing K Y from Toa Payoh Vets.

Generally, all healthy female dogs at around 36 months of age will have no complications during or after spay.
Complications refer to anaesthetic deaths, post-op deaths, bleeding and infections. The duration of spay should be less than 30 minutes and the estimated total cost is around $250-350 at Toa Payoh Vets ( including anaesthesia, surgery, post-op injections and medication and e-collar). Pl make an appointment at 6254 3326 one day in advance.

The best time to spay is 2-3 months after the last heat (bleeding)
 

Saturday, September 29, 2012

1123. Take images of cases to improve your veterinary skills

Taking images of cases with the camera phone to document your cases and to do retrospective studies of your performance will make you a better veterinary surgeon. There may be some parts of the anatomy changes which you might have missed during the examination but images taken will be there for you to review.

For example, in the tough case of the Shih Tzu with perineal urine leakage after a bladder surgery by Vet 3 to remove urinary stones, an image of the swollen perineum (presumed with leaked urine from the traumatised perineal urethra) was taken by me. See: http://www.kongyuensing.com/pic/20120913shih_tzu_bladder_stones_3rd_time_toapayohvets.jpg



This is one supporting evidence and there must be others to substantiate this urine leakage (ultrasound of scrotum filled with fluid), swelling of left inguinal area near where Vet 3 made a skin incision to access the bladder for urinary stone removal daily with blood-tinged fluid while the dog was catherised with a smaller sized urinary catheter



Note that the scrotal sac is also swollen and Vet 3 had said that ultrasound revealed fluid. According to the owner, the whole of the lower part of the inguinal area was much swollen and that was why the dog had to be hospitalised for 8 days by Vet 3 who then recommended a 2nd urethrostomy and scrotal ablation to resolve the problem of urine leakage.  This image was taken when the dog was seen at Toa Payoh Vets on Day 9 after Vet 3's bladder surgery which had removed all bladder stones (post-op X-rays showed no stones).

How to resolve this problem with the least cost to the owner? That is the tough part. Will a 2nd urethrostomy and closure of the first urethal stoma and scrotal ablation resolve the problem for once and for all?  Vet 4 at Toa Payoh Vets was asked by the owner to neuter the dog and remove the large left inguinal swelling of the size of an egg and Vet 4 stitched up the urethral stoma (first urethrostomy done by Vet 1). Would this resolve the problem? Well, it did not appear to do so as the left inguinal swelling filled with blood-tinged fluid (I presumed it was urine leakage + blood) of around 30 ml per day for the next 4 days after Vet 4's surgery.
"Closing the urethral stoma so that the dog could pee normally from the tip of the penis is good for the dog," I said to Vet 4. "But there is the daily need to aspirate the 30 ml of blood-tinged fluid from the left inguinal area. It cost the owner around $7,000 to do the past 3 surgeries to remove the bladder stone and given time, your surgical approach may work. But time means money expenditure for the owner. "

As Vet 4 had to go overseas, I took over the case and reviewed the complicated urine leakage problem. This involved talking to Vet 3 as to what had been done. Vet 3 said that an ultrasound revealed fluid inside the scrotum and this was not recorded in the case report as the owner was not charged. Ultrasound can reveal fluid in an organ but will not be able to tell whether it i urine or blood or both.

This is where the perineal swelling in this image substantiates a possible urine leakage.  It is extremely expensive to do dye test to reveal the location of the perineal urethral leakage. The surgery at Vet 3 had cost $2,000 according to the owner.

So, what's the best economical solution now? What is in the best interest of the dog? If expenses keep mounting, the dog may be put to sleep by the owner. A solution must resolve the problem.

My approach was to extend the urethra stoma which had been closed by Vet 4, do scrotal ablation, close up the inguinal sheaths and stitch the urinary catheter to the prepuce to retain it in for around 4 days to let the perineal catheter to heal. This is the theory.

In practice, this worked as the dog is now peeing normally with no blood in the urine when it came back for stitch removal on Sep 28, 2012, around 14 days after my surgery.     

Thursday, September 27, 2012

1122. The vet transports the dog for an X-ray

"Surely it is not (befitting) your status to personally drive and transport the dog to get an X-ray done!" Dr Jason Teo's transport man met me at a Clinic where he had taken a cat for x-ray of the pyometra.

"My transport man had sold his van and the others were not available," I explained.
Steven pointed to an old Mercedes outside the clinic. Its engine old and smoke from the exhaust puffing out and said: "Surely, the petrol of the Mercedes would cost more than your transport cost. Why don't you just phone me?"

"I thought you just groom dogs for Jason," I did not tell him that the black Mercedes was not mine and I don't idle the engine when I park the car. It takes some time at this clinic to get the dog X-rays. In any case, I dislike polluting the environment by idling the engine unnecessarily.

"I do dog transport when I need the money," he laughed. He is an old guard in this pet business.

I find that much can be learnt just by transporting the dog for X-ray to any clinic. In one clinic, I was made most welcome by the vets. In another clinic, I would not be permitted to see any vet nor proceed past the waiting room as it has an awesome gate-keeper. So I learnt a lot by being on the ground.
   

Follow up: The 3rd sister loves and cares for the old dog

1121. Bladder stone dog goes home - 3 sisters




"Are you the sister who spoke to me by phone about the dog having kidney stones and whether an operation is necessary?" I asked the bigger of two adult ladies who came this afternoon to pick up the 12-year-old male cross-bred that looked so much like a miniature version of a Golden Retriever.



"No," she said.

"Are you the eldest of the 3 sisters?" I asked.

"No, I am the 2nd sister."

"Is the other shorter lady the youngest sister?" I asked.

"No, she is the eldest sister."

"So, the youngest sister is the most intelligent," I said. "To seek a second opinion."

"She is the one who loves the dog most," second sister said. I had talked to her by phone many times to update her of the dog but never saw her.



I put the dog on the exam table and palpated the bladder and prostate for pain. Not a whimper unlike 2 days ago.



"I need a tissue paper to wipe away the blood," 2nd sister said. The dog was so active and had pounced on her left knee and scratched 4 inches of red rash."



"This dog needs to be neutered as Vet 1 had done an ultrasound and said that the prostate was much enlarged."

"Why must he be neutered?" 2nd sister asked.

"The male hormones are produced by the testicles and they make the prostate grow bigger and it had become inflamed and infected. The enlarged prostate caused the urethra to be narrowed, making urination difficult for this dog. Bacteria from the bladder was present and could have infected the prostate. That was why it was painful 2 days ago and earlier. Vet 1 did give an anti-male-hormone injection called Tardak and advised weekly injections. Neutering would have been the alternative. Now, the dog's prostate is not inflamed or enlarged and so the dog pees normally for the last 2 days."



The dog did not pee in front of the sisters this afternoon but he had peed a few times freely in the morning.



"I have advised no bladder stone removal operation as the dog is very thin and will wait till he has difficulty in urination the next time," I said. "Although there is no crystals or struvite crystals present in his urine analysis, it does not mean he has no struvite stones. The pH is 6.0 for the past two urine analysis but bacteria is present in the urine. The bacteria in his bladder may have gone to the prostate, causing pain and inflammation of the prostate.



As the 2nd sister is an adult, she understood what a prostate is and so I need not explain further.



EXPLANATION

1. The male dog does not urine mark for the past two days. He just pees a few times in the morning when taken out for the walk. Why? This is because he was given an anti-male-hormone injection called Tardak by Vet 1 around 1 week ago and he is "feminised."



2. The urinary pH is 6.0. In struvite stone formation, the pH is usually alkaline and urease bacteria must be present. That is the norm. However, Vet 1 had recommended K/D diet and the dog was eating it. So, the urinary pH may have been affected. It is hard to say. It is too technical to explain to the sisters about alkaline urinary pH and struvite stone formation as there is information overload.



3. I advised S/D diet for the next 3 weeks as an alternative to surgery due to the high anaesthetic risks involved at present (prostate enlargement and infection, bladder infection with bacteria). This old dog much loved by this 3rd sister and it is better to build up the dog's weight and health if the bladder stone surgery is needed in the future. Neutering is advised next week as neuter is a very short 5-10-minute surgery compared to around one hour for bladder stone removal. Struvites are more common in dogs seen by me and if this S/D trial works and X-rays of the bladder are taken in a month's time, the stones would have dissolved or reduced in size, permitting urohydropropulsion. That will get rid of all the smaller stones.



4. Owners seldom comply with veterinary instructions and so much depends on educating the owner and the 3rd sister. Somebody who loves the old dog and usually it is a lady family member who cares very much for this old companion to get things done by the vet.

1121. Bladder stone dog goes home - 3 sisters

"Are you the sister who spoke to me by phone about the dog having kidney stones and whether an operation is necessary?" I asked the bigger of two adult ladies who came this afternoon to pick up the 12-year-old male cross-bred that looked so much like a miniature version of a Golden Retriever.

"No," she said.
"Are you the eldest of the 3 sisters?" I asked.
"No, I am the 2nd sister."
"Is the other shorter lady the youngest sister?" I asked.
"No, she is the eldest sister."
"So, the youngest sister is the most intelligent," I said. "To seek a second opinion."
"She is the one who loves the dog most," second sister said. I had talked to her by phone many times to update her of the dog but never saw her.

I put the dog on the exam table and palpated the bladder and prostate for pain. Not a whimper unlike 2 days ago.

"I need a tissue paper to wipe away the blood," 2nd sister said. The dog was so active and had pounced on her left knee and scratched 4 inches of red rash."

"This dog needs to be neutered as Vet 1 had done an ultrasound and said that the prostate was much enlarged."
"Why must he be neutered?" 2nd sister asked.
"The male hormones are produced by the testicles and they make the prostate grow bigger and it had become inflamed and infected. The enlarged prostate caused the urethra to be narrowed, making urination difficult for this dog. Bacteria from the bladder was present and could have infected the prostate. That was why it was painful 2 days ago and earlier. Vet 1 did give an anti-male-hormone injection called Tardak and advised weekly injections. Neutering would have been the alternative. Now, the dog's prostate is not inflamed or enlarged and so the dog pees normally for the last 2 days."

The dog did not pee in front of the sisters this afternoon but he had peed a few times freely in the morning.







1121. Fits in a 12-year-old Silkie Terrier - what is the cause?

A Silkie Terrier had fits at around 6 am yesterday and today Sep 27, 2012. First episode. What is the cause?

"There are many causes," I said to the owner who told me that the old dog had a dental scaling 1.5 months ago at Vet 1's place and the right submandibular lymph node would be due to bacterial infection from the bad teeth.

"The lump is nodular and quite large and painful," I said. "The dog reacted to the palpation and coughed a bit. One possible cause of this early morning fit could be the sharp pain in this lump," I said. "If only dogs can talk."

I advised an X-ray. "It is best not to operate now as the lump appeared to have spread inwards," I said. "This is an inoperable tumour, likely cancerous."
"Please forgive me for asking. How do you know it is cancerous?"
"I do not know for sure, unless it has grown aggressively since 1.5 months ago. If Vet 1 had recorded the size of the lump and it is now 2 or 4X bigger, then it is likely to be cancerous." He would try to get the report from Vet 1.

"If it is just an inflamed right submandibular lymph node, then medication will reduce it considerably," I said. "We have to review in 2 weeks time. Blood test did reveal liver disorder as the enzymes are increased. However, some vets will say that the liver enzymes must be considerablv higher than today to cause fits in your dog. I mean, you ask 10 vets and you get 10 different opinions."

 
 
 
 
 
I will be working with this owner to monitor the fits after taking medication, but no fits medication for the time being. X-rays are as follows:




.

Wednesday, September 26, 2012

A kind Buddhist teacher

TOA PAYOH VETS
toapayohvets.com   Blk 1002, Toa Payoh Lor 8, 01-1477, Singapore 319074   Tel: 6254-3326, 9668-6469, 9668-6468.  judy@toapayohvets.com  
22 May, 2015
  Focus: Small animals - dogs, cats, guinea pigs, hamsters, turtles & rabbits
 
Mammary adenomas in
an American Cocker Spaniel

Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
First written: 21 September, 2012
Upd
ate:  22 May, 2015
 "Why did you  delay seeking surgery till the breast lump is gigantic in size, like two tennis balls combined?" I asked the Buddhist temple teacher who taught Buddhism and morals to over 800 children of devotees.

"The breast lumps grow very fast in the last 2 weeks," she replied. "Nobody in the family wants to bring the dog for surgery. My brother said to let her die."
The solution was surgical removal but the family did not want to pay the medical costs. She was kind to enough to bring in this old dog for surgery at Toa Payoh Vets.
Breast adenomas grow rapidly to sizes of 4 large oranges in this American Cocker Spaniel.
After mastectomy, the dog was eating and normal
"Walk-in" sutures holding the skin edges tightly and the haematoma on the left MG5 was treated by opening up the area via removal of 2 stitches. Healing by granulation was uneventful. 
The 8-year-old dog was not spayed.  Mammary adenoma was diagnosed. No malignancy, according to the histology report. I was surprised as it was a massive tumour. Dr Daniel and I operated. I took over the stitching to ensure that the stitches were tight.

I tacked in "walk-in sutures" through the muscle layer and then the skin,  using 2/0 sutures to ensure that the large long wound would not break down..
The dog came back 4 days later. There was a swelling at one end of the tumour. "

"There's
seepage at the left Mammary Gland 5 area," I said to Dr Daniel who is in charge of the case. "Just cut off two stitches," I said to him. "In this way, the serum can drain out. No need to re-stitch."
After that, we had no more visit from the Buddhist teacher. I was glad that this dog was not abandoned when she had the tumours. Such incidents do occur in Singapore. It is best to spay the female dog when she is young as breast tumours are less likely to develop in spayed dogs.
BE KIND TO OLDER DOGS & CATS --- GET TUMOURS REMOVED EARLY --- WHEN THEY ARE SMALLER. 
More case studies, go to: 
Cats  or  Dogs

Make an appointment with your vet. Or tel 6254-3326, 9668-6469 for an appointment to discuss health screening for your senior companion. Or e-mail judy@toapayohvets.com your requirements. 

Copyright © Asiahomes Internet
All rights reserved. Revised: May 22, 2015
Toa Payoh Vets









1119. Two surgeries, 10-year-old Cocker Spaniel. Urinary Stone analysis by NUH

 



 



 



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A case of two surgeries for bladder stone removal in a 10-year-old Cocker Spaniel done by an associate vet is reviewed by Dr Sing today Sep 26, 2012

April 4, 2011 blood in the urine. Did not want more tests.
May 23, 2011 dysuria - blocked bladder
May 26, 2011 blood test, x-ray, UA, cystostomy. calcium oxalate
Sep 4, 2012 dysuria - blocked bladder. x-ray, cystostomy, stone analysis

LAB TESTS
May 24, 2011 UA pH 7.0, SG 1.028, Protein 2+ Blood 4+, WBC 10, RBC >2250, Bacteria 3+, Crystals calcium oxalate occasional
Aug 28, 2011 UA pH 7.0, SG 1.029, Protein 3+ Blood 4+, WBC >2250, RBC >2250, Bacteria 3+, Crystals Nil
May 24, 2011 Blood test. ALT 629 (<59 132="132" 23="23" ast="ast" n="90%</div" total="total" wcc="wcc">
Sep 4, 2012 Stone analysis by Dept of Lab Medicine, NUH
I spoke to the lab people about the approximate %

Calcium stone Trace (10%)
Phosphate stone Trace (5%)
Oxalate stone Trace (10%)
Urate stone Positive (40%)
Magnesium stone Trace (1%)
Cystine stone negative
Ammonia stone Positive (10%)
Bicarbonate stone negative
The stone is crushed and analysed using the colorimetric method. Trace = light color. Positive = intense colour. A semi-quantitative method.
I asked my associate vet whether there were any recommendations about diet and was told Urate Diet was recommended.
U/D
FOR UROLITHIASIS, non-struvite urinary tract health
Indications: calcium oxalate, urate and cystine urolithiasis; end stage kidney disease.

This is a low protein food exhibit unusual lab vales such as USG<1 .020=".020" and="and" are="are" br="br" bun="bun" compliance.="compliance." dl.="dl." effectiveness="effectiveness" food="food" methods="methods" mg="mg" monitor="monitor" monitoring="monitoring" owner="owner" ph="ph" s="s" serum="serum" the="the" to="to" uirinary="uirinary" usg="usg">
Target urinary pH
7.1 to 7.11 increases solubility of non-struvite crystals.

Every 6 months, do a fasting serum chemistry profile and echocardiogram for underlying metaboic abnormalities
OWNER COMPLIANCE
Two cystotomies were done. Owner does not comply with instructions on using prescription calculytic diets and this is their own wish.



Tuesday, September 25, 2012

1118. Bladder stones in a 13-year-old dog



 "Is an operation needed to remove the bladder stones?" the lady asked me over the phone. "Much depends on the size and composition of the stones," I said. "If they were small struvite stones, they may be dissolved by eating a special diet."

The dog was a Golden Retriver X, medium sized, 13 years old and lethargic. A high anaesthetic risk. So I did not advise surgery. Catherised urethra 2 days. Today, could pee normally but vomited canned food.

The dog could pee normally and had a good appetite today. So I did not operate as he is very old and thin. Will S/D diet help? But his urinary pH is 6.0 and not alkaline. The urine crystals are nil and so the only way to know what composition of the urinary stones in his bladder would be to do surgery. But the dog may die on the operating table since he is 13 years old. So, this is the difficulty. The dog was given K/D diet by Vet 1 before I was handling the case. Could K/D bring down the urinary pH to below 7.0?

A trial of S/D may not be effective since the composition of the urinary stone is not known. It may be calcium oxalate but it may also be struvite. S/D diet dissolves struvite stones. The dog had antibiotics and a can of S/D diet with informed consent from the owner. For the past 2 days, he was urinating normally and had excellent appetite. I dare not do any cystotomy surgery as the risks outweigh the benefits. An S/D trial is one alternative and it may be worth a trial. It is not evidence-based, I informed the young lady owner. She understood.   

1117. Acute respiratory distress in a pug


 
 
 
The pug keeps panting non-stop. X-rays show gastric distension. What's the cause? Is there a gastric torsion? Panting slowed when lasix is given.
 
As I gave a high anaesthetic risk assessment if surgery is to be done, the owners lost confidence in me and decided to seek another vet. This is a common occurrence to all vets.

1116. Another edited version of struvite bladder stones to the editor


What are bladder stones?

Bladder stones or uroliths are common in domesticated animals. There are many types of bladder stones depending on their composition.


Struvite bladder stones

Struvite bladder stones are most commonly seen in canine cases at Toa Payoh Vets and this article is to educate dog owners regarding their diagnosis and treatment. They can be formed anywhere along the urinary tract in the kidneys, the urethra and the bladder when the urine is supersaturated with magnesium, ammonium and phosphate (MAP). MAP supersaturation may be associated with several factors, including urinary tract infections, alkaline urine, genetic predisposition and diet. Breeds usually affected by struvite bladder stones include the Miniature Schnauzer, Shih Tzu, Bichon Frise, Miniature Poodle, Cocker Spaniel and Lhasa Apso, but any breed can be affected. Female dogs are said to form approximately 85% of bladder stone cases.

Symptoms of bladder stones

Some dogs may not show clinical signs such as blood in the urine, difficulty in urination, or inability to urinate, until much later in the disease with severity of signs depending on the location, size, and number of uroliths formed. Your vet will take a comprehensive history to determine the start and severity of the disease. Physical examination includes bladder palpation to feel the crepitus (sounds of gas and stones rubbing against each other) inside the bladder or the solid stones if they are large.

Diagnosis

Urine analysis is the most useful and a sterile sample is taken by catheterisation or cystocentesis (straight from the bladder). The pH of your dog’s urine will also give a good idea of the nature of the stone. The urine sample will show the presence of bacteria, which is usually cultured to find out the type of bacteria causing the urinary tract infection. Antibiotic sensitivity tests are needed to figure out what appropriate antibiotics can be prescribed.

Uroliths need to be of a certain size before they are evident. The number and size of urinary stones seen in the x-ray may not correlate with the severity of clinical signs. A radiograph is highly recommended to find out the number and size of stones and where they are located prior to surgical removal, if surgery is required. In spite of all the tests above, the composition of the actual stone cannot be determined unless a stone sample (from the surgery or that has been urinated out) is sent for analysis.

Treatment

There are two types of treatment for struvite bladder stones; surgery or medical dissolution of the stones. The benefits of surgery include a shorter recovery period and the ability to identify the actual type of stone involved. Surgery is needed if the stones are too large as they may not dissolve by medical dissolution. Disadvantages of surgery are that it is more invasive and there are risks of death during or post operation, associated with general anaesthesia in a sick and/or older dog.

Medical dissolution takes a much longer time (about three months on average) to take effect and large stones may not dissolve at all. It revolves around three main concepts – to acidify urine, reduce the intake of MAP such that it does not saturate in the urine and dilute urine so struvite crystals do not have a chance to form. Affected dogs are usually prescribed calculytic diets and appropriate antibiotics to treat the bacterial infections. No other food or treats should be given and plenty of water drinking should be encouraged.

Most importantly, your dog’s health should be reviewed every three months with urine tests and X-rays to ensure that no new stones or crystals are formed. Be alert as to the urination pattern of your older dog and seek veterinary advice promptly if there are signs of blood in the urine, urinary difficulty or inability to pee.
 
Dr Sing Kong Yuen

BVMS (Glasgow), MRCVS

Toa Payoh Vets

 

Sep 25, 2012. Edited version for the editor

My opinion. A technical report. Quite a boring article without pictures for the layman but has most of the important facts.   

Saturday, September 22, 2012

Urgent Question About Duration of Surgery For Roborovskii Dwarf Hamster
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Sep 20 (3 days ago)

to judy
Hello,

I’m in the U.S. and I have an 18 month old male Roborovskii hamster who has two medium size abdominal “fatty tumors”. The hamster is still active and eating normally and in otherwise apparently good health, but I would like to have the tumors removed and start him on an anti-tumor/anti-aging diet.  Thus I would like to do this before the tumors become any bigger.

I love this little hamster very much.

Anyway, from the information you’ve kindly made available on your web site, and from talking to other people, I am under the impression that surgery on dwarf hamsters and Roborovskii dwarf hamsters in particular, is a very delicate operation, and the time duration must be limited, otherwise the risk of death during surgery – especially from the anesthesia exposure - becomes unacceptably high.

I know your office has had many years of experience doing all kinds of surgery on dwarf hamsters (I think Dr. Sing mentioned he’s done this for 40 years or so).

Generally speaking, based on your considerable experience, can you please give me some general idea as to the maximum length of time surgery that would be considered “safe” to a “reasonable” person under the circumstances? Thank you very much.

Regards,
Nelson

 EMAIL REPLY FROM DR SING DATED SEP 23, 2012





Thank you for your email. The general principle for all animals in good health is that the shorter the anaesthesia, the higher the chances of survival. Therefore, some surgeries in high risk cases (like old age, poor health and very small creatures like hamsters) have a good chance of survival if anaesthesia is short. In hamsters, the period of time is preferably less than 5 minutes but this is just a guideline. Much also depends on the skills and experience of the vet and therefore, there are many factors to take into account.

It is best you find a vet experienced in hamster anaesthesia and surgery.

Friday, September 21, 2012

1114. The baby-boomer generation and urinary stones

Today, Saturday Sep 22, 2012, I was at the Surgery at 7.30 am as Min has to go to get his permit personally from Tanjong Pagar as instructed in the government's letter. I told him to take a taxi and come back after lunch as Dr Daniel and Dr Jason and Ms Chong will be on duty. They don't come so early. 

At 8.34 am, a young lady phoned me to make an appointment at 3.30 pm to 4 pm.
"What's happened to your dog?" I asked.
"He has bladder stones."
"How do you know?" I was then told that she had been to a vet who took the X-rays and there was one stone initially. But now there are three.
"Should the stones be removed?" she asked.
"That depends on what type and size of the stones," I replied. "Did the vet tell you?"
"No," she had no clue and so I asked her to get the vet reports and X-rays from the vet to save on costs.
"Why didn't you get the vet to remove the stone when there was only one?"
"My dog is 12 years old," she said. "My father does not believe in surgery."
"Why?" I asked.
"Once, a vet told him that surgery was needed for the dog's arthritis. He got glucosamine from another vet and the dog is OK. Therefore no surgery is ever needed."
"Arthritis cannot be compared to bladder stones," I said. "Dogs usually don't die from arthritis, but in bladder stones, the bladder may get infected and the bacteria and toxins may travel via the blood stream and to the kidneys. The dog may become septic. Kidneys may fail and the blood is full of waste products, since the kidneys cannot filter them away. This leads to  nausea and vomiting.

"I mean you can't compare oranges to apples. You compare bladder stones to bladder stones in deciding on surgery or not. Is your dog vomiting?"

"Once in a while," she said.
"Unfortunately, the older baby boomer generation is not in favour of surgery. This leads to delays and worsening of the dog's health. By then,  Is there a financial reason?" I asked.
 

1113. Follow up- Massive perineal hernia in a Silkie

Around July 2011, the Silkie's perineal hernias were repaired. See: 
http://www.sinpets.com/F5/20110714perineal_hernia_old_Silkie_Terrier_male_dysuria_painful_backside_singapore_ToaPayohVets.htm

UPDATE TODAY SEP 21, 2012. I phoned the owner today. Around over 2 months ago, the dog suddenly refuse to eat or drink and was shivering. There was a slight swelling of the perineal hernia earlier but now the swelling had increased. As it was an emergency, the owner rushed him to another vet who operated. The bladder had prolapsed into the hernia and that was why the dog could not pee.

Now the dog is OK. There is a "hole" in the hernia as there was insufficient muscle to close up the hernia, the lady owner said.

He is well loved by the family members. He was neutered after the first perineal hernia repair and had become more fierce.

There was no delay in treatment otherwise the dog would have died.

  

Thursday, September 20, 2012

1112. Black anal area in a 10-year-old male neutered Dachshund

The owner wanted to consult me specifically. Together with my associate vet we saw the case together. The lower tail had some loss of hair due to licking and the anal skin area was very black.
My associate thinks there is nothing wrong. Some light brown anal sac oil was expressed.
"Palpate the area with your fingers and you will find that the lower half of the anal skin is hard," I said.

I believe this dog has the beginning of circum-anal tumour and asked the owner to observe closely for further enlargement in the next 2 weeks. I took a ride from her to the Potong Pasir subway.

"Are all tumours cancerous?" she asked.
"No," I said. "However they bleed when they are bigger as the dog licks them or they get traumatised, soiling the floor. So it is best to ask your vet to remove them early when they are small."

On the same day, another owner brought in a 4-month-old Boxer with a red swelling on the upper part of the anus. "It could be insect sting or trauma," Dr Daniel said and gave some medication. "I will advise an e-collar," I said to the owner. "If the swelling is still around after one week, I need to inject anti-inflam into it to shrink it."

It is best to give good advices to the owner and do palpation to feel the tumour or lump. The Boxer's will be an inflammation as it appears suddenly.The Dachshund's black anal area is due to licking and has existed just for the past 2 weeks. It is not a good sign and owner must be advised to monitor very closely. Very itchy turning to blackness pigmentation.   

1111. Prolonged bleeding in a 10-year-old female Rottweiler

Today, Thursday Sep 20, 2012, I attended to this gentle female, Rottweiler dripping with reddish brown vaginal discharge for at least 3 weeks. Usually 2 weeks. Not eating much. No fever. It was a referral and also a convenience of

"How's the urine colour?" I asked the arowana breeding farmer and his wife
"Dark yellow," he said.

"Most likely infection in the womb and the ovaries are abnormal," I said. I took blood test and schedule spay on Sunday morning after 2 days of antibiotics.

"Do you have a website for your arowana breeding?" I asked as this man is passionate about arowanas which are now not much in demand.
"Myanmar is growing explosively. China has many rich people and how can they contact you if you don't have a website?"

"I depend on referrals," he and his wife told me they have a "green arowana" specific to Myanmar. I have not seen green ones. Many breeders in Australia and US have websites announcing their high quality breeds but this farmer seems not to be interested. He sells in lots of 10 or 30/batch which he lovingly "grooms" them to a certain length. He does not like selling to those who have no experience in further rearing them as they die early.

1110. DR SING'S AUDIT CASE. Not eating - Urinary stones in another Miniature Schnauzer

AUDIT ANOTHER CASE OF URINARY STONES

Jul 29, 2012
Miniature Schnauzer, White, Female, 5 years
High fever (40C) and no appetite

Associate Vet (Vet X) palpated >10 stones in bladder

Blood test, urine test, stone analysis

Jul 30, 2012
Cystotomy

Jul 30, 2012
Blood test
Total WCC 21.6  (6-17)
N 96%  Absolute 21
L 4%     Absolute 0.82
M 0.4%
E  0.1%
B  0%

Platelets  98 (200-500)
Platelet clumping

Aug 1, 2012 
Urine test
pH 9.0   SG 1.005   Nitrite +, Protein 3+, Blood 4+, Bacteria 2+WBC 180  RBC >2250
Crystals Nil
Casts  Granular cast occasional

Aug 2, 2012 stone analysis
Calcium stone trace
Phosphate stone +
Oxalate stone trace
Magnesium stone +
Ammonia stone +

This case confirms what is known. No crystals inside the urine does not mean no struvite stones.
Alkaline pH + bacteria (urease) + bacteria  leads to formation of MAP (struvite stones).


Sep 20, 2012. Review by me. I asked Vet X to put in writing that therapeutic diet S/D has been advised at least from 1- 3months. If there is recurrence, Vet X cannot be blamed. Advice on monthly
urine analysis. Preferably X-rays 3 monthly.

The children came to buy 2 cans of S/D recently. There need to be more rigorous follow up by Vet X and documentation of advices on medical records in case of recurrence as surgical costs can be very high and owners can be very unhappy when there is a recurrence. Sometimes, they just euthanase the dog to save on costs of surgery.



 

Wednesday, September 19, 2012

1109. Follow up: Very thin vomiting Schnauzer

This Schnauzer was vomiting without us finding out the cause. Ultrasound, barium meal tests showed nothing. Yet at 7.35 pm today, he passed out 3 "pebbles" after giving enema (constipation). To me it looked like durian seeds. Will check again.

In this case, I had advised exploratory laparotomy but the owner was not in favour of this. In this surgery, I opened up and would have seen the seeds.

1108. AUDIT. Open pyometra blood test results before and after spay

Today I got a text message: "Hi Dr Sing, will I be able to obtain a sterilsation cert for my dog? I need it for renewal of dog licence."

I checked the medical records of the 8-year-old Jack Russell. Yes, she had open pyometra and was spayed in Nov 8, 2010 by my associate vet. She was 6 years old then and was presented on Nov 6, 2010. Complaint was "vomiting". Diagnosis was "Suspect pyometra."  Blood test and IV drips.

I sms her to come to collect the certificate: "Come to clinic to get the cert which is inside case file TP Ref XXXX. Refer to this Reference".
She sms me: "Thanks Dr Sing". We never spoke. Such is the situation with the younger generation!
They prefer the thumb to the tongue.

INTERESTING BLOOD TEST RESULTS FOR THIS DOG FOR VET STUDENTS


Admitted on Nov 6, 2010. Jack Russell, F, Born 2004. Wt 7 kg. Temp = 35.2C (38.5-39.5)
Nov 6, 2010 BEFORE PYOMETRA SURGERY ON NOV 7, 2010


Total WCC  53.8 (6-17)
Red cell count  4.9  (5.5-8.5)
Hb  10.9  (12-18)

N 79% Absolute 43
L 12% Absolute 6.5
M 11% Absolute 6
E  0
B  0
Atypical lympho  2%  Absolute 1.08

Platelets 7  (200-500)
Large platelets present

COMPARE WITH SITUATION OF DOG BEING BACK TO NORMAL
Dec 11, 2010, FIVE WEEKS AFTER PYOMETRA SURGERY ON NOV 7, 2010

Dog came for vaccination and blood test taken.


Present Dec 11, 2010. Jack Russell, F, Born 2004. Wt 7.4 kg. Temp = 38.8C (38.5-39.5)
Total WCC 12.4 (6-17)
Red cell count    6.1  (5.5.8.5)
Hb 13.7  (12-18)
N 78% Absolute 9.7
L 18% Absolute 2.2
M 3.3% Absolute 0.41
E 0
B 0
Atypical lympho 0%

Platelets 230 (200-500)
NO large platelets present

CONCLUSION
The dog has fully recovered as the owner did not turn up till she sms today for the sterilisation certificate which is important for lower licensing fee. It is surprisingly that the dog did not die by bleeding to death during surgery as her platelet count was 7 when the normal should be 200-500! She was anaemic too. Her rectal temp on day of surgery (Nov 7, 2012 was 36.5 C).
 It is incredible that she survived..

Blood tests are important to screen the dog's health prior to surgery. An IV drip with antibiotics is essential 24 hrs prior to surgery. NaCl + cipro, Hartman's Solutions, amino acid drips were given by my associate vet.

Rimadyrl

Anaesthesia was diazepam 0.3 ml, ketamine 0.3 ml for 7 kg BW with isoflurane maintenance.






Tuesday, September 18, 2012

1107. Follow up on shih tzu with complicated blocked

Sep 19, 2012. Today Wednesday, I examined the shih tzu's urethral opening. There was some granulation tissue trying to close it. It is only Day 7 since I did the operation (scrotal ablation and urethostomy extension) last Wednesday when Dr Daniel went to Langkawi. It took 2 hours although it seemed to be easy if you read the vet text book.


The dog pees from there. The owner is quite happy with the outcome. Financial costs had been very high to him due to recurrence. I advise S/D strictly for 1 month and then C/D. Monthly urine tests for 3 clear tests.

I also showed him another similar case where the owner of the Miniature Schnauzer had two surgeries on blocked bladder. After the first surgery, she did not accept our advice to go on therapeutuic diet but did so on the 2nd recurrence.

The dog went home today with instructions on how to clean the urethrostomy wound using clean boiled water twice a day. Urine comes out from this wound and stitch removal will be done in 7 days' time.

1106. DR SING'S AUDIT CASE - Dog with urinary stones twice

I hope this real case of calcium oxalate and struvite urinary stones in one day may make revision much easier for vet undergraduates struggling to remember the treatment for calcium oxalate and stgruvite stones!

TRUST AND AUDIT OF URETHRAL OBSTRUCTION IN A MALE MINIATURE SCHNAUZER
Sep 19, 2012

I checked the case records today and reviewed one case of an 8-year-old salt & pepper Miniature Schnauzer, not neutered, born in Feb 22, 2003. Today, I phoned the owner's mum who said that the dog is normal. As to what diet, she does not know as her children has the dog.

Sep 15, 2011. I was presented with this dog. Dysuria 7 days, incontinence (nuisance of dribbling urine), anorexic (not eating), not drinking last 2 days. Dry food usually fed.
Abdominal palpation - painful distended bladder.
Urethral obstruction. I got the following done: urine test, blood test and X-ray of bladder.

Sep 16, 2011
The case was operated by Dr Vanessa. 15 urinary stones removed from bladder. Stones sent to NUH lab for analysis.


LAB RESULTS - Significant findings

Sep 15, 2011 
1.  Blood test  - Total WCC 13.6 (normal). Neutrophils 92.7% (high) Absolute 12.6
                                                                 Lymphocytes 6.5%          Absolute 0.88

2.  Urine test -  pH 7.0  SG 1.030, Protien +, Blood 3+, Bacteria +, WCC 504. RBC 1440
                         crystals NIL

Oct 25, 2011
1.  Stone analysis by Minnesota Urolith Center
Analysis is done on nidus, stone, shell, surface and approximate % is as follows:
Stone = 100% calcium oxalate monohydrate
Shell =  5% calcium oxalate monohydrate, 95% calcium oxalate dihydrate

Due to financial situation, the owner did not want the prescription diet.

FOUR SCENARIOS
Recommendation for canine calcium oxalate prevention by Minnesota Urolith Center is:
1. Urine analysis (UA) and medical imaging.
1.1  If urine pH >6.5, USG <1 ---="---" .020=".020" crystals="crystals" no="no"> UA monthly and adjust therapy till goals are achieved. Then UA every 3-6 months.

1.2  Crystalluria Calcium oxalate
Verify persistgent crystalluria from urine sample
If USG >1.020, give canned diet or add water to food
If pH < 6.5, promote less acidic urine. Use U/D or urinary alkalinizers eg. postassium citrate.
1.3   Crystalluria Struvite
If no urease bacterial infection, no clinical problem for the dog. That means, no UTI, no problem.

1.4  Uroliths
Advise voiding urohydropropulsion if uroliths are small.
Some stones left alone in patients not showing clinical signs (haematuria, dysuria).
With persistent clinical signs, remove uroliths with appropriate methods
Submit urolith for quantitative analysis to verify composition.

Vets to review manufacturers' literature on therapeutic diets and consider other factors when pets with multiple health problems

-------------------------------



RECURRENCE
In Feb 3, 2012,  dog was aggressive when handled. Presented to Dr Vanessa for "straining to urinate". 4.5 months ago, owner declined therapeutic diet  owing to cost issues and fed only "porreidge and pork". 

X-rays revealed multiple stones inside bladder and in urethra near the bladder. Owner took possession of the X-rays
Feb 5, 2012
Emergency cystostomy. 15 stones removed.


Feb 6, 2012
Urine Analysis - pH 9.0 SG 1.025, Blood 4+, RBC 2250, WBC 0, Bacteria +, Crystals Triple phospate +, Amorphous phosphate 3+.  Struvites are present in the urine in this UA.

*Mar 15, 2012
Urine Analysis - pH 6.5 SG 1.012, Blood +, RBC 5, WBC 13, Bacteria NIL. Crystals NIL


Feb 7, 2012
STONE ANALYSIS BY NUH, Dept of lab medicine, Singapore
Calcium, stone +
Phosphate,  stone +
Oxalate, stone trace 
Magnesium stone +
Ammonia stone +
From the analysis, MAP = struvite. S/D advised until 3 urine tests are clear.

Dates of purchase of S/D by owner
Feb 28, 2012  6 cans
Mar 2, 2012  7 cans
Mar 8, 2012  6 cans
Mar 15, 2012  urine analysis*
Mar 15, 2012  6 cans
Mar 20, 2012  6 cans
Mar 27, 2012  6 cans
Apr 1, 2012  6 cans
No more news from the owner till today Sep 19, 2012 when I phoned the mother who said that the dog is OK. Urine analysis every 3 months or monthly is not done by most Singaporean owners till there are urinary problems.

However, there seems to be no problems with this dog as at Sep 2012 and now news as to what type of feeding is being given. The owner does go to other vets and so there is no definite ending to this story.







   



Monday, September 17, 2012

1105. A huge bloated abdomen - closed pyometra

1104. I don't want my old dog to be chopped up - urinary stones by ultrasound

Yesterday, an old realtor acquaintance phoned me at home. His 10-year-old Golden Retriever was ultrasound scanned by the "most expensive" veterinary practice in Singapore. The vet said his dog has cysts in the prostate and bladder stones and advised surgery to remove the stones.
"My dog is so old," he said over the phone. "I don't want him to be chopped up."
"Was a urine test done?"
"No," he said.
"How many stones were there?"
"I don't know," the realtor said to me in a worried voice. 
"Were the stones big or small?" 
"I don't know."

In many Singapore families, the dog is family and so the best vet in Singapore should be the best for the pet. The brand-name veterinary surgery.

Unfortunately, the pockets need to be very deep. "Frankly, I can't afford the surgical fees in this practice," the realtor said. "That is why I seek a second opinion from you." He has not consulted me for many years and this is common amongst Singaporean dog owners who tend to doctor-hop and to look for the glitz and presentation of new clinics or proximity. It is good that they have an estimated 50 choices of veterinary practices in Singapore. Brand-name  and beautiful veterinary practices certainly attract Singaporeans.
"There are some types of bladder stones that can be dissolved by special diet," I said. "If you have time, bring the dog to me for urine collection and testing at 9.30 am tomorrow (Sep 18, 2012)."

"My dog pees all at around 8 am when I take him out," he laughed.
"You can try to collect a clean sample of urine from him. Wait for a few seconds and collect the middle stream into a urine collection bottle which you can get from the polyclinic."

Urine analysis is important in the diagnosis and treatment of urinary bladder stones.
See my article to educate dog owners at:
http://www.kongyuensing.com/folder8/20120724struvite_stones_dogs_toapayohvets.htm





  

1103. Red slider moans


A professor who loves his 8-year-old Red-Eared Slider which came back from Seattle where he did his PhD. He took the time to send the slider for treatment as earlier, some medication he got from me to treat it at home did not work. Usually we don't advise getting medicine to treat at home, without examination. For this slider, it was lethargic. But you can't take rectal temperature and palpate and do several examination procedures as you can do for a dog or cat! So the vet must use common sense and general principles of diagnosis and treatment!

SMS TEXT BETWEEN VET AND CLIENT SAVES TIME
Sep 3, 2012
Hi Dr Sing, I've left my Red Ear Slider at your clinic. As mentioned, he is active for 15 min a day and become mostly lethargic throughout for past 4 to 5 days. He made a few moaning sounds yesterday. Many thanks for your help, Kevin Koh.


Sep 3, 2012 SMS From Dr Sing
Need to treat n observe

Reply: Okay. Thanks a lot, Dr Sing. 

Sep 5
Hi Dr Sing, is there any improvement o my red eared slider?  Many thanks for advice. Kelvin.

Slider was hospitalised. Dr Daniel gave 2 injections IM of baytril in the back muscles for 2 days. I became more active than on arrival. Cleaned. Sent home.

Sep 7
Hi Dr Sing, the slider ate some shrimps yesterday and poop this morning. Still not very active and eyes open and closed at times. Will continue to monitor. thanks. Kelvin

Sep 7 from Dr Sing
Good news. Give fibreplex

Sep 14 from Dr Sing
Is slider eating normally now?

Sep 14 from Kelvin
Hi Dr Sing, thanks for asking. Slider is more active and eating now. Kelvin.

Sep 14 from Dr Sing
What he eats daily?
Sep 14 from Dr Sing

Pork and shrimp and a little pellet. Kelvin.

Sep 14 from Dr SingInside a plate or in water?
Sep 14 from KevinIn water. Kelvin.

1102. Struvite bladder stones in Singapore dogs (edited version)

STRUVITE BLADDER STONES IN SINGAPORE DOGS

What are bladder stones?
Bladder stones or uroliths are common in domesticated animals. There are many types of bladder stones depending on their composition.

Struvite bladder stones
Struvite bladder stones are most commonly seen in canine cases at Toa Payoh Vets and this article is to educate dog owners regarding their diagnosis and treatment. They can be formed anywhere along the urinary tract in the kidneys, the urethra and the bladder when the urine is supersaturated with magnesium, ammonium and phosphate (MAP). MAP supersaturation may be associated with several factors, including urinary tract infections, alkaline urine, genetic predisposition and diet. Breeds usually affected by struvite bladder stones include the Miniature Schnauzer, Shih Tzu, Bichon Frise, Miniature Poodle, Cocker Spaniel and Lhasa Apso, but any breed can be affected. Female dogs are said to form approximately 85% of bladder stone cases.

Symptoms of bladder stones
Some dogs may not show clinical signs such as blood in the urine, difficulty in urination, or inability to urinate, until much later in the disease with severity of signs depending on the location, size, and number of uroliths formed. Your vet will take a comprehensive history to determine the start and severity of the disease. Physical examination includes bladder palpation to feel the crepitus (sounds of gas and stones rubbing against each other) inside the bladder or the solid stones if they are large.

Diagnosis
Urine analysis is the most useful and a sterile sample is taken by catheterisation or cystocentesis (straight from the bladder). The pH of your dog’s urine will also give a good idea of the nature of the stone. The urine sample will show the presence of bacteria, which is usually cultured to find out the type of bacteria causing the urinary tract infection. Antibiotic sensitivity tests are needed to figure out what appropriate antibiotics can be prescribed.
Uroliths need to be of a certain size before they are evident. The number and size of urinary stones seen in the x-ray may not correlate with the severity of clinical signs. A radiograph is highly recommended to find out the number and size of stones and where they are located prior to surgical removal, if surgery is required. In spite of all the tests above, the composition of the actual stone cannot be determined unless a stone sample (from the surgery or that has been urinated out) is sent for analysis.

Treatment
There are two types of treatment for struvite bladder stones; surgery or medical dissolution of the stones. The benefits of surgery include a shorter recovery period and the ability to identify the actual type of stone involved. Surgery is needed if the stones are too large as they may not dissolve medically. Disadvantages of surgery are that it is more invasive and there are risks associated with general anesthesia in a sick and/or older dog.

Medical dissolution takes a much longer time (about three months on average) to take effect and large stones may not dissolve at all. It revolves around three main concepts – to acidify urine, reduce the intake of MAP such that it does not saturate in the urine and dilute urine so crystals do not have a chance to form. Affected dogs are usually prescribed calculytic diets and appropriate antibiotics to treat the bacterial infections. No other food or treats should be given and plenty of water drinking should be encouraged.

Most importantly, your dog’s health should be reviewed every three months with urine tests and X-rays to ensure that no new stones are. Be alert as to the urination pattern of your older dog and seek veterinary advice promptly if there are signs of blood in the urine, urinary difficulty or inability to pee.
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Toa Payoh Vets

Acknowledgement - Thanks to Dr Daniel Sing ZongZheng for help in writing the edited article as in this blog.

The detailed article is at:
http://www.kongyuensing.com/folder8/20120724struvite_stones_dogs_toapayohvets.htm

1101. Update: Edited article on struvite bladder stones for magazine

Update: SEP 18, 2012. Magazine article for Pets Magazine -‘Pets Health and Veterinary Special 2012’ in October 2012. This Special will be positioned as an educational and informative publication to benefit the health and welfare of pets through the education of pet owners.




The edited article from the editor had assumed that the article was about bladder stones in general but it is specifically about only one type of bladder stones - struvite bladder stones and I have amended accordingly.

STRUVITE BLADDER STONES IN SINGAPORE DOGS



What are bladder stones?



Bladder stones or uroliths are common in domesticated animals. There are many types of bladder stones depending on their composition.



Struvite bladder stones



Struvite bladder stones are most commonly seen in canine cases at Toa Payoh Vets and this article is to educate dog owners regarding their diagnosis and treatment. They can be formed anywhere along the urinary tract in the kidneys, the urethra and the bladder when the urine is supersaturated with magnesium, ammonium and phosphate (MAP). MAP supersaturation may be associated with several factors, including urinary tract infections, alkaline urine, genetic predisposition and diet. Breeds usually affected by struvite bladder stones include the Miniature Schnauzer, Shih Tzu, Bichon Frise, Miniature Poodle, Cocker Spaniel and Lhasa Apso, but any breed can be affected. Female dogs are said to form approximately 85% of bladder stone cases.



Symptoms of bladder stones



Some dogs may not show clinical signs such as blood in the urine, difficulty in urination, or inability to urinate, until much later in the disease with severity of signs depending on the location, size, and number of uroliths formed. Your vet will take a comprehensive history to determine the start and severity of the disease. Physical examination includes bladder palpation to feel the crepitus (sounds of gas and stones rubbing against each other) inside the bladder or the solid stones if they are large.



Diagnosis



Urine analysis is the most useful and a sterile sample is taken by catheterisation or cystocentesis (straight from the bladder). The pH of your dog’s urine will also give a good idea of the nature of the stone. The urine sample will show the presence of bacteria, which is usually cultured to find out the type of bacteria causing the urinary tract infection. Antibiotic sensitivity tests are needed to figure out what appropriate antibiotics can be prescribed.



Uroliths need to be of a certain size before they are evident. The number and size of urinary stones seen in the x-ray may not correlate with the severity of clinical signs. A radiograph is highly recommended to find out the number and size of stones and where they are located prior to surgical removal, if surgery is required. In spite of all the tests above, the composition of the actual stone cannot be determined unless a stone sample (from the surgery or that has been urinated out) is sent for analysis.



Treatment



There are two types of treatment for struvite bladder stones; surgery or medical dissolution of the stones. The benefits of surgery include a shorter recovery period and the ability to identify the actual type of stone involved. Surgery is needed if the stones are too large as they may not dissolve medically. Disadvantages of surgery are that it is more invasive and there are risks associated with general anesthesia in a sick and/or older dog.



Medical dissolution takes a much longer time (about three months on average) to take effect and large stones may not dissolve at all. It revolves around three main concepts – to acidify urine, reduce the intake of MAP such that it does not saturate in the urine and dilute urine so crystals do not have a chance to form. Affected dogs are usually prescribed calculytic diets and appropriate antibiotics to treat the bacterial infections. No other food or treats should be given and plenty of water drinking should be encouraged.



Most importantly, your dog’s health should be reviewed every three months with urine tests and X-rays to ensure that no new stones are. Be alert as to the urination pattern of your older dog and seek veterinary advice promptly if there are signs of blood in the urine, urinary difficulty or inability to pee.





Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS

Toa Payoh Vets


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COMPARE TO MY ORIGINAL REPORT

Wednesday, August 1, 2012


1818. Struvite bladder stones in Singapore dogs

Magazine article for Pets Magazine -‘Pets Health and Veterinary Special 2012’ in October 2012. This Special will be positioned as an educational and informative publication to benefit the health and welfare of pets through the education of pet owners.



Struvite Bladder Stones in Singapore dogs

Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS

Toa Payoh Vets

July 31, 2012











Difficulty in peeing, not able to pee and peeing urine with blood are the most common reasons for dog owners to seek veterinary advices at Toa Payoh Vets. Sometimes, the owner sees stones passed out in the urine.

Urolithiasis in dogs is such a large topic of a few hundred pages as there are several types of bladder stones affecting the dog and their diagnosis and treatment vary. Therefore, only struvite urinary stones, being most commonly seen at Toa Payoh Vets will be discussed in this article.



Breeds usually affected include the Miniature Schnauzer, Shih Tzu, Bichon Frise, Miniature Poodle, Cocker Spaniel and Lhasa Apso, but any breed can be affected. Female dogs are said to form approximately 85% of bladder stone cases.



Some dogs may not show clinical signs of blood in the urine, difficulty in urination or inability to urinate until much later in the disease with severity of signs depending on the location, size,and number of uroliths formed. These stones can be formed anywhere along the urinary tract in the kidneys, the urethra and the bladder.



Struvite stones are composed primarily of Magnesium, Ammonium and Phosphate (MAP). They are formed within the urinary tract and occur when the urine is supersaturated with MAP (i.e. large quantities of the crystals are present). MAP supersaturation of urine may be associated with several factors, including urinary tract infections, alkaline urine, genetic predisposition and diet.



Your vet will take a comprehensive history to determine the commencement and the severity of the disease. Physical examination include bladder palpation to feel the crepitus (sounds of gas and stones rubbing against each other) inside the bladder or the solid stones if they are large.



However, a complete blockage of the urinary tract is life-threatening as the dog can't pee and the full bladder may rupture with delays in treatment. In such cases, a urinary catheter will be used to unblock the obstruction or the urine is extracted via the bladder as soon as possible. This is done to protect the bladder and kidney from further damage.

Blood screening, urine analysis and radiographs are usually performed to confirm the presence of urinary stones. Abnormal blood work may show if the obstruction of the urinary tract is severe. Blood tests may show changes to the kidney function or an increase in white blood cell counts affecting the health of the dog.







X-ray of a male dog that cannot pee. If the dog cannot pee, the likely cause is urethral obstruction caused by urinary stones being stuck inside the urethra.

Struvite uroliths are radio-dense and can be detected on radiographs.





X-ray of a catheter to push back the stones into the bladder in a female dog that could not pee at all as the stone was stuck inside the urethra

Calcium oxalate is another type of urinary stones seen in dogs

Urine analysis is the most useful and should always be done. A sterile sample is taken either via catherisation (passing a tube into the bladder) or cystocentesis (straight from the bladder). With the urine sample analysed, MAP crystals can be present but this is not always the case. For example, stones that are too well formed or too large may not shed crystals. Therefore, the vet should not deem the absence of crystals in the urine as no struvite or urinary stones being present in the affected dog.



In addition, urine pH gives the vet a good idea of the nature of the stone. Struvite crystals are formed very commonly in an alkaline environment in which bacteria is present. A urine sample can show the presence of bacteria. The bacteria be cultured to know the type of bacteria causing the infection and antibiotic sensitivity tests can be performed by the laboratory to advise on the appropriate antibiotics to be prescribed.



Struvite uroliths are radio-dense and can be detected on radiographs.

However, they need to be of a certain size before they are evident. The number and size of urinary stones seen in the X-ray may not correlate with the severity of clinical signs.



However, a radiograph is highly recommended for the vet to know the number and size of stones and where they are located prior to surgical removal, if surgery is to be advised.



Clients need to understand that in spite of all the tests above, the composition of the actual stone cannot be determined unless a stone sample (from the surgery or that has been urinated out)  is sent to the laboratory for analysis.



Treatment options for struvite bladder stones revolve around surgery or medical dissolution of the stones.





Benefits of surgery include faster recovery times, and the ability to identify the actual type of stone involved. Surgery is indicated if the stones are too large or too well formed as they may not dissolve medically. Disadvantages of surgery are that it is more invasive and there are risks associated with general anesthesia in a sick and/or older dog.

For clients that are not so comfortable with surgery or in cases where surgery is not advised due to health concerns (e.g. the dog is very old and in poor health), the alternative is medical dissolution. This medical solution is non-invasive but takes a much longer time to show the effect as the stones are dissolved slowly. However, large stones may not dissolve at all. One important note to take into consideration is that there is no way to accurately determine the nature of the stone without sending it for laboratory analysis. Obviously, the medical solution is not applicable to all types of urinary stones (e.g. calcium oxalate stones), but it is especially effective and useful in struvite stone dissolution.



Medical dissolution revolves around 3 main concepts. They are to acidify the urine, to reduce the intake of MAP such that it does not saturate in the urine and to dilute the urine so crystals do not have a chance to form. For struvite uroliths, there are specially formulated diets such as the Canine S/D, C/D or W/D that I have used to dissolve the stones.



Medical dissolution of stones takes a mean time of 3 months. The time taken for complete dissolution is varied depending on the size of the uroliths and the quantity. Severe cases can take up to 6 months before the stones are fully dissolved. However, very large stones will not dissolve.

Along with this diet change, I prescribe an appropriate antibiotic course to treat any primary or secondary bacterial infection. During treatment, only the prescription diet should be used. I usually advise no dog treats or other food and to encourage the dog to drink water.



The S/D diet is used initially for 1-6 months before switching over to the C/D or W/D diet. It is not recommended for:

1. Use concurrently with urinary acidifiers

2. Feeding longer than 6 months

3. Dogs with non-struvite uroliths (urinary stones).



Transition to feeding S/D should be done over a period of seven days, gradually introducing the amounts during the transition period and monitoring the patient. Most dogs will not eat the S/D diet immediately and so the owner must be educated to switch to the S/D diet gradually over at least 7 days.



After successful dissolution of struvite stones confirmed by urine analysis and X-rays, Canine C/D or W/D can be used for maintenance. Canine S/D should not be used for the prevention of bladder stones as the diet is low in MAP and protein. Long term use of this diet is not recommended as the nutrients are not sufficient.



Key benefits of Canine S/D include:

· Low levels of MAP to aid in dissolution of struvite uroliths and crystals.

· Promotion of acid urine by reducing the urinary pH to 5.9-6.1 (targeted) to increase the solubility of struvite crystals.

· Lower protein levels result in increased urine volume and more dilute urine.

· Antioxidants are added to defend cells from free radicals and to promote a healthy immune system.



In this article, I have written about the S/D, C/D and W/D prescription diets for the medical treatment of struvite urinary stones as I have used them in my practice. However, there are other equivalent prescription diets from other manufacturers and it is up to your vet to advise you as to the type of prescription diet to use or to get bladder surgery done to resolve the problem fast.



Many Singapore dog owners do not adopt my advices to review the cases 1-3 monthly and do urine tests and X-rays to ensure that no new stones are formed after surgical removal of the stones or after using the S/D diet. They are happy to see that the dog has not passed blood in the urine and does not have difficulty in urination and continue with feeding the usual dry dog food again.



In some cases, the problem recurs and it can be heart-breaking and costly if another surgery is required. So some owners elect to euthanase the dog. Regular urine tests would have been most useful in detecting the presence of struvite stones although the absence of struvite crystals in the urine does not mean that there are no stones present. Only X-rays will be able to tell. Sometimes, a dog that has had struvite stones may become later affected with another type of stone such as calcium oxalate stones and that is why regular urine tests are so important.

In conclusion, be alert as to the urination pattern of your older dog and seek veterinary advice promptly if there are signs of discoloured urine, urinary difficulty or inability to pee. For more detailed case studies of urinary stone cases seen at Toa Payoh Vets, goto:

http://www.bekindtopets.com/animals/20081201PG7_Dog_Surgery_Anaesthesia_Urinary_Tract_Problems_ToaPayohVets.htm

Acknowledgement: I thank Dr Daniel Sing for his contribution to this article and various dog owners for permitting me to record their cases in this article 

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As only one images has been uploaded to blogger.com, see the other images at:
Toa Payoh Vets webpage:


http://www.kongyuensing.com/folder8/20120724struvite_stones_dogs_toapayohvets.htm