Tuesday, September 18, 2012

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.







   



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