Saturday, December 15, 2012

1217. An old female dog had difficulty peeing. Pyometra or urethra obstruction or both?


Sunday, December 9, 2012

1214. Follow-up. "Closed pyometra" case

 
Two days ago, this 11-year-old female Maltese was operated by Dr Daniel and me. This was a strange case. Total white cell count was very high in the blood test. A swollen abdomen with a globular lump. I said it was a very full bladder on first palpation but Dr Daniel said the dog had peed all urine. An X-ray showed a big globular swelling and I was quite sure it was the bladder. Or was it a large uterus filled with pus since the owner had said that the dog had passed "sticky urine".

Some owners are not very correct with their signs and symptoms of their dog and "stickiness" in urine could be pus being discharged from the infected uterus in this old dog. The owner agreed to X-rays and blood tests. No radio-dense urinary stones were seen but this just meant that the stones would not be visible in the X-rays as not all urinary stones are. The blood tests showed a severe bacterial infection with the dog being toxic.
 

BLOOD TEST ON DEC 6, 2012

Serum urea 22 (4.2 to 6.3), creatinine 188 (89-177).
RBC 4.8 (5.5-8.5), Haemoglobin 9.9 (12-18).
Total WCC  62 (6-17),  N=98%, L 1.7%, M, E, B.
Platelets 131 (200-500) was low suggestive of toxaemia
But what cause this bad infection and how to resolve the dog's problems? As the dog was old, any delay in treatment of toxaemia would result in death. Antibiotics would give a reprieve but there was more to the health of the dog than just bacterial infection. Closed pyometra was a possible diagnosis but the X-ray of a large swelling appeared to me to be that of a swollen bladder.  My abdominal palpation was that of a swollen bladder, as big as an orange. Of course, it could be a grossly swollen uterine body as well.

The next step would be surgery and after 24 hours on an IV drip and medication, the dog was operated by Dr Daniel and myself. Time was of the essence. An old dog was high anaesthetic risk but there was no option other than surgery to resolve the health problem.

SURGERY ON DEC 7, 2012

The biggest bladder ever seen. Like 3/4 of a Thai mango. The dog had been given IV drip 12 hours ago to pep her up for surgery and increase her chances of survival.  More than 15 cm long. I aspirated the urine with a sterile syringe from the apex of the bladder and sent for urine analysis. You can see that the urine is colourless from the images in this webpage.
 

Urine colour: Colourless.
Clarity: Slight turbid.
pH 5.0 (5-8).
SG 1.012 (1.005-1.030)>2250. RBC 90 (Possible haemolysis of RBC in urine).
Bacteria 2+. Crystals Nil.
"Urinary stones might not be radio-dense and so would not be seen in the X-rays," I said to Dr Daniel who was operating. "Flush out the bladder, irrigate it. Put a catheter into the bladder and pass it out through the urethra from the bladder." There was cystitis. Negative crystals in urine do not mean no urinary stones.





 




When Dr Daniel tried to pass the catheter out from the neck of the bladder, there was obstruction. "It is possible that there could be a urinary stone stuck inside the short urethra and not visible on the X-ray," I said. After a few attempts, he managed to pass the catheter out of the urethra and the vulval lips. "There could be a urethral obstruction in the female dog as well." There could be urethral spasms as well but I would bet that there was an urethral obstruction.  Most vets don't pass the urethral catheter via the vulval vestibule as they deem it difficult to do it, unlike in the dog. Dr Daniel irrigated the bladder with saline and stitched the 1-cm incision with two layers of 3/0 mono-syn sutures.

"Check the neck of the bladder for tumours," I said. "Extend the incision of the skin and linea alba caudally. As Dr Daniel pulled up the bladder, we could see a large reddish lump at the neck of the bladder on the outside. I took an image for the owner to see as it was not possible for her to be at the operation room.  This swelling of around 8 mm x 8 mm x 4 mm could be the cause of difficulty in urination.


A swollen abdomen Massive bladder Bladder incised to check for non radio-dense stones Urethra catheterised. There was an obstruction
 
Bladder sutured. A growth is seen at the neck of the tumour Pus in infected uterus removed Dog has no difficulty peeing after surgery  
DISCUSSION WITH THE OWNERS
Today was the first time I met the father and two young adult daughters as Dr Daniel was the vet in charge of the case. "Did the dog have difficulty passing urine?" I asked.
"Yes," one daughter said. "She took a long time to pee and only a few drops of urine came out."

I reviewed the record on Dec 6 when the dog was admitted. "Urine sticky. Stools red and yellow past 2 weeks. Appetite decreased. Vomited once."  Pyometra was suspected but the onset of heat was unknown. In conclusion, there was a case of pyometra and urethral obstruction caused either by a non-radio-dense urinary stone in the urethra or the neck of the bladder tumour. The "urinary stone" was not seen as the urinary catheter appeared in the vulval area as there was flushing of the urethra from inside the bladder before removing the obstruction.

Many old intact female dogs do suffer from pyometra and in this case, there was pyometra with the uterine body wall being as thin as a piece of paper, leaking out the bacteria into the blood stream as well as into the bladder, in my observation. Fortunately, the uterine bodies were removed before they ruptured. Similarly for the bladder as it would rupture if the urine could not be passed out, as you can see how thin the wall was, from the images.

More than 7 days had passed, now being Dec 16, 2012 as I edit this report. The owners were happy that the dog leads a normal life and has no difficulty in peeing. Two weeks had passed before the owners consulted the vet. Fortunately, the dog did not suffer kidney damage in the delay in seeking treatment and that the appropriate treatment was given. The old dog has a new lease of life.

Updates and images will be at:
http://www.bekindtopets.com/dogs/20121216dysuria_pyometra_toapayohvets.htm



UPDATE:
Dec 21, 2012. The dog came for stitch removal as there was a slight stitch breakdown in the last stitch nearer to the vagina. Dr Daniel removed the stitches which were absorbable.

"There is some sticky dicharge from the vagina," the lady owner said that the dog now could pee normally and was OK.

"Most likely the vestibule in the vagina still has some pus left over from the uterus," I told her. "Since the infected womb has been removed, this pus would disappear soon. There is nothing to worry and is a common occurrence in some post-op cases of dogs with pyometra spayed."

In conclusion, the surgical outcome was good and the 11-year-old dog was alive. It would be a happy Christmas for the family.    

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