Tuesday, April 26, 2011

420. The hissing cat has difficulty in urination. Initiating cause due to amitriptyline?

Sunday, April 24, 2010. Bright sunshine, blue skies. Should be outdoors. I was at work at 9.30 am. 3 clients came in but they were my associate vet's clients and so I told him they had to wait as she comes in at 11 am. Suddenly a couple with a cat carrier came in at 10.15 am. They would be 4th in the queue and by the time, they get attended by my associate, it would be past 12.30 pm which meant a 2-hour wait. As they have no preference, I took over the case, thinking it was a simple case of a cat that can't pee. A commonly presented case, usually of an older male cat fed on dry food.

HISTORY. Cat, Male, Neutered, 7 years old. Could not pee 2 weeks ago. Vet 1 relieved urethral obstruction, gave one "2-week-lasting" SC injection. Cat went home. OK for first 2 days. Then difficulty in peeing. Squatted but no urine. After for around 2 weeks, the couple in their 30s consulted me for a second opinion on Sunday April 24, 2011, 10 am. "Be careful," the husband warned. "The cat is very ferocious since the visit to Vet 1." According to the wife, Vet 1 had used anaesthesia to catherised the cat at the first time. However, the second and third bladder irrigation via the catheter was done without sedation as witnessed by the wife who was called to help. The wife was unhappy at seeing her cat traumatised. "Now the cat hisses whenever he is taken to the vet," the wife said. "The vet may think that it is risky to give sedation/anaesthesia again," I said. "The cat may die from the sedation and that would be disastrous." I don't do repeat bladder irrigation but each vet has his own ideas.
Now the cat warned me with a loud hiss as I examined his backside and palpated his abdomen. There was no point traumatising the cat. So, I gave a sedation and asked the owner to wait. Was this a recurrence of the urethral obstruction?
SEDATION & EXAMINATION Weight: 6kg, xylazine 0.15ml ketamine 0.5ml. Catheter passed in smoothly. No obstruction. But the unusual problem was that the penis of the cat could not be extended. The prepuce had swollen to a ball-shaped lump. An unusual case. I took a picture.

After some massage, it was possible to extend the cat's penis and insert the catheter. There was no penile inflammation. Bladder palpation. Bladder was swollen to twice the ping pong ball size. Urine collected for analysis. No crystals. Blood, white cells and red cells, bacteria + present.
DIAGNOSIS. Feline Lower Urinary Tract Disease (FLUTD).
The owner was not prescribed oral antibiotics by Vet 1 but the wife said to me: "The cat had been given a "2-week-lasting antibiotic injection". Therefore, there was no need for oral antibiotics. However, Vet 1 prescribed an anti-depression oral medication which the cat objected forcefully. So the owners did not give him the amitriptyline after two tablets. This drug licensed use in people is for depressive illness, bedwetting (nocturnal enuresis) in children aged 6 years and over.

Vet 1's X-ray show that the bladder is large and distended. No urinary stones seen, according to the owner.

4109 - 4111. The cat can't pee again. He hisses at the owners and at me (the 2nd vet). Why? Is there a permanent cure for feline lower urinary tract disease (FLUTD)? The hissing cat has difficulty peeing again
One of the adverse side effects of amitriptyline is "difficulty in passing urine" and this is reasonable since it is used to prevent bedwetting in children. I don't use it in cats or dogs and so I have no experience with this drug. But after two tablets, the owner observed that the cat had difficulty peeing! So was this the effect of amitriptyline or not? The cat continued to have dysuria for the next 10 days and that was when on this bright sunshine Sunday morning, I encountered this interesting case. Interesting only to veterinary knowledge on the use of amitriptyline, not to the owners as it had been traumatising for them and their cat.

To make a long story short, the cat did not have urethral obstruction as the catheter went into the bladder smoothly. He was warded for 2 days. The diagnosis was feline lower urinary tract disease confirmed by urine analysis. This was an intelligent cat as he sat on the litter box all the time while warded for 2 days in the surgery. If you understand that a cat wants to be clean, he is leaking urine via the catheter and so, by sitting on top of the litter box, he does not mess up the surrounding area. Even after removal of the catheter, he still sat on top of the litter on day 3 when the owner came to take him home.

When the owner came to take him home, he hissed at the owner! So, the couple patiently took time to get him to relax and put him inside the crate. In the morning I had sedated him (xylazine 0.1 ml + ketamine 0.4 ml IM) to remove the 6/0 stitches tying his catheter to his prepuce in 4 places and take rectal temperature (fever 39.8 deg C) and to weigh him. I treated his fever with baytril and tolfedine injections SC.

According to the wife, at Vet 1, the e-collar had been taken out once and the cat pulled off his catheter but with the sutures still knotting one end to the prepuce. Therefore, she asked whether I had put an e-collar all the time. Better to use oral pain-killers for cats post-treatment as the cat is very difficult to medicate and will claw you.

In any case, I don't usually put catheters in cats after bladder irrigation, except in some cases such as this case and only for 1-2 days. I don't bladder irrigation more than once but some vets do, without sedation.

The cat will be on oral antibiotics for 12 days. I don't believe in giving one single injection lasting "2 weeks" as Vet 1 did, but if the owner can't medicate at home, this may be the alternative. Pound medicine into powder and add to sugary paste. Spread on cat's body or paws without the cat knowing it. But cats may be too smart and flick away the medicated sugar.

Close monitoring of water intake and canned food, urine analysis in 2 weeks. Change to sand litter. Continue canned SD diet for 1-3 months and urine test monthly for 1-3 months. Then canned food. No shampoo for the first week. The cat is shampooed once a month as the owners find its coat oily. "Cats seldom get bathed in Singapore," I said. I did not take blood test so as to lower the veterinary costs.

However, urine tests are important for diagnosis of FLUTD and this was done in this case as the owner wants to know what is happening. Bacterial antibiotic sensistivity tests of the urine was not done in this case but would be done if there is another episode, so as to save the owners some money as they had spent quite a large sum at Vet 1.

1. Cause of the FLUTD
I said to the owner on the second day: "You must have given dry food after treatment by Vet 1, thus leading to difficulty in urination."
"No, I did not," the husband said.
Then he remembered that Vet 1 had given him the dry food of Hills' Prescription SD as canned ones were out of stock. So, there was a dry food involved. Could it be the dry food? Could it be the action of amitriptyline retaining the urine in the bladder and permitting bacterial infection? Could it be the sharp pelleted litter injuring the prepuce and causing it to swell and prevent ease of urination? Could it be the re-infection of the bladder after going home? Was Vet 1's "long-term guaranteed to last 2-week" antibiotic injection of Synulox (clavulanic acid and amoxicillin) ineffective since it was apparently given once only? There are so many factors causing the urinary tract infection presented to me now and so it is hard to specify one causative factor.

It is a mystery but a urine analysis is important and must be done as part of the vet's duty of care. Certainly there was bacteria and white cells in the urine, indicating urine retention had led to cystitis or was a cause of cystitis. The SD diet had acidfied the urine apparently as the urine pH was 6.5 in the test.

It is quite painful for the couple to see their cat going to the litter box many times, tried to pee and not able to do so on the 3rd day after going home from Vet 1's treatment. They decided to seek another opinion and I was present on this bright sunshine blue-skies Sunday that I would like to spend at the Botanic Gardens.

2. Follow-up 24 hours after going home on Tuesday, April 26, 2011. I phoned at around 4 pm on April 27, 2011 as the cat had a fever of 39.8 deg C on Tuesday morning (when I took out the catheter and checked the rectal temperature under sedation). I had informed the husband of the fever and asked him to observe the cat closely. I had given tolfedine injection which would reduce the fever.

The husband said: "Everything is OK. The cat ate a lot and drank a lot on reaching home. Then he became quiet and not moving much. My wife smeared the baytril antibiotic in brown sugar onto his body and he licked it off."

This was one of the tips of medication I had given to the handsome couple in their 30s.
I replied: "It is possible that she is very tired after spending two stressful nights at Toa Payoh Vets which is a new environment for her.

"She is also not hungry after eating a lot. Check whether she has fever by feeling her lower abdomen with the hand but this is not accurate. Let me know if the cat is not eating. You have the anti-fever tolfedine tablets ready. Have you bought the sand litter?"

The owner had not and would do so. I expect this case to stabilise and that the emotional coaster-ride of the couple would fade away. The veterinary costs of two vets would be over a thousand dollars but this could not be avoided since there were so many procedures and tests.

The management at home is most important as there are many causes involved in the development of FLUTD (Feline Lower Urinary Tract Infection). The causes include uroliths (stones), urethral obstruction (plugged-penis syndrome and blocked cat syndrome), infectious causes and others (unknown causes in about 60% of the cases, physical trauma to penile area, tumours of the urinary tract, congenital abnormalities, neurological problems and intentional urinary retention (common behaviour seen in cats not given a litterbox or dirty litterbox).

In this case, the sophisticated owners told me the cat was shifted to a new house and that would be the cause.

The risk factors would be

1.1. Age. Uncommon in cats less than one year old but most common in cats 2-5 years old. This cat is 7 years old).
1.2 Sex. Male and neutered cats are at greater risk of urethral obstruction as their urethra is longer and narrower.
1.3 Neutering.
1.4 Dehydration.
1.5 Dry food high in magnesium or other minerals and high in pH.
1.6 Obesity.

All the above factors are present in this case. Dehydration could be due to the lack of adequate water intake as the cat was adjusting to the new house environment. Most cats on dry cat food do NOT get FLUTD. The causes are many and therefore, amitriptyline was not the only cause of the recurrence of the dysuria. Good management at home and regular veterinary check ups are very important to prevent recurrence of the dreaded Feline Lower Urinary Tract Disease (FLUTD).

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