Thursday, June 14, 2012

1025. The Schnauzer pees 5 urinary stones

TRUST AND AUDIT CASE STUDY on Jun 14, 2012 by Dr Sing at 6.50 pm at Toa Payoh Vets

An interesting case

XXX, Miniature Schanzuyer, Female, 5 years

May 3, 12. Dr Daniel's case. Haematuria (end stream) and stranguria,  increased frequent urination. Diet brown rice and dry dog food.

May 7, 12  X-ray & urine test. S/D diet given 2 cans. Antibiotics.
>5 urinary stones. Advised surgery to remove stones and diet change to low protein diet*.

The couple spoke to me as I was the original vet who had treated the dog earlier. They wanted spay and urinary stone removal in one surgery. I advised against doing two major surgeries in one in case of complications from infections, bleeding, death due to prolonged procedure. I did not want to do it. The couple left. No news from the couple.

May 25, 12. I was in Hong Kong and got a phone call saying the dog could not pee at all. She had passed out 5 urinary stones but was now in distress. I referred to another vet practice. Vet 1 x-rayed and catheterised and the dog could pass urine. It was a Saturday and she had said that fees,  would be higher, but Vet 1 could do spay and urinary stone removal. The owners were willing but since the fees would be higher on a Saturday, she advised another day. On Sunday, the dog was peeing and was OK. The owners decided against the operation.

"Could it be the high fees quoted?" I asked Vet 1. "How much did you quote?" She did not reply.

Jun 12, 12. I spayed the dog as requested. No urinary stone removal as requested. History from owner today. No haematuria since May 26, 12 after treatment by Vet 1 on May 25, 2012. The husband showed me 5 urinary stones that had been peed after the dog took 2 cans of S/D diet. I palpated the empty bladder. A hard mass of around 1.5x1 cm in size indicating that the 3 stones were still inside the bladder. Advised S/D diet for one month.  The owners wanted only 6 cans.  Previously, the owner wanted only 2 cans in case the dog does not eat the food.

Weighed 4.8 kg on Jun 12, 12. Had lost weight as her weight was 5.1 kg on May 3, 2012. The 5 stones could be sent for analysis to confirm struvites but due to economic reasons, I did not advise.

SPAY. Ovaries enlarged 8 mm x 8 mm x 6 mm. On heat? The owner said the dog was on heat 4 months ago.
4.8 kg
10.28 am  Dom 0.19 ml + Ket 0.24 ml IV
10.33 am - 11 am Isoflurane gas
10.40 am Skin incision - 11.07 am Last stitch = 27 minutes
2/0 absorbable x 1 pac
11.20 am - Antisedan 02 ml IM wakes up the dog.


Significant results
pH  7 (5-8)   
SG 1.026  (1.005-1.030)
Nitrite Positive (Negative)
Protein 3+ (Negative)
Blood 4+ (Negative)
White blood cells 558
Red blood cells  >2250
Bacteria +
Crystals  Triple phosphate occasional

1. The owners asked me whether Vet's 1 advice that the stones will rupture the bladder if not removed by surgery is correct. "Unlikely to do so," I said. "They are not that large. But they will irritate the bladder causing infections. "
2. Will S/D diet dissolve the remaining 3 big stones? "Not likely as they are large." I said.
So, presently, the status is that the stones are still there. Some dogs do not need stone removal but in this case, removal and prevention using prescription diet are the best course of action. The problem here is that the owner does not want to feed the S/D diet for at least one month as he took only 6 cans of S/D diet.

Jun 14, 12 Meeting

*In theory, lower protein, less ammonia produced, less likely to form struvite stones. My contention is what "low protein diet" means and what is the % of protein that constitutes "low protein" diet in practice? What practical advice should the vet give to the owner?

My meeting with the vets at Toa Payoh Vets today regarding consistent advice in a struvite case. The advice should be consistent from all vets at Toa Payoh Vets. Some owners may not want X-rays. In urine test, once there are 3 factors - alkaline pH, bacteria and struvite crystals, the recommendation should be a prescription diet like S/D diet or equivalent for 1 month and switch to C/D diet for 3 months to dissolve the stones

E-mail from owner dated Jun 13, 2012

Hi Dr. Sing,

attached is a picture of the bladder stones passed out together with the urine by XXX

The stones started to show up 2 days after putting her on the (S/D( diet prescribed by you.

The largest of the five stones came out on 24 May 2012. That was the day before she had difficulty to urinate and we sent her to your referred vet.

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