Monday, March 4, 2013

1406. Cases in 2013 & 2009: Calcium oxalate (crystals or stones) in 2 dogs

Calcium oxalate stones are radio-dense unlike urate stones.
Yesterday, I had a case of a Cavalier King Charles, female, 6 years passing smelly cloudy urine. She yelped occasionally when she peed. So I asked the owner to send me a sample of the urine.

On March 2, 2013, she collected the urine in the clean pee tray and sent it to me. Urine analysis show pH=6.5 which is acidic and calcium oxalate crystals 2+. Bacteria was "occasional" and there was no blood in the urine.

I advised X-rays which showed no stones but I could see radiodense cloudy urine inside the bladder. I palpated the bladder confirming no big stones.

I turned the dog upside down on the examination table and discussed this case with Dr Daniel. I noted that she had unusually enlarged nipples as if the dog had given birth a few times. "She had never given birth," the owner in her late 30s said to me.

White cloudy discharge appeared at the vulval area but the owner did not want to see it. "This could be pyometra," I said to Dr Daniel who disagreed. He thought it was just white turbid urine. The dog could be incontinent but the owner did not complain about incontinence or leaking urine. She said that the dog no longer came into heat although it usually happened around February. I palpated the abdomen. The dog did not experience any abdominal pain but I could few swollen uterine horns of around 2 cm in diameter. 

This dog lived in a house with a garden and sometimes the owner might miss the bleeding as the dog cleaned herself well by licking. This would account for her swollen vulval lips.   

"So what to do now?" this was what the owner wants to know. She was a busy lady and all those technical information did not interest her.  

"Put the dog on U/D diet for 3 months and don't feed any treats or food. Monitor the urine 4 weeks later to check for the presence of calcium oxalate crystals. Monitor amount of water being drunk daily."

As to why the dog "yelped" occasionally when peeing, this was a mystery. This was the complaint. Not difficulty in urination or blood in the urine as in the 2009 case I reproduced for readers below:

dogs, cats, hamsters, guinea pigs & rabbits
Mum complained that the Chihuahua peed too many times a day
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
First Written: 4 March, 2009
05 March, 2013
Be Kind To Pets
Veterinary Education
Project 2010-0129

Summary: If your dog does not pee normally, do consult your veterinarian promptly as the bladder gets inflamed severely and the wall thickens considerably over time, due to chronic infections by bacteria.


The 6-year-old male Chihuahua was in excellent body condition. Lots of good food had given him a padded body. He stayed in an apartment and seldom went down for exercise. Around the beginning of December, he stayed with another family member - the brother. At the brother's apartment, he was shut out of the bathroom which he normally used as his toilet as the brother wanted to have a clean bathroom.

History:The brother took the dog outdoors to pee. The dog took a long time to pee. Sometimes he took 2 hours to pee. But the dog could not pee normally in Jan 20, 2009. Urinary stones blocked the flow of urine as I could not push the catheter into the bladder easily. "There is a need to analyse the urine under the microscope for urinary stones, cells and infections," I advised the owner. As the dog could pee, the owner did not want any tests as that would add to the costs of veterinary service.

Chihuahua, Male, 6 years. Urethral obstruction & urinary tract infection. Toa Payoh Vets"If he can't pee, I will have no choice but put him to sleep as it is too costly to treat him," he laughed. I could not persuade him to take urine tests. Clients have the freedom of choice but they must be adequately advised and such advices are best put in writing to prevent miscommunication and mistrust in a litigious society - when the dog dies and family members become very unhappy.

"Do not worry, my family will not sue you," he laughed when I told him that the problem of difficulty in urination would recur and some family members might be unhappy with no tests being carried out.

Unhappy people see an opportunity to sue the veterinarian to gain money for "incompetent" services and negligence and to prevent other dogs from suffering the same fate of negligence. In such cases, the vet ought to give the owner a written statement that he had had been forewarned about the prognosis. I did not do it but would record this advice in my medical records.

On the 10th day after the first consultation the dog could not pee at all. "My dog did not really pee normally for the past 10 days," the slim man in his late 30s commented. Urine tests and X-rays were permitted and done.

Surgery on Jan 30, 2009. Two Calcium Oxalate urinary stones removed from a dark red bladder with walls as thick as 0.8 - 1.0 cm. Normal bladder walls are around 0.2 cm. The urinary stones could not be palpated via the bladder as they were too small and the inflamed bladder was too thick. In any case, such a thick bladder wall would prevent palpation to be done properly. The dog was hospitalised till Feb 10, 2009 when he could pee normally.

What happened after the dog went home? The following record is a follow-up as I met the owner at the Surgery on March 4, 2009.

At home in a high-rise apartment from March 4, 2009
1. "The dog urinated all over the kitchen floor for the first 4 days at home," the owner revealed his observations. "He drank a lot and peed a lot. I told him to pee onto the grating (drainage hole cover) in the kitchen.

"He is an intelligent dog and by the 8th day, he peed at the grating. He is now back to normal in peeing."

2. Going outdoors. The owner said, "I make sure that I bring the dog down to the grass at least once a day, particularly in the morning. I want to see that he pees in a large amount all at once. If the dog is indoors, he will stand on the kitchen grate to pee."

3. Urine marking. "Nowadays, after the surgery, the dog would pee a lot all at once when brought down. Then he would lift up his leg to mark but sometimes a small amount of urine would come out. Other times, nothing. Prior to surgery, he would pee a little bit at a time. I had to wait 2 hours to ensure that he urinates completely. Other dog owners were puzzled as to why my dog takes such a long time to pee. Now, there is no need."

The owner had time as he was self-employed. I don't really know what he was doing in his profession. He is a happy-go-lucky man in his forties, in my observation and sends out good vibrations.

4. Mum's complaints in the past. "For some weeks, mum had complained that she needed to wash the toilet floor many times" the man said to me in retrospective analysis. The dog used to stay with the mum in another apartment and would use the toilet floor to pee as he had been doing so for the past 6 years.

Mum would then flush the floor with water as family members had to use the toilet. But lately, mum had to do it so many times. Nobody had thought of bringing this dog for a veterinary check up. Other dog owners had also asked the man when he took over the dog to live with him in December 2008, "Why your dog takes such a long time to pee?"

"As long as two hours outdoors," the owner would wait patiently for him to pee all his urine. This behaviour is not normal but the owner did not think it was abnormal.

5. Sorrowful demeanour. "I can't remember why I brought this dog to see you," the owner said when I asked why he consulted me in the first instance. "It must be because the dog was sorrowful."

10 days before the day of surgery on Jan 10, 2009, the owner consulted me because the dog had difficulty in urinating. The urine was cloudy. The dog seemed to be incontinent, leaking urine drops onto my consultation table. The urethra was blocked.
Calcium oxalate urinary stones, 6-year-old Chihuahua being catheterised. Toa Payoh VetsCatherisation of the urethra lead to easier urination. The owner was not keen on X-rays and blood tests then due to the need to save money. Since the dog could urinate, he wanted the dog home. However, I did warn him that there would be the same dysuria again as the urethra was obstructed when I passed the catheter into the urinary bladder with great difficulty.

10 days later on Jan 10, he consulted me as the dog could not urinate. "The dog had never peed normally since I got him home," he said. Catherisation of the blocked urethra enabled the dog to pass golden yellow. The smell of urine ammonia was strong, as if, the toilet bowl's urine was not flushed for 24 hours.

This time, the owner was agreeable to urinalysis but no blood tests (complete cell count, serum chemistry) and X-rays. Veterinary costs can add up to a large amount and I understood his financial concerns. This recession would be the worst in decades, according to all the experts.

6. Urinalysis. Calcium oxalate crystals + were the significant finding. See blood test report above.

Calcium oxalate urinary stones are radiodense. Take X-rays. Toa Payoh Vets7. X-Rays. As no big stones were palpable and the bladder wall was considerably thickened, it would be wise to X-ray the bladder to see how many urinary stones were present. The owner consented. Calcium oxalate crystals are radio-dense and 2 were easily seen on the X-ray. If no X-rays were done, the owner would feel that the bladder stones were not all removed should there be a recurrence of difficulty in peeing. Therefore, X-rays are advisable except in certain cases where the urinary stones were so large that they were palpable. This is because the owner may want to reduce veterinary costs. Every test add up to the high costs.

8. Surgery. In this case, 2 stones were seen on the X-ray. It was extremely difficult to pick up the 2nd stone as both stones were around 0.5 mm in diameter and the bladder incision had to be as small as possible. A big bladder incision would not be good for the dog.

Extremely thickened bladder wall indicated that the bladder had been infected by bacteria for several years.

The infection had caused the bladder to thicken and thicken its wall to fight against the bacteria. It was a losing battle and therefore the bladder became severely reddened and swollen.

The mum was not aware of the need to get the dog examined when she had to wash the bathroom floor so many times a day - a change of the dog's behaviour.

In retrospect, her complaint of having to flush the toilet floor many times recently would be a clue to the urinary tract infection. Mum used to clean the floor once a day previously. Mum's complaints "Must clean the floor many times. The dog did not urinate in a big amount." Therefore frequency increased while urine volume decreased per occasion.

Urinary Stones in a Chihuahua. Bladder popped out. Ureter seen. Toa Payoh Vets. Urolithiasis. Calcium Oxalate urinary stones. Chihuahua. 6 years. Neck bladder incised. Toa Payoh Vets
Urolithiasis. Calcium Oxalate urinary stones. Bladder inflated to flush out stones. Chihuahua. 6 years. Surgery. Toa Payoh Vets Urolithiasis. Calcium Oxalate urinary stones. Forceps attempted to grip and pick out stone from bladder. Chihuahua. 6 years. Surgery. Toa Payoh Vets
9. Post Surgery. Today is Mar 4, 2009. Surgery was on Jan 30, 2009. The owner was now satisfied and pleased that the dog's first urination in the morning when brought outdoors was a big volume, as in the past. "There is a very small wound which seems not to heal," the owner commented. It was difficult to know what he was saying as he did not bring the dog in for consultation. Overall, he was happy so far as his best friend was living a normal pain-free life now - not having intense pain when passing urine and therefore taking a very long time to pee. Now, the dog just urinate one large volume at one go and get on with enjoying his outdoor exercise and urine-marking (with little or no urine to mark).

As at Mar 4, 2009.
Home-cooked food. Dog drank normally and not a lot as in the lst 4 days home. Urine-marking downstairs where other dogs had been. However little urine production or none at times. I said, "The dog may start to leave more urine inside his bladder in time to come. Then stones might form again."

I asked the owner to monitor the urine intake, colour and consistency over 24 hours. The dog was banned from the bedroom because he would "pee" onto the mattress which had to be thrown away. Doors would be locked. He would pee at the kitchen drainage grate but the owner would always bring him outdoors in the morning so that he could pee all urine at one go within the first time. He continued to urine-mark with little urine as this is the natural behaviour of male dogs that have not been neutered. The dog has to pee on the spots to over-ride the smell of other dogs - to mark his territory.

ConclusionX-rays are necessary before surgery in this case so as to know how many urinary stones are present in the bladder. Calcium oxalate crystals are radio-dense and will be easily spotted on X-rays. Due to financial considerations, no X-rays were done after surgery although this is recommended. Two stones were shown to the owner as evidence. It is best to produce evidence to educate the owner.

Urinalysis is also necessary. There is no guarantee that urinary stones will not be formed again. Unlike struvite (triple phosphate) urinary stones which form in the presence of alkaline urine and bacteria, calcium oxalate crystallisation is not related to the alkalinity of urine and therefore acidification of the urine in this case is not advised. If you review the blood test report, the dog's urine was acidic actually.

Will the special Hills' urinary stone prescription diet to prevent calcium oxalate crystallisation work? One veterinary book doubts this will help.

The owner feeds home-cooked food, so the answer in this case will not be known for some time. For other dog owners, it is advised that you get your dog examined by your vet at the first sign of difficulty in peeing as it is much more inexpensive to get early treatment than surgery and hospitalisation.

As at Aug 31, 2010. No complaint from the owner. This case may be one to "justify" neutering of the male dog to prevent urinary stasis and stone formation at an older age.

This male dog needs to urine-mark his
territory. He tries to retain some urine to urine-mark. Retention of urine causes crystallisation and bacterial infections of the bladder wall over the passage of time.

Urinary stones form. Urine flow gets obstructed when they get stuck in the urethra. The dog can't pee normally and to some owners, it is costly to consult the veterinarian and get treatment for the dog in pain.

It is hard for the dog owner to envisage the sequences of physiological events. Therefore advices to neuter this dog fall on deaf ears. I hope for the best for this dog. He would definitely be well cared for and much loved by the brother. If his health is good, he should live to a ripe old age of 15 years.
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