Saturday, June 28, 2014

1392. Yangon Seminar July 5, 2014 . FLUTD in a Singapore male cat

The Hissing Cat Has Difficulty in Peeing? Initiating Cause due to amitriptyline?

Sunday, April 24, 2010.
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. 

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.

 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 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

  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.

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).
beauty is in the eyes of the beholderIn 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).    


Dear Dr Sing,

It's coming close to a month since we first bring XXX & his swollen prepuce to you.
Thought you might like to know how he's faring.

He finished his course of antibiotics stress-less-ly for both him & us, thanks to your smearing his paw trick.  :)
Still on canned Hills S/D, eating about 4ounces a day.
Doesn't drink water tho, so we add a spoonful into his meals each time.
He's doing a lot better these days, more like his usual curious self before moving house.
Pees every day, some days much more than others, especially during cooler days.

There were a day and another (a week apart) when he didn't really pee, and strained to do so, but he always succeeded in the end.
Coincidentally, those days were the ones when he challenged/quarrelled with a visiting neighbourhood cat.
Guess that's to be expected because he's been living in a one-cat household environment for the past 5 years and has a dominant streak.

Generally, he seems to have recovered well and has settled into a daily routine of patrolling here and there and sleeping the afternoon away. Eat, sleep, eat, sleep. Seems like he's having a contented life.  :)

Thank you so much for helping us that fateful sunny day.
Your concern for XXX's welfare made it easier for us to go thru' a vexing time.

Best regards,
Name of owner

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