Thursday, September 17, 2015

2297. A 13-year-old male cat and dog came from North Singapore

Wed Sep 16, 2015

Unusual twos.  Two cases from the owners of a 13-year-old cat and a 13-year-old dog from the same neighbourhood in North Singapore in successive days. As Singaporeans prefer proximity, I rarely have one case from North Singapore during the past years. The location is a 30-minute drive away and it has nearer clinics than Toa Payoh Vets. 

Vet 1 from the same clinic in North Singapore treated both cases from owners unrelated and unknown to one another. So I was much surprised at the coincidences of two sick 13-year-olds. 

CASE 1 ON SEP 15, 2015
The first case was a cat not eating and lethargic. I got a blood test done as Vet 1 had done X-rays and ultrasound but was not given the permission to do X-rays. The cat did not recover and so the owner consulted me for a second opinion. She consented to X-rays which showed a low platelet count indicating toxicity causing the left kidney to be painful. I palpated the left kidney and the cat meowed in protest, telling me that it is painful. For normal kidneys, the cat will not react to palpation.

TREATMENT - Dental scaling (gingivitis on back teeth and tartar). Left ear irrigation. IV drip x 1 bottle Hartmans with antibiotic and painkiller. Overnight inpatient. The next day, the cat ate and was meowing happily. Went home.

In retrospect, the owner recalled a possible ingestion of commercial ear drops purchased from the pet shop as the owner noted that the old cat pawed at the ear drops after she had put inside the left ear. The cat could have been poisoned resulting in ear pain. This was not obvious without the blood test. Cats are very sensitive to chemicals and pain.  

Lethargic and anorexic for 7 days. The owner had purchased ear drops  to treat the left ear discharge since April 2015. Treated by Vet 1. Ok. Problem came back in June and so she decided to buy the pet shop's ear drops which irritated the cat around 7 days before the sickness. The likely cause could be the chemical toxicity affecting the left kidney which has a radio-dense stone of 3 mm in diameter.

No hairball snacks and treats
Only First Choice For Senior Cats
I warned that the left kidney had a stone which could cause kidney pain and swelling later. As at Sep 30, 2015, the cat was eating and drinking and was active. There was no ear discharge.

The old dog's veterinary bills amounted to a large sum and so the brother who works in the same building as Toa Payoh Vets referred the sister to me.
"As the dog had heart, kidney and prostatic diseases, the bills will add up," I said to the brother today. "Chronic diseases tend to cost much to treat."  Many Singaporean owners only look at the absolute amount and would pronounce to the world: "This vet is expensive and cut-throat."

"Very high risk of death on the op table," I said to the brother and sister as the chihuahua had this loud heart murmurs of Grade 4 confirmed by Vet 1.
"50%?" the brother said.
"Hard to say it is 50:50," I would not be precise as the dog's bladder swelled up to a mango size.
Vet 1 had taken out 15 ml of the urine from the bladder by cystocentesis and given a Tardak injection to reduce the massive prostatic swelling which could cause urination problems. Two weeks ago, he had given one and the dog had no problem urinating.

On going home, the dog just could not pee and some urine dribbled out despite treatment by Vet 1. This appeared to have shaken the confidence of the owner and so the brother asked her to consult me. 

The bladder ballooned.
"It is death if you don't operate. It may be death if you opeerate," the brother told the sister. There was no time to waste. 

Weight 3.5 kg. T=37.8C. Cyanotic mucous membrane.

1. I gave 1/2 tablet Fortekor 5 orally and inject frusemide 1 ml SC and waited for 1.5 hours. The bladder had swollen to a ballon.

2. IV drip. IV baytril and tolfedine.
3. Atropine 0.6 ml SC
4. No sedatives
5. Isoflurane gas only.
6. Catheter blocked from behind the os penis where the stone was lodged. Marker pen to draw the length of catether at the obstruction. This confirms that the enlarged prostate was not the cause of this anuria as the prostate could be having tumours. In any case, Vet 1 had given Tardak injection the day before.
7. I electro-incise behind the os penis and pre-scrotal for around 3cm length. A large 4mm x 4mm brown stone was seen. 3 smaller ones of 2 mm across were seen.
8. I located the urether which was around 1.3 mm in diameter as my assistant compressed the bladder, squirting out the urine.
9. I inserted the cat catheter into the narrow urethra and stitched up the 4 holes.
10. I stitch skin and muscles to either side so as not to close up the wound in front of the catheter.

The whole process of start of anaethesia by mask to completion of stitching took around 40 minutes. The dog was alive and woke up as soon as the gas was taken off. This was a big relief to me.

1.  A vet book mentioned minimal sedation and local anaesthetic for dogs with kidney or serious health problems. In this case, the heart disease was bad. So, I did not give sedation by injection.

2. In normal urethrostomy, the catether can be seen as the urethra is incised 2-4 cm since it is placed inside from the penile tip. In this case, I had to open behind the obstruction and so was not able to view the very narrow 1.3 mm cathether of this chihuahua. I used the squirting urine to locate it and anchor the cat's cathether.

3. Today, 16 hours post-op, the dog is active and alert.

4. I advise neutering in case the prostate swelled up more to obstruct urine flow, instead of Tardak injections regularly. The anaesthetic risks of dying are there.

5. Urine test and stone analysis need to be done as a minimum. I did not ask for blood test as the owner was not in favour of additional medical cost.

6. As to the need for regular weekly SC dialysis by Vet 1, I told the brother that he ought to have blood test to check on the kidneys and whether there is still renal failure. In the meantime the dog is given Hartmann's 250 ml SC once a week.    

SEP 18, 2015
I sent the Chihuahua back on Day 2 but he licked his wound causing bleeding. There was another dog in the apartment wanting to play with him.

The dog came back and I saw a large pink purplish bruise on the right side of the scrotal area due to licking. As an in-patient, he had no distractions and was recuperating well. The owner wished to have him in-patient for the next 3 days. The catheter was still in place and the urine coming out looked clear. The dog is an in-patient now and will be given dialysis SC today.    

The prostatic enlargement will cause urination problem later and Tardak injections may need to be given regularly. A neuter would be best but the owners have their worries about anaesthetic risks and so did not accept my advice. The neuter surgery is much shorter than this urethrostomy but the risks are still there. If the dog had been neutered at a young age, there will be no prostatic hypertrophy which could cause obstruction to the flow of urine.

During surgery, I noticed that the urine from the distended bladder did not flow freely after I removed the 4-mm x 4mm urethral stone. My assistant had to compress the bladder manually to release the urine. So, it is possible that the enlarged prostate or prostatic tumour will cause dysuria.

Neuter will be the best advice but the owners think of anaesthetic risks and death and so, nothing will be done till another dysuria episode comes.
Sep 30, 2015
1.  The dog is at home. He had been neutered under a 2nd general anaesthesia. Dr Daniel did the neuter on Sep 27, 2015.  As this dog had swollen testicles, he did a scrotal ablation which involved removal of the scrotal sac as well and the testicles which may be having abnormal growth. Neuter removes the testosterone hormones which cause prostate enlargement (see X-ray) and require weekly Tardak injections. If the dog had been neutered at a young age, there would be no prostate enlargement but many young Singaporean dog owners believe it is "cruel" to neuter a dog.

There was the risk that this dog could die under the 2nd anaesthesia, being very old and in poor health. But he survived, much to the happiness of the young lady owner and family.  

2. The stone analysis of the urethral stone was calcium oxalate. The two big stones are inside the bladder.

3. The blood test showed high urea and creatinine levels and low red blood cell count and haemoglobin. This confirms that the dog has chronic kidney disease and would need the twice a week dialysis. The owner now understands that the dog needs to be given the K/D diet. The dog ate a whole can but 6 hours later vomited some food. I advised that the dog, being thirsty due to kidney failure, not be given large amounts of water to drink at one time.

4. This case illustrates the need to patiently communicate with the family members regarding the costs and treatment of the heart, kidney and prostate diseases in this old Chihuahua. Medical costs are high in chronic disesease due to the various tests and procedures required. A perseverance to train the dog owner how to give  the Prescription K/D diet to avoid more damage to the kidneys and to live longer finally pays off now. All the while, the owner feeds the dog hamburgers from McDonalds as he would not eat the K/D/



May 10, 2015. The talk at M Hotel, on Sunday, a Mother's Day was limited to 50 pax and was full house. Dr Susan Little is co-owner of 2 cat clinics and an author of cat books, amongst other veterinary achievements
Here are some of her opinions.
1.1 Stablise the cat by decompressing the bladder in some cases, before catherisation. Do cystocentesis. Insert 25-G needle at 45 degrees towards the neck of the bladder. Not at 90 degrees or into the apex of bladder as bladder shrinks away freom the needle when urine is collected.
1.2. Use 3-way stop valve to draw urine and collect it for urine analysis

1.3 Massage penile tip for some time  -around 10 minutes to express out the urethral plug and so avoid the need to catetherise. This does happen in some hh of her cases.

1.4. She uses warmed saline with sterile lubricant to flush the bladder. Apparently the lubricant is effective in cleaering the mucosa?
1.5 A commercial firm sells the appropriate cat cathether. An orange one which is softer for indwelling. The one with the stylet (costs more) but can be used for both purposes - flushing and indwelling. Has a butterfly for suturing to penile skin.
1.6. Pain relief is important. Suggested opiod and NSAID.
Medocab for cats (Boelinger?) is great as it is tasteless and given in the cat's food. She uses it.  Her opinion is that tolfedine is old school and not as good as meloxicam.  

1.7  ACP 2.5 mg/cat oral as anti-spasomodic and anti-anxiety is said to be effective.
1.8. Duration of indwelling catheter depends on lab analysis of urine and blood electrolytes.
1.9. Recurring cases. She did not mention perineal urethrostomy in her lecture.
1.10. Damage to pelvic urethra from catherisation rupture case - dye seen pooling in pelvic area on X-ray shown.
1.11. Blood test. Monitor for K+

2. FIC
2.1  Only 5% are due to bacterial infections. 60-70% idiopathic. Therefore she does not prescribe antibiotics.
2.2 Most cases are self-limiting according to her, whether treatment is given or not.
2.3 Litter boxes insufficient. Should be 4 boxes for 3 cats instead of lesser.
2.4  Pain relief is important. Opiod. Her favourite is given.
She said it is easy in her practice with the nurse holding the cat. But given sedation if necessary.
Can email to her if you have queries.

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