Perineal hernia repair surgery - queries

EMAIL TO DR SING DATED DEC 29, 2014

Hi

I brought XXX to your clinic yesterday. He is the 8 year old mini Maltese with a hernia on the right. It was recommended that we send him for surgery.
 

We love him very much and are concerned that he should not go through any suffering.

May we please know the following:

1. What are the risks of surgery and the likelihood of these risks occurring?

2. What will happen if we do not go for the surgery now? Is there an option to go for surgery later?

Thank you for your time.

Kind Regards

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EMAIL REPLY FROM DR SING DATED DEC 29, 2014

I am Dr Sing from Toa Payoh Vets.

1. The risks are mainly anaesthetic deaths on the operating table as the dog is old (more than 7 years in small breeds is considered old).
It is hard to predict the chances of survival as each dog is an individual with different outcomes.  Generally, if the dog has a normal heart and lungs, is active and eating and drinking normally, with normal stools and urine, the blood tests show normal values, then the risks are less than 1%. Such dogs survive anaesthesia and perineal hernia repair. in my experience over the last 30 years.

2. The hernia gets bigger if you wait another year. The intestinal blood vessels may get twisted when the herniated intestines in the hernia turns and twists. This results in death or emergency surgery for painful obstruction of urine flow or intestinal gangrene. In such situations, the risks are much higher.

Presently, the dog has "no problems" passing urine and stools and show "no pain" although the hernia is much larger. Therefore, you have to make an informed decision as to whether you want surgery to repair the hernia.  


Hernia now is the size of an orange. When it was small, a vet had advised that there was no need to operate as the dog could pee and poop. Over time, it mushroomed to the present size. I could feel a full bladder and the intestines could be pushed inwards, reducing the size temporarily. There was only slight pain on reduction of the hernia.
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EMAIL TO DR SING DATED DEC 30, 2014

Dear Dr Sing

 

Thanks for the reply. It is really appreciated. We just have a few follow up questions - What sort of care will Pickles require post surgery? Will he require special attention? Also, will he be able to pass urine and stools immediately after the surgery?

 

Regards

EMAIL REPLY FROM DR SING DATED DEC 30, 2014
Post-op care include wound cleaning and confined to a cage for at least 14 days so that the backside and inner stitches will not break down by jumping. A diet that does not cause hard stools to form. Can pee and poop after surgery in most cases if the intestines and bladder have not suffered inflammation and infection before surgery. Stools may be passed 2-3 days later. Pain-killers will be given for at least 4 days. Antibiotics given for 14 days generally. 

Saturday Dec 27, 2014 interesting cases - perineal hernias x 2, testicular neoplasia, facial swelling of a cat

This Saturday was unusual for me. Just non-stop consultation cases today. No time for intern Goh too.


3 most interesting cases will be made into a video by Ms Goh. They can be classified under tumours (neoplasia), inflammation and others.

1. Facial swelling in a cat is an example of inflammation.
2. Two perineal hernias in two dogs on one day are lucky for Intern Goh as this is rarely encountered. They are classified under "others."
3. Testicular neoplasia in a Japanese Spitz is an example of tumours. So Intern Goh gets to see 3 types of very interesting clinical conditions..





.

What is the treatment for this cat? Vet 1 extracted the tooth without anaesthesia as the cat is old. Vet 2 prescribed antibiotics and steroids but now the cat is not eating. The swelling had gone down.
The owner had done his internet research and consulted me on oro-nasal fistulas or carnaissal tooth abscess which he believed his cat had suffered from. Cats do get carnaissal tooth abscesses just like dogs.

I thought this was a case of nasal carcinoma or malginant nose tumours. Yet on examination and X-rays, there were no obvious signs of tumour. Based on the history of sudden yanking out of the left upper cheek tooth by the first vet, there could be traumatic damage to the area and residual remnants of the roots. X-ray of the maxillary sinus swelling (X) indicated inflammation and a possible fracture fragment (Y) of the maxillary sinus.  

What is the solution?  Which cheek tooth was extracted by Vet 1 the owner did not know. It was an upper left cheek tooth.

2-month-old guinea pig screams sometimes

The owner bought a pair of 2-month-old guinea pigs and housed them together. One was screaming now and then but both were eating.

"Do you have Revolution? Are they having skin mites?" the mum asked. I put the guinea pig onto a piece of white paper and rustled the body hair. No hair dropped off and 2 or 3 black specks. The black specks were not mites as seen under the microscope.

"No mites in the body," I put a thin cotton bud into Alice's ears. "Black dirty wax was seen and the guinea pig squealed."  When I did this on the other pig, there was no pain response. Both were bought from different sellers.  

"Do they use their hind legs to scratch the sides of the body?" I asked.
"Yes, Yes," mum said.
"This is due to ear pain or infections," I explained that cats and dogs with ear infections do it consistently.

I advised ear cleaning 3X/week with the ear ointment containing insectide  and separation of the two for one month with a grated barrier such that they can smell and see each other, to prevent bullying.

Overall the guinea pigs look thin and so should be alone to put on weight

 

Email from Cairo. Cat with FLUTD? Part 2

Email dated Dec 25, 2014 from cat owner in Cairo


Hello Dr Sing Kong Yuen,

Sorry for the late response, I was waiting for all test results to come in.

We live in Egypt, where vet care is really really bad, you will notice in the x-rays that they use inferior equipment, I had to take photos with my mobile.

Please help us, please, we are losing our boy and are devastated.

Our Persian boy is 7 and a half years old..

About two weeks ago he started squatting for urine but nothing would come out, he had shown some signs of excess visiting to the litter box around last March but with no blockage and the blood tests came out normal then, so the vet said it was an infection and after a 3 day antibiotic course he was ok, this time he vomited on Sunday and sneezed so we thought it was cold , then on Monday symptoms was clear , he spent the whole day in the litter box squatting with no urination at all, by evening we took him to the vet who emptied his bladder (and clear urine came out then) and told us not to worry , and prescribed him meloxicam and enrofloxacin , we returned home he kept staying in the litter box the whole night with nothing came out, and finally he woke us up at 8am on Sunday morning screaming of pain !!

We rushed to the only vet clinic we could find open this early, they had difficulty inserting a cannula and catheter tube up the penis, but eventually they relieved him off a huge amount of very bloody urine.

Later that day his vet catheterized him and put him on meloxicam and enrophloxacin again for 6 days and IV fluids to flush his body of the urine. and said the catheter would come off in 4 days and he would be able to urinate on his own as by then the swelling that blocked him would be gone, then he went on vacation, and his substitute insists on surgery (PU) with no promise that he will have control over his urination, provided that he makes it through surgery, that is if the catheter doesn't work. Until we made our minds, he was put on epicephine for another 3 days

4 days later the catheter came off, and by then his urine was clear... after 4 hours he was squatting again.. We had to spend the night trying to express his bladder but he kept squatting.. In the morning he was catheterized, bloody urine again, and later that day drew blood and urine samples...

His BUN was very high (93 out of 30), his creatinine (3.4 out of 2) not very high yet not normal though, his white cell count is gigantic, the urine contained few crystals of magnesium, and some blood. The xray showed no big stones but turbid urine, he has crystals, he was put on Vitamin C , Cystone, Synolux antibiotic for 6 days , Azodyl , while continuing the IV fluids.

To us surgery is out of the question because of his age and kidneys, and seeing how much the procedure is not sure-fire. He is on Royal Canin Renal S/O renal wet food now and still catheterized after almost 10 days.
Now we gotta get the catheter removed but we are too scared to get to square one , after all medications and antibiotics , we really don't know what to do?, will another catheter help? Or what?

He removed the second catheter today, the penis is very swollen and I don't suspect he will be able to urinate on his own again.

/UPDATE/ he went to the litter box, squatted, and urinated a fair amount, and left the box on his own, now he is roaming the house purring looking for a place to cuddle, he is very intent on licking himself all over, not just the penis. We still fear for the next time he has to go. It is 9.15AM Cairo local time

Thanks in advance Dr.

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EMAIL REPLY FROM DR SING DATED DEC 25, 2014

 

I am Dr Sing Kong Yuen. 

1.  X-ray shows bladder packed with stones (attached).
2.  My recommendation is surgery to open up the bladder to remove the stones.

Cystotomy to open up the bladder and removed all stones, including those from the urethra. Your vet will know what to do. Then put the cat on a prescription diet which acidifies the urine, antibiotics and pain-killers. The urine must be analysed monthly for at least the next 3 months. This will be my recommendation to clients.

3.  Your vet advised PU (perineal urethrostomy) which is another surgical option. 

4.  Coincidentally, I have a similar case in the dog and operated on Dec 23, 2014. The 9-year-old dog is OK at home now. See:
http://2010vets.blogspot.sg/2014/12/1150-westie-x-had-fully-packed-bladder.html

5. There is no other option for you and the risks of anaesthesia are always there. Best wishes.



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EMAIL TO DR SING DATED DEC 26, 2014


Hello Dr Sing Kong Yuen,

 

Thanks a lot for taking time to review the case.

We have a number of questions here

1- Are you sure the bladder shown in the x-ray is full of stones? the local vet said it was just inflamed and otherwise invisible and had to inject saline fluid through catheter in order to increase it's size enough to see in the x-ray, furthermore, when he's just been to the litter box, his bladder feels very deflated, like an empty sac. We are unable to properly monitor his urine but when we can, it appears clear, not turbid or bloody.

2- Can these stones be dissolved by medication? He is taking Vitamin C and Cystone daily, I am asking because vets in Egypt are unable to perform the surgery, they say it is too risky because urine might escape and infect him, they are afraid to do it.

3- He is now urinating on his own without a catheter, on average once every 2 hours, eating and drinking well for about 24 hours now, and appears overall happy, there was inflammation in the penis and urethra when the catheter was removed, so the vet prescribed Dexa to reduce the inflammation, he said all we needed to do now was monitor him for blockages. We researched Dexa and are reluctant to continue with it considering his renal condition.

4- I saw the case you performed on (the 9-yr old terrier), the X-Ray does show a very large number of stones, and I do thank you for saving his life.

We appreciate any help you might be able to provide in prolonging his life, and Merry Christmas :)

Dr,

One other thing, I have inspected the physical film I have here for the x-ray, in the photos, it does appear to have granules because the whole photo is somehow pixelated, but in the physical film it appears smooth and opaque.

Just a thought that might help. and sorry for disturbing you.

 

 

EMAIL REPLY FROM DR SING  DATED DEC 26, 2014

Pl send the actual X-ray rather than the handphone x-ray. Stones are small and the vet might have syringed them out now.  If cat is OK, then no need surgery. If urine pH is alkaline, given acidifiers and antiibiotics and follow up with Hills' prescription C/D food or equivalent from Royal Canin etc. . 

A 7-year-old rabbit passed away on Christmas

The thin 7-year-old black and white rabbit was a present for the older boy. The rabbit was lethargic yesterday and today. Behaved abnormally by being hyperexcited and squeezed through the bars of the fencing.

I asked the caller to come before 12 noon. The family came at 11.40 am. The rabbit's tongue turned cyanotic as he stretched and wanted to spring forward. He passed away after this behaviour was exhibited. The tongue had turned pale. The eyelids were pale. There could be internal haemoorrhage as he squeezed in between the fences.

Reddish brown urine passed out, indicating a urinary tract infection. The rabbit was cremated. A sad Christmas for 2 pre-teen brothers as they felt the loss badly esp. the elder one.

The rabbit was thin and could have suffered an infection some weeks ago.

The old Jack Russell had more black and red skin spots - to follow up

Tuesday, Dec 23, 2014

The busy working lady owner of this 11-year-old male neutered Jack Russell complained that the dog's skin disease was not cured despite 2 consultations with my associate vet. "The Z/D is ineffective," she said. I asked her to show me the images of the skin diseases in her handphone.

"The red circular spots and more black circular spots are suggestive of ringworm infections," I said.
"You are in human resources and will know the diversity of human personalities," I explained. "Vets have their own findings and conclusions about skin diseases which can be due to many causes. Environmental cause such as food allergies, contact with chemicals are some causes."





"Does ringworm affect people?" she asked.
"Yes," I said. "Some people develop red rashes on their hands and lap and even chest where the dog had contact after being hugged or carried."
"I had itchy rashes on my right wrist and had to consult the doctor," she said. "It took some time to heal with antibiotics and other drugs."
"It was probably ringworm," I said. "Did you have rashes on your lap too?"
"Yes! yes!" she said.
"On your chest area?"
"No, I don't hug my dog."


"Ringworm is hard to confirm sometimes. Negative findings of hairs may not mean there is no ringworm. I need to review the dog this Sunday morning."

"Can the black spots disappear?" she asked.
"They are due to hyperpigmentation as a result of you applying some cream  for many weeks," I said.
"I didn't do it," she replied.
"Some long-time licking by the dog or lotion or wash," I said. "Black skin pigments migrate to the infected areas."

"Does the dog go to the groomer?" I asked as sometimes ringworm is contacted by grooming with infected blades and scissors.
"Yes, just last month," she said.


I need to follow up this case to determine whether it is ringworm.  

1151. A strange dog owner. Calcium oxalate crystals in the urine

This man brought in his dog's urine sample for analysis of bladder stones as a follow up.  I had advised earlier but he did not come.

Before I could say further about the presence of calcium oxalate crystals in the urine, he said: "I will go to this vet practice. They have all equipment to check my dog for calcium oxalate.  The practice's staff phoned me about "calcium oxalate." 

I told her to get her vet to X-ray for urinary stones and to test the dog with all the equipment as that was what he wanted. A strange dog owner who had not wanted to hear any advices on the urine test. 

The practice with all the equipment will definitely be more attractive to dog owners.