I reviewed another case of struvite urinary stones in a male Jack Russell with blood in the urine. The stones were struvites on analysis and were removed by my associate vet in April 2012. The stone analysis case report has the words from the vet: "called owner several times, no answer".
The lab report stated positive for stones of calcium, phosphate, magnesium and ammonia. The last 3 consituted struvite stones.
The owner did not come back after the operation and this is a very common situation as many Singapore dog owners have not reached that level of knowledge to know that struvite urinary stones can recur and can easily be detected early and dissolved using special prescription diet.
I wrote a note to this owner to let her know. It is not practical to keep track of every urinary stone removal surgery if the owner has no interest in following up. Maybe 5 years from now, the internet generation will be much more sophisticated and educated and know what to do.
In the meantime, should there be a URINARY STONE REVIEW REMINDER similar to a vaccination health wellness reminder?
Monday, September 17, 2012
Saturday, September 15, 2012
1097. Toa Payoh Vets - Advices after struvite bladder surgery
Today, Saturday Sep 15, 2012, I reviewed a case of struvite urinary stones removed by my associate vet from the bladder of a Samoyed, female, 3 years old.
Jun 17, 2012
Three dogs (labradpoodle, corgi and Samoyed) came for check up and vaccination. Vet A palpated a few bladder stones in the Samoyed and advised surgery.
Jun 22, 2012
Urine test pH 9.0, Blood 4+, Bacteria 2+, Crystals Triple phosphate 2+, Amorphous phosphate 2+
Jun 22, 2012
Cystostomy. Bladder stones removed. >6 pieces of different sizes. Stones sent for analysis.
Jun 28, 2012
Stone analysis report - Calcium trace, Phosphate +ve, Oxalate trace, Magnesium +ve, Ammonia +ve
Vet A informed owner on Jun 30, 2012 and recorded "advised s/d diet".
Jun 25, 2012. Records showed 6 cans of S/D were purchased. No more.
CONCLUSION
This is a typical case. Many owners feel that since stones are removed and a couple of cans of S/D diet has been given, that is the end of the story. The dog shares the dry food again with the other 2 dogs and struvite stones recur again later.
ADVICES
There needs to be montly urine check up and X-rays 3-monthly for bladder stones.
SD diet for 1-3 months and CD diet for another 3 months and do above-mentioned tests till no stones and no abnormally high alkaline pH + bacteria in the urine. However, owners seldom follow up and as you can see, from a sad case of the Shih Tzu with the blocked bladder I did recently, a lot of emotions and money had to be spent for recucrring bladder surgeries.
Simple prevention by check up and special dietary management will have prevent recurrences and expenses but sadly, many Singapore owners do not appear to be interested in follow ups or check up after stone removal surgeries. Many may just get the dog put to sleep if there is recurrence again and again as surgical expenses can be too much for them.
For this Samoyed owner, I wrote a letter to the owner to advise the check ups and monitoring.
Jun 17, 2012
Three dogs (labradpoodle, corgi and Samoyed) came for check up and vaccination. Vet A palpated a few bladder stones in the Samoyed and advised surgery.
Jun 22, 2012
Urine test pH 9.0, Blood 4+, Bacteria 2+, Crystals Triple phosphate 2+, Amorphous phosphate 2+
Jun 22, 2012
Cystostomy. Bladder stones removed. >6 pieces of different sizes. Stones sent for analysis.
Jun 28, 2012
Stone analysis report - Calcium trace, Phosphate +ve, Oxalate trace, Magnesium +ve, Ammonia +ve
Vet A informed owner on Jun 30, 2012 and recorded "advised s/d diet".
Jun 25, 2012. Records showed 6 cans of S/D were purchased. No more.
CONCLUSION
This is a typical case. Many owners feel that since stones are removed and a couple of cans of S/D diet has been given, that is the end of the story. The dog shares the dry food again with the other 2 dogs and struvite stones recur again later.
ADVICES
There needs to be montly urine check up and X-rays 3-monthly for bladder stones.
SD diet for 1-3 months and CD diet for another 3 months and do above-mentioned tests till no stones and no abnormally high alkaline pH + bacteria in the urine. However, owners seldom follow up and as you can see, from a sad case of the Shih Tzu with the blocked bladder I did recently, a lot of emotions and money had to be spent for recucrring bladder surgeries.
Simple prevention by check up and special dietary management will have prevent recurrences and expenses but sadly, many Singapore owners do not appear to be interested in follow ups or check up after stone removal surgeries. Many may just get the dog put to sleep if there is recurrence again and again as surgical expenses can be too much for them.
For this Samoyed owner, I wrote a letter to the owner to advise the check ups and monitoring.
Friday, September 14, 2012
1095. 8-year-old Mini Schnauzer still vomiting
Yesterday, at 8.15 pm, the gentleman came with his 8 years old, Schnauzer, Female, Spayed last year by my associare vet was still vomiting and though we close at 8 pm, I waited for the dog.
"She did not vomit when hospitalised here and ate food," my associate vet (Vet X) said. I noted that the dog was thin and moderately dehydrated.
"Was an X-ray done?" I asked.
"No," Vet X said. "An ultrasound showed nothing except some gastric fluid."
I advised a barium meal test the next day. Strange case. No pain or foreign body/lumps inside the abdomen when I palpated. Lost a lot of weight. I will follow up on this case. Some tumour in the oesophagus/upper area?
"She did not vomit when hospitalised here and ate food," my associate vet (Vet X) said. I noted that the dog was thin and moderately dehydrated.
"Was an X-ray done?" I asked.
"No," Vet X said. "An ultrasound showed nothing except some gastric fluid."
I advised a barium meal test the next day. Strange case. No pain or foreign body/lumps inside the abdomen when I palpated. Lost a lot of weight. I will follow up on this case. Some tumour in the oesophagus/upper area?
1094. Pyometra surgery cost - email query
> On Sep 13, 2012, at 0:23, Andrea ..hotmail.com> wrote:
> Subject: Re: Regarding pyometra in female dogs
> > Hi, just would like to check. If my schnauzer has bloated tummy, but no other symptoms, can it be pyometra? And if it is, how much will surgery cost to remove the uterus?
> > Sent from my iPhone
EMAIL REPLY FROM DR SING
> Date: Thu, 13 Sep 2012 13:22:29 +0800
> To: ..@hotmail.com
Need a vet examination to know about pyo. Estmated cost is from $ 500 to $700. Pl make appt with dr sing thanks
okay, then for examination, how much does the consultation cost? The range between ? - ?
EMAIL REPLY FROM DR SING
$25 to $40
1090. Article for Pet's Magazine - edited
ORIGINAL ARTICLE FROM EDITOR TO DR SING RECEIVED SEP 14, 2012
FOR EDITING
Issue Pets Vet Supplement Oct’12
Column Dogs – Toa Payoh Vets
Word Count 609
Pullout quote
Submission Date 7/8/12
Headline Struvite bladder stones in dogs
Standfirst
Notes (if any) 1pp
What are bladder stones?
Bladder stones or uroliths are common in domesticated animals. They can be formed anywhere along the urinary tract in the kidneys, the urethra and the bladder when the urine is supersaturated with magnesium, ammonium and phosphate (MAP). MAP supersaturation may be associated with several factors, including urinary tract infections, alkaline urine, genetic predisposition and diet. Breeds usually affected by struvite bladder stones include the Miniature Schnauzer, Shih Tzu, Bichon Frise, Miniature Poodle, Cocker Spaniel and Lhasa Apso, but any breed can be affected. Female dogs are said to form approximately 85% of bladder stone cases.
Symptoms of bladder stones
Some dogs may not show clinical signs such as blood in the urine, difficulty in urination, or inability to urinate, until much later in the disease with severity of signs depending on the location, size, and number of uroliths formed. Your vet will take a comprehensive history to determine the start and severity of the disease. Physical examination includes bladder palpation to feel the crepitus (sounds of gas and stones rubbing against each other) inside the bladder or the solid stones if they are large.
Diagnosis
Urine analysis is the most useful and a sterile sample is taken by catheterisation or cystocentesis (straight from the bladder). The pH of your dog’s urine will also give a good idea of the nature of the stone. The urine sample will show the presence of bacteria, which is usually cultured to find out the type of bacteria causing the infection. Antibiotic sensitivity tests are needed to figure out what appropriate antibiotics can be prescribed.
Uroliths need to be of a certain size before they are evident. The number and size of urinary stones seen in the x-ray may not correlate with the severity of clinical signs. A radiograph is highly recommended to find out the number and size of stones and where they are located prior to surgical removal, if surgery is required. In spite of all the tests above, the composition of the actual stone cannot be determined unless a stone sample (from the surgery or that has been urinated out) is sent for analysis.
Treatment
There are two types of treatment for bladder stones; surgery or medical dissolution of the stones. The benefits of surgery include a shorter recovery period and the ability to identify the actual type of stone involved. Surgery is needed if the stones are too large as they may not dissolve medically. Disadvantages of surgery are that it is more invasive and there are risks associated with general anesthesia in a sick and/or older dog.
Medical dissolution takes a much longer time (about three months on average) to take effect and large stones may not dissolve at all. It revolves around three main concepts – to acidify urine, reduce the intake of MAP such that it does not saturate in the urine and dilute urine so crystals do not have a chance to form. Affected dogs are usually prescribed calculytic diets and appropriate antibiotics to treat and bacterial infections. No other food or treats should be given and plenty of water drinking should be encouraged.
Most importantly, your dog’s health should be reviewed every three months with urine tests and X-rays to ensure that no new stones are. Be alert as to the urination pattern of your older dog and seek veterinary advice promptly if there are signs of discoloured urine, urinary difficulty or inability to pee.
Dr Sing KongYuen
BVMS (Glasgow), MRCVS
Toa Payoh Vets
_________________________________________________________________________ ARTICLE EDITED BY DR SING
What are bladder stones?
Bladder stones or uroliths are common in domesticated animals. There are many types of bladder stones depending on their composition.
Struvite bladder stones
Struvite bladder stones are most commonly seen in canine cases at Toa Payoh Vets and this article is to educate dog owners regarding their diagnosis and treatment. They can be formed anywhere along the urinary tract in the kidneys, the urethra and the bladder when the urine is supersaturated with magnesium, ammonium and phosphate (MAP). MAP supersaturation may be associated with several factors, including urinary tract infections, alkaline urine, genetic predisposition and diet. Breeds usually affected by struvite bladder stones include the Miniature Schnauzer, Shih Tzu, Bichon Frise, Miniature Poodle, Cocker Spaniel and Lhasa Apso, but any breed can be affected. Female dogs are said to form approximately 85% of bladder stone cases.
Symptoms of bladder stones
Some dogs may not show clinical signs such as blood in the urine, difficulty in urination, or inability to urinate, until much later in the disease with severity of signs depending on the location, size, and number of uroliths formed. Your vet will take a comprehensive history to determine the start and severity of the disease. Physical examination includes bladder palpation to feel the crepitus (sounds of gas and stones rubbing against each other) inside the bladder or the solid stones if they are large.
Diagnosis
Urine analysis is the most useful and a sterile sample is taken by catheterisation or cystocentesis (straight from the bladder). The pH of your dog’s urine will also give a good idea of the nature of the stone. The urine sample will show the presence of bacteria, which is usually cultured to find out the type of bacteria causing the urinary tract infection. Antibiotic sensitivity tests are needed to figure out what appropriate antibiotics can be prescribed.
Uroliths need to be of a certain size before they are evident. The number and size of urinary stones seen in the x-ray may not correlate with the severity of clinical signs. A radiograph is highly recommended to find out the number and size of stones and where they are located prior to surgical removal, if surgery is required. In spite of all the tests above, the composition of the actual stone cannot be determined unless a stone sample (from the surgery or that has been urinated out) is sent for analysis.
Treatment
There are two types of treatment for struvite bladder stones; surgery or medical dissolution of the stones. The benefits of surgery include a shorter recovery period and the ability to identify the actual type of stone involved. Surgery is needed if the stones are too large as they may not dissolve medically. Disadvantages of surgery are that it is more invasive and there are risks associated with general anesthesia in a sick and/or older dog.
Medical dissolution takes a much longer time (about three months on average) to take effect and large stones may not dissolve at all. It revolves around three main concepts – to acidify urine, reduce the intake of MAP such that it does not saturate in the urine and dilute urine so crystals do not have a chance to form. Affected dogs are usually prescribed calculytic diets and appropriate antibiotics to treat the * bacterial infections. No other food or treats should be given and plenty of water drinking should be encouraged.
Most importantly, your dog’s health should be reviewed every three months with urine tests and X-rays to ensure that no new stones are. Be alert as to the urination pattern of your older dog and seek veterinary advice promptly if there are signs of blood in the * urine, urinary difficulty or inability to pee.
Dr Sing KongYuen
BVMS (Glasgow), MRCVS
Toa Payoh Vets
Article edited.
1. Letters in bold are new.
2. * = word/alphabet deleted.
FOR EDITING
Issue Pets Vet Supplement Oct’12
Column Dogs – Toa Payoh Vets
Word Count 609
Pullout quote
Submission Date 7/8/12
Headline Struvite bladder stones in dogs
Standfirst
Notes (if any) 1pp
What are bladder stones?
Bladder stones or uroliths are common in domesticated animals. They can be formed anywhere along the urinary tract in the kidneys, the urethra and the bladder when the urine is supersaturated with magnesium, ammonium and phosphate (MAP). MAP supersaturation may be associated with several factors, including urinary tract infections, alkaline urine, genetic predisposition and diet. Breeds usually affected by struvite bladder stones include the Miniature Schnauzer, Shih Tzu, Bichon Frise, Miniature Poodle, Cocker Spaniel and Lhasa Apso, but any breed can be affected. Female dogs are said to form approximately 85% of bladder stone cases.
Symptoms of bladder stones
Some dogs may not show clinical signs such as blood in the urine, difficulty in urination, or inability to urinate, until much later in the disease with severity of signs depending on the location, size, and number of uroliths formed. Your vet will take a comprehensive history to determine the start and severity of the disease. Physical examination includes bladder palpation to feel the crepitus (sounds of gas and stones rubbing against each other) inside the bladder or the solid stones if they are large.
Diagnosis
Urine analysis is the most useful and a sterile sample is taken by catheterisation or cystocentesis (straight from the bladder). The pH of your dog’s urine will also give a good idea of the nature of the stone. The urine sample will show the presence of bacteria, which is usually cultured to find out the type of bacteria causing the infection. Antibiotic sensitivity tests are needed to figure out what appropriate antibiotics can be prescribed.
Uroliths need to be of a certain size before they are evident. The number and size of urinary stones seen in the x-ray may not correlate with the severity of clinical signs. A radiograph is highly recommended to find out the number and size of stones and where they are located prior to surgical removal, if surgery is required. In spite of all the tests above, the composition of the actual stone cannot be determined unless a stone sample (from the surgery or that has been urinated out) is sent for analysis.
Treatment
There are two types of treatment for bladder stones; surgery or medical dissolution of the stones. The benefits of surgery include a shorter recovery period and the ability to identify the actual type of stone involved. Surgery is needed if the stones are too large as they may not dissolve medically. Disadvantages of surgery are that it is more invasive and there are risks associated with general anesthesia in a sick and/or older dog.
Medical dissolution takes a much longer time (about three months on average) to take effect and large stones may not dissolve at all. It revolves around three main concepts – to acidify urine, reduce the intake of MAP such that it does not saturate in the urine and dilute urine so crystals do not have a chance to form. Affected dogs are usually prescribed calculytic diets and appropriate antibiotics to treat and bacterial infections. No other food or treats should be given and plenty of water drinking should be encouraged.
Most importantly, your dog’s health should be reviewed every three months with urine tests and X-rays to ensure that no new stones are. Be alert as to the urination pattern of your older dog and seek veterinary advice promptly if there are signs of discoloured urine, urinary difficulty or inability to pee.
Dr Sing KongYuen
BVMS (Glasgow), MRCVS
Toa Payoh Vets
_________________________________________________________________________ ARTICLE EDITED BY DR SING
What are bladder stones?
Bladder stones or uroliths are common in domesticated animals. There are many types of bladder stones depending on their composition.
Struvite bladder stones
Struvite bladder stones are most commonly seen in canine cases at Toa Payoh Vets and this article is to educate dog owners regarding their diagnosis and treatment. They can be formed anywhere along the urinary tract in the kidneys, the urethra and the bladder when the urine is supersaturated with magnesium, ammonium and phosphate (MAP). MAP supersaturation may be associated with several factors, including urinary tract infections, alkaline urine, genetic predisposition and diet. Breeds usually affected by struvite bladder stones include the Miniature Schnauzer, Shih Tzu, Bichon Frise, Miniature Poodle, Cocker Spaniel and Lhasa Apso, but any breed can be affected. Female dogs are said to form approximately 85% of bladder stone cases.
Symptoms of bladder stones
Some dogs may not show clinical signs such as blood in the urine, difficulty in urination, or inability to urinate, until much later in the disease with severity of signs depending on the location, size, and number of uroliths formed. Your vet will take a comprehensive history to determine the start and severity of the disease. Physical examination includes bladder palpation to feel the crepitus (sounds of gas and stones rubbing against each other) inside the bladder or the solid stones if they are large.
Diagnosis
Urine analysis is the most useful and a sterile sample is taken by catheterisation or cystocentesis (straight from the bladder). The pH of your dog’s urine will also give a good idea of the nature of the stone. The urine sample will show the presence of bacteria, which is usually cultured to find out the type of bacteria causing the urinary tract infection. Antibiotic sensitivity tests are needed to figure out what appropriate antibiotics can be prescribed.
Uroliths need to be of a certain size before they are evident. The number and size of urinary stones seen in the x-ray may not correlate with the severity of clinical signs. A radiograph is highly recommended to find out the number and size of stones and where they are located prior to surgical removal, if surgery is required. In spite of all the tests above, the composition of the actual stone cannot be determined unless a stone sample (from the surgery or that has been urinated out) is sent for analysis.
Treatment
There are two types of treatment for struvite bladder stones; surgery or medical dissolution of the stones. The benefits of surgery include a shorter recovery period and the ability to identify the actual type of stone involved. Surgery is needed if the stones are too large as they may not dissolve medically. Disadvantages of surgery are that it is more invasive and there are risks associated with general anesthesia in a sick and/or older dog.
Medical dissolution takes a much longer time (about three months on average) to take effect and large stones may not dissolve at all. It revolves around three main concepts – to acidify urine, reduce the intake of MAP such that it does not saturate in the urine and dilute urine so crystals do not have a chance to form. Affected dogs are usually prescribed calculytic diets and appropriate antibiotics to treat the * bacterial infections. No other food or treats should be given and plenty of water drinking should be encouraged.
Most importantly, your dog’s health should be reviewed every three months with urine tests and X-rays to ensure that no new stones are. Be alert as to the urination pattern of your older dog and seek veterinary advice promptly if there are signs of blood in the * urine, urinary difficulty or inability to pee.
Dr Sing KongYuen
BVMS (Glasgow), MRCVS
Toa Payoh Vets
Article edited.
1. Letters in bold are new.
2. * = word/alphabet deleted.
Thursday, September 13, 2012
1089. Follow up: No further leakage into SC area - blocked bladder Shih Tzu
A bright sunny morning on Thursday, Sep 13, 2012. I went to the Surgery at 8.45 am as usual. Dr Daniel is in Langkawi yesterday. I handled his post-op cases including this Shih Tzu with complications of blocked bladder. As his mentor, I took over the case as it was too complicated for him, being a recent graduate, to handle.
In any case, every vet has his or her own approach to resolving a challenging post-operation problem and his was to stitch up the original urethrostomy so that the dog could pee from the normal penile opening when he took over the case around 5 days ago from the other vet who had done a bladder surgery. But after the bladder surgery, there was large swelling in the prepuce and scrotal sac and possibly in the left inguinal area but this was denied.
But the other vet said that the scrotal sac was filled with fluid as found out on ultrasound. As to whether the fluid was urine (from a damaged urethra at the bend of the urethra via difficult initial catherisation) or pus and blood or all 3, she said that ultrasound would not be able to by thdifferentiate. Ultrasound would indicate the presence of fluid. I did not ask if she had aspirated the scrotal sac. In any case, she had recommended a 2nd hole (2nd urethrostomy) to be opened up and closed the first hole which was obstructed with pus and fibrous tissue. The owner did not want another surgery costing $1,200 and so, the case came to Dr Daniel.
He did a castration (testicles abnormally small) and removed white fatty tissue in the swollen left inguinal area (size of 6 cm x 6 cm containing around 30 ml of blood + fluid aspirated daily for the past 4 days) as requested by the owner. I had asked him why he did it as this dog already had much complications of not being able to pee normally. He ought not have done it but the owner had asked for this service.
After his excision of the left inguinal area fat, fluid + blood of around 30 ml (aspirated daily) accumulate every day for the next 3 days. Why? What was it? The urine was passed via the cathether and did not contain blood. He irrigated the bladder daily and the dog was OK, till on Day 4 when the dog had fever and there was some tissues inside the urine passed out.
As he would be going on leave and in any case, this was such a complicated emotional expensive case (the owner having spent over $2000 on the blocked bladder surgery and more money on the earlier 2 related urinary stone surgeries, excluding expenses at Toa Payoh Vets, I took over the case. There is so much time spent on commuicating with the owner who visited every evening and this time spent are not billed though young vets don't realise it.
NO FURTHER LEAKAGE
Yesterday, from 10 am, I did a 2-hour surgery to cut off the hard scrotal sac and opened up the first urethra hole done by a vet some months ago. I extended the incision. My hypothesis is that the SC fluid in the left inguinal area could have come from the bladder via the leakage from the urethral opening (lst urethrostomy) which, though stitched up with 2 interrupted sutures, was found to still be opened in between the two stitches. The opening was around 3mm in length and I suspected the leakage over 24 hours would be from there into the SC area.
However the lab could NOT determine whether the SC fluid + blood sent by me was urine or not and so this part of the mystery could not be resolved.
The important thing is that the SC area should not again be filled with 30 ml of fluid + blood every morning as in the past 4 days leading to pain for the dog and fever on the 4th day before Dr Daniel left for Langkawi (ie. on Tuesday). My hypothesis is that the urethra further up, at the bend was damaged and caused pain during urination. Therefore the dog could not pee properly and the other vet had suggested a 2nd urethrostomy nearer to the bend and scrotal ablation (cut off the scrotal sac).
Where's the leak? Was it from the damaged urethra at the bend? This was most consistent with the filling up of the scrotal sac after the blocked bladder surgery and difficult catherisation of the urethra (the other vet said a cat catheter - smaller in diameter had to be used as it was difficult to catherise the urethra due to blockage by pus and fibrous tissue around the first hole). So, urine leaked into the scrotal sac which had two testicles. The testicles became smaller due to compression of the testicles by urine and blood from the urethra damage at the bend (ultrasound had been done to show fluid inside the scrotal sac, as said by the other vet.). Urine also back-flowed to the big left inguinal area where the mass of fat had been removed.
Therefore, in theory, if I extended the first hole, the urine leakage from the bend into the SC tissues into the scrotal sac (no fluid on needle aspiration yesterday. Filled with reddish brown hard tissues and pockets of pus, with testicles already removed by Dr Daniel 3 days ago).
So, in hypothesis, if I did the above surgery (extended the first urethrostomy and do scrotal ablation), the SC fluid inside the inguinal area should not be present.
At 9 am today, I checked the dog and took some images. The hypothesis was verified and there was no swelling. The dog was much happier in the behaviour that when he was turned upside down to examine his inguinal area and do dressing, he did not protest and cried loudly as in the past 4 days.
It was good news. I hope this article will help other vets with similar complications. Never open another hole in the urethra. Just unblock the first hole and extend it. Never suture the first urethra and hope it will close as it might not. In any case, a continuous inverting suture would be needed as in uterine or gastric closing, not interrupted sutures. In any case, this area was infected badly and so, it is doubtful that it would heal well, without stricture and causing obstruction again. A dye would reveal the urine leakage area but the owner would never pay for this and the other vet said she had done nothing wrong and why should her management pay for this test?
In practical terms, resolve the owner's dog complications at the least cost. It is easy for me to criticise.
In any case, every vet has his or her own approach to resolving a challenging post-operation problem and his was to stitch up the original urethrostomy so that the dog could pee from the normal penile opening when he took over the case around 5 days ago from the other vet who had done a bladder surgery. But after the bladder surgery, there was large swelling in the prepuce and scrotal sac and possibly in the left inguinal area but this was denied.
But the other vet said that the scrotal sac was filled with fluid as found out on ultrasound. As to whether the fluid was urine (from a damaged urethra at the bend of the urethra via difficult initial catherisation) or pus and blood or all 3, she said that ultrasound would not be able to by thdifferentiate. Ultrasound would indicate the presence of fluid. I did not ask if she had aspirated the scrotal sac. In any case, she had recommended a 2nd hole (2nd urethrostomy) to be opened up and closed the first hole which was obstructed with pus and fibrous tissue. The owner did not want another surgery costing $1,200 and so, the case came to Dr Daniel.
He did a castration (testicles abnormally small) and removed white fatty tissue in the swollen left inguinal area (size of 6 cm x 6 cm containing around 30 ml of blood + fluid aspirated daily for the past 4 days) as requested by the owner. I had asked him why he did it as this dog already had much complications of not being able to pee normally. He ought not have done it but the owner had asked for this service.
After his excision of the left inguinal area fat, fluid + blood of around 30 ml (aspirated daily) accumulate every day for the next 3 days. Why? What was it? The urine was passed via the cathether and did not contain blood. He irrigated the bladder daily and the dog was OK, till on Day 4 when the dog had fever and there was some tissues inside the urine passed out.
As he would be going on leave and in any case, this was such a complicated emotional expensive case (the owner having spent over $2000 on the blocked bladder surgery and more money on the earlier 2 related urinary stone surgeries, excluding expenses at Toa Payoh Vets, I took over the case. There is so much time spent on commuicating with the owner who visited every evening and this time spent are not billed though young vets don't realise it.
NO FURTHER LEAKAGE
Yesterday, from 10 am, I did a 2-hour surgery to cut off the hard scrotal sac and opened up the first urethra hole done by a vet some months ago. I extended the incision. My hypothesis is that the SC fluid in the left inguinal area could have come from the bladder via the leakage from the urethral opening (lst urethrostomy) which, though stitched up with 2 interrupted sutures, was found to still be opened in between the two stitches. The opening was around 3mm in length and I suspected the leakage over 24 hours would be from there into the SC area.
However the lab could NOT determine whether the SC fluid + blood sent by me was urine or not and so this part of the mystery could not be resolved.
The important thing is that the SC area should not again be filled with 30 ml of fluid + blood every morning as in the past 4 days leading to pain for the dog and fever on the 4th day before Dr Daniel left for Langkawi (ie. on Tuesday). My hypothesis is that the urethra further up, at the bend was damaged and caused pain during urination. Therefore the dog could not pee properly and the other vet had suggested a 2nd urethrostomy nearer to the bend and scrotal ablation (cut off the scrotal sac).
Where's the leak? Was it from the damaged urethra at the bend? This was most consistent with the filling up of the scrotal sac after the blocked bladder surgery and difficult catherisation of the urethra (the other vet said a cat catheter - smaller in diameter had to be used as it was difficult to catherise the urethra due to blockage by pus and fibrous tissue around the first hole). So, urine leaked into the scrotal sac which had two testicles. The testicles became smaller due to compression of the testicles by urine and blood from the urethra damage at the bend (ultrasound had been done to show fluid inside the scrotal sac, as said by the other vet.). Urine also back-flowed to the big left inguinal area where the mass of fat had been removed.
Therefore, in theory, if I extended the first hole, the urine leakage from the bend into the SC tissues into the scrotal sac (no fluid on needle aspiration yesterday. Filled with reddish brown hard tissues and pockets of pus, with testicles already removed by Dr Daniel 3 days ago).
So, in hypothesis, if I did the above surgery (extended the first urethrostomy and do scrotal ablation), the SC fluid inside the inguinal area should not be present.
At 9 am today, I checked the dog and took some images. The hypothesis was verified and there was no swelling. The dog was much happier in the behaviour that when he was turned upside down to examine his inguinal area and do dressing, he did not protest and cried loudly as in the past 4 days.
It was good news. I hope this article will help other vets with similar complications. Never open another hole in the urethra. Just unblock the first hole and extend it. Never suture the first urethra and hope it will close as it might not. In any case, a continuous inverting suture would be needed as in uterine or gastric closing, not interrupted sutures. In any case, this area was infected badly and so, it is doubtful that it would heal well, without stricture and causing obstruction again. A dye would reveal the urine leakage area but the owner would never pay for this and the other vet said she had done nothing wrong and why should her management pay for this test?
In practical terms, resolve the owner's dog complications at the least cost. It is easy for me to criticise.
Wednesday, September 12, 2012
1088. Complications from 3 blocked bladder surgeries
This article shows that different vets may come to a surgical plan for complicatons of blocked surgery differently.
In summary, this 4-year-old Shih Tzu was seen by me as a puppy 4 years ago and treated twice for minor ailments. He had a blocked bladder some 7 months ago and was seen by my associate vet who diagnosed bladder stones after radiography. The owner took his dog to another vet for surgery as this vet was recommended. The vet made a hole in the urethra behind the os penis (lst urethrostomy) and the dog peed through it for the next 7 months. Then it had a blocked bladder with stones and was operated (lst cystostomy) by a vet in big vet practice 4 months ago. The dog developed same problems 3 weeks ago and the same practice operated to remove the stones from the bladder (2nd cystostomy).
However, the whole penis, prepuce and scrotum were swollen and after paying over $2,000, the owner was asked to pay $1,200 for another surgery to open a new hole in the urethra (2nd urethrostomy) as the dog could not pee properly. The owner would not want to spend more money since the stones were removed and X-ray after surgery showed no stones. He could not understand why there was a need for the $1,200 surgery to open another hole further back in the urethra and to close up the first hole done by the first vet.
The niece knew Dr Daniel and so the case came back to Toa Payoh Vets. The owner complained about a big swollen scrotal sac (which had fluid, according to the vet in the big vet practice, using ultrasound) and a large swelling of over the left inguinal area. Every day for the past 3 days, blood-tinged fluid of 30 ml would be aspirated from this inguinal area. Was it urine or not? Was it peritoneal fluid from a stitch breakdown in the linea alba of the 2nd bladder cystotomy or not?
I sent the SC fluid to the lab for analysis.
I took 2 hours this morning to cut off the infected scrotal sac, tied up the two inguinal rings, removed the two stitches of the original urethrostomy done by Dr Daniel who wanted to close it so that the dog could pee normally from the penile end. I discovered a 2 mm hole and so there could be leakage as well as from the bend of the urethra (only a small cathetheter could be passed through the bend, whereas a bigger one could pass through the penile urethra).
The uncle came again as in the past days, in the evening and asked for explanation. "It took 2 hours just to operate on this dog," I said. "The shorter the anaesthesia, the safer for the dog. No point being the best vet surgeon in the world if the done dies on the operating table due to a lengthy surgery," I advised him. He understood me. This case demanded a lot of communication and only by tomorrow morning will I know if the left inguinal area will swell again, as in the past 3 days.
The lab people phoned me and asked how to check whether the SC fluid is urine or not. "I presume you check for urea," I said. "Oh, you want the chemistry," the lab tech said.
In summary, this 4-year-old Shih Tzu was seen by me as a puppy 4 years ago and treated twice for minor ailments. He had a blocked bladder some 7 months ago and was seen by my associate vet who diagnosed bladder stones after radiography. The owner took his dog to another vet for surgery as this vet was recommended. The vet made a hole in the urethra behind the os penis (lst urethrostomy) and the dog peed through it for the next 7 months. Then it had a blocked bladder with stones and was operated (lst cystostomy) by a vet in big vet practice 4 months ago. The dog developed same problems 3 weeks ago and the same practice operated to remove the stones from the bladder (2nd cystostomy).
However, the whole penis, prepuce and scrotum were swollen and after paying over $2,000, the owner was asked to pay $1,200 for another surgery to open a new hole in the urethra (2nd urethrostomy) as the dog could not pee properly. The owner would not want to spend more money since the stones were removed and X-ray after surgery showed no stones. He could not understand why there was a need for the $1,200 surgery to open another hole further back in the urethra and to close up the first hole done by the first vet.
The niece knew Dr Daniel and so the case came back to Toa Payoh Vets. The owner complained about a big swollen scrotal sac (which had fluid, according to the vet in the big vet practice, using ultrasound) and a large swelling of over the left inguinal area. Every day for the past 3 days, blood-tinged fluid of 30 ml would be aspirated from this inguinal area. Was it urine or not? Was it peritoneal fluid from a stitch breakdown in the linea alba of the 2nd bladder cystotomy or not?
I sent the SC fluid to the lab for analysis.
I took 2 hours this morning to cut off the infected scrotal sac, tied up the two inguinal rings, removed the two stitches of the original urethrostomy done by Dr Daniel who wanted to close it so that the dog could pee normally from the penile end. I discovered a 2 mm hole and so there could be leakage as well as from the bend of the urethra (only a small cathetheter could be passed through the bend, whereas a bigger one could pass through the penile urethra).
The uncle came again as in the past days, in the evening and asked for explanation. "It took 2 hours just to operate on this dog," I said. "The shorter the anaesthesia, the safer for the dog. No point being the best vet surgeon in the world if the done dies on the operating table due to a lengthy surgery," I advised him. He understood me. This case demanded a lot of communication and only by tomorrow morning will I know if the left inguinal area will swell again, as in the past 3 days.
The lab people phoned me and asked how to check whether the SC fluid is urine or not. "I presume you check for urea," I said. "Oh, you want the chemistry," the lab tech said.
1087. Coincidence? Zhaobao article on dogs
After operating on the Shih Tzu with complicated problems, an old friend drove me to her office in People's Park. There I met her brother who said: "I read the Zhaobao. It was given free and I have never read Zhaobao. There, I read about you as a vet. I didn't know that dogs can get poisoned from eating grapes!"
I was surprised he read this newspaper and saw my interview. I don't read Zhaobao and so I did not know when the reporter would publish the article. It is rarely that I get interviewed and so this was much of a coincidence.
Another coincidence was that my old friend's dog had died of canine lymphosarcoma many years ago. Today, I met an old client who told me that her dog Sparky had passed away suddenly, due to tumours on her diaphragm, as she had surfed the net to find out.
"Did your Jack Russell recover from mouth ulcers after dental scaling?" I asked her. The dog had swollen lymph nodes on submandibular area.
"Yes," she said. "She ate and was normal in drinking, peeing and pooping. She just died 3 months later." It was nice to know she had a good quality of life.
What's so coincidental about the above. The lymphosarcomas of the two dogs and the Zhaobao incidents of the brother. Was there a message from the "datuk" above? My friend believes in the "datuk" and there are stories I had written some time ago in the powers of the "datuk".
I went back to the Surgery at 6 pm. The Shih Tzu was barking like mad which was a good sign. He had fever yesterday and pus in his urine.
I was surprised he read this newspaper and saw my interview. I don't read Zhaobao and so I did not know when the reporter would publish the article. It is rarely that I get interviewed and so this was much of a coincidence.
Another coincidence was that my old friend's dog had died of canine lymphosarcoma many years ago. Today, I met an old client who told me that her dog Sparky had passed away suddenly, due to tumours on her diaphragm, as she had surfed the net to find out.
"Did your Jack Russell recover from mouth ulcers after dental scaling?" I asked her. The dog had swollen lymph nodes on submandibular area.
"Yes," she said. "She ate and was normal in drinking, peeing and pooping. She just died 3 months later." It was nice to know she had a good quality of life.
What's so coincidental about the above. The lymphosarcomas of the two dogs and the Zhaobao incidents of the brother. Was there a message from the "datuk" above? My friend believes in the "datuk" and there are stories I had written some time ago in the powers of the "datuk".
I went back to the Surgery at 6 pm. The Shih Tzu was barking like mad which was a good sign. He had fever yesterday and pus in his urine.
Tuesday, September 11, 2012
1086. Open pyometra Jack Russell - the old vet did it
"The old vet did it," the sister said when I asked about a pyometra surgery done on her JR in Nov 2011. I checked the records and it was I who did the surgery. As part of my succession plan, many cases are now handled by Dr Vanessa and Dr Daniel Sing. So, the old clients don't see me.
However I do consult in the mornings before 12 noon and am usually at the Surgery at 8.30 am. If I handle all the cases, the associate vets will have nothing to do and not gain the necessary experience over time. I do check every case handled by the associate vets and inform them of any matters to ensure a higher standard of veterinary medicine and surgery.
Associate vets have to understand that a more demanding and sophisticated clientele requires much more expertise of Toa Payoh Vets which has been established for over 30 years. Just treating coughs and colds is not the main focus of Toa Payoh Vets. Veterinary surgical skills are being built up.
However I do consult in the mornings before 12 noon and am usually at the Surgery at 8.30 am. If I handle all the cases, the associate vets will have nothing to do and not gain the necessary experience over time. I do check every case handled by the associate vets and inform them of any matters to ensure a higher standard of veterinary medicine and surgery.
Associate vets have to understand that a more demanding and sophisticated clientele requires much more expertise of Toa Payoh Vets which has been established for over 30 years. Just treating coughs and colds is not the main focus of Toa Payoh Vets. Veterinary surgical skills are being built up.
1085. Update on bladder stone complications Shih Tzu
Yesterday, the Shih Tzu had another 30 ml of fluid aspirated from under the left inguinal skin area as also the day before. Dr Daniel told me that the owner had given instructions to operate to find the source of the leak.
"It is not as simple as that," I advised Dr Daniel. "There is the legal aspect. If the dog dies, you get the blame although you can say that the dog was already leaking "abdominal fluid" every day. You need to advise the owner to contact the original vet operating on this dog and find out what was done. The dog was said to be hospitalised for 8 days after surgery there.
Today Sep 11, 2012, the Shih Tzu has high fever 41 deg C.
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