1119. Two surgeries, 10-year-old Cocker Spaniel. Urinary Stone analysis by NUH

 

Inbox x A case of two surgeries for bladder stone removal in a 10-year-old Cocker Spaniel done by an associate vet is reviewed by Dr Sing today Sep 26, 2012 April 4, 2011 blood in the urine. Did not want more tests. May 23, 2011 dysuria - blocked bladder May 26, 2011 blood test, x-ray, UA, cystostomy. calcium oxalate Sep 4, 2012 dysuria - blocked bladder. x-ray, cystostomy, stone analysis LAB TESTS May 24, 2011 UA pH 7.0, SG 1.028, Protein 2+ Blood 4+, WBC 10, RBC >2250, Bacteria 3+, Crystals calcium oxalate occasional Aug 28, 2011 UA pH 7.0, SG 1.029, Protein 3+ Blood 4+, WBC >2250, RBC >2250, Bacteria 3+, Crystals Nil May 24, 2011 Blood test. ALT 629 (<59 132="132" 23="23" ast="ast" n="90%</div" total="total" wcc="wcc"> Sep 4, 2012 Stone analysis by Dept of Lab Medicine, NUH I spoke to the lab people about the approximate % Calcium stone Trace (10%) Phosphate stone Trace (5%) Oxalate stone Trace (10%) Urate stone Positive (40%) Magnesium stone Trace (1%) Cystine stone negative Ammonia stone Positive (10%) Bicarbonate stone negative The stone is crushed and analysed using the colorimetric method. Trace = light color. Positive = intense colour. A semi-quantitative method. I asked my associate vet whether there were any recommendations about diet and was told Urate Diet was recommended. U/D FOR UROLITHIASIS, non-struvite urinary tract health Indications: calcium oxalate, urate and cystine urolithiasis; end stage kidney disease. This is a low protein food exhibit unusual lab vales such as USG<1 .020=".020" and="and" are="are" br="br" bun="bun" compliance.="compliance." dl.="dl." effectiveness="effectiveness" food="food" methods="methods" mg="mg" monitor="monitor" monitoring="monitoring" owner="owner" ph="ph" s="s" serum="serum" the="the" to="to" uirinary="uirinary" usg="usg"> Target urinary pH 7.1 to 7.11 increases solubility of non-struvite crystals. Every 6 months, do a fasting serum chemistry profile and echocardiogram for underlying metaboic abnormalities OWNER COMPLIANCE Two cystotomies were done. Owner does not comply with instructions on using prescription calculytic diets and this is their own wish.

1118. Bladder stones in a 13-year-old dog

 "Is an operation needed to remove the bladder stones?" the lady asked me over the phone. "Much depends on the size and composition of the stones," I said. "If they were small struvite stones, they may be dissolved by eating a special diet."

The dog was a Golden Retriver X, medium sized, 13 years old and lethargic. A high anaesthetic risk. So I did not advise surgery. Catherised urethra 2 days. Today, could pee normally but vomited canned food.

The dog could pee normally and had a good appetite today. So I did not operate as he is very old and thin. Will S/D diet help? But his urinary pH is 6.0 and not alkaline. The urine crystals are nil and so the only way to know what composition of the urinary stones in his bladder would be to do surgery. But the dog may die on the operating table since he is 13 years old. So, this is the difficulty. The dog was given K/D diet by Vet 1 before I was handling the case. Could K/D bring down the urinary pH to below 7.0?

A trial of S/D may not be effective since the composition of the urinary stone is not known. It may be calcium oxalate but it may also be struvite. S/D diet dissolves struvite stones. The dog had antibiotics and a can of S/D diet with informed consent from the owner. For the past 2 days, he was urinating normally and had excellent appetite. I dare not do any cystotomy surgery as the risks outweigh the benefits. An S/D trial is one alternative and it may be worth a trial. It is not evidence-based, I informed the young lady owner. She understood.   

1117. Acute respiratory distress in a pug

 

 

 

The pug keeps panting non-stop. X-rays show gastric distension. What's the cause? Is there a gastric torsion? Panting slowed when lasix is given.

 

As I gave a high anaesthetic risk assessment if surgery is to be done, the owners lost confidence in me and decided to seek another vet. This is a common occurrence to all vets.

1116. Another edited version of struvite bladder stones to the editor

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 by medical dissolution. Disadvantages of surgery are that it is more invasive and there are risks of death during or post operation, associated with general anaesthesia 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 struvite 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 or crystals are formed. 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 Kong Yuen

BVMS (Glasgow), MRCVS

Toa Payoh Vets

 

Sep 25, 2012. Edited version for the editor

My opinion. A technical report. Quite a boring article without pictures for the layman but has most of the important facts.   

Urgent Question About Duration of Surgery For Roborovskii Dwarf Hamster

Inbox

x

	Sep 20 (3 days ago)
to judy

Hello,

I’m in the U.S. and I have an 18 month old male Roborovskii hamster who has two medium size abdominal “fatty tumors”. The hamster is still active and eating normally and in otherwise apparently good health, but I would like to have the tumors removed and start him on an anti-tumor/anti-aging diet.  Thus I would like to do this before the tumors become any bigger.

I love this little hamster very much.

Anyway, from the information you’ve kindly made available on your web site, and from talking to other people, I am under the impression that surgery on dwarf hamsters and Roborovskii dwarf hamsters in particular, is a very delicate operation, and the time duration must be limited, otherwise the risk of death during surgery – especially from the anesthesia exposure - becomes unacceptably high.

I know your office has had many years of experience doing all kinds of surgery on dwarf hamsters (I think Dr. Sing mentioned he’s done this for 40 years or so).

Generally speaking, based on your considerable experience, can you please give me some general idea as to the maximum length of time surgery that would be considered “safe” to a “reasonable” person under the circumstances? Thank you very much.

Regards,

Nelson

 EMAIL REPLY FROM DR SING DATED SEP 23, 2012

Thank you for your email. The general principle for all animals in good health is that the shorter the anaesthesia, the higher the chances of survival. Therefore, some surgeries in high risk cases (like old age, poor health and very small creatures like hamsters) have a good chance of survival if anaesthesia is short. In hamsters, the period of time is preferably less than 5 minutes but this is just a guideline. Much also depends on the skills and experience of the vet and therefore, there are many factors to take into account.

It is best you find a vet experienced in hamster anaesthesia and surgery.

1114. The baby-boomer generation and urinary stones

Today, Saturday Sep 22, 2012, I was at the Surgery at 7.30 am as Min has to go to get his permit personally from Tanjong Pagar as instructed in the government's letter. I told him to take a taxi and come back after lunch as Dr Daniel and Dr Jason and Ms Chong will be on duty. They don't come so early. 

At 8.34 am, a young lady phoned me to make an appointment at 3.30 pm to 4 pm.
"What's happened to your dog?" I asked.
"He has bladder stones."
"How do you know?" I was then told that she had been to a vet who took the X-rays and there was one stone initially. But now there are three.
"Should the stones be removed?" she asked.
"That depends on what type and size of the stones," I replied. "Did the vet tell you?"
"No," she had no clue and so I asked her to get the vet reports and X-rays from the vet to save on costs.
"Why didn't you get the vet to remove the stone when there was only one?"
"My dog is 12 years old," she said. "My father does not believe in surgery."
"Why?" I asked.
"Once, a vet told him that surgery was needed for the dog's arthritis. He got glucosamine from another vet and the dog is OK. Therefore no surgery is ever needed."
"Arthritis cannot be compared to bladder stones," I said. "Dogs usually don't die from arthritis, but in bladder stones, the bladder may get infected and the bacteria and toxins may travel via the blood stream and to the kidneys. The dog may become septic. Kidneys may fail and the blood is full of waste products, since the kidneys cannot filter them away. This leads to  nausea and vomiting.

"I mean you can't compare oranges to apples. You compare bladder stones to bladder stones in deciding on surgery or not. Is your dog vomiting?"

"Once in a while," she said.
"Unfortunately, the older baby boomer generation is not in favour of surgery. This leads to delays and worsening of the dog's health. By then,  Is there a financial reason?" I asked.
 

1113. Follow up- Massive perineal hernia in a Silkie

Around July 2011, the Silkie's perineal hernias were repaired. See: 
http://www.sinpets.com/F5/20110714perineal_hernia_old_Silkie_Terrier_male_dysuria_painful_backside_singapore_ToaPayohVets.htm

UPDATE TODAY SEP 21, 2012. I phoned the owner today. Around over 2 months ago, the dog suddenly refuse to eat or drink and was shivering. There was a slight swelling of the perineal hernia earlier but now the swelling had increased. As it was an emergency, the owner rushed him to another vet who operated. The bladder had prolapsed into the hernia and that was why the dog could not pee.

Now the dog is OK. There is a "hole" in the hernia as there was insufficient muscle to close up the hernia, the lady owner said.

He is well loved by the family members. He was neutered after the first perineal hernia repair and had become more fierce.

There was no delay in treatment otherwise the dog would have died.

  

1112. Black anal area in a 10-year-old male neutered Dachshund

The owner wanted to consult me specifically. Together with my associate vet we saw the case together. The lower tail had some loss of hair due to licking and the anal skin area was very black.
My associate thinks there is nothing wrong. Some light brown anal sac oil was expressed.
"Palpate the area with your fingers and you will find that the lower half of the anal skin is hard," I said.

I believe this dog has the beginning of circum-anal tumour and asked the owner to observe closely for further enlargement in the next 2 weeks. I took a ride from her to the Potong Pasir subway.

"Are all tumours cancerous?" she asked.
"No," I said. "However they bleed when they are bigger as the dog licks them or they get traumatised, soiling the floor. So it is best to ask your vet to remove them early when they are small."

On the same day, another owner brought in a 4-month-old Boxer with a red swelling on the upper part of the anus. "It could be insect sting or trauma," Dr Daniel said and gave some medication. "I will advise an e-collar," I said to the owner. "If the swelling is still around after one week, I need to inject anti-inflam into it to shrink it."

It is best to give good advices to the owner and do palpation to feel the tumour or lump. The Boxer's will be an inflammation as it appears suddenly.The Dachshund's black anal area is due to licking and has existed just for the past 2 weeks. It is not a good sign and owner must be advised to monitor very closely. Very itchy turning to blackness pigmentation.   

1111. Prolonged bleeding in a 10-year-old female Rottweiler

Today, Thursday Sep 20, 2012, I attended to this gentle female, Rottweiler dripping with reddish brown vaginal discharge for at least 3 weeks. Usually 2 weeks. Not eating much. No fever. It was a referral and also a convenience of

"How's the urine colour?" I asked the arowana breeding farmer and his wife
"Dark yellow," he said.

"Most likely infection in the womb and the ovaries are abnormal," I said. I took blood test and schedule spay on Sunday morning after 2 days of antibiotics.

"Do you have a website for your arowana breeding?" I asked as this man is passionate about arowanas which are now not much in demand.
"Myanmar is growing explosively. China has many rich people and how can they contact you if you don't have a website?"

"I depend on referrals," he and his wife told me they have a "green arowana" specific to Myanmar. I have not seen green ones. Many breeders in Australia and US have websites announcing their high quality breeds but this farmer seems not to be interested. He sells in lots of 10 or 30/batch which he lovingly "grooms" them to a certain length. He does not like selling to those who have no experience in further rearing them as they die early.

1110. DR SING'S AUDIT CASE. Not eating - Urinary stones in another Miniature Schnauzer

AUDIT ANOTHER CASE OF URINARY STONES

Jul 29, 2012
Miniature Schnauzer, White, Female, 5 years
High fever (40C) and no appetite

Associate Vet (Vet X) palpated >10 stones in bladder

Blood test, urine test, stone analysis

Jul 30, 2012
Cystotomy

Jul 30, 2012
Blood test
Total WCC 21.6  (6-17)
N 96%  Absolute 21
L 4%     Absolute 0.82
M 0.4%
E  0.1%
B  0%

Platelets  98 (200-500)
Platelet clumping

Aug 1, 2012 
Urine test
pH 9.0   SG 1.005   Nitrite +, Protein 3+, Blood 4+, Bacteria 2+WBC 180  RBC >2250
Crystals Nil
Casts  Granular cast occasional

Aug 2, 2012 stone analysis
Calcium stone trace
Phosphate stone +
Oxalate stone trace
Magnesium stone +
Ammonia stone +

This case confirms what is known. No crystals inside the urine does not mean no struvite stones.
Alkaline pH + bacteria (urease) + bacteria  leads to formation of MAP (struvite stones).


Sep 20, 2012. Review by me. I asked Vet X to put in writing that therapeutic diet S/D has been advised at least from 1- 3months. If there is recurrence, Vet X cannot be blamed. Advice on monthly
urine analysis. Preferably X-rays 3 monthly.

The children came to buy 2 cans of S/D recently. There need to be more rigorous follow up by Vet X and documentation of advices on medical records in case of recurrence as surgical costs can be very high and owners can be very unhappy when there is a recurrence. Sometimes, they just euthanase the dog to save on costs of surgery.