1387. Yangon seminar July 5, 2014. Guidelines on treatment of pyometra in small animals.

GUIDELINES ON TREATMENT OF PYOMETRA CASES IN DOGS AND CATS
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS. Founder of Toa Payoh Vets, Singapore
toapayohvets.com, 99pups@gmail.com

I graduated from Glasgow University in 1974 and founded Toa Payoh Vets in 1982. It is a private small animal practice in Singapore. For this July 5, 2014 Seminar, I share my approximately 40 years of experiences in the treatment of pyometra cases in dogs and cats in my practice. The focus is on the treatment of the following 3 types of pyometra. 
 
STUMP PYOMETRA
OPEN PYOMETRA
CLOSED PYOMETRA


STUMP PYOMETRA IN THE DOG OR CAT

A stump pyometra is a progesterone-mediated infection of a remnant of the uterus.

Progesterone is a female hormone causing the uterus to be enlarged and cystic, making it susceptible to secondary bacterial invasion from the vagina.

Progesterone is released by the residual ovarian tissue or from synthetic progesterone hormone treatments like Depo-M and Contracep injections in Myanmar or Ovarid tablets in Singapore. 
 

CLINICAL SIGNS may include any of the following: foul smelling vaginal discharge, loss of appetite, fever, lethargy, weight loss, vomiting and diarrhea, or excessive thirst and urination. Caterwauling in "spayed" cats.

DIAGNOSIS

1. Ultrasonography is preferred. Thickened uterine wall and intraluminal fluid. A normal uterine wall is not visible.

2. Abdominal x-ray. A large uterine stump may be seen.
3. Blood test - CBC/Biochemistry
4. Vaginal cytology - determine if there is oestrogen circulating in the blood indicating the presence of functional ovarian tissue.

TREATMENT

Antibiotics and surgery. Surgery to remove the infected uterine tissue and any remaining

ovarian tissues.
 

Surgical approach
Make a long skin incision. To locate the remaining ovarian tissues, take out the intestines. Look for the areas caudal to the kidneys. Usually, the ovarian tissues are enlarged, encasing the sutures as shown in the following image of a case of stump pyometra in the cat. The stump uterus is filled with pus.

CASE STUDY
TP 43053
Today, Jun 24, 2014. The owner came to Toa Payoh Vets to purchase 3 tablets of Ovarid 20 mg as he said that the cat was spayed by a vet on Jan 19, 2012. She still caterwauls and shows signs of heat every 2-3 months and so he asked for Ovarid tablets to suppress the heat cycle.

The first caterwauling was on Apr 22, 2012 and he was prescribed Ovarid 20 mg at 1/4 tablet SID for 7 days and 1/4 tablet alternate days for 3 weeks.  On August 28, 2013, he came to get 2 tablets of Ovarid. I advised surgery to remove the remaining ovarian tissue but he would wait and see. If stump pyometra develops, he may have no choice, but surgery.

VETERINARY SURGICAL MISTAKES CAUSING STUMP PYOMETRAS

1. Too short a spay incision into the linea alba. In such a short incision of less than 1 cm, the first swollen uterine horn and ovary of a cat or dog in estrus can be hooked out. However, there is no space for the second uterine horn and ovary to come out. The vet tugs the ovary out of this tight hole. The ovarian ligament breaks. The ovary drops into the abdomen. The vet takes out the second uterine horn, completes the surgery. 

2. The incision is too far away from the umbilical scar, usually more than 4 cm away. Therefore the ovaries are not easily hooked. Too vigorous tugging of the ovary breaks the suspensory ligament. The ovary drops into the abdomen. The vet completes the surgery.

TIPS FROM DR SING KONG YUEN
I usually incise around 1.5  cm from the umbilical scar. I make a 1-cm incision and there is no problem exposing the whole ovary and tying its suspensory ligament. If necessary especially when the cat is in estrus, I will extend my incision caudally by a cm to take out the swollen uterine horns and ligate the uterine body. I use absorbable sutures. With this approach, I never had a stump pyometra or a "spayed" cat or dog still showing signs of heat.

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OPEN PYOMETRA & CLOSED PYOMETRA are life-threatening infections of the uterus by bacteria and are medical emergencies. In open pyometra, the cervix is not closed unlike in closed pyometra and so sanguinous to mucopurulent vaginal discharge is seen.


DIAGNOSIS

1. Ultrasonography is preferred. Thickened uterine wall and intraluminal fluid. A normal uterine wall is not visible.

2. Abdominal x-ray. Large uterine horns may be seen.
3. Blood test - CBC/Biochemistry. Neutrophilia, normocytic, normochromic anaemia, hyperglobulinaemia, hyperproteinaemia, azotemia, ALT and ALP high with septicaemia or severe dehydration
4. Vaginal discharge cytology - regenerative polymorphonuclear cells and bacteria.

TREATMENT
Review the blood test results to check especially for leucoytosis, anaemia, platelet count, serum BUN and creatinine, ALT and ALP, PCV to assess the prognosis of the case for the owner. The higher the abnormal values, the poorer the prognosis. Anaesthetic and surgery informed consent form to be signed by the owner.

The following is what I do in most cases of female dogs not valued for breeding
1. Inpatient for 3-7 days
2. Immediate IV fluid (glucose, dextrose saline, Hartmann's, amino acids and multivitamins) and Baytril antibiotics for one day.
2. Spay on the 2nd day. I do not operate immediately.
3. IV tolfedine as this is anti-fever and analgesic
4. IV fluid post-op and antibiotics for 14 days.

Prognosis and outcome are good after spay if the dog has no permanent kidney damage (vomiting, high serum BUN and creatinine, anaemia, low platelet count).

For female dogs valued for breeding. Medical treatment using prostaglandin 2alpha to contract uterine muscles to expel the pus.
1. Client education that the dog must have open pyometra and not azotemic. Dog with closed pyometra may lead to uterine rupture causing peritonitis. 
2. Details of the costly treatment and monitoring are in Pyometra and Cystic Endometrial Hyperplasia, Pg. 1101, The 5-minute Veterinary Consult, 3rd Edition.

3. In one case done by my associate, the valuable Pekinese with open pyometra was

  







 

 

 

 

1386. Stump pyometra in a cat in Yangon. Depo-M pyometra in a cat in Yangon, white lion, lioness, tiger, Naypyitaw Zoological Garden

Jun 20, 2014 Diamond Crown Hotel, Rm 706

Yesterday, an ex-Captain invited me to his office and lunch. He is a very good business man. One of his diversified interest is buying small souvenirs from Singapore and selling them in his 3 retail shops. He had another retail shop printing names of buyers and messages of love on Valentine's Day and they were selling like hot cakes. Real estate and many other interests, sharing his tips with me.

On a visit to Royal Asia Veterinary Surgery, I saw one cat that had stump pyometra after operation. The images are below:

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Pyometra develops after Depo-M or other synethetic progesterone injections given to the cat in Yangon to suppress the heat cycle and therefore caterwauling and prevent pregnancy.

Financially, the cost of a spay is approximately equal to 15 injections.  Client Education is nowadays done by the vets to have the cat spayed as the injections or Depo-M or Contracep will lead to pyometra, sometimes after 1 injection, according to some vets I spoke to in June 2014. The cats are given injections IM every 3 monthly.

Dogs are also given such injections as well but some clients such as Boma's owner appreciate that spaying is the better option for the beloved dog. I saw "Boma" at the Royal Asia Veterinary Surgery and asked what "Boma" meant. "Boma" means a very pretty fair-skinned Caucasian woman! See Boma in this image below.

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The feline species ovulate only when stimulated. This is called induced ovulation. Stimulation is caused by pain of the backward facing penile barbs when the lion dismount after mating causing pain and inducing ovulation.
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TIME IS RUNNING OUT - CLOSED BECOMES OPEN PYOMETRA
NO TREATMENT DUE TO POOR PROGNOSIS AND FINANCIAL COSTS

 http://www.youtube.com/watch?v=J9WJqmVPfw8

 University of Veterinary Science, Yesin, is near Naypyitaw.

Bought 2 paintings from Scotts Market. One is Inle Lake. The other is of elephants said to be Myanmar elephants at work. The Seller has paintings and gems for sale. Bought one "hand-made" longi for a 91-year-old mother of my friend.   

1385. Health inspection for vehicle going long distances

An experienced and honest mechanic is entrusted with the vehicle health of the RAVS vehicle before long distance travel. Otherwise breakdown on the way is terrible.

Most people and pets seldom get even a yearly health examination

1384. Myanmar travel stories - pyometra, dermatosis, distemper at Royal Asia Veterinary Surgery

Jun 20, 2014  Diamond Crown Hotel, Room 711 (better unobstructed city view)

Yesterday I dropped by Royal Asia Veterinary Surgery for an hour after my visit to the rural areas of Dagon, saw Dagon and Eco-Universites. My host brought me to visit an orphanage for HIV positive orphans. Donations can be sent to the Happy Haven Humanitarian Project (set up in 2005 for children up to 15 years old),  979-982 Tabinshwehtee Road, East Dagon, Ward No. 11, Yangon, Myanmar. 

At the Royal Asia Veterinary Surgery, I saw 3 interesting veterinary cases.

1. Closed pyometra in a cat spayed by Dr Aung. Pyometra is much more common in Yangon than in Singapore as the female cat and the dog are given anti-estrus hormonal injections to prevent heat. It could be due to the culture.  In Singapore, many cats are spayed because they caterwaul, making so much noise that neighbours may not be happy.  No anti-estrus hormonal injections are given by all vets and so I don't see any case of closed pyometra in the female pet cat over 40 years of practice! In Yangon, pyometra is very common, according to Dr Aung and I actually saw one in the cat being operated by him.

2.  Canine distemper in a Cocker Spaniel, around 2 months old. The puppy was said to be imported from Taiwan. He had rapid respiration and was not eating. He had been treated by another vet for around one month. The thin puppy was on an IV drip and still active and had an appetite for the canned food.  Positive test for CDV antigen test kit. I advised a blood test for lymphopaenia. The worse the lymphopaenia, the poorer the prognosis.  Presently, no nervous signs of the disease.



3. An intact male 8-year-old Pom X has original hairs only in the head and four limbs. What is the cure? Dr Aung has to differentiate between hypothyrodism, Cushing syndrome and Sex Hormone Dermatosis in intact male dogs. Blood test for thyroid hormones and check for demodectic mites would be done. The first vet had given ivermectin injections without the outcome desired by the owner.

No polyphagia or polydipsia, according to the owner. But the dog "peed" a lot. Four times a day is a lot. This could be "urine marking" by male dogs. Testicles are normal in size and feel.    

The skin is not thinned nor the abdomen bloated as in Cushing's syndrome. So Cushing's syndrome was ruled out. Hypothyroidsim or demodecosis? Blood test for thyroxine. No demodex on skin scraping. 

Most likely a Sex Hormone Dermatosis. The owner would return for neuter of the dog.

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Myanmar Travel Stories: Beasts of burdens. Nuns. Buffalo

June 19, 2014  Hotel Bo Bo Min Rm 506

Yesterday, I left Naypyidaw, a sprawling clean capital of Myanmar. I did not get to see the government buildings as there was no time. I visited the Vet University and the Zoo.

Vast open flat lands. Some farmers were using buffalos to plough the fields. A few are threshing rice and the images below show sacks of rice being unloaded near the road side.  

A lot of luck is needed to take remarkable photos. I was having lunch in the "Silver Spoon" Cafe said ro be opened by a Singaporean. I saw robed "graduates" across the road "posing". My friend Shirley told me they were nuns.  Nuns usually wear pink robes and so this group is rarely seen by me in my few visits to Myanmar and in Yangon.

1382. Naypyidaw. Visit to Vet University, Yesin

June 18, 2014

Yesterday, I visited the Veterinary University at Yesin, Naypyidaw and the Zoo. White lions and white tigers were seen. Giraffes, hippos and Himalayan bear. A leopard or cheetah was napping. All animals in excellent bodily condition.

But the visit I like was to visit a family of my friend Shirley, living in a village near the Vet University, Yesin. The matriarch, 63 years old, brought up four sons when her husband passed away many years ago. Three went to become graduates and she is well provided and loved now.

On the 2nd floor of a building in the Veterinary University, Yesin, a notice board displayed examination marks of lst and mid-term examinations. "How's your result?" I asked the 2nd year student (right in photo, below) as her aunt said she is a very bright student. Aunts can be biased. She pointed to her name and her marks were high, showing she is focused on her studies. Lady students must book into the hostel by 6 pm. Probably 100 undergraduates per year.   

Yangon Vet Talk - treatment of urethral stones - retrograde urohydropropulsion

DRAFT NOTES FOR THE SEMINAR

FELINE UROLITHIASIS

Case study. TP 45355.
Cat, Male, Neutered, 4 years old. Apartment has 2 other cats with no similar problem. 

HISTORY & SIGNS: Since being neutered at 8 months of age, dysuria is seen lasting around a few days every 2-3 months. No veterinary treatment as the cat recovers the recurring dysuria. However, on Jun 19, 2014, the cat hid under the sofa and could not pee for a long time. Dr Daniel of Toa Payoh Vets treated him. Signs of postrenal uraemia not obvious (e.g anorexia and vomiting).

PHYSICAL EXAMINATION. Signs of outflow obstruction: 
1.  Palpation of a large painful urinary bladder palpated.
2.  Detection of urocystoliths by palpation is unreliable.
2.  Examination of distal penis and penile urethra showed urethral plugs. A cat catheter passage is obstructed.

DIAGNOSIS
DIFFERENTIAL DIAGNOSIS.
1. Other causes of dysuria, haematuria and pollakiuria and outflow obstruction.
2. Analysis of uroliths or urethral plugs to differentiate struvites from other types. Tests include urinalysis, radiography, ultrasonography and cystoscopy.   

3. CBC/BIOCHEMISTRY/URINALYSIS
3.1    Post-renal azotemia (high BUN, creatinine and phosphorus) for complete outflow obstruction. Not done in this case owing to financial constraints.
3.2   Urine tests.
3.2.1 Microscopic examination of the magnesium ammonium phosphate crystals. They look like colourless, coffin-like prisms with 3 to 8 sides. The lab report shows triple phosphate crystals.
3.2.2 Bacterial urine culture and antibiotic sensistivity tests. Not done due to financial constraints.
3.2.3 Chemical analysis of urethral plugs. Not done due to financial constraints.

4.  IMAGING

4.1 Survey radiography. Two views of the abdomen must be taken, not just one view as is sometimes done by vets in Singapore to reduce medical costs for owners.
No struvite uroliths but some struvite urethral plugs are seen. Struvites are radio-dense on X-rays.   They are most common mineral (80%) in urethral plugs in cats (The 5-minute Veterinary Consult, 3rd Edition)
4.2  Contrast urethrocystography. Not done due to financial constraints.

5. ULTRASONOGRAPHY
determines the precise location, number and size of uroliths. Not done due to financial constraints. Does not indicate the degree of radiodensity or shape of uroliths

6. CYSTOSCOPY reveals the location, number, size and shape of urethroliths and urocystoliths.  Not done due to financial constraints.
  

 







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http://www.sinpets.com/20090530Canine_Uroliths_ToaPayohVets.htm


Retrograde urohydropropulsion - usually male dogs 
1. X-ray
2. Health of dog
3. Technique - Best is to use a 30-ml syringe, soft or hard catheter, saline as 30-ml syringe provides excellent pressure as compared to 10-ml or 60-ml syringes. Some vets use 10-ml syringes and find it difficult to flush the urethral stones back into the bladder.

1380. Hypothermia & anaemia

Jun 15, 2014

A 14-year-old Maltese, not spayed came in yesterday Saturday with the following:

Recently, she had  "snoring" breath and howled when nobody was at home. Did not move when placed in a location as if immobile. Vomited twice on Friday. Drank and peed a lot.
The dog's gums were white and the rectal temperature was low at 36.8 C.  This was a dog seriously ill.

"Normal dog's temperature is from 38.5 to 39.5 C," I said to the mother and adult son. "This is not a good sign as the dog also had pale gums, meaning loss of blood or insufficient blood."

I palpated the bloated tense abdomen. There was a swelling in the lower 1/3 of the abdomen, as if the uterus was swollen with pus. I checked the nipples. The back ones discharged reddish black fluid when expressed. So, the dog could have false pregnancy and now had closed pyometra. Blood test was taken.

However the dog passed away despite I/V drips and medication. The tongue and gums had become snow white.

It is best to get female dogs spayed when they are young as old ones may suffer from closed or open pyometra (infection of the womb) and internal bleeding from toxaemia.

Fits due to tooth ache not other reasons

Saturday, Jun 14, 2014

"You know, my Papillon does not have fits," the mother who had to take care of this 14-year-old emaciated dog said to me today. "After you had extracted the rotten teeth, he has no more fits and so I did not give the anti-fits medication."

That was in Jan 12, 2014 when Dr Daniel extracted 12 rotten teeth. The dog was given IV drips, antibiotics and anti-fits medication for 3 days. A blood test was done indicating kidney disorder with high blood urea and creatinine.

She really recovered as the owner said: "My dog was eating the canine K/D diet since the extraction and so I did not give the dogs anti-fits tablets. Now, she cries whenever I carry her. She did not eat for past 3 days and would not move, like being a statute. What to do? Should I put her to sleep?"

"She is in great pain," I said. "Probably kidney pain. It is up to the owner to decide on euthanasia as the dog needs much nursing and time and you would be travelling overseas. Your daughter would not want to nurse this dog. "

There was also no budget for X-rays and other tests and so this was the best I could do, from the blood test.  Brain scan is out of question but was advised by the other vet. The dog was eating well when I followed up on Feb 26, 2014 when the owner came for 5 cans of K/D and antibiotics.

From March to June 14 today, no news from the owner. Probably not well cared for as now the dog is emaciated and in great pain.  

How long can the Papillon live? Much longer than the 14 years if given annual check up such as dental scaling and careful nursing. But many Singaporean owners do not bother with the dog's rotten teeth which pass bacteria to the heart and other organs, causing the dog to live shorter lives.

Yangon Vet Talk in July 5, 2014 - Treatment of pyometra video

Time is running out
Dog will die within a week if the father does not want the operation owing to poor prognosis and pragmatism. Why spend money if the vet (myself) said that the dog has 20% chances of survival?


https://www.youtube.com/watch?v=J9WJqmVPfw8