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.

1150. Recurrent struvite urolithiasis: A Westie X had a fully packed bladder full of stones again

In May 2013, the Westie was operated by Dr Daniel and a few thousand small stones were removed. Stone analysis showed struvite stones.  However, the owner did not come back for review. She bought some S/D from her source and then fed Hills' Ideal Balance Natural Lamb and Brown Rice Adult age 1-6 years dry dog food.

Recently the dog passes blood in the urine. The bladder X-ray from another vet yesterday showed it was packed to the gills with bladder stones. The other vet sampled the urine and stated the pH was 8.0 but did not check for urinary crystals. The vet proposed surgery and feeding of S/D cans.

handphone image from owner. Vet had given him a CD. This image does not show the kidneys which may have stones.
The dog had excellent appetite (stools in intestines). Loves to eat.  Image below is from the handphone. Appearance of stones after surgery quite likely struvites. 

  The stones were in more than 1000 pieces and weighed 87 grams. 


SURGERY ON DEC 23, 2014

I share my surgical experiences with this dog
The owner brought in the dog in the morning and was operated in the afternoon at 4 pm. The other vet had said urine pH was 8.0 and lots of white blood cells, but had not done urinary crystal tests.

The surgery took 92 minutes as the dog did not accept IV drip or injection without hard struggles. She peed and pooped in the process. I decided to give the sedation by IM using domitor 0.2 ml + ketamine 0.25 ml in one syringe. The dog struggled again after intubation and I had to switch to the gas mask and stabilise her.  This took up a lot of time. I injected atropine 0.5 ml and fursemide 1.0 ml IM after sedation.  

She was an old dog and a high anaesthetic risk.  She had survived one bladder stone removal operation 1.5 years ago and now, another similar one with the bladder packed with stones.  I could see the bladder wall thickened to 5 mm from the X-ray and this meant that the dog had chronic cystitis. Surprisingly this dog was still active and eating.

I flushed out any smaller stones. Usually I do two layers of sutures for bladder closure. I did 3 layers for this thickened wall. The dog was given drip SC post-op and peed a lot of urine after that. This showed that the bladder was not leaking.

As at Dec 24, 2014, some 18 hours after surgery, the dog is OK. This type of fully packed bladder is rare from over 100 cases operated at Toa Payoh Vets in my past 30 years of practice.

From sedation to the last stitch, the surgery took 92 minutes (E-A).  The first skin incision to last stitch (E-D) took 69 minutes. Isoflurane gas was given for 77 minutes (C-B). 

CONCLUSION
Visualise what you need. Get all equipment ready e.g. 20-ml syringes to flush out the small bladder stones, so as to minimise anaesthetic and operating time.

ADVICE TO OWNER ON DEC 24, 2014
The owner wanted the dog home on the 2nd day. Advices to prevent recurrences are:
1. S/D for 2-3 months
2. Change to C/D
3. Urine test monthly for 3 months at least with your vet
4. X-rays bladder and kidneys 6 monthly
5. No other food and treats 

Dec 27, 2014  2 pm. Tel owner.
Dog crated to prevent running around apartment. Active, ate 1/2 can S/D and wanted more. Had pooped. Very thirsty and peed a lot. No vomiting. Licks wound which is wet (but wears E-collar) and vulval area.
Had medication and tolfedine 60mg (1/2 tab/day).
Advised not too much water intake as bladder is affected. Ration to 1/2 bowl of water 3x/day. Previously drinks around 1 bowl of water per day.
Keep wound clean. 1/2 can S/D 2x/day. To call me when necessary.

--------------------------------------------------------------------------------------------------------------------------FLASHBACK-

FIRST SURGERY IN MAY 21, 2013 DONE BY DR DANIEL

STONE ANALYSIS ON MAY 21, 2013

MAP (Magnesium Ammonium Phosphate). However, the owner did not come back once for review or consulation.  One and a half years went by.......The dog was active and had an excellent appetite. Drinking was normal. But she passed blood in the urine and vomited once yesterday (Dec 22, 2014). Another vet took an X-ray and it showed a bladder full of stones.


She  quoted around $1,800 for surgery. The parents wanted Toa Payoh Vets to operate. To reduce medical costs, no stone analysis would be done. Blood test and urine tests were declined.

An old male Miniature Schnauzer cannot control his bladder

Dec 18, 2014

The not neutered 10-year-old Schnauzer could not control his bladder for the past 1 week.
"Very smelly urine," the husband said. "He has bad breath for a long time."
I palpated the lower mid abdomen. The dog winced in pain. "Schnauzers are famous for urinary stones," I advised x-rays, blood and urine tests. The client permitted x-rays and urine tests only.

No urinary stones seen but the urine had occasional triple phosphate crystals and bacteria. Diagnosis was urinary tract infection.The dog recovered his bladder control after antibiotics. I post a urine test reminder card one month after the first test but much depends on the owner as some ignore such veterinary advices. Usually vets don't have time to send such reminders too.

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COMPARE TO THE 7-YEAR-OLD SHIH TZU WITH BLADDER TUMOUR AND URINARY STONES. The dog was operated by Dr Daniel on Dec 21, 2014 yesterday. Today at 6pm, he barked when the owners came to visit. The owners did not want surgery 2 years ago in mid 2012, when X-rays showed small stones, opting for dietary dissolution.

"6 cans of prescription diet S/D will not dissolve the stones," I explained. "The dog ought to have 3 months of S/D for 2012 and urine tests and monitoring with X-rays."  It is difficult to convince owners that they have to comply with vet instructions as they find that the dog's urine was OK with feeding of S/D 6 cans.

1148. Not cured but did not come for monthly review

Poodle 6 years   muzzle, neck, ears v. itchy and bleeding. UVL +ve ringworm. Did not come back after Aug treatment. Just go to groomer and buy shampoo and anti-allergic Z/D diet from another vet nearby.

Generalised ringworm and other bacterial infections are not easy to cure. It needs daily washes and compliance with medication. Owners need to be educated as they assume medication will cure the disease. There is the environmental contamination, the towels, bedding, flooring and dog shirts which may be contaminated with ringworm spores. The dog must be clipped bald. Ear problems may involve ringworm too.

I hope this poodle will get proper home treatment and get cured.

1147. The friend saved the English Cocker Spaniel's life - tick fever anaemia

"How do you know that your friend's English Cocker Spaniel has such a big medical file?" I asked the lady who brought in a cat with 10 ingrown toe nails.

"Dr Daniel remarked that Amber's medical records are like an encyclopedia!" she replied.

1146. A 7-year-old Shih Tzu has bladder tumour and many stones.

Sunday Dec 21, 2014

This 7-year-old male, not neutered Shih Tzu, born Feb 19, 2007 got his three vaccinations from me as a puppy. On Jun 29, 2012,  he passed blood in the urine for 2-3 weeks and lost appetite. The owners said was fed only rice and wet food and did not want surgery when X-ray showed bladder stones and urine showed triple phosphate crystals +, bacteria 3+ and blood 4+ , protein 2+. pH was 7.0. SG 1.015.

Dr Daniel advised surgery. The owner wanted conservative treatment using a special diet to dissolve the stones. She bought 6 cans of prescription diet S/D for the next 12 months. This is not the correct way to dissolve the stones. The S/D diet must be fed solely for 3 months and urine tests (monthly) and X-rays (3-6 monthly) need to be done.  The owner did not comply.


BLOOD TEST  22.12.14
Urea 8.5 (4.2-6.3). Creatinine  79 (89-177).  Haematology was normal and this was a good sign for surgery as there was little or no bacterial infections or septicaemia. 

URINE TEST
pH 7.0  SG 1.01. Nitrite +, Blood 4+, Bacteria 2+, no crystals.



Today, Sunday, Dec 21, 2014, the owner consented to the surgery as the dog was peeing blood in the urine for several weeks.

Now the catheter cannot pass into the bladder as urethral stones at the bend of the urethra obstructed the passage of the catheter. I palpated the bladder. It was still solid as a golf ball but not fully obstructed. The dog surprisingly had an appetite.  An IV drip with antibiotics, pain-killers and Vit Bs is given now and surgery was by Dr Daniel in the afternoon.

A globular submucosal bladder tumour 2.5 cm x 2.5 cm x 2 cm was surprisingly found. Many small stones with some sticking in clumps,  looking like calcium oxalate uroliths were taken out. 

CONCLUSION
Many Singapore owners are not aware that medical dissolution of triple phosphate stones need to be monitored regularly with urine tests and X-rays.  In this case, the owner bought 6 cans of prescription S/D in 2012 when the stones were found in the bladder and assumed all stones will be dissolved since they fed rice and wet food.

S/D must be fed 3 months followed by C/D and there must be regular urine tests and X-rays.
   

1145. Images for perineal abscess, ear abscess etc

The maid came with the dog as he was scratching both ears and shaking his head.

1. Painful ear infections and head shaking for over 10 years with hair loss on neck skin and pigmentation in ear pinnae. The owner did not want sedation and ear irrigation and the husband wanted the dog back and sent to another vet.

 

 

 

 

 

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1. Intense perineal pain of 2 days. "Looks like a perineal hernia," I said as the dog wanted to bite. "Right anal sac area intensely inflamed."
   
   BLOOD TEST
   Creatinine 33 (89-177) not significant.
   Total WCC 23.2 (6-17), N 96% (60-70), Absolute 22 (3-11).
   Hb 11.4 (12-18). RBC 4.7 (5.5-8.5).

Given IV drip + baytril + dexa on Day 1.
Went home. Came back on Day 2 for X-rays. A skin hole appeared near the right anal sac area now. Over 100 ml of reddish brown blood with yellow materials shot out. So, this is a perineal abscess. Based on blood test, there was lots of bleeding.  

 

 

 

 

 

 

 

 

 

 

 

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