Monday, September 17, 2012

1100. Veterinary surgery report - Shih Tzu with blocked bladder

DRAFT

VET SURGERY DONE BY DR SING
The problem was that this Shih Tzu had dysuria after a second bladder surgery and the other vet recommended a second urethostomy and scrotal ablation. The first urethostomy would be closed as it had "ben blocked by pus and scars".

However, we find that the first urethostomy was not blocked. The most economical solution for the owner, in my view is to extend the first urethrostomy and excised the infected thick scrotal sac (scrotal ablation). Opening a second urethral hole would be quite traumatic and invasive.

This was done and so far, the dog could pee normally via the first urethrostomy. The owner asked for neutering and excision of a big swelling at the left inguinal area. This was done by my associate vet. In conclusion, this dog had four anaesthesias and surgeries.

In retrospect, 3-monthly monitoring with urine tests and X-rays and special diet like S/D and C/D would have prevented any surgery after the first urethrostomy. But no Singaporean owner, in my observation, has time for post-operation check ups.

1099. Sunday's interesting cases Sep 16, 2012

Sep 16, 2012.

1.  BARKERS
A wearied stress-out man whom I knew to be a tenant of Toa Payoh North industrial park came to my office at 9 am saying that "my dog was not fed and therefore barked all night long."  He said: "The barking noise is even louder at higher levels of the building esp. at 6.30 am!"

I showed him the crates and he could see bowls filled with dog food. We feed the dogs in the morning and evening. There was one particularly noisy Jack Russell whose owner went on holidays overseas to Delhi for more than 10 days and his friend did not want to help take over. His dog was spayed and he complained that she vomited 2 days after the spay. Actually he had applied tick insecticide wash on the dog. She was still eating and is normal but now the owner's friend did not want to look after her. Jack Russells are notorious barkers. My assistant Min just ignored them but actually, the caregiver should "scold" them with "no barking".

2. CAT WITH GENERALISED RINGWORM
"I last consulted you 7 years ago," the man in his late 50s said to me. His cat was 8 years old and very itchy. Raw sores up to 2 cm in diameter esp in the neck and all over the body. As he came past 11 pm, I handled the case with my associate vet (Vet X). "What's your diagnosis?" I asked. "Possibly allergy," Vet X said.

The cat had multiple circular lesions, many of them black. "Did you check the hairs microscopically?" I asked. "Yes," Vet X said but was not convinced that this was primarily a ringworm case. Cat flea bite all"ergy was probably what Vet X thought of or other forms of allergy. This is what I mean when I say that each vet will give a different diagnois to the owner in many skin disease cases and confused the owner.

I took out the UV lamp, switched off the consultation room light. I asked the owner to see the green fluorescence from the UV light on the neck sores. I asked Vet X to be around too. The light was scanned onto the left neck area where the owner said was recently affected. A turf of bright green hairs appeared in one of the neck wounds, indicating a possibility of ringworm.

"The owner had been treating the cat's skin disease for over 2 months,": I explained to Vet X. "He can't cure and so he came to consult the vet. His medication and washes had removed much of the old ringworm areas where you see black circular spots. But he could not cure the cat as the ringworm has spread and is generalised ringworm."
It is not so easy as described in the textbook to find classical ringworm in any cat or dog as most of the owners will treat themselves with pet shop medication first. It is a long road to educate vets whose mindset is straight from the text books as in real life, diseases are not so clear cut as described in vet textbooks on ringworm diagnosis!

TEACHER'S PET
"4 years ago, you removed the abscess and bandaged the skin," the lady in her 30s had a young rabbit with abscess popping out of the skin of the left hind leg. "I had difficulty removing the bandage. Now the same area has abscess again."

"I remember you," I said. "You are a teacher. It is surprising that abscess come back again after so many years."

SHIH TZU WITH BLADDER STONE COMPLICATIONS
The owner had said he would take the dog back on Sunday (today) but he did not turn up. I took out the urinary catheter. There was some mucus. "Cathethers cannot be placed too long," I said to Dr Daniel as it irritates the bladder. In this case, I placed it for around 4 days as there could be a tear in the bend of the urethra and I did not want that area to close up. If it closes up, the dog can't pee. This was a much complicated case and is being managed on prescription S/D diet.

CLOSED AT 5.10 AM
This was one of the few Sundays when the surgery closes "early" I was present and saw the crowd at 4.30 pm. Time management is important as wait times can be very long if everybody wants to see Dr Vanessa and comes at 4.30 pm. The closing time is 5 pm and I asked Dr Daniel to handle a vaccination case. No point making the lay staff work till 6.30 pm unless there is an emergency.

Associate vets should prepare the medication of spays etc early and not wait to do it when the owner comes at 4.30 pm. This is why there are delays and increasing wait times.






1098. Urinary Stone Reminder?

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?

   

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.

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?

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.