1123. VETERINARY TIPS. Take digital images of complicated post-operation cases to make you a better vet

Taking images of cases with your camerar or phone to document your cases and to do retrospective studies of your performance will make you a better veterinary surgeon. 

There may be some parts of the anatomy changes which you might have missed during the examination but images taken will be there for you to review and plan your surgery in your office.

For example, in the tough case of the Shih Tzu with perineal urine leakage after a bladder surgery by Vet 3 to remove urinary stones, an image of the swollen perineum (presumed with leaked urine from the traumatised perineal urethra) was taken by me. This is shown below:

This is one supporting evidence and there must be others to substantiate this urine leakage (ultrasound of scrotum filled with fluid), swelling of left inguinal area near where Vet 3 made a skin incision to access the bladder for urinary stone removal daily with blood-tinged fluid while the dog was catheterised with a smaller sized urinary catheter

Note that the scrotal sac is also swollen and Vet 3 had said that ultrasound revealed fluid. 

According to the owner, the whole of the lower part of the inguinal area was much swollen and that was why the dog had to be hospitalised for 8 days by Vet 3 who then recommended a 2nd urethrostomy and scrotal ablation to resolve the problem of urine leakage.  

This image was taken when the dog was seen at Toa Payoh Vets on Day 9 after Vet 3's bladder surgery which had removed all bladder stones (post-op X-rays showed no stones).

How to resolve this problem with the least cost to the owner? 

That is the tough part. Will a 2nd urethrostomy and closure of the first urethral stoma and scrotal ablation resolve the problem for once and for all?  

Vet 4 at Toa Payoh Vets was asked by the owner to neuter the dog and remove the large left inguinal swelling of the size of an egg and Vet 4 stitched up the urethral stoma (first urethrostomy done by Vet 1). 

Would this resolve the problem? Well, it did not appear to do so as the left inguinal swelling filled with blood-tinged fluid.

(I presumed it was urine leakage + blood) of around 30 ml per day for the next 4 days after Vet 4's surgery.

"Closing the urethral stoma so that the dog could pee normally from the tip of the penis is good for the dog," I said to Vet 4. "But there is the daily need to aspirate the 30 ml of blood-tinged fluid from the left inguinal area. 

"It cost the owner around $7,000 to do the past 3 surgeries to remove the bladder stone and given time, your surgical approach may work. But time means more money expenditure for the owner."

As Vet 4 had to go overseas, I took over the case and reviewed the complicated urine leakage problem. 

This involved talking to Vet 3 as to what had been done. Vet 3 said that an ultrasound revealed fluid inside the scrotum and this was not recorded in the case report as the owner was not charged. 

Ultrasound can reveal fluid in an organ but will not be able to tell whether it was urine or blood or both.

This is where the perineal swelling in this image substantiates a possible urine leakage.  It is extremely expensive to do dye test to reveal the location of the perineal urethral leakage. The surgery at Vet 3 had cost $2,000 according to the owner.

So, what's the best economical solution now? What is in the best interest of the dog? If expenses keep mounting, the dog may be put to sleep by the owner. A solution must resolve the problem.

My approach was to extend the urethra stoma which had been closed by Vet 4, do scrotal ablation, close up the inguinal sheaths and stitch the urinary catheter to the prepuce to retain it in for around 4 days to let the perineal catheter to heal. This is the theory.

In practice, this worked as the dog is now peeing normally with no blood in the urine when it came back for stitch removal on Sep 28, 2012, around 14 days after my surgery. 

Not all bladder surgery is free from complications. In this case, the perineal urethra could have been damaged. Hence the urine leaked into the perineum (causing large swellings). The urine also flowed into the scrotal sace, hence another large swelling. 

     

1122. The vet transports the dog for an X-ray

"Surely it is not (befitting) your status to personally drive and transport the dog to get an X-ray done!" Dr Jason Teo's transport man met me at a Clinic where he had taken a cat for x-ray of the pyometra.

"My transport man had sold his van and the others were not available," I explained.
Steven pointed to an old Mercedes outside the clinic. Its engine old and smoke from the exhaust puffing out and said: "Surely, the petrol of the Mercedes would cost more than your transport cost. Why don't you just phone me?"

"I thought you just groom dogs for Jason," I did not tell him that the black Mercedes was not mine and I don't idle the engine when I park the car. It takes some time at this clinic to get the dog X-rays. In any case, I dislike polluting the environment by idling the engine unnecessarily.

"I do dog transport when I need the money," he laughed. He is an old guard in this pet business.

I find that much can be learnt just by transporting the dog for X-ray to any clinic. In one clinic, I was made most welcome by the vets. In another clinic, I would not be permitted to see any vet nor proceed past the waiting room as it has an awesome gate-keeper. So I learnt a lot by being on the ground.
   

Follow up: The 3rd sister loves and cares for the old dog

1121. Bladder stone dog goes home - 3 sisters




"Are you the sister who spoke to me by phone about the dog having kidney stones and whether an operation is necessary?" I asked the bigger of two adult ladies who came this afternoon to pick up the 12-year-old male cross-bred that looked so much like a miniature version of a Golden Retriever.



"No," she said.

"Are you the eldest of the 3 sisters?" I asked.

"No, I am the 2nd sister."

"Is the other shorter lady the youngest sister?" I asked.

"No, she is the eldest sister."

"So, the youngest sister is the most intelligent," I said. "To seek a second opinion."

"She is the one who loves the dog most," second sister said. I had talked to her by phone many times to update her of the dog but never saw her.



I put the dog on the exam table and palpated the bladder and prostate for pain. Not a whimper unlike 2 days ago.



"I need a tissue paper to wipe away the blood," 2nd sister said. The dog was so active and had pounced on her left knee and scratched 4 inches of red rash."



"This dog needs to be neutered as Vet 1 had done an ultrasound and said that the prostate was much enlarged."

"Why must he be neutered?" 2nd sister asked.

"The male hormones are produced by the testicles and they make the prostate grow bigger and it had become inflamed and infected. The enlarged prostate caused the urethra to be narrowed, making urination difficult for this dog. Bacteria from the bladder was present and could have infected the prostate. That was why it was painful 2 days ago and earlier. Vet 1 did give an anti-male-hormone injection called Tardak and advised weekly injections. Neutering would have been the alternative. Now, the dog's prostate is not inflamed or enlarged and so the dog pees normally for the last 2 days."



The dog did not pee in front of the sisters this afternoon but he had peed a few times freely in the morning.



"I have advised no bladder stone removal operation as the dog is very thin and will wait till he has difficulty in urination the next time," I said. "Although there is no crystals or struvite crystals present in his urine analysis, it does not mean he has no struvite stones. The pH is 6.0 for the past two urine analysis but bacteria is present in the urine. The bacteria in his bladder may have gone to the prostate, causing pain and inflammation of the prostate.



As the 2nd sister is an adult, she understood what a prostate is and so I need not explain further.



EXPLANATION

1. The male dog does not urine mark for the past two days. He just pees a few times in the morning when taken out for the walk. Why? This is because he was given an anti-male-hormone injection called Tardak by Vet 1 around 1 week ago and he is "feminised."



2. The urinary pH is 6.0. In struvite stone formation, the pH is usually alkaline and urease bacteria must be present. That is the norm. However, Vet 1 had recommended K/D diet and the dog was eating it. So, the urinary pH may have been affected. It is hard to say. It is too technical to explain to the sisters about alkaline urinary pH and struvite stone formation as there is information overload.



3. I advised S/D diet for the next 3 weeks as an alternative to surgery due to the high anaesthetic risks involved at present (prostate enlargement and infection, bladder infection with bacteria). This old dog much loved by this 3rd sister and it is better to build up the dog's weight and health if the bladder stone surgery is needed in the future. Neutering is advised next week as neuter is a very short 5-10-minute surgery compared to around one hour for bladder stone removal. Struvites are more common in dogs seen by me and if this S/D trial works and X-rays of the bladder are taken in a month's time, the stones would have dissolved or reduced in size, permitting urohydropropulsion. That will get rid of all the smaller stones.



4. Owners seldom comply with veterinary instructions and so much depends on educating the owner and the 3rd sister. Somebody who loves the old dog and usually it is a lady family member who cares very much for this old companion to get things done by the vet.

1121. Bladder stone dog goes home - 3 sisters

"Are you the sister who spoke to me by phone about the dog having kidney stones and whether an operation is necessary?" I asked the bigger of two adult ladies who came this afternoon to pick up the 12-year-old male cross-bred that looked so much like a miniature version of a Golden Retriever.

"No," she said.
"Are you the eldest of the 3 sisters?" I asked.
"No, I am the 2nd sister."
"Is the other shorter lady the youngest sister?" I asked.
"No, she is the eldest sister."
"So, the youngest sister is the most intelligent," I said. "To seek a second opinion."
"She is the one who loves the dog most," second sister said. I had talked to her by phone many times to update her of the dog but never saw her.

I put the dog on the exam table and palpated the bladder and prostate for pain. Not a whimper unlike 2 days ago.

"I need a tissue paper to wipe away the blood," 2nd sister said. The dog was so active and had pounced on her left knee and scratched 4 inches of red rash."

"This dog needs to be neutered as Vet 1 had done an ultrasound and said that the prostate was much enlarged."
"Why must he be neutered?" 2nd sister asked.
"The male hormones are produced by the testicles and they make the prostate grow bigger and it had become inflamed and infected. The enlarged prostate caused the urethra to be narrowed, making urination difficult for this dog. Bacteria from the bladder was present and could have infected the prostate. That was why it was painful 2 days ago and earlier. Vet 1 did give an anti-male-hormone injection called Tardak and advised weekly injections. Neutering would have been the alternative. Now, the dog's prostate is not inflamed or enlarged and so the dog pees normally for the last 2 days."

The dog did not pee in front of the sisters this afternoon but he had peed a few times freely in the morning.

1121. Fits in a 12-year-old Silkie Terrier - what is the cause?

A Silkie Terrier had fits at around 6 am yesterday and today Sep 27, 2012. First episode. What is the cause?

"There are many causes," I said to the owner who told me that the old dog had a dental scaling 1.5 months ago at Vet 1's place and the right submandibular lymph node would be due to bacterial infection from the bad teeth.

"The lump is nodular and quite large and painful," I said. "The dog reacted to the palpation and coughed a bit. One possible cause of this early morning fit could be the sharp pain in this lump," I said. "If only dogs can talk."

I advised an X-ray. "It is best not to operate now as the lump appeared to have spread inwards," I said. "This is an inoperable tumour, likely cancerous."
"Please forgive me for asking. How do you know it is cancerous?"
"I do not know for sure, unless it has grown aggressively since 1.5 months ago. If Vet 1 had recorded the size of the lump and it is now 2 or 4X bigger, then it is likely to be cancerous." He would try to get the report from Vet 1.

"If it is just an inflamed right submandibular lymph node, then medication will reduce it considerably," I said. "We have to review in 2 weeks time. Blood test did reveal liver disorder as the enzymes are increased. However, some vets will say that the liver enzymes must be considerablv higher than today to cause fits in your dog. I mean, you ask 10 vets and you get 10 different opinions."

 

 

 

 

 

I will be working with this owner to monitor the fits after taking medication, but no fits medication for the time being. X-rays are as follows:




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A kind Buddhist teacher

TOA PAYOH VETS toapayohvets.com   Blk 1002, Toa Payoh Lor 8, 01-1477, Singapore 319074   Tel: 6254-3326, 9668-6469, 9668-6468.  judy@toapayohvets.com   22 May, 2015   Focus: Small animals - dogs, cats, guinea pigs, hamsters, turtles & rabbits

Mammary adenomas in an American Cocker Spaniel Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS First written: 21 September, 2012 Update:  22 May, 2015  "Why did you  delay seeking surgery till the breast lump is gigantic in size, like two tennis balls combined?" I asked the Buddhist temple teacher who taught Buddhism and morals to over 800 children of devotees. "The breast lumps grow very fast in the last 2 weeks," she replied. "Nobody in the family wants to bring the dog for surgery. My brother said to let her die." The solution was surgical removal but the family did not want to pay the medical costs. She was kind to enough to bring in this old dog for surgery at Toa Payoh Vets. Breast adenomas grow rapidly to sizes of 4 large oranges in this American Cocker Spaniel. After mastectomy, the dog was eating and normal "Walk-in" sutures holding the skin edges tightly and the haematoma on the left MG5 was treated by opening up the area via removal of 2 stitches. Healing by granulation was uneventful.  The 8-year-old dog was not spayed.  Mammary adenoma was diagnosed. No malignancy, according to the histology report. I was surprised as it was a massive tumour. Dr Daniel and I operated. I took over the stitching to ensure that the stitches were tight. I tacked in "walk-in sutures" through the muscle layer and then the skin,  using 2/0 sutures to ensure that the large long wound would not break down.. The dog came back 4 days later. There was a swelling at one end of the tumour. " "There's seepage at the left Mammary Gland 5 area," I said to Dr Daniel who is in charge of the case. "Just cut off two stitches," I said to him. "In this way, the serum can drain out. No need to re-stitch." After that, we had no more visit from the Buddhist teacher. I was glad that this dog was not abandoned when she had the tumours. Such incidents do occur in Singapore. It is best to spay the female dog when she is young as breast tumours are less likely to develop in spayed dogs. BE KIND TO OLDER DOGS & CATS --- GET TUMOURS REMOVED EARLY --- WHEN THEY ARE SMALLER.  More case studies, go to: Cats  or  Dogs Make an appointment with your vet. Or tel 6254-3326, 9668-6469 for an appointment to discuss health screening for your senior companion. Or e-mail judy@toapayohvets.com your requirements.  Copyright © Asiahomes Internet All rights reserved. Revised: May 22, 2015 Toa Payoh Vets

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.