1387. Mynamar talk: Treatment of recurring urethral obstruction in a 4-year-old male cat in Yangon and in Singapore

Each vet has his or her own way of treating a cat with urethral obstruction. In my experience of treating a Singapore cat with urethral obstruction, not every case can lead to successful outcomes.

The narrow diameter of the penile urethra can be blocked again. The recurrence after treatment  will need to be investigated in more detail. It may be a lower urinary tract infection which has not responded to antibiotics given or the presence of uroliths in the bladder or rarely in the kidneys.

Urinalysis and urine bacterial culture and antibiotic sensitivity tests may need to be done again. Radiography of the bladder and kidneys is needed to detect the presence of radio-dense struvite bladder or the rare kidney stones. Radiography of the bladder to detect the location, number and size of the uroliths may need to be done. Ultrasonography of the bladder to view the thickness of the bladder wall, the presence of intraluminal stones or tumours will be useful in causes of recurrence.  

I was visiting Dr Aung of Royal Asia Veterinary Surgery in June 2014 and videoed a case of a 4-year-old male cat with dysuria for the 3rd time being treated. The first vet had treated the cat twice, catheterising the bladder to unblock the urethra, but the dysuria recurred one week later after the second treatment. The first vet had prescribed antibiotics and a dry urine acidifying diet and sent the cat home after treatment. However the dysuria recurred and the owner sought a second opinion from Dr Aung.

GUIDELINES TO TREATMENT OF URETHRAL OBSTRUCTION IN A CAT IN TOA PAYOH VETS. The following is my procedure but my associate vet may not hospitalise the cat.

1. Radiography (2 views) of the bladder and kidneys is done. Struvite uroliths and urethral casts are radio-dense.

2. Urinalysis to check urinary pH, SG, presence of red and white blood cells and crystals. A dipstick may be used initially but a urine sample collected via urethral catherisation is sent to the laboratory.

3. CBC/Biochemistry may not be done if the owner is concerned about the medical cost.

4. The cat is sedated with an injection of combined 2% xylazine and ketamine 100mg/ml in one syringe IM. I find that the safe and effective dosage is xylazine 0.1 ml + ketamine 0.4 ml IM for a cat 2-3 kg. For a cat 3-4 kg, xylazine 0.15 ml + ketamine 0.6 ml IM. 

5. The urethra is catherised as in the video. If there is urethral plug obstructing the passage of urine, around 2-10 ml of normal saline is injected to unblock the urethra. The urine is collected in a bottle for urinalysis by the laboratory. After emptying the bladder, the bladder is irrigated with over 100 ml of normal saline with the fluid syringed out to remove any urinary sand and debri.

6. The catheter is stitched to the prepuce and the cat is an inpaatient for 2 days. The catheter is removed and the cat goes home with antibiotics, tolfedine painkillers and a gradual change to an acidifying diet like the canned Science Diet C/D for one month. I prefer to give an injection of Baytril and prednisolone SC after the treatment but the younger vets may prefer non-steroidal anti-inflammatory drugs like meloxicam or tolfedine. 

7. Follow up by telephone call is necessary. In this case of a 4-year-old neutered male cat treated by my associate vet Dr Daniel and sent home after the above treatment with vibravet paste and tolfedine tablets.  I followed up with the owner for presentation of a Singapore cat case for this Seminar while Dr Daniel does his own follow up.

The owner told me that cat quickly removed the e-collar and pulled out the stitched catheter within one day of going home. On Day 4, he started eating and meowing for attention. But he still had urinary incontinence with a wet spot of urine on the floor. This was less than on Day 1. I prescribed another 6 days of antibiotics (Baytril) and half a tablet of prednisolone 5 mg for 8 days.  She was to start on the Science Diet C/D mixing 10% with 90% of the previous food. Client education is important as the dysuria may recur if the client continues feeding the original dry food which cause alkaline urine formation. No urethral stones were seen in the bladder or kidneys in the X-rays (image in video) and triple phosphate crystals were found in the urine (image in video).

Two videos
1. Dr Aung treats a Yangon cat for urethral obstruction
2. Dr Daniel treats a Singapore cat for urethral obstruction.


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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.