Sunday, June 29, 2008

4. Pyometra in a toxaemic Golden Retriever

"Flies just would not go away when I swat them," the 65-year-old grandmother with a fair 5-year-old grandson came to the surgery. She was surprised at the tenacity of flies: "They just swarm onto the dog's vaginal discharge."

This was not good news. Flies are attracted to decaying flesh as moths are to candle light. Kamikaze flies who just cannot resist necrotic flesh.

The 12-year-old Golden Retriever had some vaginal discharge 2 months ago. The grandmother attributed it to the dog having heat. In the last 4 days, the dog passed out thick glue-like mucus from her vagina. She stopped eating for 2 days and had vomited.

"Your dog had a severe womb infection. She vomited because toxins could have damaged her kidneys and internal organs, " I did not give much hope of survival for this dog. "Why didn't you spay the dog after the breast tumour operation?"

My past procedure was to remove the breast tumour first and then spay the female dog later. In this way, hormones feeding any new breast tumour would not be available after removal of the ovaries.

The slim and fair grandmother laughed: "You said that XXX would not survive 9 months as her cancer could have spread to her body. Can you recall? breast cancer was as large as a tennis ball!"

I checked my records. It was September 2005 when the large breast tumour was removed. It was a solitary gigantic lump as large as a tennis ball. Now, in Jun 2008, the dog had a long scar where the tumour was. There was a small breast tumour around 2 cm in diameter.

My 'prediction' of 9 months' of life for this Golden Retriever had been way off the mark. It was now 33 months after tumour removal. Why would I give a definite 9 months, I cannot remember. Why not 3 months or any other number? No vet can foresee the future. But I did not argue as the grandmother had a sharp memory.

Now the dog was very sick. She had fever of 40.5 degrees C. She was not eating. She yelled in protest of great pain on the operating table when I stretched her legs to see the long 15-cm scar of the tennis-ball-sized breast lump.

She was now in poor health. If flies just zeroed into her vaginal discharge, it indicated that her womb tissues had rotted. Flies are suicidal and sticky when the tissues and discharges stink a lot. They seem to appear from nowhere and are large bodies flies from the vegetation near the house.

The grandmother understood the big risk of dying on the operating table. I boarded the dog one day to give her antibiotics, anti-fever and drips. The dog felt good 24 hours later and ate a full meal after canned food was added.

Now I had to decide. To operate 36 hours after admission or wait another day? The infected womb might rupture anytime as it was decaying. Her temperature had dropped to 37.5 degrees C, one degree below normal. She was sleepy and lethargic. This was a life and death situation. If the surgery was delayed another day, she would die due to toxic blood infusing her whole body. If the surgery was performed, she might die on the operating table as chances of survival were deemed below 50%. So, which decision to make?

The dog was given just gas anaesthesia and intubated. Her large thin-walled uterus and ovaries were removed. The reddish brown pus was copious. Bacterial toxins had seeped into the blood system by permeating past the uterine walls. The uterine horns were purplish in colour when the normal ones would be light pink.

The dog survived the surgery. After waking up, she vomited a big mass of food on the operating table. I had taken out the endotracheal tube some 2 minutes ago.

This was an abnormal event as she had been starved >12 hours prior to surgery and should not vomit anything. This indicated that the stomach was not moving the food along the gut. Another abnormal feature was the dark bluish black blood of her omental blood vessels. Normally they would be reddish.

Such negative signs were not good for the dog. I phoned the grandmother to come to see the dog after surgery which was completed around 11 am. I assessed that this dog would not survive and it would be good for the grandmother to see her. She was the dog that brought newspapers to the grandmother every morning and kept her company. However the grandmother's two adult sons needed her at the airport - one going abroad and one returning to Singapore.

At 7 p.m, the Golden Retriever just passed away quietly due to heart failure. Her gums and tongue were cyanotic. We informed the grandmother. She came around midnight.

5 days later, the grandmother came to pay the bills. "My daughter said there would be nobody in your surgery during lunch-time," grandmother said. "But there ought to be somebody."

Grandmother was correct. I had just returned from visiting abalone farms in Xiamen, China.

Grandmother was sad in her heart. Every dog's death is saddness for everyone involved. I asked grandmother to sit down and we reminisced in the consultation room. Just to know more about XXX.

Grandmother said, "XXX dog behaved strangely the night before going to the vet. She dog walked around the house and went to the back garden to stroll by herself."

"Does XXX not wander around usually?" I asked as the bungalow would have ample garden for her to roam.

"No," grandmother said. "XXX does not go to the back garden by herself at night."
"She also went to my daughter's bedroom to sit and wait patiently."

"Why would she do it?" I asked.

"She waited till my daughter gave her a second piece of Pokey biscuit. My daughter said to her 'You are permitted only one Pokey biscuit. Go away. Mommy will scold me'" the daughter told XXX off.

"But XXX would not go away. My daughter gave her a second Pokey biscuit stick and after eating it, XXX left."

Was the dog saying good-bye to the family members and the house? It is hard to explain such behaviour. Some animals might know that their life would be ending soon and wanted to say good-bye.

Grandmother stoically said to me: "My grandson keeps asking when Jesus will bring XXX back." The 5-year-old was too young to understand that death was permanent.

Would spaying her when she was younger prevent pyometra and prolong her life? Without the womb, she would not have pyometra and therefore would live to a ripe old age of another year or two? It is hard to say. Anaesthesia in dogs older than 8 years are high risk.

No vet can be assured of 100% survival in such cases. Sometimes it is best to pass such high risk cases to other vets. The daughter still grieved her loss daily for the past 5 ddays. "I guess she would be angry with me," I said to the grandmother. No comment from her.

Grandmother was stoic. Her friend had just got a stroke. She was widowed some 2 years ago and had now fortified herself.

"This dog was adopted as a puppy when there was a newspaper advertisement in the Straits Times looking for homes for the puppies to be given free," grandmother recalled. "I saw the advertisement when the newspapers were delivered at 5 am. Usually papers come at 7 am. So I went with my two sons and the owner gave us XXX. XXX used to bring the newspapers into the house every morning."

Grandmother had lots of work to do with so many dogs and children. "At one time, I looked after 8 dogs. Friends asked me to care for them for a while. They just did not come back for the dogs. I have 3 children to cook for and look after."

What an active energetic life, grandmother must have had. Though she was now 65 years of age, she looked much younger and trimmer than a 50-year-old. Usually grandmothers look matronly but she was a model for the slimming saloons.

"I cured one terrapin with enlarged closed eyes just by researching the internet," the grandmother said to me. That was great news. Most Singapore women of her age would not touch the computer.

"I can remember important dates and do calculations fast," the grandmother reminisced. "I would tell my children the price per kg for things they bought. But lately, I am not able to calculate so well."

It was good that she came during lunch time as we had some time to talk about the dog. "I can't stay long to chat," grandmother suddenly saw that time had passed so fast. "I have to go to Hong Kong,"

"Why do you have to rush to Hong Kong?" I appreciated the grandmother taking the trouble to pay the bills without being asked to do so.

"To look after my grandson for a week while my son and his wife had to go on holidays" she said. "There are two maids looking after him too."

All grandsons must surely love her very much but the one who loved her the most was the 5-year-old boy who stayed with her in Singapore. This 5-year-old boy came with the grandmother during the consultation and later around midnight to see the dog. A fair-looking boy with big eyes. He asked his grandmother for the past days with questions the grandmother told me, such as:

"Why Jesus take away XXX?"
"Why XXX has not come home?"
"Only one (pre-school) classmate knows when I said that XXX had gone to see Jesus."

The grandson had come with the grandmother during consultation as his pre-school had closed due to the presence of hand-foot-and-mouth disease prevalent in Singapore at this time.



It is extremely high risk to operate on toxaemic pyometra and old dogs. If the owner had returned to get the dog spayed one or two months after the breast tumour removal in 2005, this dog might still be alive. She might have died during the spay surgery too but the probability of her dying on the operating table when she was 10 years old would be much lower.

Singapore owners generally have not reached a high level of awareness stage that the dog must be spayed after removal of the breast tumour. They just forget about the spay once the tumour is removed. It is not prudent to remove the breast tumour and spay at the same time in old dogs as the prolonged anaesthetic time increases the risk of death on the operating table.

My present procedure would be to spay the dog first. If the owner did not return to get the breast tumour removed 2-4 weeks later, the female hormones feeding and growing the tumour would be removed as the ovaries would be taken out during the spay. Ideally, spay and mammary tumour removal should be done at the same time. But the surgery would take a long time and at the end of the long surgery, the dog might die on the operating table.

No family member can forgive or forget a death on the operating table. So it is best not to take foolish risks.

Saturday, June 28, 2008

3. Pyometra in old female dogs - To spay or not to spay? Is there a choice?

DRAFT - CYSTITIS + PYOMETRA IN AN OLD DOG


From: ...@singnet.com.sg>
Subject: Question re Dog Licking Herself More Often
To: drsing@toapayohvets.com
Date: Tuesday, June 24, 2008, 6:31 AM

Hi Dr. Sing,

It has been a while since we last corresponded.

Can I please get your advice as my dog XXX has been licking her private parts
more often recently? There's no discharge on the floor, and she's
eating per normal and active as usual. Normal urine and poo too. However when I
check inside her vulva, I see a clear discharge. It isn't much and
doesn't ooze or drip out of her body too.

Her vulva is not swollen or red; it is just normal in colour with one or 2
faint tinges of pink. When I check, her vulva feels soft to the touch, but the
part right after that, i.e. the area between the vulva and the anus, feels
firm/hard to the touch. Is that normal? NO

Is
there anything I should worry about? FYI, XXX is 9 years old and unspayed.

Could her licking be related to the possibility of her coming into heat soon?

My dog's last heat was in Feb 8 through 25. The one before that was in Sept
23 through Oct 11. It was 5 months or 20 weeks between last year's heat and
the most recent one in Feb. Do you think my dog is going on heat again soon?

When does a female dog start licking herself before her season? 2 weeks before
or?

Please advise. Thanks very much!

Best regards,
Name given

E-MAIL REPLY JUNE 24, 2008
Re: Question re Dog Licking Herself More Often - PYOMETRA
Tuesday, June 24, 2008 9:20 PM
From:
"David Sing"
View contact details
To:
...@singnet.com.sg
Cc:
drsing_98@yahoo.com

Most likely on-line diagnosis (which is not recommended or advised) is that your dog is suffering from open pyometra. In this condition, the womb of the old dog has been infected by bacteria. Large amounts of pus are produced inside the uterine tubes.

Toxins from the bacteria get into the bloodstream to damage the kidneys and other organs. In time to come, the dog cannot cope with the licking away of the copious flow of vaginal discharge. The dog gets septicaemia and starts vomiting more and more often.

The only treatment of pyometra is surgery to remove the womb and ovaries (spay). Pyometra can be an emergency in many cases as many Singapore owners delay treatment thinking that the unspayed female dog is just having heat.

I just had a 12-year-old Golden Retriever with "heat" 2 months ago. (I presumed the dog licked her vaginal discharge so the owner did not see any more discharge). 2 weeks ago, sticky yellow vaginal discharge attracted flies which would not be swatted away. She vomited 2 days before surgery. Would not eat.

Depending on its health status, some dogs die before, during or after surgery. As many Singapore pet owners consider spay as "cruelty" but are uneducated as to what is pyometra, they often seek surgical treatment very late and the vet sometimes gets blamed for the death of the dog during or after surgery.

In your case, you have no choice but to see your vet and get a professional examination and opinion. It seems that your unspayed dog has been infected for some weeks. Female dogs spayed when they are young will not get pyometra for obvious reasons - they don't have the womb. There are pros and cons of spaying.


UPDATE ON JUNE 25, 2008
Dog seen on Jun 25, 2008

Active, eating. No fever. Bad teeth and infected gums.
No copious vaginal discharge. A dot of pus seen on tissue paper.
Had a urine test at another vet some time ago - protein ++ in urine.

Palpation of uterine horns: some swelling felt. Around 1 cm thick uterine horn.
Palpation of bladder. The dog "yelped" and hunched her back, indicating acute pain response at the area where the bladder and uterine horns are located. It was good that the owner saw the pain response.

Diagnosis: Pyometra and likely a bladder infection. Owner said the urine is clear.

Advice: Antibiotics for 10 - 20 days. Spay on around 10th day. Dental work around 60th day.
On Day 2 after consultation, owner said that the vulval swelling had subsided.

This is a case of early pyometra. As the owner is close to the dog, she noticed the dog's unusual behaviour of licking the vulva. As to chances of survival during or after spay operation, this dog has a 75% chance of survival after antibiotics for 10 days. No vet can guarantee 100% for any old dog under anaesthesia.

Blood tests and X-rays will add to veterinary costs but some owners may not want to incur high costs. Surgery and general anaesthesia at Toa Payoh Vets is around S$500 - $1,000.


E-MAIL ON JUN 29, 2008

From: ...@singnet.com.sg>
Subject: FW: Kong Yuen Sing sent you a message on Facebook
To: drsing_98@yahoo.com
Date: Sunday, June 29, 2008, 1:54 AM

Dear Dr. Sing,

Thanks so much for your
detailed replies to my questions as usual.

My dog seems to be much better after starting on the antibiotics. The redness
on the vulval/anal area has gone off a fair bit, and most importantly, she
has not been licking her vulva that much. I observe her very closely and I see
her licking her vulva only once or twice a day. So that means that the
antibiotics are working very well as they should now that it's Day 4 on the
antibiotics. I'm glad we listened to your advice to put her on the course
of antibiotics first before the surgery.

You mentioned that if "IF THE INFECTION HAD GONE AND THE WOMB IS BACK TO
ALMOST NORMAL SIZE, I CAN HOOK IT UP. INCISION WILL BE LIKE THE USUAL SPAY
INCISION. AROUND 1-1.5CM.

IT IS POSSIBLE THAT I CAN HOOK THE WOMB OUT IF IT REVERTS TO NORMAL SIZE AFTER
ANTIBIOTICS. IN SUCH SITUATIONS, THE BEST TIME TO SPAY HER IS 1 MONTH
LATER."

I thought a lot about what you said, but I don't think we can wait as my
dog's last heat was Feb 8 through 21, so she is due for her next heat very
soon, whether she has a 5-month or 6-month period in between cycles this time.
If she goes on heat again while we are waiting, then we will need to wait
another month or so. Moreover, she had a UTI or bladder infection after her
heat the last time, so I'm concerned she will get the same problem again if
we let her go on heat naturally.

I am planning to let her undergo surgery as scheduled this coming Friday 4
July. It will be Day 9 of the antibiotics.

Do I give her the antibiotics on Friday morning even though she has been
fasting since 8 PM on Thursday night?

Will you be able to tell from palpation of her uterus whether it has gone back
to almost normal size, before you start the surgery, and thus decide whether to
hook out the womb out (and have a smaller incision) or open her up
slightly more
(and have the 4 cm incision) ?

How much would your transport man charge for a one-way trip from your clinic to
my home in Woodlands St 82, if I can't pick her up myself?

Thanks & best regards,
XXX

E-MAIL REPLY JUN 30, 2008
To:
...@singnet.com.sg>

No antibiotics on day of surgery.

Not able to palpate the size of uterine horns in your dog if it is small due to recovery from bacterial infection.Will try to hook out first.

I believe the transport man (independent contractor) charges $50 but you can pick up your dog even late towards midnight as we have somebody around or let her rest till the next day. You need to phone us first.

Sunday, June 15, 2008

1. Palpation for painful spots in a Shih Tzu

The pain was killing him loudly when the 4-year-old Shih Tzu was at home but he was silent, looked normal and merely limped a bit on his left fore leg when he was brought to the Surgery. He did not put much weight on his left fore and therefore I assumed he had pain in his shoulder joint or somewhere in his left leg.

After observing him walking here and there in the 80 sq. ft consultation room now packed with 3 owners, myself and my assistant, there was little space for this little Shih Tzu to walk. But he walked and was as cool as a cucumber.

"Put him lying on his right side the examination table," I asked my assistant. The Shi Tzu did not struggle. When I flexed and extended all his joints from the paws to his shoulder a few times, he did not feel any pain and so he did not cry or move away.I abducted and adducted his shoulder joint. No pain. So, why was he limping so obviously to all? I pressed his paws and the rest of his leg. No pain at all.

"He kept crying and whimpering past midnight for some hours," Mum was stressed out by this incident and probably had no sleep. "He was OK the whole day and after dinner."

"No," the teenaged daughter contradicted. "He started whining for attention at 9 p.m" and then cried.

"He was crying as if in pain for the whole night," Dad said.

"Did you give him any medication or pain-killer?" I asked.

"We thought of giving him some pannadol but no, we did not."

The next stage of the examination would be palpation. I put the dog standing on the table and used my right hand to press his abdomen. Starting from the stomach area to his bladder usually. I asked the agitated Mum and the other 2 family members to listen to the reactions of the palpation for pain of this dog I had known since he was a puppy.

"Did you hear the "hiss" sound from the Shih Tzu?" I asked the family members. A slight hunching of the back and a soft hiss that could be easily missed when I palpated the stomach/pancreas area. A painful reaction that the family members missed as it was so quick and so soft.

There was something painful in this anterior abdomen.

I started the palpation a bit forward or cranial to the stomach, just below and midway near the rib cage. That would be the location of the liver and gall bladder. I pressed the fingers of my right hand together to where the gall bladder would be.
This time, the Shih Tzu grunted like an old man. Loud. Everybody could hear it. I did not reproduce the same pain reflex as that would not be good for the dog.

So, the cause of his pain was this gall bladder area. There was mild fever. Was the dog having gall bladder infection or gall bladder stones?




"What's the bright yellow discoloration of the front half of his white coat on his shoulder?" I asked. "Is it urine on his white collar?". I doubted it was urine as this dog was well cared for. This Shih Tzu had a full white collar.

"Maybe tumeric powder?" the father said. I guessed tumeric powder referred to the chilli powder used for making curry.

"What do you use to shampoo the dog?" I asked. Yellow shampoo can discolor the white coat.

"He applied some brownish tick powder to kill the ticks as the dog had lots of ticks," the mother said. "He got the powder back from India."

"Tick powder is very poisonous if licked by the small dog," I said. "It is possible that the liver and gall bladder could be affected, causing the pain."

Mum ticked off Dad for buying tick powder from India during his business travel. So the use of tick powder is now a prohibited substance in this dog as it might poison his liver when licked.

"Does the dog jump a lot?" I asked.

"He jumps from sofa to the floor and from one piece of furniture to the next," the daughter said.

"It is possible he could have had strained his left shoulder when he missed a step on landing," I referred to the dog's limping left fore. "He could have felt the pain yesterday but now he had recovered."

If only dogs can talk. There was a slight fever and therefore infection of the gall bladder could not be ruled out.

"We have a 5-month-old Shih Tzu who plays with him," the daughter said. "The new dog is a female and was bleeding being on heat, 5 days ago." I had presumed this dog was the sole pet in the house.

"Did he injure himself while trying to mate with the female?" Twists and turns as he would be inexperienced and the female dog was not receptive at this stage of her heat and so he injured himself, causing lots of pain to his anterior abdominal area. And at night when everybody wanted to sleep, the pain radiated out from the injured area near the gall bladder.

No family member was sure about his sexual activity. This was the first time they had a female dog who was also full of ticks. It is just possible that he was too vigorous in his pursuit of the female, slipping off when the female moved away and trying again. Climbing up and falling down, hurting his anterior abdomen. A sound hypothesis?

I got the Shih Tzu clipped bald to remove all ticks. He was all right when he went home. As for the gall bladder pain, no further blood tests or X-rays would be done for the time being. It would be good to do all the ancilliary tests to confirm the diagnosis of gall bladder/liver infection.

However, from the owner's point of view, the less costly the veterinary fees are, the more appreciative they are. If there is a relapse, blood tests and X-rays would be done. It had been 3 days and there was no complaint from the family. The dog was back to normal. Today is Sunday Jun 15, 2008. I hope he has a good father's day from his pretty teenaged daughter who might be studying to be a doctor or veterinarian.