7. Chronic urinary tract infection in a pug

July 20, 2008 was a bright sunshine Sunday. It was an unusual Sunday in that my first 2 cases were pugs. Pugs are uncommon in Singapore as they went out of favour some years ago and so, getting two cases in a row was as hard a winning the 4-digit lottery.

Case 2 was a young pup that came in for a 3rd vaccination as a free vaccination was included in its sale by a pet shop. "How did you locate the surgery?" I asked the Caucasian expatriate as my surgery is difficult to locate even by the locals. The expatriate smiled and explained to the country pumpkin, "I use the GPS in my car. I key in Toa Payoh Vets and there was a map. Only that there was no address shown." I was impressed.

"How much does it cost to install the Global Positioning System in your car?" I thought I could do with one too if I do house-calls.

"About $400," he said. The expatriate certainly knew how to use technology to make life easier.

Now, back to Case 1 which was a highly emotional case for the lady owner as her pug passed clots and blobs of tissue with blood in the urine. The vet had prescribed antibiotics in higher doses and initially the pug's urine was clear. Then the pug started passing bloody tissues and she consulted me since I was the one who delivered the pug by Caesarean section according to the seller of the pug.

When antibiotics do not work in a urinary tract infection in the dog, the lady owner is often stressed. Having to clean up the apartment and the pug and then more cleaning, I guess. More bleeding. More cleaning. It is hard to imagine if one is a man who does no house work or not involved in the daily grooming of the dog.

Seven days ago on July 13, 2008

The lady owner saw me 7 days ago and today was the follow up. Seven days ago, she and her husband consulted me. She said, "As you do not spay dogs on a Sunday, I got the pug done at Vet 1. Maybe she was not properly spayed?"

"Vet 1 is a very experienced vet. He had done a good job. The pug does not have any heat now," I explained. "The bloody tissues in the urine come from the inside of the bladder. There may be urinary sand or stone irritating the bladder. The dog become incontinent, leaks her vulval area and cause bacterial infection into the bladder from her licking of the vulva."

"I consulted Vet 2 two weeks ago as my pug was passing blood in the urine. He gave a higher dose of antibiotics so as to kill all the bacteria inside the bladder. After the antibiotics, the pug passed pieces of tissues with blood."

This would be a very difficult case to handle as the lady did not follow up with Vet 2. What she wanted was to get the pug to stop passing bloody tissues during urination. There was no urine sample. I palpated the bladder and it was half full and firm, around 4 cm in diameter. There was no feeling of crepitus - a feeling of squeezing gas inside the bladder filled with small stones.

The collection of a clean urine sample from a female dog is not easy for Singaporeans. This lady was stressed out and so I did not insist on doing it. I gave the pug a different type of antibiotics and injections to relieve the pain and asked the lady to phone me in 3 days and to review in 7 days' time.

On July 17, the lady phoned me to say that the pug was no longer passing blood in the urine. She sounded happy. But I know the treatment of urinary tract infection in the spayed female pug is not easy. Follow up reviews are necessary and time-pressed owners just have no time usually. What they want is a permanent cure.

On July 20, the lady and her husband came.
"The pug can jump in the past 2 days," the wife said. Now, I did not know that the pug was not able to jump as I did not ask and she did not say during the July 13 consultation. Jumping or not had nothing to do with urinary tract infection, one would not ask such question.

But actually, this feedback is important. This indicated that the pug had sprained her back due to continual licking of her vulva due to incontinence. The pain and the itch and the sprain of the muscles must have restricted her active jumping for joy in greeting the lady owner.

If we turned the pug upside down, I could show the lady that the pug had vulval pruritus. The vulval lips were very small as the lady must have spayed the pug very young so that they had no female hormones to develop to adult size. The lady could not remember when she had the pug spayed. Now, continual licking caused the vulval area to be very black.

"Did you wash the vulval area during bathing?" I asked. "It is very dirty and becomes itchy. The black skin is caused by the pug licking this area for several months. Then trauma and bacteria infection go into the bladder through this long licking habit."

"I do not do it. I cannot restrain the pug alone." The husband said he would help out.

I sat on the chair and palpated the standing pug's bladder with my left hand. The bladder was full of urine. This was already 10.30 a.m.

"Did the pug pass urine after waking up?" I asked.

"This pug has a very bad habit. Always holding her urine for a long time. She will leak the urine a bit but will not pass urine regularly."

I said, "Most likely she felt pain when trying to pass urine. She passed a bit. I was painful. She stopped passing. So she hold her urine till the bladder becomes very full. Bladder stones form when the urine is not passed out regularly."

Is this a plausible explanation to the owners? If only pugs could talk.

"Is she leaking urine many times a day?" I asked.

"Not in the last 2 days," the lady said. Now there was urinary incontinence as well as urinary retention. What type of urinary incontinence is this pug suffering from?
There are a few classifications of urinary incontinence in veterinary medicine. I narrow down to two classes - paradoxical incontinence and hormone-related incontinence. Was the pug suffering from one or both?

Hormone-related incontinence happens to spayed dogs. Once the hormones are removed during spay or neuter, some dogs in the older age can't control their bladder. Replacement hormones help to solve this problem.

Now what is paradoxical incontinence? Is this pug suffering from paradoxical incontinence? In this situation, she might have bladder sand or small stones obstructing the urethra. So she could not urinate regularly until the obstruction is cleared. She leaked some urine. When the obstruction is cleared by the passage of the sand or small stones, she could pass out all the urine at one go, as had happened when she was outside the surgery for around one hour. That was how I managed to use the dipstick (picture) to test for blood in the urine.

After the pug had urinated, I palpated her bladder. Her bladder was now very small, around 3.5 cm in diameter. The bladder wall felt thickened. There were no single large stone, so I asked the owner to wait for 2 weeks.

It would be good to X-ray the bladder but it costs the owner money. The X-ray ought to be done with air pumped into the bladder and this involved extra cost. Urinary tract infection treatment require several consultations and the vet cost can shoot up.

Blood tests ought to be done too but they must be useful to the owner as the costs add up again.

So, in the meantime, I advised the owner to switch to a prescription diet which may dissolve the fine bladder sand. Pugs as a breed are not known to suffer from urinary stones, unlike the Miniature Schnauzer, Lhasa Apso, Dalmatians, Poodles and the Bischon Frise.

It is possible that the pug had very itchy vulva after spay. She licked the area till it became black and dirty. Bacteria went into the vagina and the urethra into the bladder over the past 3 years. Bladder became chronic cystitis. By the 3rd year, blood in the urine and then bloody tissues in the urine as the bacteria had accumulated without the owner being aware of the problem.

A clue from the lady was that the pug was "naughty and would always control her urine till her bladder was full and she would pass out a lot of urine."

Many of the urinary incontinent cases needed reviews and many Singapore owners just do not have the time or inclination to do it. In this case, a few follow ups may be necessary. This pug had been licking her front paws till they became black.

Coincidentally, 2 weeks ago, the Seller came with her pugs for the annual vaccination after receiving a vaccination reminder card from me. Her pugs had black crocodile-skin front legs like this pug.

So there seemed to be a connection somewhere from parents to progeny. If the vet can find a solution to control this pruritus - of the fore limb or vulva - the vet will be considered a "competent" vet by the owner!








The pug will be reviewed for a few times if the owners want to.

The lady was persuaded to collect urine for examination 2 weeks later and I gave her a bottle to do it. Thorough cleaning of the vulval area and wearing of the e-collar for at least 1 month.

A prescription Hill's Science diet will be fed for 1-2 months to dissolve the bladder sand which may be present. Only in 2-3 months will we know the result of the proposed treatment.

Many owners want a one treatment cure all but this is not possible in many cases of chronic urinary tract infection in a female spayed dog.




FOR VET STUDENTS:
http://courses.vetmed.wsu.edu/vm552/urogenital/micturit.htm
is a very good report on urinary problems in the dog.

6. Chronic idiopathic thrombocytopenic purpura in an old dog

DRAFT


On July 9, 2008, I was attending a breakfast Oracle Seminar on "Innovation in Asia" at St Regis Hotel. My phone vibrated.

The owner phoned me at 9 a.m to say that his 11-year-old Silkie Terrier passed away in his sleep. His dog just stopped eating for 2 days and he had told me yesterday. The dog had grown hairs and was free of ear pain after my vertical canal ablation surgery in March 2008.



So we thought he would live for some years. Then in June 2008, the dog injured his left foreleg's toe.

The owner tried to treat it himself but the dog just gnaw at his toe till it became much swollen. He had to be operated under general anaesthesia again. I prefer not to operate an old dog a 2nd time. He survived the first general anaesthesia for his ear canal removal and it is better not to take the risk again as old dogs are high risk patients. This was 11 years old and he has reached the limit of his life span.

Now, this dog has a blood clotting disorder. His blood just does not clot easily during surgery. I did not do a blood platelet test to confirm that he had a low platelet count to save on costs for the owner. There is no cure for the idiopathic thromobocytopenic purpura. Idiopathic means that the cause is unknown although it is believed that the body makes antibodies to destroy its own platelet.

This dog would be suffering from a chronic idiopathic thromobocytopenic purpura and like the disease in people, he could live to an old age.



He had a left severe ear pain. Hard as a rock - that's what his left ear vertical canal felt to me. The cure was removal of this vertical canal, a surgery called vertical canal ablation. Now, would he die under general anaesthesia - being aged and thin? At the time of surgery, I did not suspect he had chronic idiopathic thromobocytopenic purpura. In retrospect, some blackish bruises on his bald body could be a tell-tale sign but old dogs may have such blemishes.

In any event, he survived the ear and toe amputation surgeries under general anaesthesia. He lived the last few months of his life without pain in his left ear and for that the owner was very happy that the dog passed away peacefully. I only talked to the owner by phone and had never met him as he is a busy person.



Tentative diagnosis of chronic idiopathic thromobocytopenic purpura in this case:
1. blood does not clot in the ear canal before vertical canal ablation surgery (see pictures).
2. a large haematoma after surgery (swelling above his left parotid salivary gland and where the vertical ear canal was removed, under the healed wound). At the toe amputation surgery, I checked the left facial swelling which was painful if palpated. It was just blood that did not clot. It was around 30 ml of liquid blood.
3. some purplish blood when the bandage wrapping the toe area is removed (see picture).
4. bruises in his body.

The dog was an extremely high anaesthetic risk and yet he survived 2 anaesthesias. Gas anaesthesia at the lowest dose was given. Intubation was done. No tranquilisers or pre-anaesthetic medication was used. No problems encountered during the anaesthesia although this was an old dog nearing the end of his life span. Pain-killers given for 7 days after surgery.

http://www.bekindtopets.com/animals/tpvets_May1308.htm
showed my first meeting with this gentle dog. I thought he was a hairless Chinese crested dog cross bred as he had not much hair. I was glad that the owner did not rush to put him to sleep on March 31, 2008. His wife was against euthanasia and well, this dog spent his last 4 months having a good time with the owner. We just did not expect him to pass away so soon as we got to know him more and his hair was growing back. He looked younger and handsome as his golden Silkie Terrier hair grew luxuriantly in his face and I thought he was rejunvenated. So his early passing away saddened me too.

"The dog is nearing the end of his life span," I said. "He h

DETAILED REPORT TO BE WRITTEN LATER.

5. Pyometra in a 4-year-old Lhasa Apso that eats to live

The female Lhasa Apso had sticky vaginal discharge for some time. She was very thin and had a poor appetite for some months.

The owners went to Vet 1 near midnight. The owner did not want blood tests, X-rays or the immediate surgery advised. They had spent some money earlier for a severe diarrhoea treatment of the dog. Veterinary costs can add up when there is prolonged illness requiring many treatments and the family needed to reduce costs.



In this case, it would be prudent not to rush into immediate surgery as the risks of the female dog dying on the operating table would be very high. The challenge is when to commence the removal of the infected womb so that the dog would not die? Give antibiotics and fluid therapy for at least one day and check the rectal temperature to get better odds.



In this case, the dog survived the surgery after around 2 days of treatment. Although I gave her at less than 30% chances of survival, she surprised me. When the vet deems the ill dog a poor anaesthetic risk, the dog would many times prove the vet wrong.



In this case, the family of parents and 2 children came to the surgery and hand-feed the dog 2 hourly for the 2 days before surgery. Feeding 2 hourly after surgery was also essential post-op care. The dog lived.

This dog seemed to be the type that would eat to live, not live to eat.

Yet in Case 3, the other Lhasa Apso with pyometra that I would operate on Friday July 4, 2008 was so much different.

The other Lhasa Apso would be 9 years old and lived to eat. She was trim but not thin. "Always asking for more food," the owner said.

She was given antibiotics for some 7-10 days before surgery. She had very little sticky vaginal discharge as the owner was told to make her wear pads so as to collect some evidence of pyometra - pus in the womb. What would her chances of survival on the operating table?

I assess as more than 50% as the dog was active, trim and eating well. No vomiting. But pyometra had been there for some months as the dog had licked off the vaginal discharge without the owner's knowlege. 2 very small breast tumours had formed. No vet can guarantee 100% survival and this is where early discovery of pyometra or early age spay of the female dog would be preferred. Pyometra can be very stressful for some lady owners, causing sleepless nights prior to surgery.