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:
is a very good report on urinary problems in the dog.