Sunday, April 24, 2010. Bright sunshine, blue skies.
Should be outdoors. I was at work at 9.30 am. 3 clients
came in but they were my associate vet's clients and so I
told him they had to wait as she comes in at 11 am.
Suddenly a couple with a cat carrier came in at 10.15 am.
They would be 4th in the queue and by the time, they get
attended by my associate, it would be past 12.30 pm which
meant a 2-hour wait. As they have no preference, I took
over the case, thinking it was a simple case of a cat that
can't pee. A commonly presented case, usually of an older
male cat fed on dry food.
HISTORY. Cat, Male, Neutered, 7 years old. Could not pee 2
weeks ago. Vet 1 relieved urethral obstruction, gave one
"2-week-lasting" SC injection. Cat went home. OK for first
2 days. Then difficulty in peeing. Squatted but no urine.
After for around 2 weeks, the couple in their 30s
consulted me for a second opinion on Sunday April 24,
2011, 10 am. "Be careful," the husband warned. "The cat is
very ferocious since the visit to Vet 1." According to the
wife, Vet 1 had used anaesthesia to catherised the cat at
the first time. However, the second and third bladder
irrigation via the catheter was done without sedation as
witnessed by the wife who was called to help. The wife was
unhappy at seeing her cat traumatised. "Now the cat hisses
whenever he is taken to the vet," the wife said. "The
vet may think that it is risky to give
sedation/anaesthesia again," I said. "The cat may die from
the sedation and that would be disastrous." I don't do
repeat bladder irrigation but each vet has his own ideas.
Now the cat warned me
with a loud hiss as I examined his backside and palpated
his abdomen. There was no point traumatising the cat. So,
I gave a sedation and asked the owner to wait. Was this a
recurrence of the urethral obstruction?
SEDATION &
EXAMINATION Weight: 6kg, xylazine 0.15ml ketamine 0.5ml.
Catheter passed in smoothly. No obstruction. But the
unusual problem was that the penis of the cat could not be
extended. The prepuce had swollen to a ball-shaped lump.
An unusual case. I took a picture.
After some massage, it was possible to extend the cat's
penis and insert the catheter. There was no penile
inflammation. Bladder palpation. Bladder was swollen to
twice the ping pong ball size. Urine collected for
analysis. No crystals. Blood, white cells and red cells,
bacteria + present.
DIAGNOSIS. Feline
Lower Urinary
Tract Disease (FLUTD).
The owner was not prescribed oral antibiotics
by Vet 1 but the wife said to me: "The cat had been given a "2-week-lasting
antibiotic injection". Therefore, there was no need for
oral antibiotics. However, Vet 1 prescribed an anti-depression
oral medication which the cat objected forcefully. So
the owners did not give him the amitriptyline after two tablets.
This drug
licensed use in people is for depressive illness,
bedwetting (nocturnal enuresis) in children aged 6 years
and over.
Vet 1's
X-ray show that the bladder is
large and distended. No
urinary stones seen,
according to the owner.
One of the adverse side effects
of amitriptyline is
"difficulty in passing urine" and
this is reasonable since it is used to prevent
bedwetting in children. I don't use it in cats or dogs and
so I have no experience with this drug. But after two
tablets, the owner observed that the
cat had difficulty peeing! So was this the effect of
amitriptyline or not? The cat continued to have dysuria
for the next 10 days and that was when on this bright
sunshine Sunday morning, I encountered this interesting
case. Interesting only to veterinary knowledge on the use
of amitriptyline, not to the owners as it had been
traumatising for them and their cat.
To make a long story short, the cat did not have urethral
obstruction as the catheter went into the bladder
smoothly. He was warded for 2 days. The diagnosis was
feline lower urinary tract disease confirmed by urine analysis. This
was an intelligent cat as he sat on the litter box all the
time while warded for 2 days in the surgery. If you
understand that a cat wants to be clean, he is leaking
urine via the catheter and so, by sitting on top of the
litter box, he does not mess up the surrounding area. Even
after removal of the catheter, he still sat on top of the
litter on day 3 when the owner came to take him home.
When the owner came to take him home, he hissed at the
owner! So, the couple patiently took time to get him to
relax and put him inside the crate. In the morning I had
sedated him (xylazine 0.1 ml + ketamine 0.4 ml IM) to remove the 6/0 stitches tying his catheter
to his prepuce in 4 places and take rectal temperature
(fever 39.8 deg C) and to weigh him. I treated his fever
with baytril and tolfedine injections SC.
According to the wife, at Vet 1,
the e-collar had been taken out once and the cat pulled off his
catheter but with the sutures still knotting one end to
the prepuce. Therefore, she asked whether I had put
an e-collar all the time. Better to use oral pain-killers
for cats post-treatment as the cat is very difficult to medicate and will claw you.
In any case, I don't usually put catheters in cats after
bladder irrigation, except in some cases such as this case
and only for 1-2 days. I don't bladder irrigation more
than once but some vets do, without sedation.
The cat will
be on oral antibiotics for 12 days. I don't believe in
giving one single injection lasting "2 weeks" as Vet 1
did, but if the owner can't medicate at home, this may be
the alternative. Pound medicine into powder and add to
sugary paste. Spread on cat's body or paws without the cat
knowing it. But cats may be too smart and flick away the
medicated sugar.
Close monitoring of water intake and canned food, urine
analysis in 2 weeks. Change to sand litter. Continue
canned SD diet for 1-3 months and urine test monthly for
1-3 months. Then canned food. No shampoo for the first
week. The cat is shampooed once a month as the owners find
its coat oily. "Cats seldom get bathed in Singapore," I
said. I did not take blood test so as to lower the
veterinary costs.
However, urine tests are important for diagnosis of FLUTD and this was done in this case
as the owner wants to know what is happening. Bacterial
antibiotic sensistivity tests of the urine was not done in this case but
would be done if there is another episode, so as to save
the owners some money as they had spent quite a large sum at
Vet 1.
P.S.
1. Cause of the FLUTD
I said to the owner on the second day: "You must have given dry
food after treatment by Vet 1, thus leading to difficulty
in urination."
"No, I did not," the husband said.
Then he remembered that Vet 1 had given him the dry food
of Hills' Prescription SD as canned ones were out of
stock. So, there was a dry food involved. Could it be the
dry food? Could it be the action of amitriptyline
retaining the urine in the bladder and permitting
bacterial infection? Could it be the sharp pelleted litter
injuring the prepuce and causing it to swell and prevent
ease of urination? Could it be the re-infection of the
bladder after going home? Was Vet 1's "long-term
guaranteed to last 2-week" antibiotic injection of Synulox
(clavulanic acid and amoxicillin) ineffective since it was
apparently given once only? There are so many factors
causing the urinary tract infection presented to me now
and so it is hard to specify one causative factor.
It is a mystery but a urine analysis is important and must
be done as part of the vet's duty of care. Certainly there was bacteria and white
cells in the urine, indicating urine retention had led to
cystitis or was a cause of cystitis. The SD diet had
acidfied the urine apparently as the urine pH was 6.5 in
the test.
It is quite painful for the couple to see their cat going
to the litter box many times, tried to pee and not able to
do so on the 3rd day after going home from Vet 1's
treatment. They decided to seek another opinion and I was
present on this bright sunshine blue-skies Sunday that I
would like to spend at the Botanic Gardens.
2. Follow-up 24 hours after going home on Tuesday,
April 26, 2011. I phoned at around 4 pm on April 27,
2011 as the cat had a fever of 39.8 deg C on Tuesday
morning (when I took out the catheter and checked the
rectal temperature under sedation). I had informed the
husband of the fever and asked him to observe the cat
closely. I had given tolfedine injection which would
reduce the fever.
The husband said: "Everything is OK. The cat ate a lot and
drank a lot on reaching home. Then he became quiet and not
moving much. My wife smeared the baytril antibiotic in
brown sugar onto his body and he licked it off."
This was one of the tips of medication I had given to the
handsome couple in their 30s.
I replied: "It is possible that she is very tired after
spending two stressful nights at Toa Payoh Vets which is a
new environment for her.
"She is also not hungry after eating a lot. Check whether
she has fever by feeling her lower abdomen with the hand
but this is not accurate. Let me know if the cat is not
eating. You have the anti-fever tolfedine tablets ready.
Have you bought the sand litter?"
The owner had not and would do so. I expect this case to
stabilise and that the emotional coaster-ride of the
couple would fade away. The veterinary costs of two vets
would be over a thousand dollars but this could not be
avoided since there were so many procedures and tests.
The management at home is most important as there are many
causes involved in the development of FLUTD (Feline Lower
Urinary Tract Infection). The causes include
uroliths (stones), urethral obstruction (plugged-penis
syndrome and blocked cat syndrome), infectious causes and
others (unknown causes in about 60% of the cases, physical
trauma to penile area, tumours of the urinary tract,
congenital abnormalities, neurological problems and
intentional urinary retention (common behaviour seen in
cats not given a litterbox or dirty litterbox).
In this case, the sophisticated owners told me the cat was
shifted to a new house and that would be the cause.
The risk factors would be
1.1. Age. Uncommon in cats less than one year old but most
common in cats 2-5 years old. This cat is 7 years old).
1.2 Sex. Male and neutered cats are at greater risk
of urethral obstruction as their urethra is longer and
narrower.
1.3 Neutering.
1.4 Dehydration.
1.5 Dry food high in magnesium or other minerals and
high in pH.
1.6 Obesity.
All the above factors are present in this case.
Dehydration could be due to the lack of adequate water
intake as the cat was adjusting to the new house
environment. Most cats on dry cat food do NOT get FLUTD.
The causes are many and therefore, amitriptyline
was not the only cause of the recurrence of the dysuria.
Good management at home and regular veterinary check ups
are very important to prevent recurrence of the dreaded
Feline Lower Urinary Tract Disease (FLUTD).
UPDATE FROM AN E-MAIL BY THE OWNER ON MAY 18,
2011
Dear Dr Sing,
It's coming close to a month since we first bring
XXX & his swollen prepuce to you.
Thought you might like to know how he's faring.
He finished his course of antibiotics stress-less-ly
for both him & us, thanks to your smearing his paw
trick. :)
Still on canned Hills S/D, eating about 4ounces a
day.
Doesn't drink water tho, so we add a spoonful into
his meals each time.
He's doing a lot better these days, more like his
usual curious self before moving house.
Pees every day, some days much more than others,
especially during cooler days.
There were a day and another (a week apart)
when he didn't really pee, and strained to do so,
but he always succeeded in the end.
Coincidentally, those days were the ones when he
challenged/quarrelled with a visiting neighbourhood
cat.
Guess that's to be expected because he's been living
in a one-cat household environment for the past 5
years and has a dominant streak.
Generally, he seems to have recovered well and has
settled into a daily routine of patrolling here and
there and sleeping the afternoon away. Eat, sleep,
eat, sleep. Seems like he's having a contented
life. :)
Thank you so much for helping us that fateful sunny
day.
Your concern for XXX's welfare made it easier for us
to go thru' a vexing time.
Best regards,
Name of owner
p.s. enjoy reading your blog. so interesting
!!
E-MAIL
REPLY FROM DR SING DATED MAY 18, 2011
XXX's FLUTD cause appears to be OK now. Good news.
It is always good to hear from owners. Thank you
for the valuable feedback and details of his
lifestyle. Thanks for compliments about the website.
UPDATE AS AT JUN 12, 2011 (Sunday)
No news from the young couple who had consulted me
one Sunday regarding their cat not being able to pee
again. The above e-mail was from them. I was
reviewing my images and am uploading two more
pictures of the cat treated one Sunday morning in
April 2011.
EVENTS OF RELATED THEMES
HAPPEN IN 3'S
TWO OTHER FELINE FLUTD CASES HAPPENING WITHIN A SHORT TIME
ARE:
TOA
PAYOH VETS
