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Tuesday, September 25, 2012

1118. Bladder stones in a 13-year-old dog

"Is an operation needed to remove the bladder stones?" the lady asked me over the phone. "Much depends on the size and composition of the stones," I said. "If they are small struvite stones, they may be dissolved by eating a special diet."

The dog was a Golden Retriever X, medium sized, 13 years old and lethargic. A high anaesthetic risk. So I did not advise surgery. Catherised urethra 2 days. Today, he could pee normally but vomited canned food.


5633 - 5634. Difficulty in urination due to an enlarged infected prostate and bladder stones

The dog could pee normally and had a good appetite today. So I did not operate as he is very old and thin. Will S/D diet help? But his urinary pH is 6.0 and not alkaline. The urine crystals are nil and so the only way to know what composition of the urinary stones in his bladder would be to do surgery. But the dog may die on the operating table since he is 13 years old. So, this is the difficulty. The dog was given K/D diet by Vet 1 before I was handling the case. Could K/D bring down the urinary pH to below 7.0?

A trial of S/D may not be effective since the composition of the urinary stone is not known. It may be calcium oxalate but it may also be struvite. S/D diet dissolves struvite stones. The dog had antibiotics and a can of S/D diet with informed consent from the owner. For the past 2 days, he was urinating normally and had excellent appetite. I dare not do any cystotomy surgery as the risks outweigh the benefits. An S/D trial is one alternative and it may be worth a trial. It is not evidence-based, I informed the young lady owner. She understood.

Thursday, September 27, 2012

1121. Bladder stone dog goes home - 3 sisters

"Are you the sister who spoke to me by phone about the dog having kidney stones and whether an operation is necessary?" I asked the bigger of two adult ladies who came this afternoon to pick up the 12-year-old male cross-bred that looked so much like a miniature version of a Golden Retriever.

"No," she said.
"Are you the eldest of the 3 sisters?" I asked.
"No, I am the 2nd sister."
"Is the other shorter lady the youngest sister?" I asked.
"No, she is the eldest sister."
"So, the youngest sister is the most intelligent," I said. "To seek a second opinion."
"She is the one who loves the dog most," second sister said. I had talked to her by phone many times to update her of the dog but never saw her.

I put the dog on the exam table and palpated the bladder and prostate for pain. Not a whimper unlike 2 days ago.

"I need a tissue paper to wipe away the blood," 2nd sister said. The dog was so active and had pounced on her left knee and scratched 4 inches of red rash."

"This dog needs to be neutered as Vet 1 had done an ultrasound and said that the prostate was much enlarged."

"Why must he be neutered?" 2nd sister asked.

"The male hormones are produced by the testicles and they make the prostate grow bigger and it had become inflamed and infected. The enlarged prostate caused the urethra to be narrowed, making urination difficult for this dog. Bacteria from the bladder was present and could have infected the prostate. That was why it was painful 2 days ago and earlier. Vet 1 did give an anti-male-hormone injection called Tardak and advised weekly injections. Neutering would have been the alternative. Now, the dog's prostate is not inflamed or enlarged and so the dog pees normally for the last 2 days."

The dog did not pee in front of the sisters this afternoon but he had peed a few times freely in the morning.

"I have advised no bladder stone removal operation as the dog is very thin and will wait till he has difficulty in urination the next time," I said. "Although there is no crystals or struvite crystals present in his urine analysis, it does not mean he has no struvite stones. The pH is 6.0 for the past two urine analysis but bacteria is present in the urine. The bacteria in his bladder may have gone to the prostate, causing pain and inflammation of the prostate.

As the 2nd sister is an adult, she understood what a prostate is and so I need not explain further.

EXPLANATION
1. The male dog does not urine mark for the past two days. He just pees a few times in the morning when taken out for the walk. Why? This is because he was given an anti-male-hormone injection called Tardak by Vet 1 around 1 week ago and he is "feminised."

2. The urinary pH is 6.0. In struvite stone formation, the pH is usually alkaline and urease bacteria must be present. That is the norm. However, Vet 1 had recommended K/D diet and the dog was eating it. So, the urinary pH may have been affected. It is hard to say. It is too technical to explain to the sisters about alkaline urinary pH and struvite stone formation as there is information overload.

3. I advised S/D diet for the next 3 weeks as an alternative to surgery due to the high anaesthetic risks involved at present (prostate enlargement and infection, bladder infection with bacteria). This old dog much loved by this 3rd sister and it is better to build up the dog's weight and health if the bladder stone surgery is needed in the future. Neutering is advised next week as neuter is a very short 5-10-minute surgery compared to around one hour for bladder stone removal. Struvites are more common in dogs seen by me and if this S/D trial works and X-rays of the bladder are taken in a month's time, the stones would have dissolved or reduced in size, permitting urohydropropulsion. That will get rid of all the smaller stones.

4. Owners seldom comply with veterinary instructions and so much depends on educating the owner and the 3rd sister. Somebody who loves the old dog and usually it is a lady family member who cares very much for this old companion to get things done by the vet.

Wednesday, October 3, 2012

1127. Follow up: 3rd sister and 13-year-old X with 3 bladder stones

Oct 2, 2012, a Tuesday. I took time off and went to Khin Khin Employment Agency at Peninsula Plaza to teach her manager more about the management of the business. The Government had increased the foreign worker quota and clamped down on phantom workers.

Now, a company must employ 5 Singaporeans before it can employ 1 foreign worker instead of 4 to 1. In addition, many companies have been fined for using "phantom workers" who are mainly retirees and others not gainfully employed by the company to make up the 4 Singaporeans to get approval for 1 foreign worker.

After the elections in which foreign workers were said to depress wages of Singaporeans, the foreign worker quota is raised and the foreign worker levy on employer is increased. "Many of the retirees are now out of CPF contributions since they were phantom workers," I observed.

The euro crisis and economic recession reduced the demand for foreign workers. Some have to be sent home due to the increased quota and loss of phantom workers. So Khin Khin and other employment agencies find that they have little demand for their services from the small businesses looking for waitresses and drivers. No quota at all. Close shop or do other services.

As Khin Khin is in Yangon, I dropped in to check on her manager Ni Ni. He had been working 6 months on the S Pass and is supporting his wife and son in Yangon.

Suddenly a young lady in her late 20s and wearing greyish dental braces appeared at the door. Khin Khin's office door does not shut unlike other offices. She came closer and said to me: "Have I seen you somewhere before?" I was astonished. I could not recall. I did see her somewhere.

"Are you Dr Sing?" she asked. "Yes," I said.
"Do you remember my dog Brandy?"
"Yes," I said. "The 13-year-old cross bred with three bladder stones.
What a coincidence. I phoned her earlier to tell enquire about her dog's urination situation. The dog was OK but not eating the S/D.

I did advise neutering to reduce the enlarged and inflamed prostate to be done on Monday. But it is Wednesday today. The dog was no longer painful in the prostate when I discharged it 3 days ago but it was very painful when I took over the case. An enlarged painful prostate with bacteria in the bladder can cause painful and difficult urination, other than the 3 bladder stones. But it is hard to explain to the 3 sisters. After all, the dog is peeing normally. Owner compliance is much more difficult.

I did not remove the bladder stones because this dog was so skinny and might die under anaesthesia. Neutering is a short surgery and so I advised it to prevent prostate enlargement and inflammation. But it is extremely difficult to convince the owner to do it and this is a common situation in all medical practices.

UPDATE ON OCT 9, 2012. No complaints from the sisters and no neutering so far.