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Date:   04 June, 2012  
Focus:
 Small animals - dogs, cats, hamsters, guinea pigs, turtles & rabbits
Recurrent Blood in the Urine in a Corgi - Part 1
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
 04 June, 2012  
toapayohvets.com 
Be Kind To Pets
Veterinary Education
Project 2010-0129

Every dog owner and probably person will be warned about anaesthetic risks. For owners who don't want the risk, there are groomers in Singapore who find this opportunity to provide a service involving dental scaling of dogs without any anaesthesia.

Vets do not use anaesthetic on dogs unnecessary to avoid any anaesthetic risks as the high emotions of grieving of dogs dead during anaesthesia are terrible for the vet and the staff.

Since most dogs will not tolerate manual dental scaling, the groomer's assistant must grip the dog's legs tight to enforce cooperation. It is like the old days when people are held tightly by men during surgeries or given a dose of whisky. In dogs, the groomer can't sedate as the service is supposed to be no anaesthetic or sedation.

Recently I had a case of a poodle that had stopped eating for over 3 days and could not stand up. The two teenaged daughters were worried that their dog may die. The mother had taken the dog to a groomer in Sembawang pet shop to get dental scaling done. I remembered this case as the mother was running a mini-mart and I had vaccinated her dog some 3 years ago. It was a puppy then. I had the dog's blood checked, gave the IV drip and antibiotics. There was hypoglycaemia. The dog's mouth probably was very painful after enforced dental scaling by the groomer and so he would not eat. He recovered within 2 days of treatment and went home to two happy teenaged daughters and a relieved mother.

Yesterday, Oct 31, 2011, I had this 9-year-old Corgi whose lady owner was vacillating as to whether to get her dental scaling done or not. Her dog would lick at the vagina after the course of antibiotics lasting as long as one month and the urine would have blood clots or blood when all the antibiotics have been taken.

She had consulted several vets in one brand name practice for more than 10 times over the last two years after being referred to this practice by another vet who could not cure her dog's blood in the urine problem. This was because the brand name practice has all the facilities, according to the vet referring her to this practice. Ultrasound of the kidney and bladders, urine tests, urine culture and sensitivity and blood tests were done at various times over the two years. There was said to be an X-ray done but the practice said there was no record available.
 
Corgi, Female, Spayed, 9 years - Recurrent UTI. No blood in urine when given antibiotics
Some lab results from Vet 2
Blood in urine on 29-10-11 again. Phoned Dr Sing. Very smelly urine when examined.
Date 3-9-11 4-4-11 20-3-11 27-2-11 19-9-11 3-7-10 27-5-10 9-1-10 20-4-10
                   
SG 1.034     1.036 1.048 1.024 1.042   1.037
pH 7.4     6.5 7.7 7.2 7.7   7.1
Pn +         2+ 2+   2+
RBC >1000     2-4 20-30 2-4 >500   200-300
Bacteria 2+     + 3+ 2+ +   3+
Struvites 2+       3+ 1+     3+
Polyps present     No significant growth          
Urine Culture   Proteus
mirabilis
             
Ultrasound   Polypoid cystitis Chronic cystitis     Bladder wall thickened. floating echogenic      
WBC 6-8     2-4 4-8 4-6 0-2   40-50
Others Blood test normal           Bladder not palpable, fat, pollakiuria, stranguria Obese, vulval fold and muzzle eczema  
Vet 2's lab reports give some clues to the recurrent UTI. It is always easier to diagnose with lab reports done. The case is being followed up by me. Ultrasound on Oct 29, 2011 revealed no stones, polyps or transitional cell carcinoma inside the bladder but lots of floating cellular masses.  Struvites stones not seen in 2 X-rays but there were radio-dense urine,

On the first day, no urine was available from this female dog for test. Catherisation would need anaesthesia and I did not do it since lab results from Vet 2 showed a pattern of struvite formation. It was not possible to wait for the urine as the dog had to go home. No urinary crystals on urine test, pH=7.0 from urine test taken by the owner 2 days after Dr Sing's antibiotic treatment.

My present treatment aims at dissolving the struvite and preventing its formation inside the bladder. Antibiotics. Urine acidified. SD diet to dissolve struvites advised for 3 months. Owner took 1 month's supply of SD diet first. Needs monthly follow-up but most owners don't contact the vet till blood appears in the urine. Recurrent UTI is a difficult problem to resolve and the blood in the urine is very worrying to the owner. Will there be a solution? It is hard to say now.

But her dog would pass smelly urine with blood after a course of antibiotics prescribed by these vets. She was not happy with this situation. One vet had advised surgery of the bladder to remove "polyps" but had told her about anaesthetic risk and that the surgery was not meant to be a cure for the recurring problem of passing blood in the urine.

She phoned me to seek another opinion recently. I have the benefit of these tests. Three urine tests at different times showed struvites in the urine. The facilities or tools of the trade were used by the vets but the owner's problems were not resolved.

It was like my car's problem. My car would display "Check coolant level" and I would send the car to my usual mechanic for 4 times. The mechanics were two older men in their late 60s distinguished with snow-white hairs and specialising in the brand of car I drove. I presumed they must have the experience as their hairs were all white. I never bargained or squeezed them for discount after they service my car, as is the case with many pet owners at Toa Payoh Vets.

At the 4th time "Check coolant level," message flashed, I asked the mechanic whether he could do the job. I had to replace 2000 ml of water in 5 days after he had assured me that he had resolved my problem.

I cannot afford putting my car overnight and then encounter the same problem again. The old man pointed to some water spots on the radiator and said he knew what to do. He diagnosed the radiator cap as being damaged and therefore leaked the coolant. He said he had used pressure tests and there was no other leakage. Earlier he had put some liquid which could seal any cracks but they did not work.

Yet, I got the same problem. On the 5th time, he said he would check again. He said the 5-month-old German-made radiator was faulty and had replaced with a French-made radiator. The supplier of the German-made radiator would not provide a replacement and therefore I had to pay him $500. "The 'check coolant level' was reported within 2 months of getting the German-made radiator," I said. "I wish to speak to the distributor as he is selling faulty goods and cheating people." The old man said it was of no use. "I was referred to another mechanic down the road," I said to the old man. "You could not resolve my problem for so many times."

With the new radiator replaced, I checked the water level 5 days later. There was a need to top up 200 ml of water. So, was there a leakage or not? I have to wait and see.

My situation is similar with that of the Corgi owner as I entrusted my mechanic to resolve my problem. He recommended replacement of the radiator and some pumps and the bill came up to $7,000!

Only that she had consulted the same practice for over 10 times without resolution of her problems and I would not be surprised if she had spent $7,000 too. I did not ask her. But I could empathise with her.

DENTAL SCALING DONE TODAY
I use the same guideline for sedation
A 10-kg healthy young dog - 0.4 ml domitor + 0.5 ml ketamine IV

The Corgi weighed around 14 kg but she was old. Blood tests were normal but no chest x-ray of the heart was done today as this is the usual practice. In human anaesthesia, a chest x-ray at Singapore General Hospital where I went for surgery, was mandatory.

In this Corgi, I gave 0.1 ml domitor + 0.1 ml ketamine mixed with 0. 3 ml normal saline and gave IV. This was less than 20% of the formula but the dog was sedated 80%. I used isoflurane gas to top up.

"No need," my assistant Min said when I told him to apply a tourniquet.
"Sometimes it is not needed," I said. "But I see that you have wasted a lot of time in some cases where no tourniquet was used as the blood collection or injection was not possible at the first attempt."
The dog had a tourniquet and the cephalic vein was distended. The sedatives were given.

I monitored the isoflurane gas + oxygen very carefully as the lady owner entrusted me and expected the dog to be OK. Eyelid blinking to be zero and maintenance of isoflurane was 0.5 - 1%. The dog had bilateral cataracts but I could monitor the closing of the pupil. It still took 45 minutes to complete the whole dental scaling. Solid teeth. Tartar only esp. on PM4 upper, both sides.

The owner had said, "My dog had only one anaesthesia and that was when she was spayed." I said: "That was some 6 years ago and she was healthy then. I advise an X-ray of the chest."

ULTRASOUND OF THE BLADDER AND X-RAY OF THE CHEST AND ABDOMEN AT 11.30 AM
I collaborate with an experienced vet who did the ultrasound and X-rays. I brought the Corgi personally to discuss with him the use of the tools of the trade - the ultrasound and the X-rays and how he would interpret the results. I had wanted a contrast cystography involving injecting dyes into the dog and X-raying the kidneys and bladder to check for tumours and stones. However the cost of $500 inclusive of anaesthesia was above budget. I had to find other lower cost alternatives and in any case, there was anaesthesia which I had just performed during dental scaling in the morning.

To cut a long story short, the ultrasound showed lots of floating sandy particles inside the bladder as reported by previous vets doing the ultrasound. There was thickened bladder wall but no polyps or transitional cell carcinoma inside the bladder. "Otherwise the Doppler would show blood flowing into the mass on the inside of the bladder," the vet I collaborated with said to me. "There was zero blood flow and therefore the sandy particles were separate from any mucosa." Excellent use of the tools of the trade, I must commend him. 

On X-rays, I could see radio-dense bladder indicative of struvites (as reported by urine tests by the previous vets). The owner collected urine in the morning but I had treated the dog with antibiotics 2 days ago. I wanted the X-ray to see if there were large struvite stones. There were none.

Lots of radio-dense sandy particles float inside the bladder. Could they be struvite sand or inflammatory cells?
Yet the urine test taken on the same day is negative for epithelial, white blood and red blood cells and crystals, mucus threads, yeast and bacteria. 

The urine test I sent to the lab today show normal urine. Amber, clear, no nitrite, protein, glucose, ketones, urobilinogen (normal), bilirubin, blood. Urine microscopy - no white or ed blood cells, no epithelial cells, casts, crystals, bacteria, mucus threads. yeast or others.

The pH was 7.0 (5-8) and SG was 1.018 (1.0905-1.030).
Based on history, the sandy particles would be struvites or inflammatory cells.

I had to treat the dog 2 days ago as it was quite distressing for the owner. In any case, urine bacterial culture and sensitivity tests had been done by the other vets and Proteus mirabilis was found in one time. So, I did not repeat again to save the owner some money. Baytril had worked and the dog was no more passing blood in the urine while on antibiotics.

What is the next step now that the bladder is shown to be free from tumours and polyps which would cause recurrent UTI? I recommend dental scaling which was done. The next step would be SD diet for 3-4 months to acidify the urine. If this works, it will be happy days for the owner. I will use urine acidifiers and review the case in 4 weeks. Will I succeed where others fail? Only time will tell whether I can resolve the lady's pet problem of recurring UTI. This dog was well beloved as not many Singapore owners would bother to take the dog for over 10 times to treat for blood in the urine. One or two times and that's it for the old girl!

CONCLUSION
The history of the case reports from the other vets is much more important than one urine test. At urine pH of 7.0, it may be considered that the urine tends towards alkaline.

I would say that struvite sand and inflammatory cells are still present. This is evident from the ultrasound where there is "swirling" masses seen inside the bladder, as if it is full of sand and debris. However, no blood supply pulsates to any "polyps" nor are "polyps" seen in the ultrasound. This indicates that the dog has no bladder tumour.

The dog has chronic cystitis and recurrent UTI. Tumours have been ruled out as a cause. Blood test before antibiotic treatment was normal and so a other-source of infection via the blood is ruled out. This leaves struvites are a cause. The pH 7.0 is not acidic. Nor alkaline but this should be reduced to produce acidic urine to stop bacterial growth. 

P.S. The dog's heart was enlarged but when I auscultated the heart, the heart sounds were normal. "Why is the heart enlarged?" the owner asked. "It may be due to old age or congenital or other reasons," I said. The dog did feel short of breath at certain times. Will update this webpage as regards the resolution of the dog's recurrent blood in the urine problem.

Go Red For Women - Heart attack awareness for the older woman - toapayohvets, singaporeRecurrent UTI in the old Corgi - Part 2.
Follow-up in Dec 2011. Feeding canned S/D diet for 3 months
http://www.sinpets.com/F6/20111210recurrent-urinary-tract-infection-old-female-spayed-corgi-singapore-t
oapayohvets.htm


 Recurrent UTI in the old Corgi - Part 3.
Follow-up in Jun 2012. No more smelly urine or peeing >2X/day
Part 3. An old Corgi with recurrent urinary tract infection - A Happy Ending.

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