Your Pet's Best Friend

Big Bladder Stone

 I’ve posted a case like this in the past, but it never ceases to amaze me.  This dog doesn’t look like she feels very happy, and that’s accurate.

“She doesn’t feel very good.   She has to go out a lot, and she’s drinking a lot of water. I think I saw some blood in her urine.”  How long has that been going on?  “Just a couple of days.” 

She is an older female that has never been spayed, so I’m worried about the possibility of a uterine infection.  The first test I want is an abdominal ultrasound.  I really want to get a look at that uterus. 

The uterus looks okay, but there’s this huge acoustic shadow from the bladder makes it hard to get a good look at the uterus.  It takes a minute for me to shift my point of view from this huge shadow being “in my way” to it being “the thing I’m looking for”.  That’s what a huge bladder stone looks like on an ultrasound, because it doesn’t let any sound waves through.

I took an X-ray to get a better look at it.  Wowsers! That’s a big one.  Not only that, but if you look closely you can actually the bladder wall.  It is so thick from chronic inflammation that you can see it on the X-ray.  Normally, you just see a silhouette of the bladder.

The only remedy for this situation is surgery, which is usually pretty straightforward.  Any surgery can have complications, but these usually do quite well.

So here’s the weird thing: this dog has only been showing outward signs noticeable to the owner for a couple of days.  You can see that this thing is pretty doggone big, and very rough.  It looks like a whole bunch of tiny stones packed together, which is what it is.  These are struvite stones (calcium magnesium phosphate) and in dogs they occur secondary to bladder infections.  Something like that takes months to form.

You might say that this dog’s owner just couldn’t have been paying any attention to the dog or he would have noticed this a long time ago.  I might say that, too, except that I have run into this several times before, and with clients that I knew well – people who do NOT ignore their pets.  I don’t know how it can happen that such a long term problem shows no outward signs, but sometimes it does. 

Bottom line, when you first notice that your pet is having problems, it may not necessarily be something that is just starting.  Maybe instead of “watching it for a few days” you need to get it checked out as soon as you can.

Outward signs of bladder-stones

This is Missy May.  She's a pretty good little dog, pretty healthy aside from an occasional mild allergic flare-up.  She came in yesterday because of urinary problems.  She had been squatting and straining pretty frequently for the last couple of weeks, and now she has had some "accidents" in the house.  Her owner very thoughtfully managed to bring a little urine specimen for us.  It was full of white blood cells, which is never normal. 

Dogs with bladder problems usually keep emptying the bladder as often as possible, trying to relieve their irritation.  This makes it hard to catch them with a full bladder, so you may not get much of a picture with the ultrasound (works better with a full bladder; fluid is your friend with ultrasound).

So we took an X-ray.  There's a lot of stuff on the radiograph, stool in the colon, and so forth, but the area outlined in red is her urinary bladder.  It is full of stones, dozens of them (cystic calculi for you scientific types).  Whoa, those didn't all just magically form in the last two weeks.

"It's funny, " I said to Missy's owner,"but I often see these dogs who have lots of stones, or big stones, and the people just noticed outward signs in the last couple of days.  You know that they must have been there a long time, as big as some of them are.  Yet, up until just lately nobody noticed a thing, and now the dog is squatting and straining and just producing tiny amounts of urine.  Missy May must have had those stones for longer than three weeks."

"Don't you remember, Doctor?  I mentioned at her checkup [in JULY] that she was urinating more frequently?" Dang! No, I didn't remember that.  I looked at her chart, and there it is: Owner feels that the dog is urinating more frequently, not necessarily more volume, no increase in water intake, no accidents in the house.

Lots of older dogs have increased urine output, no big deal, but it would have been a good idea to worrk it up.  I apparently got caught up in the rest of her visit, mentally put this on the back-burner, where it sat until it caught the kitchen on fire.  Jeez.

Were there any stones then?  Don't know.  I'll bet there was a bladder infection, though.  These stones sure look like struvite (we don't have the analysis back yet).  Struvite stones in dogs are considered ALWAYS to be secondary to a bladder infection.

Treatment would probably have been exactly the same back then, but the dog would not have had as long a period of discomfort.

The Take-Home Message:  If you feel like your problem has not been handled, don't be bashful about reminding me.  Beat on me to get my attention, if you have to.  Just because I handled two other problems doesn't mean it's okay to skip one.

Bladder Blockage

This is Sinatra.  The shelter folks gave him that name because of his "Ol' Blue Eyes".  Those eyes are pretty droopy here, as he is still suffering from a combination of light sedation, and heavy uremia [waste building up in the bloodstream when the kidneys cannot get rid of it].  He had been straining to urinate for a couple of days, had quit eating, had vomited once.  His urinary bladder was as big as a softball, and felt about as hard.  Not a good situation.  The owners felt he was still able to urinate; they were wrong.

Before trying to catheterize him, we gave him a very light sedative and emptied his bladder via cystocentesis [Do a sterile prep on his belly and put a needle right into the bladder to empty it.].  It would have been pretty hard to backflush any crystals or mucus into that much pressure.  We removed 120cc [versus an average 30cc in a full cat bladder] of the worst hematuria [bloody urine] that I have ever seen.

Lots of times when we centrifuge a bloody urine sample, it turns out to be less than 1% blood cells, even when it looks almost like pure blood.  The tube on the left is what Sinatra's urine looked like.  On the right is a tube that has been centrifuged, showing that the urine is about 10% red blood cells.  This is not good, showing that the bladder is really suffering from being over-stretched for so long.

Fortunately, despite the damage and being so sick, Sinatra is making a really rapid recovery.  He is tolerating his urinary catheter [necessary to let the damaged bladder stay empty while it heals] and is already eating and drinking.  He takes his medicine great and has a sweet personality, even under these circumstances.  I love this cat -- he's easy to take care of, and he's making me look good.

She can't go to the bathroom

Old Yeller Alert

A while back, I posted about Curly Sue having blood in her urine.  She turned out to have a bleeding disorder instead of a urinary problem.   Last week, she developed a urinary problem.   One day my receptionist asked me what the dose would be for a mild laxative. "They say that Curly Sue is straining to have a bowel movement."  I suggested some Metamucil, but also suggested that they be sure whe was urinating okay (even though female dogs rarely become obstructed -- their urethra is short, straight and stretchy, so it doesn't get stopped up very easily).

The next day, her owners called back and decided that they had been mistaken: she wasn't having trouble defecating, she was actually straining to urinate.    I wasn't too surprised by that, as the squatting and straining looks pretty similar.  Since female dogs rarely have blockages, I suspected that she had a bladder infection. When they told me that she was making frequent attempts to urinate, but producing very little, I was even more sure that cystitis (bladder inflammation) would be the problem.  However, as Sherlock Holmes once said, "It is a capital mistake to theorize in advance of the data."

When Curly Sue walked in, she was dripping urine in a steady trail of drops.  That does not go along with a bladder infection.  With the bladder infection, you feel you like really, really have to go, even though you just went and got emptied out.  If you just got emptied out, you wouldn't be dribbling.  If you're incontinent and can't stop dribbling, you wouldn't be having to strain.  Something doesn't jibe here.

She could have had  a stone lodged in the urethra, causing a partial blockage (rare though that is in females), but she didn't.

She could have reflex dyssynergia.  This is a weird neurological condition where your "squeezing-out" muscle and your "hold it in" muscle aren't in sync.  When the "squeeze" is on, the "hold it" should be off and vice versa.  In those dogs, when they strain to empty, their sphincter paradoxically shuts down and tries to hold it in.  When they quit trying to squeeze, the sphincter opens and they dribble.

She could have had that, but she didn't.  Her abdomen was tense, and when I ultrasounded her bladder, it was hugely full.  Then we found the big mass of tissue surrounding the neck of the bladder.  The ultrasound alone couldn't tell you exactly what it was, but it was a big mass that normal dogs don't have.  It proved to be cancerous and inoperable and the end of the trail.

Curly Sue had a long life, and dodged a big bullet in the summertime.  I guess all good things come to an end, but she will be greatly missed.

One more lesson in how hard it is to make the diagnosis over the telephone.

Big Bladder Stones

Of course, I really should say "Cystic Calculi", but does that communicate as well as "bladder stones"?   These babies weigh 8 grams apiece and they're bigger than a pair of dice. Too bad they only have 5 sides each.  Of course, even if you painted numbers on them, it would take a while before they lost that vague, telltale odor of urine.

That smooth tan appearance is pretty typical of struvite (magnesium-ammonium-phosphate), though we won't have our lab analysis back for a bit.  As I've mentioned in a previous post, this type of stone in dogs is now considered to always be secondary to a urinary tract infection.

This particular little dog had been doing some pretty frequent squatting, lots of trips outside, and finally developing traces of blood in her urine.  That's a common history.  What's not so common is that it had been going on for six months.  People do get busy with other things, don't they?  Ah, well, it allowed these cool-looking stones to develop: so smooth, and really filling the whole bladder.

When you consider that this dog only weighs six pounds, I suppose that would be like a couple of baseballs in the average-sized person.  Don't you know she's glad to get rid of those rascals?  Mercy.

Urethral blockage in female dogs

When someone calls and says that their dog or cat is "constipated", we don't just automatically hand out a list of laxatives over the phone.  We always ask "What is your pet actually doing?  Passing small hard stools?  Squatting and straining a lot?" It is usually the latter.  This is often the outward appearance of a pet who cannot empty his bladder, due to a blockage of some sort.  Unlike constipation, it is a condition that rapidly becomes life-threatening

Urethral blockage in tomcats is fairly common.  Their urethra is very narrow [like Dale on "King of the Hill"] and has to make a sharp turn on the way out. When they have bladder problems, they can get clogged with very fine, sandy crystals, or even with just little plugs of mucus.  This is a life-threatening situation. If the bladder cannot empty, then the kidneys shut down, and it doesn't take much of that to put you over the edge.  In prolonged cases, the bladder wall can become severely damaged, as well.  Urethral blockage in male dogs is not uncommon, even though their urethra is pretty big (compared to a tomcat's).    Unfortunately, as in the above diagram, it not only has to make that 180-degree turn, but it runs into a bony channel that will not stretch.  These situations move you to the front of the line, as they can become critical in a matter of hours (which have usually already passed before the owner gets hep to the problem).

Female dogs very rarely become obstructed with urinary stones.  Their urethra is short, straight, and stretchy (a little bit, anyway).  The stones are generally either too big to start down the pipe, or small enough to get through it.   So when someone says that their female dog or cat is straining a lot, we don't get too worked up.  Maybe they are constipated, maybe it's a bladder infection, maybe it's a stone that will require surgical removal, but it's not likely to be an emergency.

On the other hand, sometimes one weirdly-shaped stone can lodge and cause a blockage.  Or worse, start a pile-up, much like the stones in this tube... which were removed from just such a pile-up today.  With a stack like that, you can't just pass a catheter or flush them back up into the bladder.  You wind up with the dog's tummy open, the bladder up, out, and open, and catheters flushing saline from both ends.  You float a couple of stones this way, then the other way, and finally they're all out.  It can be a bit of a tedious process.  Of course, it's not something you get a lot of practice at.  This is only the third such case I've seen in 29 years.

These are probably struvite stones (Magnesium ammonium phosphate), though we won't know for sure until the analysis comes back.  In cats, they can be controlled with dietary alterations. In dogs, they are considered to always be secondary to a bladder infection.  This gal will be taking antibiotics for a couple of weeks, based on her urine culture results.  She will also be getting a urine specimen checked on a regular basis in the future.

Take-home message: pet is squatting and straining = get him (and her, too) to the veterinarian.