1392. Yangon Seminar July 5, 2014 . FLUTD in a Singapore male cat

http://www.sinpets.com/F5/20110437urinary-tract-infection-amitriptyline-cystitis-toapayohvets-singapore.htm



The Hissing Cat Has Difficulty in Peeing? Initiating Cause due to amitriptyline?


Sunday, April 24, 2010.
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. 

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.

 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 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


  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.

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

1391. Biography of Dr Sing Kong Yuen for MVA

Recent Advances in Veterinary Practice No.3
Myanmar Veterinary Association, July 5, 2014

BIOGRAPHY - Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS

Jun 27, 2014
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS, 64, Singaporean was awarded a Colombo Plan Scholarship to study veterinary science in Glasgow University, UK in 1969. He graduated as a veterinarian in 1974. He was a military Provost-Veterinary Officer during his National Service full-time from 1974-1977 with the Singapore Armed Forces. He was a government veterinarian treating pigs and poultry from 1977 – 1982.

In 1982, he founded Toa Payoh Vets, a private small animal practice. He was employed as a Singapore Turf Club equine veterinarian from 1982 – 1990. From 1982 to 2014, he practices at Toa Payoh Vets (www.toapayohvets.com) focusing on dogs, cats, hamsters, chinchillas, rabbits and turtles.

PHOTO

http://www.asiahomes.com/singaporetpvet/images/9996Toa_Payoh_Vet_Mar202.jpg

Attached.

1390. FINAL COPY TO MVA. Urolithiasis in dogs and cats.

Recent Advances in Veterinary Practice No.3
Myanmar Veterinary Association, July 5, 2014

DIAGNOSIS & TREATMENT OF UROLITHIASIS IN DOGS AND CATS
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Founder of Toa Payoh Vets, Singapore. 
www.toapayohvets.com, judy@toapayohvets.com

Urolithiasis is the formation of urinary stones (uroliths) within the urinary tract (kidneys, ureter, bladder and urethra). The outflow of urine is obstructed, leading to inflammation, septicaemia, shock and death. 

The 3 most common uroliths found in the canine cases in Toa Payoh Vets, Singapore are struvites (magnesium ammonium phosphate), calcium oxalate and urates. Cystine and silica urolithiasis are uncommon. (IMAGES). In feline cases, infection-induced struvites are the most common type seen but oxalate urolithiasis do occur in cats.

This paper shares my experiences with the treatment of urolithiasis  for the last 40 years. I graduated from Glasgow University in1974 and am still practicing.  My guidelines are as follows:

1. A correct diagnosis is important.

1.1 History. Do a thorough physical examination including weighing the dog, taking rectal temperature.
 
1.2 Clinical signs. Important ones are dysuria, haematuria and pollakuria.
 
2. Bladder palpation (large distended bladder, stones inside the bladder and crepitus). Abdominal pain or discomfort. Palpation of a likely “bladder” stone is not reliable and it is best to get radiography or ultrasonography performed to confirm its presence. For some owners who want the cheapest medical costs, I had removed bladder stones after bladder palpation without X-rays. I do not recommend this method. The bladder “stone” palpated may not be present  during surgery.  In any case, write in your case record under AMA (Against Medical Advice), that the owner does not want radiography as advised, to defend yourself against allegations of negligence.

3. Vaginal discharge (mucopurulent) may be seen with chronic lower urinary tract infections.

4. Blood test. CBC/Biochemistry. Leucocytosis, neutrophilia and thrombocytopenia indicate septicaemia and a poor prognosis.  High serum BUN and creatinine will point to kidney damage. Inform the owner about the poor prognosis if relevant, before surgery to remove the bladder stones.   

TIP. Always advise a blood test to screen the health of the dog and possible kidney damage to determine the anaesthetic risks and prognosis.  Leucocytosis, neutrophilia and thrombocytopenia indicate septicaemia and a poorer prognosis.    

5. Imaging. 
5.1 Survey radiography shows radio-dense stones such as struvites, calcium oxalate and silica.  Cystine and urate uroliths are radiolucent and the vet may need to perform contrast cystography or ultrasonography.

I prefer to inject 20 ml of air into the canine bladder via the urinary catheter, to show clearly the number of bladder stones (IMAGE). In female dogs, the use of a vaginal speculum or finger to guide the urinary catheter into the bladder will require more patience, time and practice as compared to the male dog’s urethral catherisation. I note that many vets do not catheterise females.  

TIP. Some vets perform only the lateral view to reduce medical costs. Two views must be done as radio-dense objects in the lateral view may not be located within the bladder.

TIP. If no radio-dense uroliths are seen on survey radiography, many vets diagnose that there is no urolithiasis. They don’t do contrast cystography or ultrasonography.  Perform routinely urinalysis which may reveal the presence of cystine or urates, both of which are radio-lucent.

TIP. I encountered cases where some vets just X-ray the bladder and urethra area. They miss radiography of the kidney area where uroliths may also be present. It is important to X-ray the abdomen and pelvis as uroliths may be present in the kidneys, ureters, bladder and urethra.

5.2 Ultrasonography shows the thickened bladder wall (chronic cystitis), location, number and size of uroliths. It will show the presence of bladder wall tumours which may be the cause of haematuria. Normal bladder wall cannot be detected by ultrasonography.

6. Urinalysis. I have heard from one client that her vet consider urinalysis unnecessary if surgery is to be done. Urinary pH and SG, presence of blood, bacteria and crystals can be useful in the post-surgical management and prevention of recurrence of urolithiasis.  

TIP. Some vets state that the absence of urinary crystals in the urine mean that no uroliths are present. This is not true as stones can be present without crystals in the urine.

7. Bacterial urinary culture and antibiotic sensitivity test are rarely done to reduce medical costs.

8. Chemical analysis of the uroliths.  Chemical analysis of the stones removed by surgery or passed out in the urine is one procedure that all vets should not forget. Some clients do not want to pay the cost of analysis and this should be recorded in the case notes under AMA (Against Medical Advice).  I heard from an Australian vet at his talk in 2013, that there was a vet who just removed the stones and not send them for analysis even though there was recurrence of urolithiasis. This vet lost a loyal client.

In Singapore, Hills’ Science Diet provides a free stone analysis to be done by the University of Minnesota. I send the stones to the local laboratory for analysis as results come back much earlier.

9. Client Education & Informed Consent Form.
9.1. Outflow obstruction caused by urolithiasis is a medical emergency. Prognosis depends on the health of the dog as shown in the blood test results of CBC/Biochemistry as well as physical examination.

9.2  Informed consent for anaesthesia and surgery explaining the high risks involved esp. for old dogs. This is important as there have been litigation against Singapore surgeons who have not fully explained the risks of anaesthesia and surgery.

9.3  An estimated amount of medical costs must be given to the owner before the surgery. A pyometra surgery and anaesthesia in small breeds cost around $800 in Toa Payoh Vets in 2014.  

10. PRE-OP STABILISATION
1. Immediate I/V fluid therapy, antibiotics and pain-killers for 1-2 days. I usually give Hartmann’s, dextrose and amino acids, baytril and spasmogesic IV. The dog is an in-patient.

11. ANAESTHESIA & SURGERY
11.1   I use 25-50% of the calculated dosage I/V for sedation/induction depending on the health of the dog. Then I intubate and maintain with isoflurane + oxygen anaesthesia. If the dog is very weak and lethargic, I use entirely isoflurane + O2 anaesthesia and find this to be very effective and safe.

11.2 My calculated dosage is as follows: For a young 10-kg dog, Domitor + Ketamine IV = 0.4 ml + 0.5 ml respectively.

11.3 For very old (over 10 years) dogs and/or in poor health, I use only isoflurane + oxygen gas.

11.4  Clipping and cleaning to be done before sedation outside the operating room reduce anaesthetic time and risks.

 

12.  URETHRAL OBSTRUCTION IN DOGSOutflow obstruction due to stones obstructing the urethra is a common situation in male neutered cats at Toa Payoh Vets. Some dogs do have this problem too.

Briefly, the procedures after diagnosis of urolithiasis are as follows: Sedation, urethra catheterization, syringe normal saline to flush the stones into the bladder (use 30-ml syringe instead of 10-ml) and remove all stones from the bladder surgery. It may be very difficult to flush larger urethral stones into the bladder (voiding urohydropropulsion) when they are lodged at the bend of the urethra. I know of one case of recurring urolithiasis where the vet used a hard catheter and rupture the urethra, leaking urine into the skin (IMAGE). 

Some vets prefer incising the urethra behind the os penis to remove the stones and open up the bladder to remove the bladder stones. I had one case of the owner wanting to euthanase the male dog that had a urethral opening performed by another vet, as the dogs keeps dribbling urine from this opening, soiling the apartment floor. Voiding urohydropropulsion (flushing uroliths back into the bladder) might have prevented euthanasia in this case.

13.  URETHRAL OBSTRUCTION IN CATS
A most common problem in male neutered cats seen at Toa Payoh Vets. Sedation, urethral catherisation to unblock the urethra followed by bladder irrigation several times normal saline till the bladder is cleared of blood and debri. I stitch up the catheter to the prepuce, put the cat on an Elizabeth collar and ward the cat for 2-3 days. I removed the stitched catheter before sending the cat home.

Some vets send the cat home on the same day and in one case, the cat just bite out the urinary catheter despite the wearing of the Elizabeth collar. It is important that the vet do urinalysis and teach the client how to switch over to the Prescription Diet. Follow up by phone calls is necessary but sometimes not done by the busy vet. The owner must be warned about recurrence if he does not comply with medical (not able to give antibiotics)  and dietary instructions (feeding same dry food).

In recurrence, survey radiography and more detailed tests to check other types of uroliths such as calcium oxalate may be present, instead of struvites, may need to be done. 

A video of a case of urethral obstruction handled by Dr Aung of the Royal Asia Veterinary Surgery will be screened.  
http://www.youtube.com/watch?v=0IsujynE480

14. UROCYSTOLITHIASIS. BLADDER SURGERY14.1 Empty the full bladder before surgery. In male dogs, I may inflate the bladder with 20 ml of normal saline to enable it to be easily accessed.  

TIP. The full bladder may be just below the skin. If the vet is not careful, the bladder may be cut spilling urine into the peritoneum.
 
TIP. Be careful. Avoid contamination of the peritoneum with urine and small uroliths by packing the surgical area next to the bladder with many sterile swabs.  

14.2 Sutures. For closure of the bladder wall, I usually use two layers of continuous inverting suture if the bladder wall is thickened by inflammation. I use 3/0 braided absorbable sutures (Polysorb) in all my bladder closures. My associate vet, Dr Daniel prefers the 3/0 monofilament absorbable sutures (Monosyn).

14.3  I use Anti-sedan IM to reverse and abolish the effects of Domitor sedation in cases where the dog is still not conscious after the surgery. The dog is usually awake within 5 minutes of the injection.

14.4   Post-op Nursing. The dog is hospitalised around 3 days to lower the medical costs. She goes home with antibiotics for another 10 days and an Elizabeth collar. Tolfedine pain-killers are given for the first 4 days.

15. Outcome. If the dog is not extremely ill, she recovers very well from the surgery. The blood test is useful in client education as regards any permanent kidney damage (high serum BUN and creatinine and phosphous).

16.  Practise evidence-based medicine as clients are better educated and have high expectations. Some 10 years ago, in one case, the dog kept vomiting and died despite being spayed. I did not do the blood test to check for kidney damage as the owner wanted the cheapest medical cost. Her family members sent mass e-mails to everyone in Singapore advising them to avoid me. There are strangers and a doctor who phone me to let me know.  Nowadays, they use Facebook or pet forums to voice their grievances against the vet.

16.1 AMA (Against Medical Advice). Nowadays, I give the client a written record that he does not want blood tests, X-rays or procedures as advised by me. I have the written evidence in case of litigation or complaint. In computerized records, there is the allegation of falsifying evidence by deleting the earlier record but vets using manual records need to keep proper records to protect their reputation.

17. NEPHROLITHIASIS
Nephrolithiasis is rarely seen at Toa Payoh Vets and I have no experience of the surgery to remove kidney stones. I had two cases in 2013/2014 (IMAGES). One involved a Miniature Schnauzer with recurring cystourolithiasis. Another was an old Poodle. Both owners did not want to spend money on further tests and the dogs died soon.  A senior vet had done the rare case and said that the dog felt great pain post-surgery. Also, he said that the kidney was swollen and infected (nephritis). An Australian vet who gave a talk in 2013 said that he would operate only if 70% of the kidney tissues are still functional.     

TIP. Shock wave lithotripsy to blast and break up kidney stones is too expensive for almost all  dogs and cats.

18. URETERAL UROLITHIASIS SURGERY
Ureteroscopy and lithotripsy may be used to remove the ureteric stones in people. I have not encountered cases of ureteral stones in dogs and cats. 

19.  PREVENTION OF RECURRENCE OF UROLITHIASIS
19.1  Presently, only struvite stones can be dissolved/prevented using prescription diet that acidifies the urine, e.g. Hills’ S/D and C/D or Royal Canin Urinary S/O (no pork ingredients important for certain religions). 

In my opinion, bigger struvite stones of over 1 cm diameter cannot be dissolved using dietary means although the Minnesota Urolith Center had mentioned this could be done in 2-3 months. Many clients don’t have the time to monitor the progress and do more survey radiographs. Surgery is usually the best way.  

19.2  One of my clients did not want the bladder stones in her Miniature Schnauzer removed by surgery and the dog had one episode of urethral obstruction but is OK now without surgery (IMAGE). Another client had a male Pekinese keeps peeing out stones for many months as the owner did not want any radiography or urinalysis (IMAGE). He had to rush the dog as he developed urethral obstruction after midnight.  He died during attempts to unblock the bladder by the emergency vet who was “blamed” for the death.   

19.3  Non-compliance by clients. Many Singapore clients do not know how to get the dog or cat to eat the prescription diet and so give up. The vet has to advise on how to do it. Mix 10% of the new diet and increase to 100% in 2-4 weeks. No other food or dog treats.

19.4  Feed canned food only.  No more dry food if possible. Feed home-cooked food. No more treats or sharing other pet’s dry food.

19.5 Get the dog or cat to drink more water e.g. more exercise, add ice.
 
20. Urine monitoring every month for the first 3 months so as to confirm that the prescription diet is effective in acidifying the urine and to check for bacteria and crystals in the urine.

21. Survey radiography every 3-monthly so that small stones can be removed by retrograde urohydropropulsion (eliminate stones via the catheter). None of my clients in the past 40 years bother to adopt this advice! 

22. Diet management. Some will just buy the Prescription Diet regularly and that is all they do.

CONCLUSION
My paper shares some of my urolithiasis experiences in practice. Much more detailed research and advices on treatment and prevention can be obtained from the website of the Minnesota Urolith Center, University of Minnesota
e.g. urate urolithiasis in cats is at:
http://www.cvm.umn.edu/depts/minnesotaurolithcenter/prod/groups/cvm/@pub/@cvm/@urolith/documents/asset/cvm_asset_108328.pdf

A video of a case of recurring urethral obstruction handled by Dr Aung of the Royal Asia Veterinary Surgery will be screened. I happened to visit him at that time and filmed the video for discussion at this talk.   

MY COMMENTS ON THIS CASE (IN RETROSPECT)
Recurring urolithiasis is a complex  problem to resolve. The owner doctor-hops to find a solution and previous treatment by the other vet may be hard to obtain.

In this case, in retrospective review today as I write this paper some 7 days after my visit, I have the following questions:

What was the composition of the uroliths in the urine as seen by the first vet?
Did the first vet do a survery radiograph and urinalysis? Ultrasonography? Blood test?
What was the urinary pH on the first visit?
He or she had prescribed Royal Canine Urinary S/O for this cat and so the pH was acidic now. Was the urethral plug or urolith confirmed struvites? Or oxalate or urate stones?  Were there stones in the kidneys?  

http://www.youtube.com/watch?v=0IsujynE480

1389. FINAL Copy - MVA - Guidelines on pyometra treatment email to the MVA

Recent Advances in Veterinary Practice No.3
Myanmar Veterinary Association, July 5, 2014

GUIDELINES ON TREATMENT OF PYOMETRA CASES IN DOGS AND CATS
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Founder of Toa Payoh Vets, Singapore. 
www.toapayohvets.com, judy@toapayohvets.com

Pyometra is an infected uterus filled with pus. The uterine lining (endometrium) becomes cystic and hyperplastic due to the effects of oestrogen and progesterone. Bacteria from the vagina enters the cervix to invade the uterine lining leading to inflammation and pus formation.  

If the cervix remains closed, the pus accumulates in large quantities inside the uterus (closed pyometra). If the cervix is open, the pus is discharged via the vagina (open pyometra).  (VIDEO & IMAGES)

If there are ovarian remnants after spay, the stump of the uterus may become infected (stump pyometra). This occurs any time after ovariohysterectomy.  (IMAGE CAT STUMP PYOMETRA X 2)

In Singapore, almost all home cats are spayed to prevent them caterwauling (loud cries of heat). So pyometra in cats is uncommon.  However, many dog owners do not spay their dogs for reasons such as cruelty and therefore pyometra of older bitches is encountered often .

Yangon appears to have a higher incidence of pyometra in cats and dogs as they have been treated with the synthetic progesterone (Depo-M or Contracep)  IM every 3-4 months to suppress the heat cycle.   (IMAGE OF DEPO-M & CONTRACEP). However, client education has led to more owners opting for ovariohysterectomy (IMAGE OF DOG BOMA).   

This paper shares my experiences with the treatment of pyometra for the last 40 years. I graduated from Glasgow University in1974 and am still practicing.  My guidelines are as follows:

1. A correct diagnosis is important.
1.1 History of estrus. Do a thorough physical examination including weighing the dog, taking rectal temperature and checking for false pregnancy or mating.

TIP. Always ask the owner when the vomiting intact female dog has the last estrus.  Pyometra occurs usually 1-12 weeks after estrus. I see many cases around 2 months after estrus. Pyometra may co-exist in pregnancy (20-24 days after ovulation) but it is rare.

1.2 Clinical signs. Important ones are fever, polydipsia, polyuria, abdominal swelling, vaginal discharge and nipple discharge of false pregnancy. Many owners do not provide correct information saying that the vomiting dog has been fed a wrong type of food and had diarrhoea. I had a case when the vet misdiagnosed the closed pyometra as acute gastroenteritis (IMAGE OF HUSKY). The dog died of septicaemia and shock when I did the emergency ovariohysterectomy. Some owners say that the dog does not have polydipsia but has polyuria.

2. Uterine palpation (large uterus for closed pyometra). Abdominal pain or discomfort (dog bites) may be present in a swollen abdomen.

TIP. Practise abdominal palpation in every dog or cat  and you will be able to feel swollen loops of uterine horns in the abdomen. The radiographs will show the swellings (IMAGE OF SONIA, Jack Russell) of closed pyometra.

3. Vaginal discharge (serosanguinous or mucopurulent) is seen in open pyometra (IMAGE & VIDEO).

4. Blood test. CBC/Biochemistry. Leucocytosis, neutrophilia and thrombocytopenia in closed pyometra cases. Anaemia. High serum BUN and creatinine will point to kidney damage.  

TIP. Always advise a blood test to screen the health of the dog and possible kidney damage to determine the anaesthetic risks and prognosis. Some closed pyometra cases may have permanent kidney damage and will continue to vomit even after spay as in one case of a Miniature Schnauzer whose owner’s father procrastinated surgery. The owner was satisfied that the vomiting was due to kidney damage rather than from my surgery as I had interpreted the high serum BUN and urea to her from the blood test.  Without this blood evidence, some owners blame the vomiting on the vet doing an incompetent spay.   

5. Imaging. 
5.1 Survey radiography may show large distended uterine horns or loops in closed pyometra.
5.2 Ultrasonography shows thickened uterine wall (cystic endometrial hyperplasia and intraluminal fluid (pus). Normal uterine wall cannot be detected by ultrasonography.

6. Client Education & Informed Consent Form.
6.1. Pyometra is a medical emergency. Prognosis depends on the health of the dog as shown in the blood test results of CBC/Biochemistry as well as physical examination.
6.2  Informed consent for anaesthesia and surgery explaining the high risks involved esp. for old dogs. This is important as there have been litigation against Singapore surgeons who have not fully explained the risks of anaesthesia and surgery.
6.3  An estimated amount of medical costs must be given to the owner before the surgery. A pyometra surgery and anaesthesia in small breeds cost around $800 in Toa Payoh Vets in 2014.  

PRE-OP STABILISATION
1. Immediate I/V fluid therapy, antibiotics and pain-killers for 1-2 days. I usually give Hartmann’s, dextrose and amino acids, baytril and spasmogesic IV. The dog is an in-patient.

ANAESTHESIA & SURGERY
1.  I use 25-50% of the calculated dosage I/V for sedation/induction depending on the health of the dog. Then I intubate and maintain with isoflurane + o2 anaesthesia. If the dog is very weak and lethargic, I use entirely isoflurane + O2 anaesthesia and find this to be very effective and safe.

1.1 My calculated dosage is as follows: For a young 10-kg dog, Domitor + Ketamine IV = 0.4 ml + 0.5 ml respectively.

1.2. For very old (over 10 years) dogs and/or in poor health, I use only isoflurane + oxygen gas.

2. Clipping and cleaning to be done before sedation outside the operating room reduces anaesthetic time and risks.

3. Make a long incision carefully to get the swollen uterus out easily and without rupturing the friable parts, contaminating the abdomen with pus.

TIP. The full bladder may be just below the skin. If the vet is not careful, the bladder may be cut spilling urine into the peritoneum.

3.1  I use the 3-haemostat method to clamp and ligate. I release the middle of the 3 haemostats. Then I ligate on the clamped grooved area vacated by the middle of the 3 haemostats.

TIP. I see some vets use only 2 haemostats and do not ligate over the clamped area. So, the ligature slips leading to bleeding.  Some vets using this method ligate two the ovarian ligament in two areas instead of the usual one spot.

For the uterine body, I usually ligate the clamped area of the middle of the 3 haemostats. In big breeds, I used the inverting continuous suture to close the stump and ligate the stump.

TIP. Be careful. Avoid contamination of the peritoneum with pus leaked from the uterus.  

4. Sutures. For medium to large breed dogs, I use 2/0 braided absorbable sutures (Polysorb). For small breeds I use 3/0 sutures. My associate vet, Dr Daniel prefers the monofilament absorbable sutures (Monosyn).

5. I use Anti-sedan IM to reverse and abolish the effects of Domitor sedation in cases where the dog is still not conscious after the surgery. The dog is usually awake within 5 minutes of the injection.

6. Post-op Nursing. The dog is hospitalised around 3 days to lower the medical costs. She goes home with antibiotics for another 10 days and an Elizabeth collar. Tolfedine pain-killers are given for the first 4 days.

7. Outcome. If the dog is not extremely ill, she recovers very well from the surgery. The blood test is useful in client education as regards any permanent kidney damage (high serum BUN and creatinine and phosphous).

8. Practise evidence-based medicine as clients are better educated and have high expectations. Some 10 years ago, in one case, the dog kept vomiting and died despite being spayed. I did not do the blood test to check for kidney damage as the owner wanted the cheapest medical cost. Her family members sent mass e-mails to everyone in Singapore advising them to avoid me. There are strangers and a doctor who phone me to let me know.  Nowadays, they use Facebook or pet forums to voice their grievances against the vet.

8.1 AMA (Against Medical Advice). Nowadays, I give the client a written record that he does not want blood tests, X-rays or procedures as advised by me. I have the written evidence in case of litigation or complaint. In computerized records, there is the allegation of falsifying evidence by deleting the earlier record but vets using manual records need to keep proper records to protect their reputation.

SURGERY FOR STUMP PYOMETRA
Make a long incision to access the retained or remnant ovarian tissues located caudal to the kidney area. The remnant ovary is usually cystic and enclosing the sutures. (IMAGE).

MEDICAL TREATMENT FOR VALUABLE BREEDING FEMALE DOGS & CATS
1. PGF2alpha is an effective pregnancy terminating drug. It causes uterine contractions to expel the pus. In closed pyometra, the uterus may rupture. I have no experience with this treatment.

However, a senior vet in Singapore had one successful case. He incised the linea alba to be able to view the swollen uterine horns. He passed catheters into the uterine horns to suck out the pus and pumped normal saline and antibiotics to irrigate the uterus. The Pekinese gave birth to one pup at the next cycle.     

CONCLUSION
In most practices, the client wants “cheap and good” surgery. Sometimes the kinder vet tries to reduce medical costs by not taking blood tests or doing only one view in radiography. No ultrasonography will be done. It is best to practice evidence-based medicine by taking blood test and X-rays. Pyometra is a medical emergency and if the dog does die on the operating table, all family members feel that the vet is incompetent. After all, he has not done blood tests which other vets would have done.    

A Video of one of my recent case of closed and open pyometra will be screened. It is at:  
http://www.youtube.com/watch?v=J9WJqmVPfw8.

Written notes about the video:

When the vet (myself) said that the dog had a very low chance of survival on the operating table and the medical costs were high in this closed-open pyometra case, the owner felt that it would  a waste of money paying for such a high risk anaesthesia.  He decided to bring the dog home after my I/V treatment to die at home.

But I noticed that there was this 12-year-old boy who cried his heart out. Some vets don't follow up as the owner had decided and they had no time to "solicit" for business and risk being rejected.

But this little boy loves this 14-year-old dog very much as tears streamed down his face when the father decided on no operation. He knew the outcome would be death from septicaemia (leucocytosis, neutrophilia, thromobocytopenia in the blood test).

I phoned the father (owner) the next morning. The dog was still passing bloody vaginal discharge and had become lethargic.

I reduced the surgical costs to give this high anaesthetic risky canine patient a chance to live.

Time was running out on her as she became sick again. Her serosanguinous vaginal discharge flowed out like a burst dam.

If she survived the operation, the little boy would get his companion back to health and that was what mattered to me in this case.

 "Don't wait till you have finished work this evening to bring the dog down," I advised the father. "Bring her down now while she still has a fighting chance to live. Time is running out."

Dr Daniel operated immediately in the afternoon. The dog was warded one night. The little boy was most happy to have his companion back home the next day with his mother. "Are you happy now?" I asked him as he carried his friend carefully into the car. "Yes," he beamed to me his best smile.

This is a case where a vet can make a difference if he take the time to follow up before time has run out for a little boy's best friend. Now, as at Jun 25, 2014, around 2 months after spay, the 14-year-old dog is normal.

This case encourages the vet to care for the sick pyometra dog by following up with the owner the next day. Reducing the medical costs would be needed in some cases where money was a concern.

1388. Myanmar Seminar - Video; Closed and open pyometra

Recent Advances in Veterinary Practice No.3
Myanmar Veterinary Association, July 5, 2014

GUIDELINES ON TREATMENT OF PYOMETRA CASES
IN DOGS AND CATS
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
Founder of Toa Payoh Vets, Singapore. 
www.toapayohvets.com, judy@toapayohvets.com

Pyometra is an infected uterus filled with pus. The uterine lining becomes cystic and hyperplastic due to the effects of oestrogen and progesterone. Bacteria from the vagina enter the cervix to invade the uterine lining leading to inflammation and pus formation.  

If the cervix remains closed, the pus accumulates in large quantities inside the uterus (closed pyometra). If the cervix is open, the pus is discharged via the vagina (open pyometra).  (VIDEO & IMAGES)

If there are ovarian remnants after spay, the animal may develop pyometra of the stump of the uterus (stump pyometra) any time after ovariohysterectomy.  (IMAGE CAT STUMP PYOMETRA X 2)

In Singapore, almost all apartment cats are spayed to prevent anti-social noises of caterwauling and so pyometra in cats is uncommon.  However, many dog owners do not spay their dogs for reasons such as cruelty and therefore pyometra is more frequently seen in veterinary practice.

Yangon appears to have a higher incidence of pyometra in cats and dogs as they have been treated with the synthetic progesterone (Depo-M or Contracep)  IM every 3-4 months to suppress the heat cycle.   (IMAGE OF DEPO-M & CONTRACEP). However, client education has led to more owners opting for ovariohysterectomy (IMAGE OF DOG BOMA).   

This paper shares my experiences with the treatment of pyometra for the last 40 years after my graduation from Glasgow University in1974.  My guidelines are as follows:

1. A correct diagnosis is important.
1.1 History of estrus. Do a thorough physical examination including weighing the dog, taking rectal temperature and checking for false pregnancy or mating.

TIP. Always ask the owner when the vomiting intact female dog has the last estrus.  Pyometra occurs usually 1-12 weeks after estrus. Pyometra may co-exist in pregnancy (20-24 days after ovulation) but it is rare.

1.2 Clinical signs. Important ones are fever, polydipsia, polyuria, abdominal swelling, vaginal discharge. Many owners give false information saying that the vomiting dog was fed a wrong type of food and had diarrhoea. I had a case when the vet misdiagnosed the closed pyometra as acute gastroenteritis (IMAGE OF HUSKY). The dog died of septicaemia and shock when the owner consulted me. Some owners say that the dog does not have polydipsia but has polyuria.

2. Uterine palpation (large uterus for closed pyometra). Abdominal pain or discomfort (dog bites) may be present in a swollen abdomen.

3. Vaginal discharge (serosanguinous or mucopurulent) is seen in open pyometra. VIDEO.

4. CBC/Biochemistry. Leucocytosis and neutrophilia, anaemia, thrombocytopenia, high serum BUN and creatinine, low haematocrit.

TIP. Always advise a blood test to screen the health of the dog and possible kidney damage to determine the anaesthetic risks and prognosis. Some closed pyometra cases may have permanent kidney damage and will continue to vomit even after spay as in one case of a Miniature Schnauzer whose owner’s father procrastinated surgery. The owner was satisfied that the vomiting was due to kidney damage rather than from the surgery as I had interpreted the high serum BUN and urea to her from the blood test.  Without this blood evidence, some owners blame the vomiting on the vet doing an incompetent spay.   

5. Imaging. 
5.1 Survey radiography may show large distended uterus or loops.
5.2 Ultrasonography shows thickened uterine wall (cystic endometrial hyperplasia and intraluminal fluid (pus). Normal uterine wall cannot be detected.

6. Client Education & Informed Consent Form.
6.1. Pyometra is a medical emergency. Prognosis depends on the health of the dog as shown in the blood test results of CBC/Biochemistry.
6.2  Informed consent for anaesthesia and surgery explaining the high risks involved esp. for old dogs.
6.3  Financial costing explained. VIDEO.

PRE-OP STABILISATION
1. Immediate I/V fluid therapy, antibiotics, pain-killers for 1-2 days as inpatient case.

ANAESTHESIA & SURGERY
1.  Use 25-50% of the calculated dosage for I/V sedation depending on the health of the dog.. Intubate and maintain with isoflurane + oxygen gas. I use only isoflurane + oxygen gas anaesthesia in very old or sick dogs as this will be much safer to ensure survival. 

1.1 My calculated dosage is: For a young 10-kg dog, Domitor + Ketamine IV = 0.4 ml + 0.5 ml respectively.

1.2. For very old (over 10 years) dogs and in poor health, I use only isoflurane + oxygen gas.

2. Clipping and cleaning to be done before sedation outside the operating room.

3. Make a long incision carefully. The full bladder may be just below the skin and may be incised spilling urine into the peritoneum.

3.1  I use the 3-haemostat method to clamp the blood vessels of the ovary and uterus. I ligate  the clamped grooved area vacated by the middle of the 3 haemostats.  For the uterine body, I usually ligate in two areas. In big canine breeds, I use the inverting continuous suture to close the stump to prevent pus leaking and contaminating the abdomen.

I note that some vets use 2 haemostats and ligate below the haemostat while they cut off the tissues between the 2 haemostats.  In this method, the ligature may slip off causing bleeding.

4. Sutures. For medium to large breed dogs, I use 2/0 braided absorbable sutures (Polysorb). For small breeds I use 3/0 sutures. My associate vets like the monofilament absorbable sutures (Monosyn).

5. I used Anti-sedan IM to reverse and abolish the effects of Domitor sedation. The dog usually is awake within 5 minutes of the injection.

POST-OP NURSING

6. The dog is hospitalised around 3 days to lower the medical costs. She goes home with antibiotics for another 10 days and an Elizabeth collar. Tolfedine pain-killers are given for the first 4 days.

7. Outcome. If the dog is not extremely ill, she recovers very well from the surgery. The blood test is useful in client education on the permanent kidney damage (high serum BUN and creatinine and phosphous).

8. Practise evidence-based medicine by doing blood tests, urinalysis and radiography. Some 10 years ago, in one case, the dog kept vomiting and died despite being spayed. I did not do the blood test as the owner wanted the cheapest medical cost. This owner or her family members sent mass e-mails to everyone in Singapore advising them to avoid me. Nowadays, they use Facebook or pet forums anonymously to bad-mouth any vet who did not perform to their expectations.

8.1 AMA (Against Medical Advice). Nowadays, I give the owner a written record that he did not want blood tests, X-rays or lab tests as advised by me.

SURGERY FOR STUMP PYOMETRA
Make a long incision to access the ovary caudal to the kidney area. The remnant ovary is usually cystic and enclosing the sutures. (IMAGE).

MEDICAL TREATMENT FOR VALUABLE BREEDING FEMALE DOGS & CATS
1. PGF2alpha is an effective pregnancy terminating drug. Causes uterine contractions to expel the pus. In closed pyometra, the uterus may rupture. In Singapore, a senior vet had one successful case. He incised the linea alba to access the swollen uterus. He passed catheters into the uterine horns to suck out the pus and pumped normal saline and antibiotics to irrigate the uterus. The Pekinese gave birth to one pup at the next cycle.    

Video of one case of pyometra,  produced as educational video as follows:
http://www.youtube.com/watch?v=J9WJqmVPfw8. A 14-year-old X had closed and open pyometra. This video will be screened.





Written notes about the video:

When the vet (myself) said that the dog had a very low chance of survival on the operating table and the medical costs were high in this closed-open pyometra case, the owner probably felt that it would not be justified paying for such a high risk anaesthesia.  He decided to bring the dog home to die.

But I noticed that there was this 12-year-old boy who cried his heart out. Some vets don't follow up as the owner had decided and they had no time to "solicit" for business and risk being rejected..

But this little boy loves this 14-year-old dog very much as tears streamed down his face when the father decided on no operation. He knew the outcome would be death from septicaemia (leucocytosis, neutrophilia, thromobocytopenia in the blood test).

I phoned the father (owner) the next morning. The dog was still passing bloody vaginal discharge and had become lethargic.

I reduced the surgical costs to give this high anaesthetic risky canine patient a chance to live.

Time was running out on her as she became sick again. Her serosanguinous vaginal discharge flowed out like a burst dam.

If she survived the operation, the little boy would get his companion back to health and that was what mattered to me in this case.

 "Don't wait till you have finished work this evening to bring the dog down," I advised the father. "Bring her down now while she still has a fighting chance to live. Time is running out."

Dr Daniel operated immediately in the afternoon. The dog was warded one night. The little boy was most happy to have his companion back home the next day with his mother. "Are you happy now?" I asked him as he carried his friend carefully into the car. "Yes," he beamed to me his best smile..

This is a case where a vet can make a difference if he makes time to follow up before time has run out for a little boy's best friend. Happiness in the boy's face when the dog went home the day after surgery would be hard to describe. "Are you happy now?" I asked him as he sat at the back of the car with this old dog. "Yes," he nodded vigorously while his mummy was most happy too..

Time was running out as the bacterial toxins would cause permanent kidney damage. The father's decision to operate  saved the dog's life. .

Now, as at Jun 25, 2014, around 2 months after spay, the 14-year-old dog is normal.

This case encourages the vet to care for the sick pyometra dog by following up with the owner the next day. Reducing the medical costs would be needed in some cases where money was a concern.

OTHER VET EDUCATIONAL VIDEOS FOR REFERENCES OR AS A BACK UP AS THERE IS NO TIME FOR SCREENING.
http://www.youtube.com/watch?v=C7EyNdXES6I. A Golden Retriever has open pyometra.  Not for screening owing to lack of time.

http://www.youtube.com/watch?v=7c_QNAHP3wY. Enactment by 2 interns. A Maltese has closed pyometra. Part 1.


http://www.youtube.com/watch?v=P54Q6NZgK7w. Enactment by 2 interns. A Maltese has closed pyometra. Part 2.