Buddys Bad Luck A Case of Cystic and

Buddy’s Bad Luck: A Case of Cystic and Urethral Calculi in a Dog Olivia Miller AUCVM Class of 2015

History � 10 year old male, castrated Miniature Schnauzer. � Presented on 11/18/2014. � ~5 days of dribbling urine and stranguria. � Cystic and urethral calculi. � Current medications and treatments: ◦ Amoxicillin, enrofloxacin, meloxicam. ◦ IV fluid support, intermittent urinary catheterization to relieve obstruction. ◦ On a diet of canine s/d. � Previous cystotomy in 2011.

Presentation: � HR: 124 bpm � RR: 32 brpm � T: 101. 4 F � MM: pink, slightly tacky � CRT <2 s � BCS 3/9 � Stiff, slow gait. � Significant bruising, edema of the inguinal and scrotal regions.

Initial Plan: �CBC/Serum Chemistry �Thoracic radiographs �Abdominal radiographs �Contrast Urethrogram

CBC/Serum Chemistry: � CBC: unremarkable � Chemistry: ◦ Mild decreases in albumin, calcium. ◦ Mild increases in ALT, AST, ALP, bilirubin, BUN � Thoracic Radiographs:

Abdominal Radiographs

Urethrogram

Problem List: �Cystic calculi �Urethral tear �Soft tissue damage

New Plan: �Off ◦ ◦ to Surgery! Cystotomy Urethrotomy +/- Urethrostomy Collect samples for stone analysis, culture/sensitivity.

Canine Urethrotomy � Temporary incision. ◦ In comparison to urethrostomy- permanent opening created. � More common in males. � Performed by making a sharp incision on midline and gently extracting calculi using instruments and saline lavage to push calculi into the incision site. � Primary closure. wound closure or secondary wound

Canine Cystotomy � Incision in ventral side of the bladder. ◦ Note location of trigone, apex, and ligaments. � Place stay sutures. ◦ -placed at 9, 12, and 3 o’clock positions. � Aspirate urine- suction or syringe. � Evaluate interior of bladder. � Calculi removal. � Excise a small piece of the bladder wall along the incision to submit for culture/histopathology. � Single or double layer closure.

Stage 1: Urethrotomy Locating the urethra. Subcutaneous stones.

Stage 2: Stone removal Using the gallbladder stone spoon. ~Half of the calculi we removed.

Stages 3 & 4: Damage Assessment and Cystotomy Locating the urethral tear. Beginning the cystotomy.

Stages 5 & 6: More stone removal! Removing bladder stones. Passing a urinary

Stages 7 & 8: Passage of a urinary catheter and closure Checking for any obstructions. Placing a pexy.

Post-Op Care: �IV fluids: LRS at 15 m. L/hr. �Monitor urinary catheter/urine production. �Hydromorphone 0. 05 mg/kg IV q 4 -6 hours. ◦ Transition to oral Tramadol 4 mg/kg PO q 6 -8 hours. �Meloxicam 0. 1 mg/kg PO with food q 24 hours. �Warm pack incision/surrounding soft tissues. �Royal Canin Urinary S/O. �Monitor incisions. �Daily bandage changes and lavage of surgical site.

Comparing Radiographs:

Canine Urinary Calculi �What are they? ◦ Organized concretions of mineral and organic matrix. ◦ Two predisposing factors: supersaturation of the urine with minerals and changes in urine p. H. �Common Types: ◦ Magnesium ammonium phosphate (struvite), calcium oxalate, and urate. �Less Common: ◦ Xanthine, cysteine, calcium phosphate and silica.

Struvite Calculi � The most common in dogs. � Composed of magnesium, ammonium, and phosphate. � Clinical Signs: ◦ Alkaline urine (p. H > 6. 5) ◦ Urinary tract infection. ◦ Large, radiodense calculi on radiographs. � Causes: ◦ Urinary tract infection with urease producing bacteria (often Staphylococcus or Proteus spp. ) ◦ Sterile causes: Hereditary, dietary

Treatment/Prevention � Treatment: ◦ Surgical removal ◦ Culture and susceptibility of urine/urinary calculi. ◦ Appropriate antimicrobial therapy for 14 days, then re-culture urine. ◦ Medical management: Low protein diet (ex: Hill’s S/D or Royal Canin Urinary S/O) � Prevention: ◦ Keep urinary tract infection free. ◦ Dietary management with acidifying diet. ◦ Urine culture every 3 months, repeat radiographs every 6 months.

Back to Buddy: �Culture results: and susceptibility ◦ Heavy growth of Staphylococcus intermedius group ◦ Susceptible to amoxicillin/clavulanic acid! �Placed on 22 mg/kg every 8 hours for 14 days. �Stone analysis results: ◦ Magnesium ammonium phosphate (struvite) and calcium phosphate calculi.

Summary of Hospitalization � Length of Stay: 11/18/14 - 12/09/14 � Treatments: ◦ Daily bandage changes through 12/02/14 ◦ Tramadol and meloxicam. ◦ Warm compress. ◦ Amoxicillin-clavulanic acid. ◦ Dietary management with Royal Canin Urinary S/O ◦ Removal of urinary catheter on 12/05/14. ◦ 12/08/14: Repeat radiographs revealed the “jelly bean shaped” calculus was still present. Successfully removed later that afternoon! ◦ 12/09/14: Discharged

Update on Buddy �Buddy is doing very well at home! ◦ Playful and eating well! ◦ Though still urinating through the urethrotomy site…

Take Home Points �Things don’t always go according to plan. �Take post-op radiographs!

References � Ettinger, Stephen J. ; Feldman, Edward C. Textbook of Veterinary Internal Medicine. 7 th Edition. St. Louis, MO: Saunders, 2010. Print. � Smeak, Daniel. Urethrotomy and Urethrostomy in a Dog. Clinical Techniques in Small Animal Practice, Vol 15, No 1. 2000. pp 25 -34. � Thrall, Donald E. Textbook of Veterinary Diagnostic Radiology. 5 th Edition. St. Louis, MO: Saunders, 2007. Print. � Tobias, Karen M. , and Spencer A. Johnston. Veterinary Surgery. Vol. 1. St. Louis, MO: Saunders, 2011. Print.

Acknowledgements � Jarrod � My Family & Friends � Dr. Kry � Dr. Tillson � My Omega Tau Sigma Family � Soft Tissue Surgery Rotation � Ophthalmology Rotation � Class of 2015

Questions?

Chemistry Test Result Reference Range Albumin 2. 0 g/d. L 3 – 4. 3 g/d. L ALT 196 U/L 13 – 151 U/L AST 61 U/L 18 – 55 U/L ALK PHOS 368 U/L 14 – 152 U/L Total Bilirubin 0. 21 mg/d. L 0 – 0. 2 mg/d. L BUN 38. 9 mg/d. L 9 – 34 mg/d. L Calcium 9. 0 mg/d. L 9. 6 – 12 mg/d. L