Feline Urethral Obstruction, a Common Cat Emergency

I'm superstitious and I know it. I holler at my staff when they exclaim what a peaceful day it has been in the clinic. Such statements practically guarantee that a complicated life threatening emergency will walk in the door at 4:55 p.m. I find myself "knocking on wood" to secure little blessings and remarkable recoveries. Also, I am convinced bad things (or just plain weird things) happen in threes.

Within a 24 hour period this week, we had three feline emergencies -- urethral blockage.

Male cats have a narrow urethra, the tubular passage from the urinary bladder to the outside world. Because it is so narrow any number of things can plug it up causing an excruciating and life threatening emergency. Bladder stones, "crystals," mucus and blood clots can get stuck anywhere along the urethra preventing the cat from emptying his bladder.

Signs this is happening include spending an inordinate amount of time in the litter box, licking excessively under the tail (specifically the penis), straining so hard to urinate that stool comes out (or vomit), yowling in pain (especially when touched on the belly), walking funny (because the bladder, located between the hind legs, is distended and painful), decreased appetite or thirst, or hiding.

A male cat crying while repeatedly posturing
to urinate yet producing little or no urine
can signal urethral obstruction, a life
threatening veterinary emergency

By the time most owners notice these signs, the cat has already been blocked for several hours. A "wait and see" attitude in a blocked kitty will result in a dead kitty. If the cat is not seen by a veterinarian for treatment the bladder will continue to stretch (sometimes causing permanent damage to the muscles and nerves involved in contraction) and may rupture, kidney function will be compromised, and vital electrolytes will go haywire. In particular, if the potassium gets high enough the cat can have a heart attack and die.

Any time an owner calls worried about a male cat yowling in pain or straining to "poop or pee" I want to see it immediately. Urethral blockage is usually pretty simple to rule out, so I'd rather be safe than sorry if the cat is acting weird for some other reason!

No two "blocked" kitties are the same. However, I generally follow a certain diagnostic and treatment protocol initially:

Yellow arrow points out numerous large bladder stones in
this cat which will require surgical removal

1. Take x-rays of the abdomen to determine if there are bladder stones that need to be surgically removed after dealing with the immediate problem of "unblocking" the cat. 
2. Perform bloodwork to assess kidney function, electrolyte balance, blood counts, and more. 
3. With the cat under sedation a urinary catheter is passed to relieve the pressure in the bladder.
4. A urine sample is obtained to check for infection, crystals, kidney function, etc. Medications and diet changes may be prescribed based on this information.
5. The kitty is hospitalized for one or more days while we flush the bladder, treat infection, rehydrate the patient, rest the kidneys and balance electrolytes. 
6. After the urinary catheter is removed the cat is closely monitored to make sure he does not re-block.

Most cats who have been treated for urethral blockage require special lifelong management at home. This often includes a prescription diet made to dissolve and prevent crystals from forming. Canned food is recommended to increase water consumption and flush the bladder of crystals and cellular debris. Unfortunately some cats with recurring obstructions require special surgery to open up their urethral opening so they "pee like a girl cat" and are less likely block again.

Cats are famously good actors. They hide discomfort and serious illness until the last possible moment. Routine veterinary care including periodic blood and urine tests is very important for keeping cats healthy especially as they age. Subtle changes in your cat's weight, appetite, thirst and litter box habits, socialization and behavior can signal important changes in health. Trust your instincts and get him to the veterinarian!

Leapin' Livers! Leptospirosis and Other Liver Problems

I am exhausted. And demoralized.

Since late Thursday evening I have been caring for a critically ill terrier on intravenous fluids. Up every couple of hours each night for potty breaks, medicating and TLC. During the in-between times watching "Doggie TV", my closed circuit camera system broadcasting the antics of hospitalized pets to the comfort of my couch (not very stimulating programming...lots of sleeping going on in the clinic!) Just when I thought he was ready to go home on Saturday, he started to relapse.

Denny* is a six-year-old Cairn terrier who presented for vomiting, diarrhea and not eating. Extensive bloodwork and fecal tests all pointed toward acute liver failure. The liver is a very important organ that comes under attack from all sorts of day-to-day insults. Although the liver has hundreds of vital functions, one function is an all around "detoxifier." Everything that passes through the lips of an animal is dealt with by the liver:  bacteria, viruses, toxins, medications. Most of the time anything with potential to harm is effectively neutralized and silently excreted from the body. Sometimes the liver's defenses are overcome and the animal becomes ill. Luckily the liver also has great regenerative potential, so with some intensive care, elimination of the inciting cause, and time, many of these animals recover fully.

Electron micrograph of Leptospira bacterium

Due to his age and vaccine status, Denny was first suspected of having a bacterial infection in his liver called leptospirosis. This organism is shed in the urine of infected wild animals such as racoons or domestic animals like cattle and dogs. The infection is acquired by drinking contaminated water or snuffling around an area where another infected animal has urinated (the bacteria can pass through mucous membranes such as lips, noses and breaks in the skin). Leptospirosis is a zoonotic disease, meaning people can catch it from their infected animal. Some animals become very sick from liver or kidney disease, while others are asymptomatic carriers of the disease, shedding the bacteria wherever they urinate! Yikes! Although leptospirosis is treatable with common antibiotics, if the infection has triggered widespread inflammation in the system the animal may not respond to treatment.

While there is a specific test for leptospirosis, it takes time to run at the outside laboratory and Denny needed treatment immediately. We started him on intravenous fluids to help flush the buildup of liver toxins from his bloodstream, anti-vomiting medications and antibiotics. By Friday evening he was able to keep down water, small amounts of food made for liver failure patients, and oral medications. He was perky and stronger than when he arrived Thursday evening. He even lifted his leg to pee!

On Saturday morning I made preparations for sending Denny home. But by the afternoon, Denny refused to drink and started vomiting again. And his diarrhea returned, a bright orange color signaling continued problems with his liver. Still bright, Denny clearly is not improving enough to go home.

My heart is sinking. It's not the normal progression of things for uncomplicated leptospirosis. Other differential diagnoses are spinning through my mind as I try to make sense of Denny's disease. Does Denny, though not old, have a liver tumor? Does he have leptospirosis or other infection complicated by raging hepatitis? Does he have a heretofore asymptomatic congenital liver disease such as a shunt, a condition where blood loaded with nutrients and waste products bypasses the liver processing center? I'm dwelling a lot on this last one because I know more about his genetic background than I do most of my patients. His parents are my patients too. And they are nearly twice his size!

Portography, a special imaging technique, showing a
large liver shunt. A special dye is injected into the splenic
vein (from right of image) which then travels to the liver.
Here the dye mostly bypasses the liver (middle)
straight back to the heart (left of image).

This size difference worries me because dogs born with liver shunts are generally smaller than their counterparts and may be "poor doers" throughout life. Severely affected animals may show symptoms early on, but some pets find a way to compensate for the disease and may have little to no sign of disease for years. Maybe they do poorly under anesthesia at the time of spaying or neutering. (This is why preanesthetic testing is so important...to catch any early signs of liver problems before anesthesia.) Maybe they are intermittent pukers or have other easily overlooked symptoms of illness throughout life. Maybe as adults they just have some unexplained liver elevations on wellness blood screening and are acting perfectly happy otherwise.

Denny's owner allowed me to speak with the breeder, who has been able to keep tabs on most of her puppies long after adoption. Turns out Denny was diagnosed with a temporary heart murmur in early puppyhood which later resolved. In addition to being petite, Denny has been intermittently vomiting for years, a medical problem unique to him among his canine family members. She also reports that Denny's brother died at age 5 from a vague illness involving his liver!

Because liver shunts require specialized imaging or invasive biopsies for definitive diagnosis, the expense of which is outside most families' reach, we are left with more questions than answers oftentimes. I'm not sure how Denny's situation will resolve. Time is the nearly magical ingredient in so many of these tough cases. Denny's owners are committed to giving him a good chance, so we will continue IV fluids and symptomatic medications for now, buying his liver more time to rest, regenerate and recover if possible.

The Tale of the Cat's Tail

Peppy showed up at his home Sunday afternoon dragging his tail awkwardly behind him. An adult neutered country cat, Peppy occasionally sneaked out of the house in the evening and stayed away all night. This time, he barely made it back to the house alive and definitely not in one piece.

Tail degloving injury before amputation

Peppy's owners noticed a gaping wound on his tail and what appeared to be a fang mark on his back. They rushed him over to my clinic for inspection and treatment.

Poor Peppy had what we veterinarians refer to as a "degloving" injury. This means the skin on his tail had been peeled back exposing the muscle and tendons beneath. He also suffered from multiple bite wounds on his back and hocks (ankles). Our best guess is Peppy barely escaped from some large predator such as a coyote or dog.

Aside from being horribly contaminated--full of straw, hair and dirt--the major problem with Peppy's injury was the extent of the wound and the location. Simply suturing the skin together would not do. Peppy's tail skin was torn way up by his rump and merely a narrow strip of skin held it to his body at all. This meant there was a poor blood supply which would be needed for healing. Moreover, the injury had happened hours ago and was no longer bleeding, meaning the tissue was not fresh and any closure would probably just fall apart. Amputation of the tail was the answer.

It may seem drastic, but amputation of a mangled appendage (tail or limb) in a dog or cat is often the best course of treatment. Pets don't feel sorry for themselves like people often do and hardly miss the painful, damaged limb or tail. In fact, they often consider it a relief to have the injured part off.

Peppy after tail amputation

Peppy was hospitalized overnight for antibiotic therapy, fluids to treat mild dehydration and pain medications. He hunkered in a corner of the kennel unwilling to move his mangled tail. The next morning Peppy's tail was amputated.  After recovering, Peppy was a different cat. He moved around his kennel easily (in fact he stayed still barely long enough for the post-op photo), ate hungrily and was extremely affectionate. I do not doubt he will have some issues jumping at first not having a tail for balance, but he will learn.

It's not just outdoor cats that end up needing tail amputation. This past winter I amputated the tail of a fluffy indoor kitty who had lost the blood supply to the end of her tail when a decorative ribbon became too tight. While she managed to keep most of her tail (only the damaged part needed to be removed), she too appeared to feel great relief after the amputation.

I appreciate my patients' attitude toward the injuries and insults they endure. Most pets take the loss of a limb or tail in stride and happily get on with life. As I often say to their owners, "We have a lot to learn from our animals!"

Weathering the Storm: Managing Noise Phobias

The recent thunderstorms have brought more than just a lot of rain to my Wisconsin community. My veterinary office has been flooded with calls from anxious owners wondering what can be done for their thunderstorm phobic dog.

Fear of thunderstorms and other loud booming noises like gunfire and fireworks is fairly common among dogs. Unfortunately, like most anxiety issues, this type of fear can worsen with time and age. The phobia is stressful for both the pet and the owner. Sometimes it is downright dangerous for the dog if he becomes destructive or escapes (thinking of Winn-Dixie here)! 

There are many reasons why some dogs react so negatively to storms and loud noises.  A dog's superior sense of hearing means these noxious sounds are louder and noticeable from even a great distance.  Your family may change routine when a storm is approaching. Anxiety or irritability among the human family members can feed your pet’s fear.  Noise phobia symptoms have varying degrees of severity and can be managed with a variety of tips and techniques.

DO

• keep your pet indoors during a thunderstorm and fireworks.  Many fearful dogs have been lost when they ran from their yards in terror during storms and fireworks.
• keep your pet in an interior, windowless room to reduce his exposure to the noise and light triggers behind his phobia.
• turn up the stereo or television to drown out some of the outside noises.
• provide toys, games, treats and positive interactions during a thunderstorm or fireworks to help distract your pet and to create as positive of an experience as possible.
• try to have someone with your dog so he does not feel abandoned. 
• consider an over-the-counter natural pet anti-anxiety supplement. Many of my patients have experienced lower stress levels during storms, fireworks, travel and in general thanks to natural supplements (ask your veterinarian for suggestions).
• consider using a Thundershirt as another alternative to medications. I love this "technological advance" for anxious animals, although the technique is old as the hills. Like swaddling for colicky babies or Temple Grandin's homemade squeeze chute for self-calming, the Thundershirt appears to provide security and comfort during stressful situations. 
• ask your veterinarian for additional training advice or specific behavior modification techniques (such as protocols to desensitize the dog to the sounds of a thunderstorm).  
• consult your veterinarian to determine if your pet would benefit from behavior modifying or anti-anxiety medications.

DON'T

• punish your dog when he is scared. Punishment only confirms to him that there is something to be afraid of and make negative behaviors worse.
• fuss, pet or try to reassure your dog when he is scared. By speaking in a high-pitched, soothing voice and lavishing extra attention on your dog you are unwittingly rewarding and reinforcing the fearful behavior. 
• be tense during storms.  Be upbeat and act normally so your dog picks up on your body language and emotions and becomes more confident during storms.

Your dog may never enjoy a good thunderstorm or thrill at a fireworks display, but with consistent, gentle behavior management I hope that you will be able to once again.