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Date:   30 April, 2010  
Focus: Small animals - dogs, cats, hamsters, guinea pig & rabbits.

Toa Payoh Vets Clinical Research
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to a veterinary student studying in Australia
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2 Pug Cases on a Sunday in 2008 
Dr Sing Kong Yuen, BVMS (Glasgow), MRCVS
ate:  30 April, 2010 
Be Kind To Pets
Veterinary Education
Project 2010-0129
July 20, 2008 was a bright sunshine Sunday. It was an unusual Sunday in that my first 2 cases were pugs. Pugs are uncommon in Singapore as they went out of favour some years ago and so, getting two cases in a row was as hard a winning the 4-digit lottery.

Case 2 was a young pup that came in for a 3rd vaccination as a free vaccination was included in its sale by a pet shop. "How did you locate the surgery?" I asked the Caucasian expatriate as my surgery is difficult to locate even by the locals. The expatriate smiled and explained to the country pumpkin, "I use the GPS in my car. I key in Toa Payoh Vets and there was a map. Only that there was no address shown." I was impressed.

"How much does it cost to install the Global Positioning System in your car?" I thought I could do with one too if I do house-calls.

"About $400," he said. The expatriate certainly knew how to use technology to make life easier.

Now, back to Case 1 which was a highly emotional case for the lady owner.

On July 13, 2008  the lady and her husband consulted me. She said, "The Seller said you delivered this pug by Caesarean. So, I came to see you as Vet 2 had not solved my problem with higher doses of drugs. Now, lots of tissues passed out in her urine" 

I examined the pug and noted that this dog had been licking her vulval area for many months. The vulval area had turned as black as the road tar. 

"Is the pug spayed?" I asked. Spayed dogs have their own urinary problems.

"As you do not spay dogs on a Sunday, I got the pug done at another practice," the lady explained. " Vet 1 did not do a competent spay. So the pug now passes tissues of blood."

"Vet 1 is a very experienced vet, " I explained. "He had done a good job as the pug does not have any bleeding due to heat nowadays."

I continued, "The bloody tissues when the pug urinated come from the inside of the bladder. There may be urinary stones irritating the bladder causing the tissues to break down. The dog dares not urinate normally due to pain. She leaks her urine when the bladder is too full. She also licks her vulval area to clean herself. Bacteria gets into the bladder from her licking of the vulva as the opening for passing the urine is inside the vulva."

This would be a very emotional case to handle as the lady did not follow up with Vet 2. What she wanted was to get the pug to stop passing bloody tissues during urination. There was no urine sample. I palpated the bladder and it was half full and firm, around 4 cm in diameter. There was no feeling of crepitus - a feeling of squeezing gas inside the bladder filled with big stones. It does not mean that there were no bladder stones just on palpation alone.

The collection of a clean urine sample from a female dog is not easy for Singaporeans. This lady was stressed out and so I did not insist on doing it. I gave the pug a different type of antibiotics and injections to relieve the pain and asked the lady to phone me in 3 days and to review in 7 days' time.

On July 17, 2008, the lady phoned me to say that the pug was no longer passing blood in the urine. She sounded happy. But I know the treatment of urinary tract infection in the spayed female pug is not easy. Follow up reviews are necessary and time-pressed owners just have no time usually. What they want is a permanent cure with one injection and medication.

On July 20,2008 (today), the lady and her husband came.
"The pug can jump in the past 2 days," the wife said. Now, I did not know that the pug was not able to jump as I did not ask and she did not say during the July 13 consultation. Jumping or not had nothing to do with urinary tract infection, one would not ask such question.

But actually, this feedback is important. This indicated that the pug had sprained her back due to continual licking of her vulva due to incontinence. The pain in the bladder, the vulval itch and the sprain of the muscles must have restricted her active jumping for joy in greeting the lady owner. And that was important for the owner.

We turned the pug upside down. I showed the lady that the pug had vulval pruritus. The vulval lips were very small as the lady must have spayed the pug very young so that they had no female hormones to develop to adult size. Urine could be trapped in the vulval folds, causing pain and itchiness. The pug keeps licking to relieve herself of the vulval itch. Over the years, the skin in this area became very black due to hyperpigmentation.

The lady could not remember when she had the pug spayed.

"Did you wash the vulval area during bathing?" I asked. "It is very dirty and becomes itchy. The black skin is caused by the pug licking this area for several months. Then trauma and bacteria infection go into the bladder through this long licking habit."

"I do not do it. I cannot restrain the pug alone." The husband said he would help out as I looked at him.

I sat on the chair and palpated the standing pug's bladder with my left hand. The bladder was full of urine. This was already 10.30 a.m.

"Did the pug pass urine after waking up?" I asked.

"This pug has a very bad habit. Always holding her urine for a long time. She will leak the urine a bit but will not pass urine regularly."

I said, "Most likely she felt pain when trying to pass urine. She passed a bit. I was painful. She stopped passing. So she hold her urine till the bladder becomes very full. Bladder stones form when the urine is not passed out regularly."

Is this a plausible explanation to the owners? If only pugs could talk.

"Is she leaking urine many times a day?" I asked.

"Not in the last 2 days," the lady said. Now there was urinary incontinence as well as urinary retention. What type of urinary incontinence is this pug suffering from? There are a few classifications of urinary incontinence in veterinary medicine. I narrow down to two classes - paradoxical incontinence and hormone-related incontinence. Was the pug suffering from one or both?

Hormone-related incontinence happens to spayed dogs. Once the hormones are removed during spay or neuter, some dogs in the older age can't control their bladder. Replacement hormones help to solve this problem.

Now what is paradoxical incontinence? Is this pug suffering from paradoxical incontinence? In this situation, she might have bladder sand or small stones obstructing the urethra. So she could not urinate regularly until the obstruction is cleared. She leaked some urine. When the obstruction is cleared by the passage of the small stones or the bladder is about to rupture, she could pass out all the urine at one go. This happened when she was outside the surgery for around one hour. That was how I managed to use the dipstick (picture) to test for blood in the urine.

After the pug had urinated, I palpated her bladder. Her bladder was now very small, around 3.5 cm in diameter. The bladder wall felt thickened. There were no single large stone, so I asked the owner to wait for 2 weeks.

It would be good to X-ray the bladder but it costs the owner money. The X-ray ought to be done with air pumped into the bladder and this involved extra cost. Urinary tract infection treatment require several consultations and the vet cost can shoot up. Blood tests ought to be done too but they must be useful to the owner as the costs add up again. Pugs as a breed are not known to suffer from urinary stones, unlike the Miniature Schnauzer, Lhasa Apso, Dalmatians, Poodles and the Bichon Frise.

It is possible that the pug had very itchy vulval lips after spay. She licked the area till it became black and dirty. Bacteria went into the vagina and the urethra into the bladder over the past 3 years. Bladder became chronic cystitis. By the 3rd year, blood in the urine and then bloody tissues in the urine as the bacteria had accumulated without the owner being aware of the problem.

A clue of painful urination from chronic (long-standing) bladder infection was from the lady's comments that the pug was "naughty and would always control her urine till her bladder was full and she would pass out a lot of urine."

Many of the urinary incontinent cases needed frequent follow up reviews and many Singapore owners just do not have the time or inclination to do it. In this case, a few follow ups may be necessary. This pug had been licking her front paws till they became black.

Coincidentally, 2 weeks ago, the Seller came with her pugs for the annual vaccination after receiving a vaccination reminder card from me. Her pugs had black crocodile-skin front legs like this pug. So there seemed to be a connection somewhere from parents to progeny. If the vet can find a solution to control this pruritus - of the fore limb or vulva - the vet will be considered a "competent" vet by the owner!

The pug will be reviewed for a few times if the owners want to. The lady was persuaded to collect urine for examination 2 weeks later and I gave her a bottle to do it. (To collect urine, use a new syringe to suck in the freshly passed urine from the newspapers or floor, put into the bottle and give it to the vet on the same day).   

Thorough cleaning of the vulval area and wearing of the e-collar for at least 1 month. Many owners want a one treatment cure all but this is not possible in many cases of chronic urinary tract infection in a female spayed dog. Most owners do not follow up by sending in a sample of urine for testing as in this case. After all, the dog was peeing normally.  This pug was also not scratching and her vulva area was no longer as black as before. So the lady was very happy. But for how long?   

Update: Aug 6, 2008. When antibiotics do not work in a urinary tract infection in the dog, the lady owner is often stressed. Having to clean up the apartment. More cleaning as blood spots stained the floor. More bleeding. More cleaning.

It is hard to imagine if one is a man who does no house work or not involved in the daily grooming of the dog.

It is extremely difficult to get a urine sample from the owner presently as there is no urinary complaint. Will there be a recurrence?  Catheterisation of the urethra is one possibility but the vet must respect the owner's wishes not to incur more veterinary costs.

Chronic urinary tract infection needs to be reviewed by the vet a few times. Blood tests, urine tests and X-rays may be needed when the problem recurs. No point in giving more antibiotics as the cause may be bladder stones irritating the bladder mucosa and causing infection and bloody tissues to be urinated out. This case is likely to be bladder stones, but the owner did not want further investigations.

But it may just be a simple urinary tract infection due to the seepage of urine into the juvenile vulval lips trapped in a grown up perineal area. Causing itchiness and licking. If the licking stops by giving hormone replacement, the bacteria will not enter the bladder via traumatic licking of the vulva. Therefore the urinary tract infection problem is solved. As simple as that?  Only time will tell. 

UPDATE IN 2010: As at April 27, 2010, I have not any complaint from the owner for nearly two years. It is possible that the owner had consulted other vets or the pug had no more blood in the urine problem.

FOR VET STUDENTS: Urine analysis by the lab is preferred to the urine dipstick. However, the owner did not want to pay for the expenses. Get the owner's permission before doing any lab test as the some owners don't pay as they say they have not given permission.  

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