Vets Clinical Research
Making veterinary surgery alive
to a veterinary student studying in Australia
using real case studies and pictures
Cases on a Sunday in 2008
Sing Kong Yuen, BVMS (Glasgow), MRCVS
30 April, 2010
Be Kind To Pets
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
"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
"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
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
The lady could not remember when she had the pug
"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
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
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
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
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
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.
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.
make an appointment: e-mail
tel: +65 9668-6469, 6254-3326
Be Kind To Pets
All rights reserved. Revised: April 30, 2010
Toa Payoh Vets