Peeing Pebbles, the Struvite Soliloquy

Prepping a patient (Harley) for a cystotomy.

Today's question on Pawbly (http://www.pawbly.com/) was a good reminder of why an open ongoing dialogue with your vet is so important. 

I also was curious why this person was so adverse to a prescription diet? (The limitation of a one-way dialogue via email is that I can't ask question, I love to ask questions,,we will work on the chat version of this service as our next evolution to this service). I think that there is some adverse feelings towards prescription diets and I know they are expensive. I wanted to share this question and answer in my blog and I wanted to discuss another JVC patient with a similar history.

Here is the Pawbly question;

I have a Bichon Frise who recently (last Thanksgiving) had 62 stones removed. She recoved nicely but her pH is still high. She is eating raw (Nature Variety). I put in Berry Balance in her food as well as Ammonil DL-Methionine Tablets), Biotic pH and Milk Thistle. Her pH did look like it came down a bit and she doesn't seem to be in pain as much. Is there anything else that I can feed her without going to prescription dog food (Science Diet).

Here is my answer;

Hello and 

Thanks for your question.

Unfortunately I would need more information to be able to specifically advice you on what to do.

First, I don't know what kind of stones were in your dogs bladder?. (Note, 62!!! I have retrieved a whole mess of stones, but to be truthful I never counted them).

I think that you feel that you need to alter the pH to reduce the likelihood of the stones forming, but it isn't as simple as that in many cases. The pH does influence the ability of stones to form but there are other factors also.

So I am going to go out on a limb and presume that your dog had struvite stones?

Struvite stones are formed because of infection, and NOT pH. So, the task to prevent the stones is to treat and prevent the infection. OK, here's where is gets a little tricky. The urine may consistently stay high because of the UTI (urinary tract infection), the bugs that are the infection are urease producing organisms. These urease producing bugs are usually Staph, it is the infection that causes the struvite and the infection changes the pH. So, the way to get rid of your high pH and your stones is to get rid of your infection..I know one vet who says "if you get consistently high pH you get your pet in the vet."

Most bacteria are happy critters at a pH of between 4-9, and dogs and cats can't acidify their urine below 5.5 so you can't ever acidify the urine low enough to prevent a UTI.

Also the experts advice is to make sure that you are checking the urine frequently throughout the day and using a pH monitor (not a urine stick), these can be found at any home or garden store, they are the monitors people use for testing their water. (It will be a little expensive but it is accurate..) Also, if it is struvite you might be able to dissolve the stones and therefore avoid another surgery.

I am not an advocate for adding things to the diet. I don't think it will help your current situation and I have unfortunately seen too many very well intentioned people make a bigger problem than they started with.

To identify IF and what kind of infection your dog might have you will need a culture and sensitivity done. Your veterinarian will take a sterile sample of urine from your dogs bladder and submit it to the laboratory for them to grow on a culture. They can then specifically identify what type of bug is present and also exactly which antibiotic to use to kill them.

I will tell you that in my experience the little white dogs seem to have the most problems with urinary stones..and I think that the prescription diets work very well, and adding lots of water to their food and encouraging water intake with a fountain or soupy food helps.

IF, your dog didn't have struvite then you would need to talk to your vet about a treatment plan for the specific stone. I do not think that it is question of pH in almost all cases. And some stones can only be resolved by surgery.

I hope that this helps, and I hope that your dog stays happy and healthy,

If you need any assistance from us you can find me at Jarrettsville Veterinary Center, we have an ultrasound and we could take a peek at your dogs bladder to get a sterile sample and see if any stones are floating around.

Sincerely,
Krista

Not to long ago I was asked by one of the groomers if I could help her mother in laws dog who she had noticed was having bloody urine. She was pet sitting for their dog because her mother in law was in the hospital recovering from a serious illness. Turned out that she had 2 patients on her hands, one was recovering in the hospital and one was coming to visit ours. When she brought in Harley we were all amazed to learn that she had been hematuric (blood in the urine) for a very long time. As soon as the vet on duty palpated her belly we knew the source of her blood. She had a two fist sized sand filled sac of a bladder. It was very easily palpable and within minutes every set of hands in the building were on Harley. An x-ray put a digital picture to what we could already surmise. The next stop was asking me if I would extract them.

The bladder exteriorized from the abdomen and packed so that contents cannot spill back into the belly.
The bladder should be an empty sac but the numerous stones make it look full.
Can you imagine living with a bladder full of stones?

Removing stones from the bladder.

That's a big stone!

The next week Harley had her cystotomy (bladder surgery). 

Harley and her mom are both recovering well and we will continue to monitor Harley any signs of a return of her stones, or a change in pH, urine color, urine frequency, and at least twice yearly urinalysis.

The final stone tally. A bucketful!

Urinary calculi (stone) should be submitted for a calculi analysis. This is imperative in the treatment plan and prevention of future stones.

Disney's Dilemma

A few years ago a very nice woman came into the clinic with her not very nice dog Disney. Disney was all black, about 40 pounds, and had a long fluffy full coat. She was always overweight even though she always tried to hide it all under a big full jet black coat. I tried many, many, times to convince Mrs. Nicks that Disney was overweight and needed a strict diet, (i.e. no more table scraps), but I knew that she lived with her elderly mother, who she cared for, and between the loneliness of caring for a mom with dementia, and the mom with dementia not ever remembering not to feed Disney table scraps, it was pretty much a lost cause.

The first two years of knowing Ms. Nicks and Disney we had the routine examinations, vaccinations, repetitive pleading of trying to get some weight off Disney, etc. etc. then one day Ms. Nicks called me to tell me that Disney was going outside trying to pee but only a few drops were coming out. And she kept going to the door, and Ms. Nicks kept taking her out, but all Disney could produce were a few drops of urine. I told her to bring Disney in right away. I was expecting to find that Disney had cystitis, (inflammation of the urinary bladder). So all I needed was a few drops of urine, and all Disney needed was an anti-inflammatory and an antibiotic and we were on the mend.

When Disney arrived I gave her an examination. I cannot ever express to the new vets out there how absolutely imperative it is to always give a full complete comprehensive examination.  Instead of finding an empty flaccid small sensitive bladder low in the pelvis, I found a very large full distended painful bladder that took up almost the entire caudal (back half of the) abdomen.  I took a gasp and swallowed the horrified look in my heart. We next went to x-ray. I was hoping to not find anything obstructing her ability to urinate, like a tumor, stones lodged in the neck of the bladder, etc. I was afraid to try to manually express her bladder by pushing too hard on it. You see at this point the bladder has been so distended for so long that often it is a thin weak balloon, and any amount of pressure can cause it to rupture. If the bladder ruptures it will spill the urine into the abdomen and the urine acts like caustic acid to the sensitive peritoneum (the lining of the inside of your abdominal wall). My next plan was to try to sedate Disney to place a urinary catheter. My first priority was to relieve her bladder distension and then try to figure out why this was happening to her. We placed an i.v. catheter collected our blood work and then gave some i.v. sedation. Within minutes there was a flood of dark pungent urine everywhere. I took a deep sigh of relief for Disney. We sutured the catheter in place and started her on the aggressive i.v. fluids I knew she needed to start correcting all of her kidney and electrolyte abnormalities. The next few days Disney seemed to feel more and more like herself. Which in Disneys terms meant she was less and less of a cooperative patient. When she was feeling well enough to not be able to be handled at all I called her mom and sent her home.

During her time in the hospital we ruled out everything except a neurogenic cause to her problem. This meant that the root of her inability to empty her bladder was because she either couldn’t squeeze the muscle of her bladder wall down tight enough to empty, or she couldn’t open the valves that keep the bladder shut. So I started her on all of the medications I could to try to tell her nerves and muscles to work the way they were supposed to. This plan worked for a few months.

Over the next year there were many interrupted evenings of meeting Disney at the clinic to try to repeat the procedures we had tried so successfully the first time. Each time it became harder and harder to get her relief. Until finally one evening I told Ms. Nicks that I would have to open up her abdomen and try to empty her bladder from the inside. I remember crying with her in the surgery room. I knew that Ms. Nicks knew that I was having as much of a difficult time making the decision as I was. I knew that my only hope of getting Disney off of the surgery table alive was with a urinary catheter being placed from inside the balloon instead of my usually threading it through the urogenital opening.  I looked into Ms. Nicks eyes, both of us sobbing, and she said to me, “I know you want to know why she can’t urinate, and I know you want to try to help her again, but I can’t put her through any more”. It was a hard painful decision for all of us. Ms. Nicks had lost her mom a few months ago, and she was losing her last companion. I knew that putting Disney under general anesthesia and exploring her abdomen and bladder might fill in some of the answers I had not been able to get before. But I also knew that we were at the end of her or her mom’s ability to treat her. I lowered my head and told her mom that I was so sorry. I then said goodbye to Disney and injected the pink syrup into her i.v. catheter. I turned off her monitors and I cried over her as she died.

I have talked to Ms. Nicks many times since that day. She still comes to our Christmas parties, and she still drops in to say hello every so often. I have even called her to see if she would be interested in helping us by fostering a dog. But she always tells me that she still isn’t ready for another dog yet. And I understand, and tell her that we miss Disney too. Even though I am pretty sure Disney never liked me back.

If you would like tolearn more about neurogenic anuria and cystitis please see the link below;
http://tinyurl.com/3fwekct