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My 10 year old female pug Wheezy has been at the hospital…

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My 10 year old...

My 10 year old female pug Wheezy has been at the hospital for 3 days because her belly distended, became hard and she was unable to void. She has had a urinary catheter inserted and removed to determine if she was able to void after draining her bladder. She was not able to void and the catheter was reinserted for several hours before she underwent the scoping of her urethra, and after that procedure. She had previously undergone ultrasound of the bladder, X-rays, and IV fluids to try to flush out the stones that they thought were causing a blockage. No masses, lesions, adhesions, growths, etc. were found during the scoping however, in excess of 38 small stones were removed. Upon each catheterization and the scoping, the physician found the tubing and scope slid easily into her urethra with no difficulty. No lesions, obstructions or abnormalities were discovered. Her testing is all within normal limits. She has had previous neurological problems (going lame) in the past which they are now assuming is the cause of her inability to void. Because our funds are limited and each test, operation and procedure is extraordinarily expensive, the doctor felt that trying to find the cause could be the unreachable goal, and putting Wheezy through more invasive testing and surgery made no sense since it could be caused by so many different neurological deficits it might be truly impossible to determine.

Veterinarian's Assistant: I'm sorry to hear that. This sounds like it might be serious. I'll let the Veterinarian know what's going on ASAP. Is there anything else the Veterinarian should be aware of about the dog?

The latest plan is to keep Wheezy catheterized for 5 more days in the hospital to allow her bladder to shrink as much as possible and they started her on a medication which forces her bladder to urinate but talked about giving her an antispasmodic medication and valium as well. Her IV will be removed tomorrow and she will be started on water and food. At the end of the 5th day, her catheter will be removed and if she can void she will be sent home with the three medications that force her bladder to void, stop spasms, and calm her down. The doctor told me that she would have to be watched every minute of every day for signs that the medications failed and she is blocked. If that happens she will have to be brought immediately back to the hospital and catherterized to remain alive. The doctor said that there is only a 30% success rate using these medications and that we should seriously examine Wheezy's quality of life under such circumstances. She also said that ANY change of ANYTHING could trigger this syndrome and prevent her from urinating, and that there was no rhyme or reason to a triggering event.

Submitted: 8 months ago.Category: Dog Veterinary
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Answered in 3 days by:
9/18/2017
Dog Veterinarian: Denver ER Doc, Dog Veterinarian replied 8 months ago
Denver ER Doc
Denver ER Doc, Dog Veterinarian
Category: Dog Veterinary
Satisfied Customers: 1,495
Experience: Small Animal Medicine and Surgery Internship, Veterinary Acupuncture trained, Wildlife and Exotics
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Hi there, so sorry to hear about everything that is going on with Wheezy!! I am Dr. Paul, an experienced emergency vet and happy to help.

Did you have a specific question about Wheezy that I can help answer?

Thanks,

Dr. Paul

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Customer reply replied 8 months ago
Thank you Dr. Paul. I wanted to know if there is any treatment(s) other than the medications (which has only a 30% success rate) available for Wheezy's inability to urinate? I have lost faith in the Internal Medicine (IM) doctor assigned to her case. She told me that even if neurology had been consulted and a neurological cause found, the ONLY treatment available would be the medication, making the need for neurology's involvement moot. However, after some online research for dogs with this syndrome (inability to urinate) and some who failed the medication option, I found articles stating they were given either spinal/disc surgery or laser treatment which in several instances eliminated the urination problems and even improved the dogs' gait. I could not access the full articles without membership but read enough to find several similarities in the presentations of these dogs and Wheezy. I firmly believe that the IM doctor should have started with a neurological consult before any procedures (other than inserting a catheter) were performed since a neurological problem is the most obvious cause of her blockage. Had that been done my limited resources would not have been wasted on confirming information the IM doctor already obtained from other evidence in her possession:
1. surgically scoping Wheezy's urethra for a blockage was not necessary because IM knew she was catheterized three times without any impediment or difficulty;
2. X-ray showed she had numerous tiny bladder stones no larger than 0.4cm making the need for the expensive and rather useless bladder ultrasound unnecessary since they use a 2 dimensional ultrasound which duplicates and shades the actual number of stones [making according to the IM doctor, an accurate count of the stones not possible] and has no capability to measure the height, width or depth of any stone [they do not have a 3 dimensional ultrasound machine which does not shade or duplicate the stones and is capable of accurately measuring each stone];
3. abdominal surgery to remove the bladder stones was not necessary because the largest stone was .04cm which would have passed easily through her urethra opening; and,
4. two additional days of administering IV flushing of her system to force out the bladder stones and/or sediment was not necessary after 24 hours when she showed absolutely no improvement or change on repeated X-ray.
Each of these unnecessary treatments further taxed her system because they required her to be sedated and closely monitored. The sedation and monitoring were also very expensive. I have spent $6,500.00 so far on useless and invasive testing that I believe could have been more prudently spent to find the cause and cure.I saw Wheezy today. The IM doctor had removed her catheter sometime before we arrived and started her on the medication that prevented urethral spasms. She has been on the medication that forces the bladder to contract for several days. If Wheezy is unable to urinate by tomorrow, and her belly starts to distend and harden again, the IM doctor reiterated that she would have to be put down as this was no way for her to live. Wheezy looked great and was so happy to see me and my husband. She was playful and anyone looking at her can see she has plenty of life left in her. Isn't there some other way to help her? Hasn't anyone figured out a successful way to manage this syndrome? Terminating her life because of urinary incontinence seems so drastic and cruel. And its not like she is old, given her age (10), pugs live to be 16 and 17 years old.I do not want Wheezy to suffer, but I don't know if putting her through other tests or treatments (if any are available) is going to make her suffer. Since I no longer trust the words of the IM doctor, I would be grateful for any help and insight you can send my way so I can make an informed and more knowledgeable decision about her future.
My sincerest thanks,
Jeanne
Dog Veterinarian: Denver ER Doc, Dog Veterinarian replied 8 months ago

Hi there, thank you for the extensive and well thought out reply. Let me see if I can address your concerns one at a time:

"I wanted to know if there is any treatment(s) other than the medications (which has only a 30% success rate) available for Wheezy's inability to urinate? " -- There is no way to know without an underlying diagnosis. More on this below, but without knowing whether this is a neurologic problem, tumor, etc., there is no way to know which medication might help. Starting bethanocol was possible since they ruled out an overt blockage, but other than that, therapy would need to be aimed at the specific underlying diagnosis.

"She told me that even if neurology had been consulted and a neurological cause found, the ONLY treatment available would be the medication, making the need for neurology's involvement moot. However, after some online research for dogs with this syndrome (inability to urinate) and some who failed the medication option, I found articles stating they were given either spinal/disc surgery or laser treatment which in several instances eliminated the urination problems and even improved the dogs' gait." -- As I was not there for the conversation, I certainly can't comment on the validity of what was said. If a neurologic cause is found, that still doesn't necessarily tell us whether this is from disc compression, spinal stroke, or a spinal tumor. MRI would likely be necessary to diagnose this, which involves general anesthesia and more expense. If disc disease was discovered, surgery or other medications might be an option. If a tumor, not usually surgical, but might be able to try some chemotherapy to shrink it and relieve symptoms.

"surgically scoping Wheezy's urethra for a blockage was not necessary because IM knew she was catheterized three times without any impediment or difficulty" -- Not necessarily true. If there was a small tumor at the base of the bladder or another typoe of tumor compressing the wall of the urethra, it might be movable by catheterization in order to allow urine flow. If nothing shows up on x-ray, scoping or CT scan would be the main ways to look for this type of tumor.

"X-ray showed she had numerous tiny bladder stones no larger than 0.4cm making the need for the expensive and rather useless bladder ultrasound unnecessary since they use a 2 dimensional ultrasound which duplicates and shades the actual number of stones [making according to the IM doctor, an accurate count of the stones not possible] and has no capability to measure the height, width or depth of any stone [they do not have a 3 dimensional ultrasound machine which does not shade or duplicate the stones and is capable of accurately measuring each stone" -- Did they not do a full ultrasound? This might provide more information as to whether this was a tumor that had spread or something like that. Also, there are bladder stones that do not show up on x-ray, but can be seen on ultrasound.

"abdominal surgery to remove the bladder stones was not necessary because the largest stone was .04cm which would have passed easily through her urethra opening" -- Again, I wasn't there, so I don't know the rationale. What I would consider is that when enough of those small stones conglomerate, they can block a urethra. If said blockage goes on long enough, it can result in the bladder over-distending and losing its ability to empty.

"two additional days of administering IV flushing of her system to force out the bladder stones and/or sediment was not necessary after 24 hours when she showed absolutely no improvement or change on repeated X-ray.
Each of these unnecessary treatments further taxed her system because they required her to be sedated and closely monitored. The sedation and monitoring were also very expensive." -- Was all of her bloodwork normal? Sometimes the IV fluids are to bring down renal values. Even if not, I would presume that they were hoping to support bladder emptying and give it some time to see if she would regain control. This is typically best done in hospital in case her bladder needs to be expressed or catheterized, and in case anything else changes.

That said, I certainly understand that these things get expensive very quickly in a specialty facility. I have worked in them for many years, and it is often difficult to balance financial realities with wanting to do everything you can for the animal and owner. Medicine is certainly not a black and white field, so sometimes you have to make decisions based on the best information available. This is not always easy, and sometimes does not lead to a diagnosis or cure. Believe me, your doctors and techs get just as frustrated as you do. We hate not finding the answer.

"Isn't there some other way to help her? Hasn't anyone figured out a successful way to manage this syndrome? Terminating her life because of urinary incontinence seems so drastic and cruel. And its not like she is old, given her age (10), pugs live to be 16 and 17 years old." -- Again, as above, without knowing the underlying cause, choosing another treatment plan would be a shot in the dark, so she is being treated symptomatically for what they can safely give her. Unfortunately, it puts you in a spot where you either have to commit to further testing (MRI would make the most sense) or consider her quality of life. A "syndrome" is simply a collection of symptoms, not a diagnosis, so there is not necessarily a more specific therapy. There are other options for the incontinence, but they work much better in humans than animals. Intermittent or indwelling urinary catheters are a nightmare to manage in small animals and are prone to increased infection risk. Surgical implantation of a urinary pathway is invasive and carries many of the same risks. Diapers are messy and a hassle. It all comes down to her quality of life. As for age, 12-15 is great in a healthy pug, but not terribly common. Given their breed proensities for major medical issues, we see a lot of them develop major problems at 10-12.

This is a lot of info to digest, I know. But I wanted to give it to you to think on for a bit, then let me know what other questions you have. I am sorry to hear that Wheezy is going through all of this. These cases are very frustrating.

Thanks,

Dr. Paul

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Dog Veterinarian: Denver ER Doc, Dog Veterinarian replied 8 months ago

Hi there, checking back in to see if my reply made it through and to see if you need anything else?

Thanks,

Dr. Paul

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Customer reply replied 8 months ago
Sorry this has taken so long, but I have been dealing with Wheezy and my other pug (at home) who thinks Wheezy has passed. All of her testing (blood, urine, etc.,) were within normal limits. They did not do a full ultra sound. They performed one in the ER for the purpose of finding internal bleeding and then they destroyed this test. They performed the bladder ultrasound on the 2-D machine that distorts the results (I have no idea why this was used at all after the doctors acknowledged the machine doubles and obscures the actual number of stones, cannot measure depth, length or width of any stones, etc.). The doctor said pursuing the cause was pointless and would be costly and put her under unduly invasive testing with no
guarantee of ever learning the cause(s).
Can you tell me if I can learn to express her bladder for her? Is that a possibility given her symptoms? That is my only remaining question. And if yes, how do I do that or where can I get that information from.I appreciated your insight, however, one comment you made questioned the validity of what I wrote and that bothers me tremendously. My being inaccurate in my report to you of what the doctors said to me would invalidate any answer you give me, and that is the last thing I want when Wheezy's life is at stake. You wrote: "As I was not there for the conversation, I certainly can't comment on the validity of what was said." Perhaps next time you should accept that people paying for your services are earnest in their presentation because the well being of their beloved animal is at stake.
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