Expert: Jessica - 7/24/2009

Question
QUESTION: Hi Jessica,

I tend to ramble, so I will try to make this to the point.

My baby, Trigger (4 years old, domestic short hair) started experiencing urination problems on or around 6/22/09. He was peeing in places other than the litter box, like the bathroom sinks, in front of the closet, etc. I noticed there was some blood present, so I rushed him into the vet. This was the first time at this vet.

They did extensive bloodwork at our request ($150), urination with sedimentation, 2 x-rays ($136), ultrasounds and started him on the antibiotic Zeniquin for 2 weeks. There were no abnormalities in the results, aside from the urination part. His bladder was empty, he kept peeing everywhere because of some inflammation (I believe). The only way they could get a sample was to collect it off of the floor. They checked for crystals and saw none, I believe they saw some bacteria or something that made them want to try Zeniquin.

It took almost the 2 weeks, but he returned to normal for the most part (His last Zeniquin pill was on July 6th. He was finally back to going in the litter box, though on July 4th I did notice a little blood, but it wasn't like the first time I saw blood. That time it was thick, and this time it was more diluted and mixed with urine.

My paperwork does not show the result of the urine analysis, but I believe it showed some inflammation. At that same visit the vet said it could be a UTI (which I have been told by many vets is rare) or he could have crystals. They did no further testing at this time. That bill was $415.

Cut to 7/15, and I noticed Trigger was starting to urinate in unusual places again, and this time he was hissing and he bit my girlfiend once. Not bad, but enough to scare her a little.

We both thought that this was the same as a few weeks earlier, some inflammation and his bladder was empty and the antibiotics just didn't clear things up.

So I called the vet on 7/16 (Thursday) and told them the situation, and the woman told me that they always tell clients to schedule a follow up after finishing medication. I was a little mad, and told her NOBODY told us to do that. They did check a few time WHILE he was on the Zeniquin, but did not say to do a follow up, because we would have.

I brought Trigger in, and they ran a basic blood test which is understandable, but they also did 2 more x-rays (saying it was to check for stones - even though they just did 2 x-rays 3 weeks earlier), ultrasound, etc...Everything they did 3 weeks earlier. This time Trigger's bladder wasn't empty, but really full!! He couldn't urinate at all and they said he had been that way for probably 8-12 hours. They also were able to get a good urine sample (they put in a catheter) and they found struvite crystals and his PH was 8.

Over the course of Trigger's troubles I had been consulting with a vet in Canada (her first response to me was she thought it was crystals or cystitus. She told me that a urine culture should have been done, and if they couldn't have gotten a good urine sample for a UI, they could give him a fluid IV.

I told this to the vet on 7/16 and she said they couldn't get a pure sample that way, because Trigger would have fluids in him and it wouldn't be his natural urine. I went along with that (at the time). I also didn't question the second round of x-rays). I also demanded that they do a urine culture.

The bill this time was almost $900. The paperwork also calls it a "Recheck exam" but it wasn't. They didn't recommend a recheck, I had to find out a recheck was necessary after he already started having trouble again.

Trigger had to go to an emergency clinic because the catheter had to stay in for 24 hours and I was given BUPRENORPHINE and METACAM. They paperwork didn't say anything as to the cause, they just told me crystals. On the report that was faxed to the emer. clinic, it says possible UTI, could be other urinary tract issues suchas FLUTD, stones (I can't believe it could be stones since they did x-rays on 2 different occasions!!!)

The main vet at the emergency clinic said that METACAM is hard on kidney's and said to stop using it, so we did. (The first vet gave him 1 dose). He stayed there Thursday night and Friday night (we visited him both days) and came home Friday and was peeing normally but in smaller amounts. He was still going in unusual places though. They also prescribed CLAVAMOX, yet another antibiotic.

The paperwork from the emer. clinic says: Diagnosis: UO (not sure what that is), UTI, struvite crystalluria.

Today is is actually really good, really friendly again. His urinations are still small, but they said they is normal. He has only had the catheter out a few days.

Now here is my real problem: They got the urine culture results back yesterday, and it is negative. So why are they giving him all of these antibiotics if he doesn't have a UTI?

Plus, should they have given him fluid the first time he was there (when his bladder was empty) to get a better UA sample? They also should have told us to do a follow up visit, that probably would have seen crytals for sure. If both of these things were done, then they probably would have seen crystals, and saved Trigger a lot of pain and us another $1500.

Plus they did the x-rays again, just 3 weeks later. That was almost $200.

What are they looking for when they do a blood test?

They said the x-rays was to look for stones, is that true? I thought they could see stones in other ways, like an ultrasound.

What do they use ultrasounds for as well?

My girlfriend and I think that these antibiotics are worthless, because he doesn't have a UTI, but he had stones.

Do you think they are ok for a cat with crystals and a PH or 8, or are there other meds that would have been better. It just seems like they are not even trying to find out what the actual problem is, just throwing medicine at the problem. Clavamox too, another anitbiotic.

Also, what do you think about the first vet, and how they handled things? They did 2 sets of x-rays 3 weeks apart and there was nothing the first time. Plus they didn't recommend a follow up, they prescibed METACAM which is hard on the liver (not good since Trigger is having urinary problems, they vet said they couldn't get good results from a urine sample if he was on fluids which I found out isn't true, and they forgot to fax the bloodwork to the overnight clinic so the vet there could examine it. They also forgot to write on the paperwork they did actually do a culture, because it is not listed. I think I may be forgetting something else, but that is enough, you know? We are not going back there, and we are talking about lodging a complaint with the board of veterinarians.

It just really made us mad, REALLY pissed me off. I mean, these are our childern (we have Harley too, another cat).

Please let me know what you think, especially about the antibiotics and if they are actually ok for a cat who doesn't have a UTI, but crystals.

We are just worried about the effects of these drugs on him, especially since they seem like they aren't the right ones for him.

Thanks for your help, we really appreciate it!!!!

David

ANSWER: Hi David.  Sorry to hear you are having so many problems.  It’s always frustrating when you feel you are not receiving acceptable service, especially when it pertains to the health care of a loved one!  And it’s even worse when bills just keep piling up.  Here are my opinions.

Q. Now here is my real problem: They got the urine culture results back yesterday, and it is negative. So why are they giving him all of these antibiotics if he doesn't have a UTI?

A. Cats who have urinary tract crystals are very often given antibiotics at times when the crystals are causing bleeding.  This is because when the bladder lining is being damaged by the crystals, as evidenced by blood in the urine, it is very easy for bacterial infections to set in.  Antibiotics are generally given as a preventative measure, since a missed bacterial infection could move to the kidneys, where it can cause irreversible damage.  Trigger’s urinary pH is also higher than normal, which will further predispose him to infections at this time, so it’s probably wise for him to stay on the antibiotics.

Q. Plus, should they have given him fluid the first time he was there (when his bladder was empty) to get a better UA sample?

A. This is a maybe.  This is stressful to the cat because it requires a daylong visit in the hospital to wait for the urine to pass, and it’s an added expense for the owner.  So many vets don’t suggest going this route because in MOST cases, cats with completely empty bladders do have infections, and antibiotics do clear up the problem.  The vet should have advised you, however, that if the symptoms had not ALL cleared within just a few days, to come back and have a recheck. He also could have offered a special litter kit that causes urine to drain to the bottom so you could collect a specimen at home (this would have to be done prior to starting treatment to be considered accurate).

The vet is correct that giving Trigger fluids may have thrown off the urinary concentration test if he was checking for kidney function.  But I believe of primary importance were the lower urinary tract values here, and those should not have been affected.

Q. What are they looking for when they do a blood test?

A. There are lots of different work ups available, but when there is urine in the blood, they are often checking kidney values (creatinine and blood urea nitrogen) and to see if any white blood cells are elevated.  Depending on which kind of white blood cells are elevated, it could indicate either a bacterial infection or severe inflammation in response to urinary crystals or stones, or a condition like cystitis.  

Q.  They said the x-rays was to look for stones, is that true? I thought they could see stones in other ways, like an ultrasound. What do they use ultrasounds for as well?

A. X-rays are often the best way to diagnose urinary tract stones.  This is because of their dense, opaque nature.  Radiographs are not able to penetrate through stones, so they show up prominently on x-rays.  Ultrasounds are an excellent tool for diagnosing soft tissue causes of bleeding in the bladder, such as polyps, cysts and tumors, which are difficult to detect on an x-ray.

I believe the first vet checked kidney function with the battery of blood tests that ran you $150.  This is included in a typical blood-chem and the cost is about right.  If I assume correctly, the vet knows Trigger’s kidney function, and it is presumably up to par.  So it should be perfectly fine for him to be on the Metacam.  Personally, I would continue to use this, especially if the buprenorphine knocks him out.  Buprenoprhine is a narcotic, so you don't want to use it long-term.

I can certainly see that the second set of x-rays was run as a precaution.  Stones form as crystals clump together.  It’s conceivable to think that there may have been a formation of crystals too small to be detected on the x-ray three weeks beforehand that would have been visible when you brought him back.  So I cannot say I think the entire thing is a fraud.  But it is frustrating when you wish it was all dealt with differently from the start!

I guess the most important thing is that Trigger was saved in time.  You may certainly feel free to file a complaint.  In the meantime, I guess I would start asking friends about who they go to!

Best wishes!

Jessica


---------- FOLLOW-UP ----------

QUESTION: Hello Jessica,

I really appreciate your response...I REALLY DO!!!! :)

I actually stopped the Clavamox after 4 days (8 pills).

I then saw your response that there could still be bleeding because of the stones, so I called the vet and they said it was ok to resume, even though Trigger didn't have it for 24 hours.

As for your other answers, they all pretty much cleared up everything. We understand now it would have been ok for Trigger to go on the Metacam, all of his organs are good.

So we aren't as mad at the vet as we were, BUT we were still mad that they didn't tell us to do a follow up, then when I called back when Trigger was having the problem again (or a new one anyway) they said they always tell people to do a follow up after meds. They didn't, and that's enough for us to bring him somewhere new. We are bring him to a Dr. Epping who has been featured on Monster Quest and another show here in Minnesota.

Here is one last thing for you:

They told us that Trigger would still probably continue to pee outside the box, more frequently and in smaller amounts. They said this would last between 3-5 days after having the catheter removed.

He had it removed last Friday night at 6pm (it says removed ucath so I assume that's the catheter) so it has been about 6 days and 7 hours since it has been removed.

As far as I could tell, he hasn't been going outside the box for the past 3 or 4 days, but I noticed him doing that today.

Ever since he has come home (last Saturday), his urinations have been about the size of a peach pit, pretty small. But then 2 days ago it was a pretty big amount, but he was in there for a little while.

And last night when he was in the box urinating, he was in there for about 3 to 4 minutes. It was like he was just squating there, then all of a sudden I heard it coming out and a lot of it, then it would stop, then start again. Sort of like someone turning a faucet on and off. When he was done, it was a big amount, about 6 times as big as his most recent urinations.


Should they be back to normal by now? I mean, he is going and still about 8 times (or more) a day, most of the time it's about 20 seconds long. He doesn't SEEM to be straining or making any painful noises at all.

Could it be that it's just taking a little longer? He definitely isn't back by like last week, so that's good.

We actually have a follow up at the new clinic Monday where they will probably get a urine sample and possibly blood.



Also, the first day he was home, I noticed some diarrhea. I talked to the emergency clinic where he was and they said it was ok. They also told us to cut out his dry food (which we have) and gave us 6 cans of Purina UR for urinary problems.

He also had more diarrhea about 30 minutes ago (as well as another one of those 3 minute cat box things). I heard some grunting from him that I didn't notice before, and it was another one of those bigger urinations.

Aside from those 3 bigger ones, they have been peach pit sized. And he has had dirrhea twice since he has been home?

So to sumarize, is it still normal for him to have smaller, frequent urinations (sometimes still sitting in there for 3 minutes), and could the diarrhea be from the Purina UR?

Sorry one last thing :) I heard that the Purina UR isn't good to use for a long time. Have you heard this too, and if so, what wet food do you recommend for cats who have had (and still may have) struvite crystals?

Thanks again, you are really helping us out with your expertise!!!

David

Answer
Hi there.  I’m glad you have a follow up on Monday.  The irritation associated with the catheter should probably be gone by now, but he could certainly still be suffering discomfort due to urinary crystals.  This may be why he’s still urinating in small amounts so frequently.  I would continue to use either the buprenorphine if you still have some, or Metacam, to help relieve this pain.  If Trigger still seems to be visiting the litter box frequently and passing small amounts of urine by Monday, the vet might consider placing him on a medication such as phenoxybenzamine.  This helps to relax the bladder so that Trigger may be able to carry more urine without feeling so irritated, and then pass it in larger quantities, less frequently. This can be beneficial because bacteria and crystals are more likely to pass from the bladder when there is a full, forceful urine stream, rather than short, weak trickles of urine.

Trigger’s diarrhea could be due to his diet change, but I suspect it might also be due to the antibiotics.  Clavamox tends to do a number on the stomach.  This is because it kills beneficial bacterial in the gut.  There are some probiotics your vet could give you to help try to add the beneficial bacteria back in.  These would include Probiocin, BeneBac and Purina’s FortiFlora.  You can also buy these online or at some pet stores.  But you can also get many of these same beneficial bacteria in some plain yogurt.  Your vet could put up the probiotic for your, or if your kitty will let you, feed him a teaspoon (5 mls) of plain yogurt each day while he’s on the Clavamox to combat diarrhea.

Purina UR is actually a pretty good food to feed on a permanent basis.  It prevents the two most common types of urinary crystals and helps to dissolve struvite stones and aids in the management of cystitis.  I think this is a fine food to keep him on and is something I would aim for actually.  If he doesn’t like it, you might consider Royal Canin’s Urinary SO, which is a similar formula with a slightly different ingredient list.  If he refuses all prescription diets, the most important thing would be to keep him away from all dry food from now on.