Blocked bladders

Re: Blocked bladders

Evelyn Barbour-Hill — Thu, 05 Jan 2012 23:46:27 GMT

[quote user="Anthony Todd"]

[quote user="Evelyn Barbour-Hill"]there's nothing to be gained by messing up the urethra with repeated blocking-unblocking episodes.[/quote]

Better not to mess up the urethra in the first place!

[/quote]

I quite agree.

Re: Blocked bladders

Anthony Todd — Thu, 05 Jan 2012 22:45:39 GMT

[quote user="Evelyn Barbour-Hill"]there's nothing to be gained by messing up the urethra with repeated blocking-unblocking episodes.[/quote]

Better not to mess up the urethra in the first place!

Re: Blocked bladders

Evelyn Barbour-Hill — Thu, 05 Jan 2012 20:09:23 GMT

[quote user="Anthony Todd"]

[quote user="Evelyn Barbour-Hill"]Then you can do a perineal urethrostomy[/quote]

Would I be right in thinking this follows urethral stricture after repeated unblocks and is seldom, if ever, done with a first block?

[/quote]

Well, in my policy anyway, it follows repeated blocking for whatever reason. At what stage I decide it's indicated varies with the pattern of the individual patient, but certainly I'm ready to do it much earlier in the progress of the patient than when I was an assistant. I suppose you could sum it up this way: if you know in your heart that one day this cat is going to need a urethrostomy, there's nothing to be gained by messing up the urethra with repeated blocking-unblocking episodes.

Re: Blocked bladders

Anthony Todd — Thu, 05 Jan 2012 19:37:36 GMT

[quote user="Evelyn Barbour-Hill"]Then you can do a perineal urethrostomy[/quote]

Would I be right in thinking this follows urethral stricture after repeated unblocks and is seldom, if ever, done with a first block?

Re: Blocked bladders

Robin Grimmer — Wed, 04 Jan 2012 15:18:12 GMT

strangest urethral obstruction case I had was an entire tom cat, never been to the vets and the owner brought him in in a morbund state.

Rock hard bladder and the cause of the obstruction was a grass seed! I can't remember what the outcome was, I think the cat was ok.

Re: Blocked bladders

Rob Loxley — Wed, 04 Jan 2012 13:36:18 GMT

[quote user="Bob Russell"]I suspect more than a few blocked cats do die undiagnosed at home. [/quote]

Last cat we had post-mortem'd (young male, sudden death) had a complete urethral obstruction with a crystal plug. Given the suggestion that cats don't die from the metabolic complications of urethral obstruction, the bladder hadn't ruptured and the rest of its PM showed no other disease, I'd be interested to hear what it might have caused its demise within 24hrs of being seemingly fine?

Re: Blocked bladders

Bob Russell — Wed, 04 Jan 2012 10:18:29 GMT

[quote user="Judith Joyce"]

[quote user="Anthony Todd"]I come back to my experience, and all the posts here, that very very few cats die when blocked, and before or after unblock, but the published data that over 6% die [Penn data], when probably they had all the bells and whistles, seems at variance. [/quote]

There is an obvious pattern here........... there are no reports of cats dying in the care of their (unqualified) owners; very few die in the care of general veterinary practitioners but significantly more die in the hands of specialists. The conclusion is obvious - blocked cats should be treated at pet shops.

EBM at its best!

Malcolm N

[/quote]

A lot of cats die at home! It has to be on the cards that some of these may be as a result of rupture of the bladder secondary to blockage. How many cats come in with owners proudly spouting that the cat has never seen a vet? How many moribund cats arrive with the histories of being a bit unwell for a few days?

I suspect more than a few blocked cats do die undiagnosed at home.

My priority is to get the bladder emptied. I will generally run bloods at the same time and have seen some frightening K+ levels. These levels rapidly return to normal once the urine is flowing freely.

Re: Blocked bladders

Judith Joyce — Tue, 03 Jan 2012 23:33:52 GMT

[quote user="Anthony Todd"]Don't beat yourself up, mate.[/quote]

Don't worry, I'm not!

[quote user="Anthony Todd"]Although I detected the sarcasm[/quote]

I didn't intend sarcasm, merely a mild piss-take. I apologise for the weak pun.

Malcolm N

Re: Blocked bladders

Anthony Todd — Tue, 03 Jan 2012 23:26:37 GMT

[quote user="Judith Joyce"]significantly more die in the hands of specialists.[/quote]

Don't beat yourself up, mate, I'm sure you try your best.

It's only one summary, and no one's quoted the actual paper, what if say 20% had body temps of <98 on admission?

How many of your's have died before during or after, might give a truer picture? I reckon the figure will be near zero.

Although I finally detected the sarcasm, it is something that Penn should wish to explain, so that the peasants at the coal face, and others higher up, might benefit, but it's probably in the full paper.

Anyone care to publish it here, if we're allowed??

[quote user="Judith Joyce"]EBM at its best[/quote]

Well perhaps, if the summary had attempted to give the apparent reasons for the high death rate, it would be better, but it's still better than just anecdotes.

Re: Blocked bladders

Judith Joyce — Tue, 03 Jan 2012 22:17:05 GMT

EBM at its best!

Malcolm N

Re: Blocked bladders

Andrew Mellor — Tue, 03 Jan 2012 16:06:37 GMT

[quote user="Hannah Wynne Richards"]

Andrew What's your dosage

Wynne

[/quote]

Diazepam 0.05ml/kg + ketamine 0.025ml/kg I/V can top up with 1/2 dose again if inadequately sedated,

Re: Blocked bladders

Anthony Todd — Mon, 02 Jan 2012 11:59:54 GMT

[quote user="Mark Holmes"]I am fairly confident that given a high K most would survive a ga and unblock. Can you predict which would survive and which would die? As anything its about managing risk. In risk management there are a number of categories from high risk with low significance consequencies to low risk with catestrophic consequencies. So if we accept your proposition that the risk is low how do you consider the significance of the cat's death? In my opinion the risk is low but the consequence high and therefore some consideration and treatment justified. Given the speed that bloods are available and the ease with which things can be addressed

[/quote]

I come back to my experience, and all the posts here, that very very few cats die when blocked, and before or after unblock, but the published data that over 6% die [Penn data], when probably they had all the bells and whistles, seems at variance.

Is it the inevitable GA, the delay [surmised], the probability that they get terminal cases [T95!!], or all the other drugs, fluids etc which they would undoubtedly administer, probably prior to the unblock which "gold standard" more and more now dictates.?

Re: Blocked bladders

Kate Richardson — Mon, 02 Jan 2012 11:06:08 GMT

[quote user="Julian Earl"]In answer to Kate if the questions were directed at me: the cat had bloods, all perfectly okay, cat well, presented fresh and relieved immediately. Repeating the cystocentesis would not be a problem at all per se, but wouldn't solve the problem which is why I said I didn't particularly want to repeat it a lot, not on its own anyway.[/quote]

Not sure which question you mean?

[quote user="Julian Earl"]

Re. Anthony's question about complications: I had a female cat collapse yowling with tremors and retching almost instantly after removing the needle. The cat was back to normal within thirty to sixty seconds but I was convinced I must have ruptured the bladder. I peformed an immediate laparotomy and everything was fine apart from a remarkable amount of bruising around the ventral bladder. The volume was small, probably 2ml spread around, not enough to cause hypovolaemic collapse at all, but it was rather more than I expected from what was a puncture by a 23g needle through a not very inflamed or thickened bladder.

Still don't know why the cat reacted that way and the owner was absolutely fine about it all, I think grateful that we reacted so promptly to what I thought was a catastrophe.

[/quote]

Due to increased vagal tone which is a rare complication of cystocentesis, and they recover spontaneously as in your case.

Re: Blocked bladders

Mark Holmes — Mon, 02 Jan 2012 10:27:02 GMT

I am fairly confident that given a high K most would survive a ga and unblock. Can you predict which would survive and which would die? As anything its about managing risk. In risk management there are a number of categories from high risk with low significance consequencies to low risk with catestrophic consequencies. So if we accept your proposition that the risk is low how do you consider the significance of the cat's death? In my opinion the risk is low but the consequence high and therefore some consideration and treatment justified. Given the speed that bloods are available and the ease with which things can be addressed

Re: Blocked bladders

Anthony Todd — Mon, 02 Jan 2012 09:47:40 GMT

[quote user="Anthony Todd"]Yeah, you may be right.[/quote]

Like a dog with a bone I can't leave the pre-unblock bloods alone.

As there have been anecdotes of sky-high [K+] yet the cat seems clinically fine how many of them actually die from hyper K+?

Are some not assuming that it is as vital as hypo[ K+] which is unlikely in blocked cats, I realise.

Anecdotes here all say that perioperative death is rare and some [or many] may not have had pre unblock bloods so we can assume that 12% would have had high[K+] and not been treated specifically.

Why isn't the death rate higher? Why is the Penn death rate over 6%? What does Penn do differently?

I have the feeling that, just because an abnormal blood parameter is found, there is this urgent urge to correct it whereas, in actuality, the high value may not be as harmful as imagined, and will correct itself when the block is cleared or when kidney filtration returns via temporary cystocentesis.

Re: Blocked bladders

Mark Holmes — Mon, 02 Jan 2012 08:12:54 GMT

[quote user="Judith Joyce"]

[quote user="Mark Holmes"]Can I suggest before penile amputation people consider cystotomy[/quote]

There is no place for isolated penile amputation in the management of these cases. We see two or three cases a year which have been treated by penile amputation and redirection/suturing of the penile urethra (approximately) to skin. In some cases, the primary surgeon has referred to this procedure as a perineal urethrostomy (PU) - it isn't! In the cat, PU requires deep dissection beyond the attachment of the ischiocavernosus muscle to allow mobilisation of the pelvic urethra which is drawn caudally to form the urethrostomy. This manoeuvre is essential as the pelvic urethra has a very much larger bore than the penile urethra. Any sludge that is in the bladder can be flushed out through the new orifice at the end of surgery.

Malcolm N

[/quote] Sorry I said penile amputation rather than perineal urethrostomy. I appreciate the inceased diameter of the urethra proximally. However my point is that I have found it can be avoided if the bladder is flushed at cystotomy and a tempory cystomy tube used for a few days while things recover. Given the potential complications of PU. Which is technically more demanding, leaves the cat prone to UTI and problems with stoma care particularly in long haired often obese cats. I think its best avoided where possible. So far not one has needed PU and they have all been managed on diet post op. A cystostomy tube is much easier to manage than an indwelling catheter, and better tollerated and doesn't further traumatise the penis or urethra.

Re: Blocked bladders

Robin Grimmer — Sun, 01 Jan 2012 23:02:08 GMT

That was my question really - would PU remove the inflamed urethra? It's all very well shortening the distance from bladder to the outside,but doesn't stretching it make it narrower as well? And if it is still inflamed, would it help anyway?

< I have heard it said that PU predisposed to urinary tract infection.

Re: Blocked bladders

Julian Earl — Sun, 01 Jan 2012 22:39:47 GMT

[quote user="Evelyn Barbour-Hill"]

[quote user="Julian Earl"]I cannot see the benefit of surgery if the blockage is not related to crystals but due to inflammation.[/quote]

Well, if it cures the cat when medication is failing to do so..........................

[/quote]

In answer to Kate if the questions were directed at me: the cat had bloods, all perfectly okay, cat well, presented fresh and relieved immediately. Repeating the cystocentesis would not be a problem at all per se, but wouldn't solve the problem which is why I said I didn't particularly want to repeat it a lot, not on its own anyway.

Still don't know why the cat reacted that way and the owner was absolutely fine about it all, I think grateful that we reacted so promptly to what I thought was a catastrophe.

Re: Blocked bladders

Robin Grimmer — Sun, 01 Jan 2012 20:38:05 GMT

[quote user="Anthony Todd"]

Can anyone report on the negatives of cystocentesis ie disasters, sequelae, contraindications, bleeds etc. Just the dreadful incidental- non- evidential anecdotes will do. It appears that fear of complications is the main negative reason but is it?

[/quote]

I've done lots of conscious routine cystos (ie not blocked cats) and lots of cystos on blocked cats (always under GA) and not had any problems. I use a 25g needle. The only disaster I saw was when a colleague attempted a conscious cysto in a blocked cat with a very firm bladder. Cat wriggled and bladder ruptured.

Re: Blocked bladders

Evelyn Barbour-Hill — Sun, 01 Jan 2012 20:18:59 GMT

Temporary cystostomy is practical and useful, if rather messy and unpleasant for the cat, as a way of keeping the bladder draining while everything returns to normal. Then you can do a perineal urethrostomy (if the features of the case have told you that this is indicated) under good conditions almost as an elective procedure.

Re: Blocked bladders

Judith Joyce — Sun, 01 Jan 2012 19:14:14 GMT

[quote user="Mark Holmes"]Can I suggest before penile amputation people consider cystotomy[/quote]

Malcolm N

Re: Blocked bladders

Kate Richardson — Sun, 01 Jan 2012 17:59:59 GMT

[quote user="Anthony Todd"]

[quote user="Kate Richardson"]I don't understand your problem about taking bloods[/quote]

Yeah, you may be right. I just imagine in practice, certainly mine, these days, procedures now take an age and then all the faffing whilst decisions are made etc.

I was against mainly on the evidence of many, viz: "never did 'em and never lost a blocked bladder and the biochem corrects itself" [I assume] after the unblock anyway.

[/quote]

Anthony, I am in general practice too. Maybe you have been assuming there is a lot of faffing around taking and running bloods and making decisions when actually there isn't.

[quote user="Anthony Todd"]

Even "I've done probably 100 and such-and-such has happened" will be useful.

[/quote]

I probably do anywhere between 0 and 5 cystos per day (for diagnostic purposes, not blocked cats obviously!) and have never had a disaster. Its the quickest and easiest way to obtain a urine sample from a cat. I would guestimate at 99% of the cats tolerate this better than taking a blood sample. I have even had a couple suddenly decide no way and wriggle away whilst the needle was still in the bladder with no ill consequences (and I have checked these after with the ultrasound). The only negative aspect I have on occasion, mainly when the bladder is quite small, is if I get some blood in the urine, I sometimes suspect this is iatrogenic opposed to haematuria.

Re: Blocked bladders

Anthony Todd — Sun, 01 Jan 2012 17:25:56 GMT

[quote user="Kate Richardson"]I don't understand your problem about taking bloods[/quote]

Yeah, you may be right. I just imagine in practice, certainly mine, these days, procedures now take an age and then all the faffing whilst decisions are made etc.

I was against mainly on the evidence of many, viz: "never did 'em and never lost a blocked bladder and the biochem corrects itself" [I assume] after the unblock anyway.

Sounds as if my great i/v catheter improvement idea is not an improvement though.

Even "I've done probably 100 and such-and-such has happened" will be useful.

Re: Blocked bladders

Mark Holmes — Sun, 01 Jan 2012 17:23:39 GMT

Can I suggest before penile amputation people consider cystotomy. I used to do it frequently but haven't now done one in ages instead prefering cystotomy for repeat blockers. Cystotomy and a few days with cystostomy tube last year saved the penis of 5 cats I would have otherwise amputated. Each had a HUGE amount of thick struvite present (like tar) which was completely flushed out. Much greater quantity than was appreciated on ultrasound.

Re: Blocked bladders

Kate Richardson — Sun, 01 Jan 2012 15:03:04 GMT

Thanks Malcolm, I won't be trying it then!