Cat that has blocked again

Re: Cat that has blocked again

Anthony Todd — Sat, 21 Jul 2012 13:33:15 GMT

[quote user="Anthony Todd"]I assume there's no crystals buried in the sludge?[/quote]

Paper in latest JSAP (2012) 53 411-415 which might be of interest particularly relating to the use of atracurium besylate [Tracrium, 10mg/ml GSK], a smooth muscle relaxant, which significantly increased the chance of clearing urethral plugs when diluted and instilled into the urethra.

Incidentally the authors quote Osbourne and others [1996] that the "composition of the plugs is indeed predominantly a mixture of matrix made by proteins and epthelial/blood cells plus a variable amount of mineral crystals (mainly struvite).

Glad I'm not totally alone.

Re: Cat that has blocked again

Anthony Todd — Wed, 18 Jul 2012 16:46:27 GMT

[quote user="Neil Wheadon"]He's on Royal Canin urinary diet[/quote]

Is this it?

http://www.royalcanin.co.uk/downloads/vetlibrary/pets_with_lower_urinary_tract_disease_and_bladder_stones.PDF

I wonder if they would do urinary ion levels viz: Mg++ [unlikely with acid pH], and oxalate, for you.

They may have access to more sophisticated lab work ie cytology of the mucus etc.

I assume it's not dried food, but the pouches?

Does the cat block just behind the penis??

I assume there's no crystals buried in the sludge?

What's the SG and is it always the sameish?

Re: Cat that has blocked again

Neil Wheadon — Wed, 18 Jul 2012 16:05:36 GMT

No problem

No previous issues, he's very healthy

Soft mucousy plug, catheter in and out, unblocks easily.

He's on Royal Canin urinary diet

Urine examined shortly after unblocked as crystals will disappear later if present

It's a bit of a mystery as to why he keeps blocking, but the worry is that he does

Neil

Re: Cat that has blocked again

Anthony Todd — Wed, 18 Jul 2012 15:57:13 GMT

[quote user="Neil Wheadon"]

None seen on all 3 occasions Anthony and NO NEED TO SHOUT

[/quote]

Sorry, but I don't think you mentioned that fact, and I'm banging on about crystals as the cause so maybe I'm myopic. And i didn't realise it was a different cat the the OP!

I must say I find that odd, any previous history prior to your unblocking? Wedid have some which had obvious struvite on visual exam and were "negative crystals" at the lab. And some say you get more +ve crystals if you look at a fresh sample?

Jackson used to measure [Mg++] because if the pH is altered they go back into solution.

Why is the cat blocking? Do you flush anything out of the urethra? Is the urethra stenosed?

Please don't take all this as a one to one tutorial with your grandmother and sucking eggs...." src="http://www.vetsurgeon.org/emoticons/v2/kiss.png" />

[no good at planting kisses but I hope you get the sentiment]

Re: Cat that has blocked again

Neil Wheadon — Wed, 18 Jul 2012 15:42:05 GMT

None seen on all 3 occasions Anthony and NO NEED TO SHOUT

Re: Cat that has blocked again

Anthony Todd — Wed, 18 Jul 2012 15:38:45 GMT

[quote user="Neil Wheadon"]We have a gorgeous gnger male cat that has blocked 3 times.[/quote]

Back to the 70s please! WHAT SORT OF CRYSTALS ARE THEY!!

[quote user="Neil Wheadon"]The PDSA have recently analysed their data[/quote]etc.

Totally agree, I used to back flush them sometimes twice daily, if they had a full bladder, with a 20G venocath or a small blue or pink irrigating catheter NOT cut down.

Indwelling catheters make vets a fortune and seem to inflame the urethra, that's when they haven't been chewed off and returned to the bladder or punctured the bladder wall or all sorts of other complications.

Cats pee better at home!!

Re: Cat that has blocked again

Anthony Todd — Wed, 18 Jul 2012 15:31:32 GMT

[quote user="Malcolm Ness"]The tip of the penis is no longer there after a PU.[/quote]

Yes, even I realise this but it is a common observation in blocked cats without a PU and has been mentioned as occurring after a PU [the one where he says it's "infection"]...

I also wonder if the bacturia after a PU is significant and may not just be incidental, in an area compromised by not having a tip of a penis ie not having the normal urethral structure and protective measures?

The other thing re bacturia is that it is leapt upon by clinicians and antibiotics invariable prescribed which take the credit and confirm the diagnosis without regard to or mention of the blunderbuss of treatment coincidentally given, ie []usually] steroids, muscle relaxants, vital diet change, increasing water consumption, more exercise, less stress etc. etc.

Remember Rich and Fabricant thought FLUDT was caused by a virus, and wasn't swine fever thought to be caused by E coli until someone found the virus??

Re: Cat that has blocked again

Andrew Kent — Wed, 18 Jul 2012 13:31:06 GMT

[quote user="Malcolm Ness"]If you are using the ??2005/2006 retrospective study from Zurich that was published in JSAP, I am not sure that it provides the confidence that appear to underpin your statements. The cases were all operated in a tertiary referral hospital so little can be concluded or extrapolated about surgeon experience. The most common "long term" complication was recurrent bacturia/urinary tract infection. Case numbers were small (?? 50 or 60) and a lot (1/4 or 1/3) were lost to follow up.[/quote]

reads like paper criticism to me.

Re: Cat that has blocked again

Malcolm Ness — Wed, 18 Jul 2012 11:24:38 GMT

[quote user="Andrew Kent"]So you criticise the paper when it disagrees with your opinion [/quote]

No. I pointed out that your definition of "owner satisfaction" as owner happy that the cat wasn't going to die was made up. That's all.

Re: Cat that has blocked again

Malcolm Ness — Wed, 18 Jul 2012 11:13:47 GMT

[quote user="Andrew Kent"]So you criticise the paper when it disagrees with your opinion [/quote]

No. I pointed out that your definition of "owner satisfaction" as owner happy that the cat wasn't going to die was made up. That's all.

Re: Cat that has blocked again

Andrew Kent — Wed, 18 Jul 2012 11:07:09 GMT

I fully agree that a PU is a good procedure in a cat that cannot be unblocked, nobody can really argue that. But it is often used in cases that are completely inappropriate and where the long term consequences do not outweigh the initial condition. As always case selection is the key - I am not saying that PU's should never be performed - but that there are colleagues out there who see them as a quick fix for any male cat with LUTD and this is simply not the case.

Re: Cat that has blocked again

Andrew Kent — Wed, 18 Jul 2012 11:03:35 GMT

So you criticise the paper when it disagrees with your opinion but quote it to support the bits you like (your 80% owner happy rate is also from this paper).

Re: Cat that has blocked again

Malcolm Ness — Wed, 18 Jul 2012 10:59:37 GMT

[quote user="Anthony Todd"]So I see you just ignore the crystals but seem to consider bacturia as significant and the cause of "recurrences" or failures.[/quote]

The tip of the penis is no longer there after a PU.

Re: Cat that has blocked again

Neil Wheadon — Wed, 18 Jul 2012 10:28:52 GMT

OK shoot me down here but here goes.

We have a gorgeous gnger male cat that has blocked 3 times. If he blocks he needs unblocking very quickly and I have in the last 2 months seen 5 cases where cats have died a horrible death because the owner hasn't noticed. (Be honest who looks at their cat 24/7)

My worry, and this is the same as the owner I spoke too is that he will block again when we aren't there to look at him

If there is a proceedure that will solve this issue then fantastic. Yes they may get UTI's and yes we still have to deal with the underlying issue, but I can deal with this at relative leisure and although uncomfortable with a UTI, Custard the cat isn't going to suffer a horrible death because we fancied a W/E away.

He hasn't had a urethostomy, as touch an oak tree he hasn't blocked again, but I can truly appreciate the concerns of this client where maybe a year ago I couldn't..

I find the follow up arguements fascinating, and we should listen to more evidence based medicine. The PDSA have recently analysed their data and have concluded that for simple blockages, you should flush the bladder and then take the catheter out as the outcome is deemed better. It's a leap of faith to do this, but I do this now and it seems to be true.

Neil (Sorry Michael I mentioned the cat again)

Re: Cat that has blocked again

Anthony Todd — Wed, 18 Jul 2012 10:13:36 GMT

[quote user="Malcolm Ness"]In those cases PU done properly resolves the problem predictably and almost always permanently.Happy client happy cat that is no longer at significant risk of blockage/death/euthanasia.[/quote]

So I see you just ignore the crystals but seem to consider bacturia as significant and the cause of "recurrences" or failures.

Surely the crystals gathering on the penis tip or near the PU must give you a clue, or do you regard this as an infection too? [surely not, so why ignore it when identification and diet control can work completely before or after PU?]

Re: Cat that has blocked again

Malcolm Ness — Wed, 18 Jul 2012 10:04:09 GMT

[quote user="Andrew Kent"]Yes 90% of clients were satisfied (ie pleased their cat isn't now going to die[/quote]

The bit in brackets you made up - stick to the facts.

[quote user="Andrew Kent"]They may not obstruct but I'm not sure we have accomplished [/quote]

The PROBLEM with these cats as presented to me is that they are blocked either again (suggesting the probability of a problem that will continue to recur) or blocked in a manner that cannot be relieved otherwise. In those cases PU done properly resolves the problem predictably and almost always permanently.Happy client happy cat that is no longer at significant risk of blockage/death/euthanasia.

The fact that the recurrent bacturia is not resolved is not ideal neither is it news and in that, PU is no less effective than any of the other proposed treatments. In an ideal world we would all be using proven effective "cures" but in my world the best I can usually offer is effective resolution of clinical problems.

If you are using the ??2005/2006 retrospective study from Zurich that was published in JSAP, I am not sure that it provides the confidence that appear to underpin your statements. The cases were all operated in a tertiary referral hospital so little can be concluded or extrapolated about surgeon experience. The most common "long term" complication was recurrent bacturia/urinary tract infection. Case numbers were small (?? 50 or 60) and a lot (1/4 or 1/3) were lost to follow up.

PU is a salvage surgery and as such only indicated when there isn't a better alternative so the key question has to be what better alternative is there when presented with a blocked cat that can't be unblocked (yes, they do exist) or a cat that has already had several uncomfortable and costly (about the same cost as a PU) un-blocks +/- bladder flush and owner counselling??

Re: Cat that has blocked again

Anthony Todd — Tue, 17 Jul 2012 23:45:33 GMT

[quote user="David Mills"]The underlying disease that leads to blockage is a medical condition.[/quote]

[quote user="David Mills"]PUs are useful and have their place[/quote]

Well PU certainly isn't a cure, although I think it is usually offered as one.

[quote user="David Mills"]it does not cure the underlying FIC/FLUTD; indeed it appears that nothing does, repeatedly[/quote]

This is why I bang on!

Stress, ideopathy etc. etc. and now PUs are in the mix and everyone seems to ignore all these crystals at the end of the penis or the PU, in fact some call crystals infection for heaven's sake....

By the time you've stenosed the urethra with your repeated unblocks and made it worse with a botched PU, crystals, the primary cause, are way down the list.

Yes, I know many say they don't find crystals and/or they're "normal" anyway; they find infection too but often these are reblocks, which have been dealt with as above and the fundamental cause has not been corrected.

Frustrating, and it's been going on for over 40 years, since the days of silver solid catheters and struvite in cats fed only on fish, long before dried food was invented.

Re: Cat that has blocked again

David Mills — Tue, 17 Jul 2012 22:59:11 GMT

[quote user="Andrew Kent"]They may not obstruct but I'm not sure we have accomplished any more than that [/quote]

True. The underlying disease that leads to blockage is a medical condition. PUs are useful and have their place both for welfare reasons and economically, but it does not cure the underlying FIC/FLUTD; indeed it appears that nothing does, repeatedly. As yet. I do think these PU cats do need very careful monitoring because I cannot think that many are not still in pain.

Re: Cat that has blocked again

Andrew Kent — Tue, 17 Jul 2012 22:24:00 GMT

Yes 90% of clients were satisfied (ie pleased their cat isn't now going to die) but in that study the complication rate was 30% short term (some attributable to technical errors) but over 50% long term. They may not obstruct but I'm not sure we have accomplished any more than that and the cases that are often selected for this are inappropriate.

Re: Cat that has blocked again

Andrew Kent — Tue, 17 Jul 2012 22:18:27 GMT

Surgery was done at university of Zurich, they found no difference between different levels of surgical experience. Clearly case selection is important - this is often overlooked!

Re: Cat that has blocked again

Gerry Henry — Tue, 17 Jul 2012 21:21:07 GMT

[quote user="Andrew Kent"]My issue with PU is that it is often described to people as a quick fix for their recurrent problems when in reality it has a very high incidence of complications, both long and short term. Only 32% of cats have a disease free long term outcome!

[/quote]

The stats are utterly meaningless unless you know who was doing the surgery and whether were they end stage salvage procedures or timely, preventitive ones. Touch wood I've never had one go wrong.

Re: Cat that has blocked again

Malcolm Ness — Tue, 17 Jul 2012 21:18:24 GMT

[quote user="Andrew Kent"]Well 50% of cats will get long term complications (recurrent UTI, strictures, recurrence of LUTD, urolithiasis). I am guessing you may not see these as the surgery is long done by then. You may be right about the immediate post operative complications.[/quote]

No. We have a large primary care practice so many of our cases hang around long term for us to see.

The numbers you cite don't correspond with my recollection of the literature (which is sparse) or with my experience of several hundred cases over 25 years or so. I don't expect to see these cats back for any kind of revision or repeat of a GA procedure or a re-catheterisation. We will see some cats representing with some dysuria but that is typically managed effectively with medical or no treatment. It is well known that PU does not stop the recurrent bacterial infections and there was a neat controlled study (affected cats vs normal cats operated - the affected cats continued to get intermittent bacturia but the previously normal cats got none. One decent size case series reports almost 90% client satisfaction with overall complication of about 35% of which almost all were low grade. There is an account of a smaller series (?? 10 or 15 cases) of "complications" all of which were attributed to identifiable surgical technical errors indicating that this is a surgery undertaken not infrequently by surgeons who are not completely up to speed with the technique - I am fairly sure that this is the reason that feline PU has a mixed reputation.

Re: Cat that has blocked again

Andrew Kent — Tue, 17 Jul 2012 20:57:53 GMT

[quote user="Malcolm Ness"]

[quote user="Andrew Kent"] a very high incidence of complications, both long and short term.[/quote]

Almost every PU "complication" I have ever seen would have been better described as a technical error.

[/quote] Well 50% of cats will get long term complications (recurrent UTI, strictures, recurrence of LUTD, urolithiasis). I am guessing you may not see these as the surgery is long done by then. You may be right about the immediate post operative complications.

Re: Cat that has blocked again

Malcolm Ness — Tue, 17 Jul 2012 20:53:42 GMT

[quote user="Andrew Kent"] a very high incidence of complications, both long and short term.[/quote]

Almost every PU "complication" I have ever seen would have been better described as a technical error.

Re: Cat that has blocked again

Andrew Kent — Tue, 17 Jul 2012 20:45:30 GMT

My issue with PU is that it is often described to people as a quick fix for their recurrent problems when in reality it has a very high incidence of complications, both long and short term. Only 32% of cats have a disease free long term outcome!