Haematuria following cystocentesis - a thought for the day

Re: Haematuria following cystocentesis - a thought for the day

Stephen Courtney — Fri, 30 Nov 2012 22:57:34 GMT

I do my cystos laterally, use left hand to move and hold the bladder up against the abdominal wall, spirit swab and then use a 23G 5/8 inch needle, inserted at a fairly oblique angle. most cats hardly notice it. and neither do the owners, who are usually holding for me. i don't clip, and i don't use a 1 inch needle as there is no need, the bladder is right under the muscle layer!

If the bladder is too small, or the cat too fat, or stroppy, then i don't do it. similar constraints for blood samples to be honest, and i find cystos far far easier.

the value of a sterile urine sample for assessing renal function in cats is huge. You need to be able to assess specific gravity and proteinuria, rule out DM, and perform sediment examinations, often pretty smartly.

the fact that human medics don't worry about sterile samples is hardly an endorsement. One of my GP clients was worried about his dog's renal function. He was surprised when i asked him for a urine sample, and even more surprised when i tested it with a dipstick and a refractometer and was able to tell him, immediately, that his dogs urine was well concentrated, very normal, and therefore a blood sample would be unlikely to show renal failure. He wondered aloud why doctors didn't test their patients urine like that...i was too staggered to comment. you mean they don't?

A cysto is no more an invasive procedure than a blood sample, and it wasn't that long ago that taking blood from a cat, or putting one on a drip, was considered cutting edge.

Re: Haematuria following cystocentesis - a thought for the day

Alex Gough — Fri, 30 Nov 2012 17:48:34 GMT

[quote user="Hannah Wynne Richards"]

I think cysto will proove a discredited technique in another generation

Wynne

[/quote]

The abdomen, the chest, and the brain will forever be shut from the intrusion of the wise and humane surgeon

Attributed, Science, medicine, and health

John Eric Ericksen, British surgeon, appointed Surgeon Extraordinary to Queen Victoria, 1873.

I never make predictions, and I never will.

Gazza

Re: Haematuria following cystocentesis - a thought for the day

Kate Richardson — Fri, 30 Nov 2012 17:30:36 GMT

[quote user="Rob Davis"]

[quote user="Martin Atkinson"]: my new graduate says she was taught to perform cystocentesis laterally whereas I've always gone midline.[/quote]

I too have always gone midline. I always clip and prep the skin, do others not bother with this?

[/quote]

Me as well midline. I don't usually clip or prep.

For culture, I stick a swab in the urine and send that with the urine sample in a plain tube.

Re: Haematuria following cystocentesis - a thought for the day

Anthony Todd — Fri, 30 Nov 2012 17:06:31 GMT

[quote user="Hannah Wynne Richards"] I agree with and I think cysto will proove a discredited technique in another generation[/quote]

Nonsense [says one holier than I so I'm loving the use.] But in the dogs bum thread.

In blocked bladders it is a hydraulic no-brainer.

signed by the inveterate luddistic dinosaur who still thinks anal glands cause anal irritation and blocked bladders are caused by crystals and Stephens anaesthetic machines [I could go on...]

Re: Haematuria following cystocentesis - a thought for the day

Simon Neuhoff — Fri, 30 Nov 2012 17:01:16 GMT

Interesting to read the different techniques. I have always opted for a lateral, standing technique - left hand to hold bladder up against body wall, clipped and prepped with alcohol. Majority of cats tolerate it very well. I have no observed any complications as yet. I do get the odd bit of haematuria which I tend to interpret in light of the rest of the findings.

Re: Haematuria following cystocentesis - a thought for the day

Claire Fisher — Fri, 30 Nov 2012 16:58:12 GMT

[quote user="Rob Davis"]

[quote user="Martin Atkinson"]: my new graduate says she was taught to perform cystocentesis laterally whereas I've always gone midline.[/quote]

I too have always gone midline. I always clip and prep the skin, do others not bother with this?

[/quote]

I go laterally, left side, stabilise bladder with left hand, aspirate with right. Clip and spirit skin.

Re: Haematuria following cystocentesis - a thought for the day

Michael Woodhouse — Fri, 30 Nov 2012 16:34:21 GMT

[quote user="robloxley"]Have you read J Small Anim Pract. 2011 Oct;52(10):510-4 "The effect of boric acid on bacterial culture of canine and feline urine" ?[/quote]

No I hadn't read it but it comes up on google.

I tend to follow the sampling requirements of the lab that I am sending samples to. Idexx requests the urine in boric acid for culture, and plain for microscopy. Hence why I usually split it. Sadly we are not on a Currier route and whilst most samples get there the next day I have had samples delayed in the post for up to a week. I'm not paying the extra cost of Special Delivery, nor taking every sample to the post office personally. The cost would be prohibitive.

It is a mildly interesting study, but there are many questions left unanswered. What if the sample takes 3 days to get to the lab? What if it's sat in a sorting office at 30°C over a bank holiday weekend in summer? What if the sample freezes solid in the post box?

It would be interesting to compare leaving the sample for more days at room temperature or looking at the effects of warmer and colder temperatures. Would be quite a good final year project for someone. I strongly suspect that as time went on or temperature went up the boric acid would outperform the plain sample.

I always spin blood down and send a blood smear too.

Re- cysto. I have no objection to the procedure per-say. I have done them and they are easy. I still stand by the fact that they are on the whole not needed. The parallels with phlebotomy are not fair - a vet nurse or human phlebotomist (after a half day course before being set loose on real humans) will take blood. Entering the abdominal cavity, even if just using a hypodermic needle, is an act of veterinary surgery. Complications on Vetstream include peritonitis and adhesions. You don't need to squeeze very hard to manually express bladders, it's more a case of maintaining gentle pressure. I can't think of a cat that hasn't let me (ignoring blocked ones). I'd rather do it this way than stab a needle.

I've always done them standing and inserted the needle ventrally having stabilised the bladder with my other hand.

Re: Haematuria following cystocentesis - a thought for the day

Rob Davis — Fri, 30 Nov 2012 16:27:44 GMT

[quote user="Martin Atkinson"]: my new graduate says she was taught to perform cystocentesis laterally whereas I've always gone midline.[/quote]

I too have always gone midline. I always clip and prep the skin, do others not bother with this?

Re: Haematuria following cystocentesis - a thought for the day

Jo Cobbett — Fri, 30 Nov 2012 16:14:51 GMT

[quote user="ashvetenry"]

[quote user="robloxley"]

Have you read J Small Anim Pract. 2011 Oct;52(10):510-4 "The effect of boric acid on bacterial culture of canine and feline urine" ?

[/quote]

Can you precis it pls?

[/quote]

I remember reading it, and I think the conclusion was that on cystocentesis samples, results are more accurate from plain tubes than boric acid tubes (fewer false negatives). The samples were all received by the lab within 12-24 hours of being taken. They didn't have any contaminants growing in the plain tubes.

Re: Haematuria following cystocentesis - a thought for the day

ashvetenry — Fri, 30 Nov 2012 16:11:08 GMT

[quote user="robloxley"]

Have you read J Small Anim Pract. 2011 Oct;52(10):510-4 "The effect of boric acid on bacterial culture of canine and feline urine" ?

[/quote]

Can you precis it pls?

Re: Haematuria following cystocentesis - a thought for the day

Martin Atkinson — Fri, 30 Nov 2012 15:56:03 GMT

Update: urine culture has come back negative after 3 weeks on antibiotics so pyuria should not be as a result of the previous pyelonephriitis, cat does have a history of idiopathic cystitis though, so, even though it is not symptomatic presently, its going back on Cystease and staying on antibiotics for another 3 weeks to thoroughly nail the pyelonephritis. Thanks all for the thoughts on the source of the blood cells, it is, as said, food for thought. But before I go I'll leave you with another conundrum: my new graduate says she was taught to perform cystocentesis laterally whereas I've always gone midline. It occurred to me that there was greater danger of getting a loop of intestine in the way laterally and thus introducing bacteria into an otherwise sterile bladder

Re: Haematuria following cystocentesis - a thought for the day

Rob Davis — Fri, 30 Nov 2012 15:31:14 GMT

[quote user="Kate Richardson"]

Try with an assistant just lifting the front legs, palpate the bladder and using a 1inch 23g needle straight in, withdraw 5mls or less of urine and out you come. Takes less than 5 seconds.

[/quote]

Do you not clip or prep the skin first?

Re the OP, I think it is impossible to tell whether to blood is iatrogenic unless you look at it under the microscope immediately. If there is a relatively high urine SG, the rbcs will lose water through osmosis and appear shrivelled; if the haemorrhage is iatrogenic then they will appear normal if looked at straight away. If urine is isosthenuric, then this will not apply.

Re: Haematuria following cystocentesis - a thought for the day

Kate Richardson — Fri, 30 Nov 2012 15:13:53 GMT

If I had to rely on methods other than cysto to obtain urine from cats I would look at lot lot lot less urine samples from cats and miss a lot of valuable information

Re: Haematuria following cystocentesis - a thought for the day

Hannah Wynne Richards — Fri, 30 Nov 2012 14:23:28 GMT

Not at all Kate When there was discussion about anaesthesia I was one of the few who were defending sevo as vastly superior to iso and also am using alfaxan not propofol and bought digital radiography and also an endoscope 5 years ago and have up to date monitoring equipment and on-site lab, so I have ample proof I'm very far from a stick in the mud It's just I evaluate all new ideas-take on board those I agree with and I think cysto will proove a discredited technique in another generation

Wynne

Re: Haematuria following cystocentesis - a thought for the day

Kate Richardson — Fri, 30 Nov 2012 13:58:14 GMT

[quote user="Hannah Wynne Richards"]

I'm with Micheal Cysto is something new since I qualified and quite frankly strikes me as unnecessarily invasive

Wynne

[/quote]

There are always going to be new things that come along- are you against all of them? Cysto is now recognised as a routine way of collecting urine from cats, I agree with others who have said it is less stressful and uncomfortable than expressing, and I find less likely to get iatrogenic blood from a cysto than expression. The majority of cats hardly feel it, and in most cases they tolerate it better than a blood sample which you could argue is an invasive procdure as well. Maybe if you got used to doing it instead of being frightened or wary of it you would change your mind. If you can palpate the bladder, in all but the fattest of cats it is really easy. Try with an assistant just lifting the front legs, palpate the bladder and using a 1inch 23g needle straight in, withdraw 5mls or less of urine and out you come. Takes less than 5 seconds.

Re the OP, you cannot tell for certain if the blood in a cysto sample is iatrogenic or reflects haematuria, so a free catch sample is better for that, I don't think expression has any advantage over cysto in this respect as you can get iatrogenic blood from this too. Generally if there is true haematuria though there will be much more blood in the sample. If the blood is due to inflammation then the white cells seen should be mainly neutrophils and you will see a lot more than you would expect. I tend to find there are virtually no wbcs seen when you examine the sediment if the blood is iatrogenic.

Re: Haematuria following cystocentesis - a thought for the day

Rob Loxley — Fri, 30 Nov 2012 13:30:56 GMT

[quote user="Michael Woodhouse"]If I am submitting a sample to the lab for culture I send half fresh and hallf in the boric acid (red top) tubes. Doesn't everyone?[/quote]

Have you read J Small Anim Pract. 2011 Oct;52(10):510-4 "The effect of boric acid on bacterial culture of canine and feline urine" ?

Re: Haematuria following cystocentesis - a thought for the day

Thomas Johnson — Fri, 30 Nov 2012 12:43:57 GMT

I find cystocentesis much easier and less stressful than expressing a bladder. As long as the bladder's moderately full I can usually manage without needing the cat held in a particular way, and without restraint in the majority of cases.

Re: Haematuria following cystocentesis - a thought for the day

Michael Woodhouse — Fri, 30 Nov 2012 10:01:20 GMT

[quote user="Martin Atkinson"] I challenge you to empty the bladder of a clinically normal concious male cat at all let alone without risking some iatrogenic bleeding and that is before considering if the sample will be free from contamination or not. The latter is however a point raised in another thread - that people provide a free catch sample and that seems to suit the medics (I presume this is why they use oxalic acid sample tubes) but hopefully humans are a bit cleaner in the nether regions hmmm.... perhaps another thought for the day)![/quote]

You don't need to empty the bladder, just collect enough urine for a dipstick and culture. ~5mls.

If I am submitting a sample to the lab for culture I send half fresh and hallf in the boric acid (red top) tubes. Doesn't everyone?

Quick google search:

For chemical urinalysis and conventional (culture based) microbiological testing, unpreserved specimens exceeding the two hour limit that have not been refrigerated should not be accepted for analysis due to potential bacterial overgrowth leading to disintegration of cells and casts*, invalidation of bacterial colony counts and errors in chemical urinalysis.

A variety of urine preservatives is available that allow urine to be maintained at room temperature while still providing urinalysis test results comparable to those achieved with fresh specimens or those stored under refrigerated conditions.

The labs provide the tubes FOC.

Re: Haematuria following cystocentesis - a thought for the day

Hannah Wynne Richards — Fri, 30 Nov 2012 09:12:13 GMT

I'm with Micheal Cysto is something new since I qualified and quite frankly strikes me as unnecessarily invasive

Wynne

Re: Haematuria following cystocentesis - a thought for the day

Martin Atkinson — Fri, 30 Nov 2012 08:50:32 GMT

[quote user="Michael Woodhouse"]ust squeeze the bladder. Cats tolerate it very well, and catch in a small sterile kidney dish[/quote] I challenge you to empty the bladder of a clinically normal concious male cat at all let alone without risking some iatrogenic bleeding and that is before considering if the sample will be free from contamination or not. The latter is however a point raised in another thread - that people provide a free catch sample and that seems to suit the medics (I presume this is why they use oxalic acid sample tubes) but hopefully humans are a bit cleaner in the nether regions hmmm.... perhaps another thought for the day)!

[quote user="Nicola Lawlor"]Would there not be a higher ratio of wbc to rbc in the urine if there is inflammation when compared to the blood counts though?[/quote] That's part of the post - the lab gave a WBC count but only flagged RBCs as ++.

Re: Haematuria following cystocentesis - a thought for the day

Rob Loxley — Fri, 30 Nov 2012 00:00:21 GMT

hmmm, I cysto umpteen cats a day and they tolerate it much better then manual bladder expression

Re: Haematuria following cystocentesis - a thought for the day

Michael Woodhouse — Thu, 29 Nov 2012 22:59:17 GMT

Just squeeze the bladder. Cats tolerate it very well, and catch in a small sterile kidney dish. If midstream urine ok for people it's ok for cats.

There is no need for such an invasive procedure.

Re: Haematuria following cystocentesis - a thought for the day

Nicola Lawlor — Thu, 29 Nov 2012 22:39:56 GMT

Would there not be a higher ratio of wbc to rbc in the urine if there is inflammation when compared to the blood counts though? If there is a difference then this is likely due to a urinary tract issue, but if the ratio is the same then probably only the blood contamination causing this.

Re: Haematuria following cystocentesis - a thought for the day

Arlo Guthrie — Thu, 29 Nov 2012 22:26:15 GMT

I've moved it into the small animal clinical forum now!

Re: Haematuria following cystocentesis - a thought for the day

Wren — Thu, 29 Nov 2012 21:53:08 GMT

I don't know the answer but for some reason this appears under 'equine - clinical'. I was going to give you major kudos for cysto-ing a horse!