Chronic lower urinary tract issues - bladder ultrasound images

Re: Chronic lower urinary tract issues - bladder ultrasound images

Kate Richardson — Tue, 27 May 2014 20:47:17 GMT

Re: Chronic lower urinary tract issues - bladder ultrasound images

Laura Marshall — Tue, 27 May 2014 20:24:40 GMT

Brief update in case anyone following my saga:

Repeat bloods on Friday revealed all parameters back to normal, except HCT which had been diluted to 20% (from 29%). Taken on IVFT to assess and she was sent on on Saturday.

Have just seen her back this evening and this is the best I've seen her! Bright, happy, eating and drinking well, maintaining weight and hopefully hydration!

Re: Chronic lower urinary tract issues - bladder ultrasound images

Laura Marshall — Thu, 22 May 2014 12:36:26 GMT

[quote user="Kate Richardson"]

I bet she has either got pyelonephritis or this is post renal given the hyperkalaemia (if its true- very sensible to repeat)- is having difficulty voiding urine? I think you are going to struggle with her, and maybe its one where you have to have a very frank discussion with the owner as sub cut fluids would be a good idea but it depends on how involved they want to get and can commit to. Obviously meloxicam is not an option now. HCT likely secondary to chronic disease although regeneration might suggest haemorrhage or even haemolysis (secondary to the inflammation). But long term without anti-inflamm pain killers- not sure that's the best thing for the cat. Poor you, poor cat. But not your fault, some you win, some you don't

[/quote]

Sadly, exactly what I'm thinking and we have started to have this discussion already. I don't think that she's the kind of girl who will allow subcut fluids at home (when she's well she likes to be a little cranky!), but I can't see anything else that I can do now. She's really bright and happy now, and she's eating very well, but this will not doubt change when she comes off the fluids again (of which I have already discussed with her owners).

Re: Chronic lower urinary tract issues - bladder ultrasound images

Anthony Todd — Wed, 21 May 2014 17:36:42 GMT

[quote user="Anthony Todd"]

This wouldn't be just a chronic struvite FLUDT or FUS or whatever the buzz achronym is today? Females never block with this and, I suppose if it was chronic, there would be inflammation etc. of the bladder wall.

My guess the bacteria are just opportunistic.

"Severe haemorrhagic urocystitis" is what all male blocked cats get; females just don't block.....

[/quote]

In the total absence of diagnostic histology I hope someone will tell me why I am so wrong, apart from the the obvious concurrent renal disease.

If it was a repeat male block I'd say the bladder wall was typical.

What evidence is there that the bladder wall has any cancer [if it has, it seems remarkably evenly disseminated?]

Re: Chronic lower urinary tract issues - bladder ultrasound images

Kate Richardson — Wed, 21 May 2014 17:10:48 GMT

Re: Chronic lower urinary tract issues - bladder ultrasound images

Rob Loxley — Wed, 21 May 2014 16:09:19 GMT

[quote user="Laura Marshall"]She just doesn't seem to be able to keep herself going once IVFT is stopped[/quote]

Are they up for home subcut fluids?

Re: Chronic lower urinary tract issues - bladder ultrasound images

Laura Marshall — Wed, 21 May 2014 15:59:12 GMT

Well I readmitted her last eat bloods and IV fluids for the recurrence of dehydration.

HCT 29% (30-45), retics 108.9 (3-50). Urea >46.4 (5.7-12.9), creat 269 (71-212), phos 3.06 (1-2.42), globs 58 (28-51). K+ 7.6mmol/l (3.5-5.8).

Cobalamin is pending, as is a repeat K+ as I'm not sure I believe that value. Am hoping that the anaemia is due to the bleeding post biopsy (haematuria was marked!!!). USG was 1.015.

She's better in self today, weight coming back up again, she's eating and is polydipsic. She just doesn't seem to be able to keep herself going once IVFT is stopped.

I can't help but feel that we're nearly at the end of the road. Even though she was on a low dose of NSAIDs, I have discontinued this as hyperphos is new with regards to her renal parameters. Very deflated at the moment!

Re: Chronic lower urinary tract issues - bladder ultrasound images

Anthony Todd — Wed, 21 May 2014 08:16:53 GMT

My guess the bacteria are just opportunistic.

"Severe haemorrhagic urocystitis" is what all male blocked cats get; females just don't block.....

Re: Chronic lower urinary tract issues - bladder ultrasound images

Anthony Todd — Tue, 20 May 2014 23:18:16 GMT

[quote user="Laura Marshall"]calcium aggregates.[/quote]

I've never heard of this. Is this just another name for struvite crystals which would fit with the "severe haemorrhagic urocystitis" which is linked in the same sentence?

Re: Chronic lower urinary tract issues - bladder ultrasound images

Kate Richardson — Tue, 20 May 2014 11:27:21 GMT

Might be worth checking for other concurrent problems such as anaemia and hypokalaemia, poss B12 as she may losing more than she can take in?

Re: Chronic lower urinary tract issues - bladder ultrasound images

Laura Marshall — Mon, 19 May 2014 22:46:10 GMT

Thanks for your help. I'm worried we're not out of the woods. She's now off her food again and dipped a little in weight. Not sure what else I can do now. Hoping that anti-inflammatory action will help.

Re: Chronic lower urinary tract issues - bladder ultrasound images

Kate Richardson — Mon, 19 May 2014 15:11:21 GMT

Good work! Marbocyl and meloxicam for 4- 6 weeks then rescan to reassess bladder appearance. Earlier if stops responding. Repeat tissue culture if you can? May well need 3 months of treatment possibly long term. Thanks for the update!

Re: Chronic lower urinary tract issues - bladder ultrasound images

Laura Marshall — Mon, 19 May 2014 14:57:28 GMT

Time for an update:

Dental has been performed and she's been doing great in herself (until she went a little off her food yesterday) and catheter biopsy was taken at the same time. Lots of thick fluffs of tissue present in this sample and I sent it for cytology, culture and sensitivity and one large chunk that I put in a histopath pot for good measure! On my phone I have some microscopy pictures taken from some slides that I made, but I now have the results from the rest.

SIGNIFICANT Bacterial Counts
SAMPLE TYPE DOGS CATS
Cystocentesis >=10^3 >=10^3
Catheterization >=10^4 >=10^3
Midstream voiding >=10^5 >=10^4

>10^5 cfu/ml Enterobacter cloacae cultured

CYTOLOGICAL INTERPRETATION
Maild dysplasia of transitional epithelium
Marked bacteriuria
Mild pyuria
Moderate hematuria

CYTOLOGICAL DESCRIPTION
The smears are highly cellular and contain many large thick clumps of variably preserved transitional epithelial cells. These are mildly to moderate swollen but appear cuboidal to polyhedral with round central nuclei, finely stippled chromatin, small or indistinct nucleoli and and moderately amounts of pale to mid basophilic cytoplasm. There is mild anisocytosis and anisokaryosis within this population which appears fairly uniform. Also present are many large clumps of small bacterial rods and low numbers of swollen neutrophils containing similar bacteria. The background contains blood and cellular debris.

COMMENT
There is a marked bacteria and mild pyuria suggesting a urinary tract infection and inflammation. Culture has previous been reported. The smear also contains many large clumps of transitional epithelial cells but these are relatively uniform in appearance and the mild atypia noted could reflect hyperplasia secondary to inflammation or a well differentiated carcinoma. The high cell yield likely reflects collection method. Recommend treating the infection and repeating the cytology or biopsy to further evaluate the bladder wall.

DIAGNOSIS
Haemorhagic cystitis with mineralization (calcium)

HISTOLOGY
Lump of tissue from catheter suction of bladder submitted for histopathology.

This sample contains numerous clusters of well differentiated urothelium admixed with free red blood cells (haemorrhage), fibrin, and calcium aggregates. Multifocally, the urothelium is mildly hyperplastic, piling up to 2 cell layers thick,

COMMENT
The most common cause of severe haemorrhagic urocystitis (feline urologic syndrome) in cats is obstructive urolithiasis (struvite crystals in a rubber like protein matrix). At the site where calculi lodge there is local pressure necrosis, ulceration of the mucosa and massive haemorrhage. Retention of the urine as a result of obstruction often leads to over colonization of uropathogenic E. coli. This is serious condition, shock and death can result due to intractable haemorrhage and/or overwhelming bacteraemia/septicaemia.

Random comment for the histopath!

The sensitivity showed several resistant antibiotics (including anomy-clav which she had been started on), but is sensitive to marbofloxacin, which she is now on. She has been having some vetegersic sublingually at home.

Today I hear she's not eating as well as she was, and so I'm inclined to start her on meloxicam again. Additional thoughts, as always, well received!

Re: Chronic lower urinary tract issues - bladder ultrasound images

Kate Richardson — Thu, 15 May 2014 10:10:15 GMT

[quote user="Braden Collins"]

[quote user="mariette asselbergs"]

" I also used meloxicam as there was so much inflammation plus it theoretically can be 'anti-neoplastic'." (Kate Richardson)

I was intrigued by this remark. Can you explain a bit more, do you mean damping down inflammation can be anti-neoplastic, ir do you mean the metacam itself?

Mariette

[/quote]

A lot of tumours have an over-expression of Cox-2 pathways, so NSAIDs can help with control (plus do some other magic things I don't understand). FNA can be pretty useless for bladder lesions as the cells become so dysplastic with inflammation it is very hard to diagnose. I would be looking for a biopsy (possibly tru-cut if skilled enough). There is a risk of seeding, but if it's a bladder tumour it's pretty stuffed anyway so a bit of an academic worry in this case.

[/quote]

As Braden said re the Cox 2 pathways- I have also used meloxicam successfully in 1 oral squamous cell carcinoma.

I disagree about FNA of bladder lesions, I think you have to accept their limitations and I agree they are not always diagnostic but there is much less risk associated with performing an FNA than a trucut biospy- I would suggest less risk of seeding (which I also agree is more of an academic worry), less risk of haemorrhage, can be done under sedation or possibly even conscious depending on the patient and operator skill level. I don't think personally I would attempt a trucut biopsy without a general anaesthetic. In my experience FNAs for these types of bladder changes have proved rewarding. Given the chronicity of this case, it makes neoplasia less likely but not impossible.

If the cat is eating and drinking and 'well' otherwise I wouldn't worry about meloxicam- I use it happily in chronic renal cats with arthritis as long as they are eating and drinking normally. They often eat better and renal parameters improve. This cat will surely feel much better with anti-inflammatories and pain relief on board regardless of the underlying pathology of the bladder

Re: Chronic lower urinary tract issues - bladder ultrasound images

Braden Collins — Wed, 14 May 2014 15:45:06 GMT

[quote user="mariette asselbergs"]

" I also used meloxicam as there was so much inflammation plus it theoretically can be 'anti-neoplastic'." (Kate Richardson)

I was intrigued by this remark. Can you explain a bit more, do you mean damping down inflammation can be anti-neoplastic, ir do you mean the metacam itself?

Mariette

[/quote]

Re: Chronic lower urinary tract issues - bladder ultrasound images

Matt Hilary — Tue, 13 May 2014 15:00:15 GMT

[quote user="mariette asselbergs"]

" I also used meloxicam as there was so much inflammation plus it theoretically can be 'anti-neoplastic'." (Kate Richardson)

I was intrigued by this remark. Can you explain a bit more, do you mean damping down inflammation can be anti-neoplastic, ir do you mean the metacam itself?

Mariette

[/quote]

Piroxicam (and therefore possibly meloxicam by extension) has been used to treat bladder TCCs.

http://www.ncbi.nlm.nih.gov/pubmed/7983623

Re: Chronic lower urinary tract issues - bladder ultrasound images

mariette asselbergs — Tue, 13 May 2014 14:56:31 GMT

" I also used meloxicam as there was so much inflammation plus it theoretically can be 'anti-neoplastic'." (Kate Richardson)

I was intrigued by this remark. Can you explain a bit more, do you mean damping down inflammation can be anti-neoplastic, ir do you mean the metacam itself?

Mariette

Re: Chronic lower urinary tract issues - bladder ultrasound images

Anthony Todd — Sat, 10 May 2014 15:23:20 GMT

[quote user="robloxley"]It might - in humans sensitivity is reported variously from about 20-60%, so a fair false negative rate[/quote]

Are these all in cases with suspicious ultrasound appearances of the bladder wall?

It's quick, non-invasive, safe and so much cheaper than the more involved procedures; if you emptied the bladder and gave it a good massage you'd get a better sample of cells too.

Re: Chronic lower urinary tract issues - bladder ultrasound images

Rob Loxley — Sat, 10 May 2014 09:26:44 GMT

[quote user="Anthony Todd"]I wonder whether cytology of spun urine wouldn't reveal some significant cells if the wall was cancerous??[/quote]

It might - in humans sensitivity is reported variously from about 20-60%, so a fair false negative rate

Re: Chronic lower urinary tract issues - bladder ultrasound images

Anthony Todd — Fri, 09 May 2014 19:14:00 GMT

I wonder whether cytology of spun urine wouldn't reveal some significant cells if the wall was cancerous??

Re: Chronic lower urinary tract issues - bladder ultrasound images

Laura Marshall — Fri, 09 May 2014 15:26:53 GMT

Thanks for the responses everyone, very helpful. I agree about concerns for FNAing and have put a no cysto note on her file, so urine samples have all been free catch. I have wondered about catheter sample and think a GA for the dental work will provide a good opportunity to do this. Just hope I can catheterise her! I think infection within the bladder wall itself is something I have not given enough thought to, getting distracted with clear culture and sensitivity.

Re: Chronic lower urinary tract issues - bladder ultrasound images

Kate Richardson — Fri, 09 May 2014 10:55:09 GMT

I had a similar case a couple of years ago. I would FNA the bladder wall; yes theoretical risk of seeding cells but how else are you going to know what you are dealing with. My case had very dysplastic cells in the bladder wall but they weren't neoplastic; however there was always the potential for them to become neoplastic I guess. Without tissue culture difficult to say if infection in the bladder wall but if not neoplastic I would assume infection in the wall itself and long courses of antibiotics may be required ie at least 3 months continous treatment. I also used meloxicam as there was so much inflammation plus it theoretically can be 'anti-neoplastic'. My case required antibiotics long term although we did manage to get onto pulse therapy at some stages, but we also had good response to initial treatment with amoxyclav which then stopped be effective so changed to cephalexin, before ending up on trimethoprim sulphonamides, may have used marbofloxacin at some stage as well from memory. Meloxicam was continuous. Bladder wall never looked normal at any stage but did improve. Managed the cat for a couple of years before it was pts'd for an unrelated condition (I think but will check records!) I would be reluctant to biopsy these bladders as I would be concerned re healing; I think the suction biopsy is worth trying.

Your cat may have concurrent renal disease or possibly pyelonephritis directly related to the bladder. The elevated UPC is going to be due to the inflammation most likely rather than renal in origin so I am not sure I would be using an ACE-inhibitor at this stage- you may be better revaluating once (hopefully) the urine is free from inflammatory changes to assess if there is any possibility of renal proteinuria. I think a negative urine culture in this case may not mean a lot, as I suspect there may be infection within the bladder wall, so I wouldn't use a negative culture as a marker for stopping antibiosis; I would go on bladder wall appearance and urine sediment/haematuria/protein.

So I would go ahead and perform a dental treatment and fna the bladder whilst under GA.

Re: Chronic lower urinary tract issues - bladder ultrasound images

Laurence Webb — Fri, 09 May 2014 09:13:02 GMT

I'd be a bit cautious about cysto or FNA from the bladder. If it's neoplastic you can seed tumour cells. Would the owner permit you to repeat the ultrasound and catheterise the bladder? Urine cytology and culture might yield something but you could also use ultrasound to direct a catheter to the lesion and attempt to harvest cells by suction. Admittedly my success rate for diagnostic samples has been fairly low with this.

Re: Chronic lower urinary tract issues - bladder ultrasound images

Andrew Kent — Thu, 08 May 2014 18:25:29 GMT

What are the specific clinical signs that she is showing and what are the owners main concerns?

As the history is so long a polypoid lesion seems most likely, though they could be blood clots as well. If they are polyps then even with the negative culture I would be suspicious of chronic infection so may be worth taking another cysto. If polyps and infection are present you will be unlikely to resolve it without removing the polyps and they are reasonably big. This may have all occurred due to chronic infection because of dilute urine from CRF.

But I would think what you do depends on the owners main concern - if that is LUT signs then they will be unlikely to improve whilst these lesions remain.

Andy