urinary crystals

RE: urinary crystals

Thomas Johnson — Wed, 06 Jan 2016 08:54:50 GMT

[quote user="Anthony Todd"]

It may have no action on incontinence though, but I see that estriol has been licensed in the US for that.

http://www.fda.gov/AnimalVeterinary/NewsEvents/CVMUpdates/ucm265611.htm [2015]

[/quote]

And in the UK, it's the active ingredient in Incurin, which is my (and probably a lot of other vets) first choice for treating urinary incontinence in older spayed bitches.

http://www.noahcompendium.co.uk/MSD_Animal_Health/Incurin_1_mg_tablets/-55033.html

RE: urinary crystals

Anthony Todd — Tue, 05 Jan 2016 23:33:29 GMT

[quote user="Andrew Kent"]I'm going to bow out now because this is in danger of becoming very repetitive, but with an established, published and effective surgical treatment for this i don't see any reason to suggest trying something experimental with documented side effects. [/quote]

Yup, checked multiple references and surgical results are good with few caveats.

My treatment certainly wasn't experimental, always worked with no side effects, apart from occasional apparent oestrus [until the dose was adjusted] and I would still recommend it if the better surgical correction is contraindicated or refused.

It may have no action on incontinence though, but I see that estriol has been licensed in the US for that.

http://www.fda.gov/AnimalVeterinary/NewsEvents/CVMUpdates/ucm265611.htm [2015]

RE: urinary crystals

Andrew Kent — Tue, 05 Jan 2016 20:16:53 GMT

I'm going to bow out now because this is in danger of becoming very repetitive, but with an established, published and effective surgical treatment for this i don't see any reason to suggest trying something experimental with documented side effects.

Andy

RE: urinary crystals

Anthony Todd — Tue, 05 Jan 2016 19:12:42 GMT

[quote user="Andrew Kent"] I have seen some of these with current oestrogen related compounds used at standard therapeutic doses.[/quote]

With respect, and we see the same with steroid condemnation on here, the doses are either inadequate or vastly excessive, and remember the "thyroxin is toxic" thread....

I seemed to need very small doses on oestrogen to enlarge the vulva and/or prevent incontinence.

I'd feel convinced if someone currently tried it and reported back here but, as with lots of threads, condemnation occurs with absolutely no evidence or trial at all.

RE: urinary crystals

Andrew Kent — Tue, 05 Jan 2016 16:46:42 GMT

[quote user="Anthony Todd"]My recollection is that repeat treatment was certainly not under a month and "onset" of signs slow, so easy to treat early. Mind you stilboestrol was very cheap and easy to give and titrate. I don't think there was ever one that didn't stop within 7 days.[/quote]

I guess its a matter of opinion but I think a (hopefully) curative surgery is probably preferred to monthly hormone dosing to most owners.

[quote user="Anthony Todd"]

[quote user="Andrew Kent"] potential adverse effects of oestrogens concerning[/quote]

What are these, at low intermittent dosages?

[/quote]

Difficult to know because the formulations that that you used are not around any more, but with oestrogens in general the risk of adverse effect is not directly dose related and can include behavioural change, bone marrow suppression, increased risk of cancers (mammary). I have seen some of these with current oestrogen related compounds used at standard therapeutic doses.

[quote user="Anthony Todd"]Has anyone ever seen it in an unspayed bitch or incontinence for that matter? Obesity doesn't help certainly.[/quote]

I have seen it in entire dogs, its uncommon because 95% of the cases I see are neutered so difficult to find an association and usually associated with obesity.

RE: urinary crystals

Anthony Todd — Tue, 05 Jan 2016 12:24:53 GMT

[quote user="Andrew Kent"]I have heard this discussed but the experience of other people who have tried this was that the benefit was so short lived,[/quote]

I'm sure they will have published a case series......

My recollection is that repeat treatment was certainly not under a month and "onset" of signs slow, so easy to treat early. Mind you stilboestrol was very cheap and easy to give and titrate. I don't think there was ever one that didn't stop within 7 days.

[quote user="Andrew Kent"] potential adverse effects of oestrogens concerning[/quote]

What are these, at low intermittent dosages?

[quote user="Andrew Kent"]But if your experience is different it would be a great case series to publish.[/quote]

I suppose when you have such good results consistently you don't have to make a case and Bill Gates was just getting DOS going and computers were the devil's disciple anyway!

[quote user="Andrew Kent"]I do wonder with medical treatment how many of them improved because you improved the sub-clinical incontinence (and therefore less licking, less peri-vulvar dermatitis) rather than improving conformation.[/quote]

Sure, the recessed vulva enlarged and "exteriorised". Probably the incontinence stopped concurrently, as you say, which helped.

[quote user="Andrew Kent"]There is more to this condition than hormones anyway, as demonstrated by this dog who was not neutered young - and obesity has a significant factor as well.[/quote]

Has anyone ever seen it in an unspayed bitch or incontinence for that matter? Obesity doesn't help certainly.

RE: urinary crystals

Andrew Kent — Tue, 05 Jan 2016 11:15:41 GMT

[quote user="Anthony Todd"]Sorry Andrew, I've treated so many of these over the years and never had a failure. Not sure what oestrogens are available now though, and you have to repeat when necessary.[/quote]

I have heard this discussed but the experience of other people who have tried this was that the benefit was so short lived, and the potential adverse effects of oestrogens concerning, that surgery has become the preferred option and then doesn't need ongoing medication.

But if your experience is different it would be a great case series to publish.

I also agree that the issue now is availability of hormones as they are quite restricted.

I do wonder with medical treatment how many of them improved because you improved the sub-clinical incontinence (and therefore less licking, less peri-vulvar dermatitis) rather than improving conformation.

There is more to this condition than hormones anyway, as demonstrated by this dog who was not neutered young - and obesity has a significant factor as well.

Andy

RE: urinary crystals

Anthony Todd — Tue, 05 Jan 2016 10:19:08 GMT

[quote user="Andrew Kent"]So I suspect that the vulval conformation is important here and likely one of the primary factors in reinfection, but in a dog neutered as an adult I would be doubtful that this would respond to any medical therapy.[/quote]

Sorry Andrew, I've treated so many of these over the years and never had a failure. Not sure what oestrogens are available now though, and you have to repeat when necessary.

Of course it totally cured, with repeats as necessary, incontinence and night-time leakage too when the "modern" treatment had failed.

"Wisdom" had it that it was "caused" by spaying when immature but that didn't seem always to be the case.

PS: It's just dawned on me it's HRT!! Got to be acceptable now, not even dreamed of way back then.....

RE: urinary crystals

Andrew Kent — Tue, 05 Jan 2016 09:55:21 GMT

So I suspect that the vulval conformation is important here and likely one of the primary factors in reinfection, but in a dog neutered as an adult I would be doubtful that this would respond to any medical therapy. Weight loss might help but I suspect surgical episioplasty would be needed to resolve. The difficulty with these issues is that there is no test that shows it is definitely the cause so it has to be corrected on the understanding it may not help.

With the history of this dog I would also wonder about a low grade (sub-clinical) incontinence. I think this can be difficult to recognise, especially in dogs with vulval hooding, but small volumes of urine leaking and therefore an increase in licking can be another factor.

The only other thing that jumps out a bit from your history is the identification of ammonium urate crystals once - was this at an external lab or in-house? Some normal animals can get them transiently but it always makes me concerned about porto-systemic shunts which can be another potential cause of recurrent UTI.

I also think that if it has been nearly a year since the dog had any abdominal imaging this would be worthwhile to look for bladder wall changes and stones.

As I said before, these are frustrating cases!

Andy

RE: urinary crystals

Mair Tyler — Mon, 04 Jan 2016 23:35:28 GMT

Not a drug I've come across... I'm surprised this dog has such a small vulva given that it was spayed at 3.5 years of age. The dog is also obese which isn't helping with skin folds, etc! I did wonder if acidifying the urine would help prevent recurrence but I guess there's the risk of oxalate stones developing then? The antibiotic treatment DOES seem to work but it just keeps recurring -and not necessarily within days/weeks of stopping treatment so I presume most of the time we are killing all the bacteria and therefore it's a reinfection. Mind you the dog has never had more than a fortnight of antibiotics which really isn't a very long course for a chronic problem like this although the culture done in February was negative after a 2-week course.

RE: urinary crystals

Anthony Todd — Mon, 04 Jan 2016 23:17:12 GMT

[quote user="Mair Tyler"]OK finally get back on here to give you some more [/quote]

Me too, although a lot of questions, not many answers.

As far as the immature vulva problem which is, for the dog, as serious as the "cystitis".

I don't know if you can still get stilboestrol tablets, but if you can a low dose as necessary, will completely resolve this until the next time. Dose needs to be something like 2.5mg and probably not for more than 3 days. True test of dose is whether male dogs are interested then stop and reduce dose by half the next time.

If no stilboestrol tabs then injectable oestrogen at a low dose as necessary.

As far as the cystitis is concerned the pathogenesis concerns me. The knowledge is that the infection causes the pH to increase, then the struvite crystals pptate. Stop the infection, the ph reduces, crystals back into solution; fixed.

I just wonder whether it could be the other way round?

pH increases for other reasons; crystals pptate irritating bladder mucosa-> infection?

I suspect a low Mg++ WET diet might be the answer to both problems 'cos it doesn't look like the current therapy is, and a diet trial will be a lot cheaper than more exams etc.

RE: urinary crystals

Mair Tyler — Mon, 04 Jan 2016 22:48:24 GMT

OK finally get back on here to give you some more history.

First of all I've managed to get the age and breed wrong!! Oops -sorry!! It's a 7-year-old CKCS FN. Not sure why I had westie in my head!

Been with us since a pup, regularly vaccinated, etc. Spayed when it was about 3.5 years old. Has had history of colitis issues in the past though no problems since April 2013.

Going back through its history it actually had some urinary 'incontinence' issues between the ages of 6-9 months. Was dribbling urine, wetting the bed, etc. Antibiotic course made no difference, nor did propain/incurin. Urine dipstick was NAD. Transurethral cystoscopy was done and no anatomical abnormality was noted (ectopic ureters, etc). It was therefore assumed to be a behavioural problem and appeared to resolve after using a DAP collar. She had one more episode of urinating in the house aged 2 years and was treated for a false pregnancy (galastop) on2 occasions prior to being spayed in Feb 2012.

Aug 2013: cystitis symptoms, improved on Noroclav (2 week course).

Oct 2013: cystitis symptoms, improved on Noroclav (10 day course).

Dec 2013: had a 10 day course of Noroclav for an upper resp tract infection.

April 2014: cystitis symptoms, improved on Noroclav (2 week course)

Nov 2014: cystitis symptoms, improved on Noroclav (10 days)

Jan 2015: cystitis symptoms, vulval inflammation/matted fur. 7 day course Noroclav.

Jan 2015 (2 weeks later): cystitis symptoms, vulval inflammation. Urine dipstick blood +, protein+++, pH8.5, SG 1.040. Sediment not checked in-house. Full bloods done -all OK. Urine sent to lab: large number of ammonium urate crystals & moderate amount struvite crystals. Proteus cultured (though from free-catch sample!) -resistant to tetracycline & clindamycin. Treated with 2-week course Noroclav.

Feb 2015: abdominal xray (plain xrays) -NAD, transurethral cystoscopy -NAD. Urine sample obtained for repeat culture & analysis: no bacterial growth, no crystalluria, pH 6.0, SG 1.035, small number RBCs, trace protein.

March 2015: booster vacc, o reports toileting as normal.

April 2015: cystitis symptoms, given 1 week course Noroclav.

July 2015: cystitis symptoms, urine dipstick: pH 8.5, trace protein, SG 1.028. Given 2 week course Noroclav.

Oct 2015: cystitis symptoms, matted fur around vulva. Vulva quite small wiht some skin folds around it. Urinalysis: SG 1.031, blood +++, protein +++, leucocytes +, pH 8.5. Noroclav given at higher dose for 2 weeks.

Dec 2015: blood noticed in urine, given 10 day course Noroclav.

Dec 2015 (1 week later) blood in urine, given a further 10 day course Noroclav. Urinalysis: SG 1.036, pH 8.5, blood +++, protein +++, crystals as pictured above!

RE: urinary crystals

Anthony Todd — Thu, 31 Dec 2015 14:33:12 GMT

[quote user="Andrew Kent"]But it is mostly not infection related, and actually struvite stones have become much less common in cats than they were previously with calcium oxalate becoming more common.[/quote]

Yes, but that's because the usual cat's diet now is high in Mg++ so, to dissolve the inevitable struvite, rather than reduce the essential Mg++precursor,which is high in cereal [a big component of dry diet] the manufacturers add an acidifier, NH4Cl, and, in an acid urine, you get oxalate precipitated.....

RE: urinary crystals

Andrew Kent — Thu, 31 Dec 2015 09:07:50 GMT

[quote user="Mair Tyler"]

FN Westie I think middle-aged. No other systemic disease. I didn't see the dipstick results yesterday -the nurses just asked me to look at the crystals they'd found. She's had recurrent UTI's for months, the case has only recently come my way. She's had bloods, radiographs and transurethral cystoscopy. Culture & sensitivity has been done on 2 occasions I think -sensitive to potentiated amoxycillin (which she seems to respond to when it flares up) and once a negative culture (post-antibiotics). She does have quite a small vulva. Just a bit frustrating case as now the owner rings us asking for repeat courses of ABs when required which isn't really ideal... I'll check back through the history tomorrow and try and post a bit more information.

[/quote]

Thanks Mair - it would be good to have a little more info.

I see a lot of dogs with recurrent or chronic UTI's and they are often very frustrating cases. The first thing I try to establish (based on history, cultures and urinalysis) is whether this is persistence of infection or reinfection.

If persistence then I am looking for resistance, nidus etc.

If reinfection then causes for this - systemic illness, structural abnormalities.

Some cases a clear cause cannot be determined and those cases can require long-term antibiotics - either continuous or pulse depending on preference - along with other supportive treatments.

Andy

RE: urinary crystals

Andrew Kent — Thu, 31 Dec 2015 09:04:36 GMT

[quote user="Martin Atkinson"]

[quote user="Andrew Kent"] perhaps the most important aspect of the diets now is making the urine more dilute so reducing saturation?![/quote]Which is why I advise owners to put their cats on moist food once there has been an incidence of urolithiasis. It has always seemed counter-intuitive to put them on dry food albeit pH/ingredient altering dry food.

[/quote]

Agreed - the dry urinary diets are higher in salt to encourage drinking but that seems less intuitive to me also.

RE: urinary crystals

Martin Atkinson — Thu, 31 Dec 2015 08:40:38 GMT

RE: urinary crystals

Hannah Wynne Richards — Thu, 31 Dec 2015 08:17:30 GMT

How long were your antibiotic courses?

Wynne

RE: urinary crystals

Mair Tyler — Wed, 30 Dec 2015 22:11:41 GMT

RE: urinary crystals

Andrew Kent — Wed, 30 Dec 2015 22:05:58 GMT

Hi Mair

yes it is likely that the infection has come first but it would be good to know a bit more about the case. What's the signalment and history? What does the urinalysis look like? has the dog had imaging? And are there are predisposing factors? (systemic disease, vulval conformation etc)?

RE: urinary crystals

Mair Tyler — Wed, 30 Dec 2015 21:55:55 GMT

So it's infection causing crystals rather than the other way round then? How long a course of antibiotics would you give and is there anything else we should be doing? Doesn't appear to be any underlying cause. Would a urinary diet /altering pH help prevent infection occurring?

RE: urinary crystals

Andrew Kent — Wed, 30 Dec 2015 21:48:48 GMT

[quote user="Emily Rainbow"]

Do you still see struvite secondary to infection in cats? Or are they mostly primary calculi-related issues?

[/quote]

infection is not usually as associated with infection in cats although alkaline urine (which could occur from infection) could still favour formation plus cats with stones are at an increased risk of infection so could occur as a sequel.

But it is mostly not infection related, and actually struvite stones have become much less common in cats than they were previously with calcium oxalate becoming more common.

Andy

RE: urinary crystals

Emily Rainbow — Wed, 30 Dec 2015 20:26:35 GMT

Do you still see struvite secondary to infection in cats? Or are they mostly primary calculi-related issues?

RE: urinary crystals

Andrew Kent — Wed, 30 Dec 2015 19:40:38 GMT

[quote user="Martin Atkinson"]

[quote user="Andrew Kent"]Different pathophysiology, in cats its a tubular disorder in dogs its related to pH.[/quote]Interesting discussion. Is this why Royal Canin urinary diets in cats are one size fits all and not pH corrected now so just deprive the crystals of the raw materials to form?

[/quote]

I'm definitely not a nutritionist but my understanding is that whilst acidification of urine does reduce the formation of struvite (by enhancing solubility) it favoured the formation of calcium containing crystals so was swapping one problem for another.

I think therefore that diets have gone away from altering pH as much as they did before towards modification of the ingredients. But I think the formation of struvite in cats is still not fully understood and likely involves a large number of factors (breed, sex, diet, lifestyle) - so perhaps the most important aspect of the diets now is making the urine more dilute so reducing saturation?!

Andy

RE: urinary crystals

Anthony Todd — Wed, 30 Dec 2015 18:44:54 GMT

[quote user="Martin Atkinson"]

[/quote]

Nah, Oliphant Jackson sussed that in 1070 but nobody listened, and they all say, in 2015, it's "stress"!!! Total baloney, but not trendy. [it used to be "hormones"]

Just try playing with a ball when you've got a blocked bladder.....

RE: urinary crystals

Anthony Todd — Wed, 30 Dec 2015 18:41:44 GMT

[quote user="Andrew Kent"]The infection comes first,[/quote]

Thanks mate,makes sense now it is explained.....