Unusual Bladder Images

RE: Unusual Bladder Images

Thomas Johnson — Wed, 12 Jun 2019 08:52:32 GMT

[quote user="Thomas Johnson"]I have advised her owners to finish the one week course of Baytril and continue the Metacam. I am planning to see her back in 1 week to re-examine her, repeat the ultrasound scan and collect another urine sample.[/quote]

I saw her back yesterday afternoon. Her owner reports that she is completely back to normal. Bright, eating well and urinating normally. Clinical examination was unremarkable. On ultrasound the bladder lesion, suspected vesicourachal diverticulum, was smaller, about 5mm diameter. Urine was collected by cystocentesis and there was no blood on the dipstick. I'm not planning to do anything else at the moment, if any of the clinical signs recur the owner will contact me.

I found a couple of post-mortem pictures of bladder diverticula on this website https://vet.uga.edu/ivcvm/courses/vpat5215/urinary/lower/LOWER_1.htm

RE: Unusual Bladder Images

Thomas Johnson — Tue, 04 Jun 2019 16:39:53 GMT

I saw her back this afternoon. Her owners report that she still seems a bit subdued, but otherwise is normal. She is eating well, mainly wet food. She mainly toilets outside, when she presented to us 1-2 weeks ago she was going out a lot more frequently to toilet, but this has now returned to normal. She is kept in overnight and has a litter tray which she uses occasionally.

On clinical examination there initially seemed to be some pain on palpation of her mid-caudal abdomen, probably not far enough caudally to be related to her bladder. There was no further reaction though on careful palpation of her whole abdomen, her bladder was about half full and comfortable, and there was very little faeces palpable in her descending colon. I palpated over her spine in case her initial reaction was due to spinal pain, but there was no reaction. I also palpated her stifles and there was no obvious thickening or reaction to palpation.

I have advised her owners to finish the one week course of Baytril and continue the Metacam. I am planning to see her back in 1 week to re-examine her, repeat the ultrasound scan and collect another urine sample.

RE: Unusual Bladder Images

Anthony Todd — Mon, 03 Jun 2019 17:35:49 GMT

[quote user="Anthony Dennison"]

So why have you hijacked this thread denying that FLUTD isn't a thing? You've been on the losing side of these arguments before Tony, cat food has improved from what is used to be. There is no evidence of uroliths on the scan so it's definitely not stones or crystals - why keep going on about it then?

[/quote]

I've never even mentioned or considered FLUTD, in this thread but cystitis has been mentioned, which, I suppose is part of FLUTD

Oh boy, FLUDT is a thing though, and the food manufacturers have gone to great chemical and PR lengths to minimise the possibility, and smoke-screen the cause too, since you mention it.

PS I didn't know crystals could be picked up on a scan. and anyway they're considered "normal" in cats' urine now, although where uroliths come from must be some sort of act by a higher force.

I don't think this case is connected to FLUDT though, signs etc. seem different apart from what sounds like a source of haemorrhage; the "dysuria" could well be constipation.

RE: Unusual Bladder Images

Anthony Dennison — Mon, 03 Jun 2019 14:27:39 GMT

[quote user="Anthony Todd"]Surely you've got a plain bladder haemorrhage and a very suspicious abnormality on ultrasound way past my expertise to diagnose.[/quote]

[quote user="ksg"]

1. This female cat is obese

2. Moderate and likely significant colonic fecal impaction.

3. Moderate to severe osteophytes on both stifles.

My "penny" of thoughts: look at the bigger picture..

Hope it helps..

[/quote]

Spot on. The other thing to try is check height of the litter trays at home - if they're having to step over a tall edge to get in and they're arthritic they may not do it until desperate. Having a tray with a low step on it may help.

RE: Unusual Bladder Images

Lucy Fleming — Mon, 03 Jun 2019 09:47:07 GMT

[quote user="Thomas Johnson"] I wonder if the culture is a false negative[/quote] Possible, with previous antibiotic treatment. Any bacteria visible on the sediment examination? Does the lab report the presence/ absence of antibacterial activity in the urine? If there's no bacteria visible on the sediment, I'd be more inclined to believe a negative culture. Similarly, I'd expect a +ve for blood on the dipstick in a cysto sample, but if seeing blood on microscopy (which I think you said you did?) I wouldn't really expect that to be from cysto alone.

I may very well be mistaken, as I don't really do/ look at a lot of double contrast studies, but is there a small urethrolith (just cranial to the pelvis?) and possibly a couple of little nephroliths as well? The nephroliths (if present!) may not be relevant to the current presentation but worth watching. I'm afraid I can't help much with the vesicourachal diverticulum idea as I've never seen one. Would it be expected to cause problems at an earlier age if it was significant? Is this the first time the cat has had an episode?

RE: Unusual Bladder Images

Thomas Johnson — Mon, 03 Jun 2019 08:47:15 GMT

[quote user="Emily Rainbow"]

whereabouts on the bladder is that scan image from? Could this be a an ectopic ureter? An IVU could be useful if suspected.

[/quote]

The abnormality on the bladder ultrasound is at the cranial pole, as seen on the contrast radiograph, so I thought an ectopic ureter very unlikely.

RE: Unusual Bladder Images

Emily Rainbow — Mon, 03 Jun 2019 07:14:45 GMT

whereabouts on the bladder is that scan image from? Could this be a an ectopic ureter? An IVU could be useful if suspected.

RE: Unusual Bladder Images

Utlendigur — Sun, 02 Jun 2019 21:46:49 GMT

I've seen one vesicourachal diverticulum but that was in a dog, and it was huge - plain xray showed what appeared to be two fairly full bladders, one cranial to the other. Can't remember the age of the dog but it was adult, and presented with recurrent cystitis and UTIs. I did remove it but I had a very obvious abnormality to aim for. Inside it was a bit like an inspissated sterile abscess.

As an aside, I get frustrated that an interesting topic, yet again gets hijacked (1/3 of posts from the same poster), and the original question gets sidetracked as, for example, a minor detail in the history is fixated upon, or people get sucked into explaining repeatedly that things have changed and the reasons why One of the reasons why I don't visit the forum as much these days.

RE: Unusual Bladder Images

Charlotte Marshall — Sun, 02 Jun 2019 21:12:36 GMT

Personally I never use baytril in cats due to the risk of blindness (I know it is a small risk). I always use marbofloxacin instead.

RE: Unusual Bladder Images

Anthony Todd — Sun, 02 Jun 2019 16:38:09 GMT

[quote user="Thomas Johnson"]haematuria due to cysto[/quote]

With loads of cystos done there should be plenty of experienced opinions coming?

Always struck me as "likely" but never seems to be mentioned on here?

Actually, wouldn't the blood be in the next sample drawn or in the next void, as the needle would be way past the "puncture" and drawing back before the blood got to the needle??

RE: Unusual Bladder Images

Thomas Johnson — Sun, 02 Jun 2019 09:11:30 GMT

[quote user="ksg"]..'Urine was collected by cystocentesis and there was a lot of blood on the dipstick'.. Iatrogenic haematuria due to cysto ?![/quote]

Two urine samples have been collected, the first by cystocentesis, the second by catheterisation 3 days later, both had blood on the dipstick and on microscopy.

RE: Unusual Bladder Images

ksg — Sat, 01 Jun 2019 18:17:13 GMT

Anthony (& Thomas).

I am referring to the history Thomas provided:

..'showing signs of cystitis'..: In my opinion can be easy confused with constipation

..'There was no improvement and she started vomiting'..: Still could be due to constipation.

..'Urine was collected by cystocentesis and there was a lot of blood on the dipstick'.. Iatrogenic haematuria due to cysto ?!

..'culture and sensitivity negative ' Does not really help us to exclude or support differential diagnosis .

Unfortunately the history provided is not complete to understand the "full" picture- i.e Life style, Indoors/outdoors, other animals in house hold, previous episodes of FLUTD?, No haematuria noted by vet/owner until cysto done?, Physical examination performed- painful bladder, constipation palpable? (ab)normal fecal production- when was hospitalised on IVF, etc)

Hope it helps to navigate the collective thoughts.

Cheers

RE: Unusual Bladder Images

Anthony Todd — Sat, 01 Jun 2019 16:57:39 GMT

[quote user="ksg"]I have a feeling you are on the right track.[/quote]

Why is there blood in the urine and where is it coming from? [not decided??]

[I'm surprised at how "low" the large bowel is in the abdomen]

I'll bet it is on ad-lib dried food!!

RE: Unusual Bladder Images

ksg — Sat, 01 Jun 2019 16:27:24 GMT

Bingo..

I have a feeling you are on the right track..

Good luck

RE: Unusual Bladder Images

Thomas Johnson — Sat, 01 Jun 2019 15:31:00 GMT

[quote user="ksg"]

Viewing your abdominal radiography I have noticed the following:

1. This female cat is obese

2. Moderate and likely significant colonic fecal impaction.

3. Moderate to severe osteophytes on both stifles.

My "penny" of thoughts: look at the bigger picture..

Hope it helps..

[/quote]

That is very helpful thank you, it is sometimes too easy to focus on one thing. The cat's weight we are aware of! I had noted the amount of faeces, but only really as an incidental finding and it might be worth considering whether this is adding to the cats excessive straining in the litter tray. It's at home for the weekend and we're seeing it back early next week so will make sure to check with the owner whether it is passing faeces okay at home. The osteophytes I hadn't noted, hopefully the Metacam will help with any pain from the stifles.

RE: Unusual Bladder Images

Anthony Todd — Sat, 01 Jun 2019 15:02:47 GMT

[quote user="Thomas Johnson"]Have you ever seen a case of a vesicourachal diverticulum, [/quote]

No I haven't.

With such obvious pathology in the strange absence of other signs of FUS apart from the haematuria it may be that the ultrasound has found a significant bladder defect. I assume the crystals were zero??

Do the ultrasounds of these VDs always look like that, with a translucent circular centre?

I can't see why a cystotomy/laparotomy is so contraindicated, particularly as, in this case, and in my geriatric opinion, the signs are not really of classic crystalluria leading to haematuria but rather of a primary bladder wall lesion leading to the bloody urine.

How does the bladder feel when empty ie is it "normal" or a bit "lumpy"??

RE: Unusual Bladder Images

Thomas Johnson — Sat, 01 Jun 2019 14:41:34 GMT

[quote user="Anthony Todd"]As often, or nearly always, abdominal surgery will be the only thing that is likely to give you significant diagnostic information and probably you can fix the problem totally, and before you get the histo to the lab.[/quote]

Have you ever seen a case of a vesicourachal diverticulum, and if not have you looked it up before commenting on this case, if you do you you will see why, if this is the diagnosis, I'm in no hurry to operate on this cat. For example this quote, "Vesicourachal diverticula visible on contrast cystography have been reported in 25 % of cats with signs of hematuria, dysuria and urethral obstruction. Clinical evidence suggests that diseases that induce increased intravesicular pressure can cause potential diverticula to open up. Once the underlying condition causing increased pressure is resolved, the diverticula disappear. As such, vesicourachal diverticula appear to be a consequence rather than a cause of FLUTD." From this article:

https://www.vin.com/apputil/content/defaultadv1.aspx?pId=11196&id=3854223&print=1

Or this paper:

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1748-5827.1989.tb01487.x

RE: Unusual Bladder Images

Anthony Todd — Sat, 01 Jun 2019 14:24:56 GMT

[quote user="Thomas Johnson"]Why are you so sure it isn't a cystitis?[/quote]

Because there aren't excessive WBCs and there seems there is a FB [in effect] in the bladder and lots of blood without stones or crystals

I speak with some authority as I have had all those signs until I passed a blood-curdling stone [not that I think there is a stone in this case].

If I had that suspicious image I reckon I'd be for the theatre?

As often, or nearly always, abdominal surgery will be the only thing that is likely to give you significant diagnostic information and probably you can fix the problem totally, and before you get the histo to the lab.

RE: Unusual Bladder Images

ksg — Sat, 01 Jun 2019 14:24:07 GMT

Hi Thomas,

Viewing your abdominal radiography I have noticed the following:

1. This female cat is obese

2. Moderate and likely significant colonic fecal impaction.

3. Moderate to severe osteophytes on both stifles.

My "penny" of thoughts: look at the bigger picture..

Hope it helps..

RE: Unusual Bladder Images

Thomas Johnson — Sat, 01 Jun 2019 14:04:52 GMT

[quote user="Anthony Todd"]

Surely you've got a plain bladder haemorrhage and a very suspicious abnormality on ultrasound way past my expertise to diagnose.

But, with such an obvious abnormality, it's something to explore surgically? Can you palpate anything?

It isn't a cystitis though, and certainly [for once?] my leaping onto FUS was nonsense 'cos there's no signs.

I'm sure any adult human would have had some sort of large, painful undignified invasion by now but a cystotomy/exlap can't not be the next step, in this case probably to resect that suspicious mass or cyst.

I'm sure you're thinking of that.

[/quote]

What I'm thinking is that if this is a congenital defect and the cat has got to the age of 10 with no previous urinary issues, is it an incidental finding and the cat just needs treatment for the clinical signs of cystitis (stranguria, pollakiuria and haematuria)? If that is the case I don't want to put this cat through a completely unnecessary invasive surgical procedure. Why are you so sure it isn't a cystitis?

RE: Unusual Bladder Images

Anthony Todd — Sat, 01 Jun 2019 13:56:28 GMT

[quote user="Thomas Johnson"]I'm struggling to understand what would cause bladder irritation/haemorrhage without any inflammation. [/quote]

Surely you've got a plain bladder haemorrhage and a very suspicious abnormality on ultrasound way past my expertise to diagnose.

But, with such an obvious abnormality, it's something to explore surgically? Can you palpate anything?

It isn't a cystitis though, and certainly [for once?] my leaping onto FUS was nonsense 'cos there's no signs.

I'm sure you're thinking of that.

RE: Unusual Bladder Images

Thomas Johnson — Sat, 01 Jun 2019 12:40:07 GMT

[quote user="Anthony Todd"]Sounds as if it may just be a bladder irritation/haemorrhage without any "inflammation" [/quote]

I'm struggling to understand what would cause bladder irritation/haemorrhage without any inflammation. Also the main point of my original post is that there is clearly an abnormality in this bladder visible on both the ultrasound and double contrast radiograph, my main concern is whether or not it is contributing to the clinical signs and whether or not I need to do anything about it.

RE: Unusual Bladder Images

Anthony Todd — Sat, 01 Jun 2019 11:52:15 GMT

[quote user="Thomas Johnson"]Two points, one is that you are quoting Jo Dyer, not me, though I do agree with her. The second is that there is no evidence of uroliths, and no crystals were seen in the urine, so no need to change diet.[/quote]

Sorry, my mistake re quotation. So why the diagnosis of "cystitis" if I assume, there were no confirmatory cytology and only blood? Would fit with the ultrasound??

Sounds as if it may just be a bladder irritation/haemorrhage without any "inflammation" or, to be true, crystals..

I hope any crystals weren't not mentioned as they are now "normal"?........

RE: Unusual Bladder Images

Thomas Johnson — Sat, 01 Jun 2019 11:38:35 GMT

[quote user="Michael Woodhouse"]

Of all the antibiotics in the world, why Baytril?

[/quote]

You are right, it probably wasn't ideal to use a fluoroquinolone. I didn't want to use another beta-lactam as there had been no response to co-amoxiclav. I should have used something else, possibly doxycycline.

RE: Unusual Bladder Images

Thomas Johnson — Sat, 01 Jun 2019 11:33:33 GMT

[quote user="Anthony Todd"]

[quote user="Thomas Johnson"]Rightly or wrongly, I always treat cystitis in cats as stress-related/behavioural unless proved otherwise. [/quote]

I know I'm flogging a dead horse again [and again] but why do anything else but change the diet to low Mg and low oxalate and, in multicat environments, free-er access to water?

I'll bet that will always work unless the cat has another secret [neighborly] source of a high Mg and/or oxalate [dried] food.

Why on earth would the obligatory, vital, but always de-emphasised diet, always be necessary in "stress"?

[/quote]

Two points, one is that you are quoting Jo Dyer, not me, though I do agree with her. The second is that there is no evidence of uroliths, and no crystals were seen in the urine, so no need to change diet.