PUPD Dog workup and uncooprative owner

Re: PUPD Dog workup and uncooprative owner

mariette asselbergs — Thu, 09 Jun 2011 17:19:26 GMT

Julie, I have two elderly English Bull Terriers exactly the same! I might even try the eye drops, never thought of it, just accepted the ladies to be a bit on the demented side...

And I like Stephen's practical approach re all the testing, specially in geriatric dogs. The core question is: what treatable possibilities do we have here? The owner is not asking for a prognosis (possibly scared of testing and finding the uncurable thing), but to fix it. So I would agree: Concentrate on the possible fixable options, and - however frustrating this is - forget about the perfect diagnosis in this case.

Mariette

Re: PUPD Dog workup and uncooprative owner

Julie Innes — Mon, 06 Jun 2011 20:53:19 GMT

I was going to say consider DDAVP drops too. I've found a lot of old dogs seem to have problems concentrating their urine (including my own 16yo beagle, who has been thoroughly tested for everything, several times!!) I wonder if it is a bit like the way things "regress" as animals age. I know (from my children!) that it is not uncommon for children to not produce ADH in quantities at night until they are almost 7 yo, leading to night wetting. I've often wondered if perhaps older dogs somehow similarly slow their production of ADH as they age, as I have now seen lots of elderly dogs with no symptoms other than PU/PD and dilute urine, all other tests clear. It's not a proper hypothesis, obviously, but I have wondered about it, but never been able to find any research to back this up- anyone know if this is something that has been investigated??

Re: PUPD Dog workup and uncooprative owner

Stephen Courtney — Mon, 06 Jun 2011 20:21:16 GMT

these cases are a nightmare. Client is not helping but you cannot make them listen, and in this case the dog is not suffering, the owner is. You are not the one cleaning up loads of urine all the time.

You can either work it up some more or trial some treatments, or do nothing and eventually it will be some one else's problem.

If there is truly no option of further investigations ( and you can investigate these up the wazoo and get nowhere) then just try some stuff. I'd do the desmopressin DDAVP drops, intraocular 1 drop twice a day. If this is the best you can do, then making things more complicated is irrelevant, the client won't let you do this properly, just make sure they understand that this is all you can do given the constraints they have placed on you.

Asking for a second opinion, either from another vet within the practice or perhaps a respected vet in a neighbouring town, might be an idea. People can be stupid about the thought of tests, often because they think the dog has 'cancer' and it is pointless.

If you think about the differentials here, there are few really treatable options. i would not use vetoryl without a confirmed diagnosis, but using desmopressin will do no real harm. It is a short acting drug and if there are problems...just stop giving it!

Re: PUPD Dog workup and uncooprative owner

Rob Loxley — Mon, 06 Jun 2011 20:16:06 GMT

[quote user="Andrew Kent"]

[quote user="robloxley"]If you really can't do any further testing then a desmopressin trial would be my next step[/quote]

I think that would be a mistake unless you have more conclusively excluded HyperA

[/quote]

Agreed, but it sounded like further testing was not an option.

Re: PUPD Dog workup and uncooprative owner

Andrew Kent — Mon, 06 Jun 2011 19:21:37 GMT

[quote user="robloxley"]If you really can't do any further testing then a desmopressin trial would be my next step[/quote]

I think that would be a mistake unless you have more conclusively excluded HyperA because often these cases will respond partially to DDAVP even if it is not DI and that complicates the matter even further. These are complicated cases and as others have said communication and managing expectations is key.

Andy

Re: PUPD Dog workup and uncooprative owner

Rob Loxley — Sun, 05 Jun 2011 22:56:12 GMT

[quote user="Kirsten Simpson"]17-OH Progesterone[/quote]

Can you get the lab to run this on the existing pre & post ACTH samples?

[quote user="Louise Alexander"]I can't fix it if I don't know what is wrong. End of. We either continue to find out what is wrong, or we guess and you deal with the urine leakage that occurs in the interim until we get a eureka moment![/quote]

If you really can't do any further testing then a desmopressin trial would be my next step.

Re: PUPD Dog workup and uncooprative owner

Louise6732 — Sun, 05 Jun 2011 22:16:05 GMT

Although there is the obvious clinical issue - PUPD, perhaps the main problem here is communication/owner understanding. If this owner was a joy and did what you asked/accepted everything, would you still be as stressed?

It might be helpful to get a colleague to do a full clinical exam and then have a chat with the owner with you present also? Sometimes people get the message when two vets are saying the same thing (not that I think you've done bad clinical exam, but sometimes fresh eyes spot an answer with your long term puzzle cases!)

Also, just give it to him straight - I can't fix it if I don't know what is wrong. End of. We either continue to find out what is wrong, or we guess and you deal with the urine leakage that occurs in the interim until we get a eureka moment!

Louise

Re: PUPD Dog workup and uncooprative owner

Andrew Kent — Sun, 05 Jun 2011 21:53:53 GMT

I think a urine cortisol:creat in this case would be excellent, not to rule in cushings but to rule it out, in that if negative you have effectively excluded it. Of course if positive you do need further testing. I think potential hyperA cases are very difficult due to the complexities of diagnosis in some cases. Andy

Re: PUPD Dog workup and uncooprative owner

Kirsten Simpson — Sun, 05 Jun 2011 21:15:58 GMT

I discussed the possibility of doing this with the other vet here and it we have thought about it. It's fairly expensive stuff, yes? I watched an Idexx Webinar recently on Adrenal disease and he said to go through ALL the tests before declaring it non-Cushings (Eg ACTH stim then LDDST then 17-OH) before deciding to test or treat for DI :/ He def doesn't want the dog euthed. I have discussed all the causes of PUPD thoroughly many many times with the owner and he just doesn't seem to take anything in. Sigh. I'll have to bite the bullet and ring him tomorrow and discuss through the the options. I'd be loathe to diagnose a do with Cushings from a urine cortisol alone :S Maybe that's just me. Hopefully he'll be ok for further bloods but I dunno.

Re: PUPD Dog workup and uncooprative owner

Kate Richardson — Sun, 05 Jun 2011 21:07:40 GMT

Maybe sit down and have a really good chat about the sort of tests you want to do, as would imagine it won't have to involve a scalpel. Talk about his past experience- it may be that the dog had multiple ga's and surgical procedures or other invasive procedures/investigations previously and he envisions the same happening again, maybe with no definitive answers at the end of the day? You may be able to reassure him that you aren't planning anything invasive, or even a ga, as most PUPD cases don't need such investigations. I think some owners think all investigations are the same regardless of what you are investigating!

Failing that, have you considered Diabetes Insipidus? If you have ruled out the obvious causes (renal disease, UTI, Cushings, liver disease, any change in diet to mean increased salt intake?) then DI a definite consideration and you could consider a trial on desmopressin? We had a very similar case a few months back, ruled out the common causes, owner refused further investigations, and wanted the dog euthanased, but after a chat, was happy to trial desmopression, whilst accepting the risks of a non specific diagnosis, can't remember the exact contraindications for desmopressin, but essentially, responded really well to it, and went on to live happily for another year or so, before being euthanased for something completely unrelated.

Re: PUPD Dog workup and uncooprative owner

CatherineThomas — Sun, 05 Jun 2011 20:14:52 GMT

Maybe you could send urine off for cortisol:creatinine as this is something simple. They don't even need to bring the dog in. And if it does indicate cushings at least thats some evidence to show the owner to try to convince then to continue with further tests

Re: PUPD Dog workup and uncooprative owner

Claire Edgington — Sun, 05 Jun 2011 19:55:22 GMT

Very difficult situation! I would really like to repeat biochem/haem to see if any changes from last time. Was ALKP up last time and that's why you're suspicious of Cushings? LDDST would be very useful to do. Any other clinical signs? If everything was normal what about water deprivation test to check for DI? Very difficult if o doesn't want to do anything. I can see a very frustrating conversation on the horizon.........