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Compendium November 2012 (Vol 34, No 11)

Clinical Snapshot: Signs of Lower Urinary Tract Disease in a Cat

by Alexander M. Piazza, BS, Jane E. Keegan, DVM, David A. Allman, DVM

    Case Presentation—Part 1

    A 2-year-old, neutered domestic shorthaired cat was referred to Michigan State University Veterinary Teaching Hospital (MSU-VTH) for signs of lower urinary tract disease. The cat, which was adopted 5 months before presentation, had been a stray. The owners reported that the cat would show slight discomfort when it was picked up and when its left pelvic limb was handled. One month before presentation to MSU-VTH, the cat was castrated by the referring veterinarian. After castration, the cat was kept indoors for the first time, and dysuria, pollakiuria (intervals of 20 to 30 minutes), stranguria, and hematuria were noticed immediately. The cat was reexamined by the referring veterinarian and treated with a 1-week course of an antibiotic that the owners could not identify. The clinical signs failed to resolve, and the cat was referred to MSU-VTH, where ultrasonography was performed (FIGURE A).

    Figure A. Ultrasonographic transverse image of the urinary bladder.

    1. What are the likely diagnostic differentials for cats with the presenting clinical signs in this case?

    2. What diagnostic tests should be performed?

    3. What is unusual about Figure A?

    Answers and Explanations—Part 1

    1. Studies in North America and Europe indicate that the most common lower urinary tract diseases in young to middle-aged cats are idiopathic cystitis (~65%) and urolithiasis (~25%). Conditions encountered less commonly include bacterial urinary tract infection, congenital anomalies, neurogenic disorders, neoplasia, and trauma.1,2

    2. Recommended diagnostic tests include a complete blood cell count, a serum chemistry panel, urinalysis with culture, abdominal radiography, and urogenital ultrasonography. Diagnostic tests should be prioritized based on the most commonly encountered differentials given a patient’s signalment and clinical presentation. Combined, a complete blood cell count, serum chemistry, and urinalysis with culture provide data that can be used to rule out many metabolic, physiologic, or endocrine disorders. Similarly, abdominal radiography provides valuable information about abdominal organ health and can identify the presence of radiopaque material in the urogenital system. In contrast to abdominal radiography, urinary bladder ultrasonography is sensitive for detecting radiolucent or small uroliths, masses, wall thickening, and ureteroceles. In this case, ultrasonography of the urinary bladder was conducted first because of a high suspicion of feline lower urinary tract disease.

    3. FIGURE A shows an oblong, irregularly shaped, hyperechoic structure measuring 1.03 cm in length within the urinary bladder (white arrow), as well as echogenic material adjacent to this structure (yellow arrow).

    Figure A. Ultrasonographic transverse image of the urinary bladder. White arrow: Metal foreign object measuring 1.03 cm located within the lumen of the urinary bladder. Yellow arrow: Organized echogenic region suggestive of a blood clot or sediment formation.

    Case Presentation—Part 2

    After identification of a hyperechoic structure with posterior shadowing, abdominal radiography (FIGURES B and C) was performed to further evaluate the composition, size, and number of the objects in the lumen of the urinary bladder. Retrospectively, abdominal radiography alone would have been sufficient to diagnose this unique problem.

    Figure B. Right lateral and dorsoventral abdominal radiographs. White arrows: Metallic opacity, consistent with metal shrapnel, in the urinary bladder. Yellow arrows: Small metallic opacities consistent with a shrapnel trail leading toward the urinary bladder.
     

    Figure C. Craniocaudal and lateral left pelvic limb radiographs. White arrows: The proximal diaphyses of the tibia and fibula are moderately widened with a moderate amount of smooth, homogenous bony proliferation. Multiple pinpoint to moderate-sized, irregularly shaped metallic opacities are present in the soft tissues caudomedial to the distal femur and around the tibia. Yellow arrows: The largest metallic fragment (0.7 × 0.6 cm) is in the superficial soft tissue along the distolateral fibula.

    4. Based on Figures A, B, and C, what is your diagnosis?

    5. What is the recommended treatment protocol?

    Answers and Explanations—Part 2

    4. In addition to the structures indicated by the arrows in FIGURE A, the cranioventral portion of the bladder wall is moderately thickened at 0.7 cm (approximately 0.3 cm is considered normal). These findings suggested that there were a foreign object and an adjacent blood clot or sediment within the lumen of the urinary bladder. Diagnostic differentials for these findings include urolithiasis and foreign object with secondary chronic cystitis.

    FIGURES B and C both show a rounded, irregularly shaped metallic opacity overlying the urinary bladder. (All other intraabdominal organs were radiographically unremarkable.) Several smaller metallic opacities are distributed throughout the soft tissue and caudal-medial muscle bellies of the left pelvic limb. FIGURE C shows a smoothly margined region of periosteal proliferation over the proximal diaphysis of the left tibia. Also within this region are variably sized, irregular metallic opacities within the bone and surrounding soft tissues. These findings suggest a healed comminuted proximal left tibial fracture secondary to a gunshot wound, with shrapnel remaining within the lumen of the urinary bladder, along the length of the tibia, and within the soft tissue around the femur.

    The findings are most consistent with a single gunshot wound leading to tibial fracture and a ruptured urinary bladder. Subsequent spontaneous resolution of the tibial fracture and urinary bladder rupture were suspected, along with signs of lower urinary tract disease resulting from shrapnel.

    5. Gunshot wound severity depends on the kinetic energy of the projectile at impact and the total energy absorbed by the patient. Maximum kinetic energy absorption occurs when the bullet comes to rest in the patient’s body.3 Tissue density and thickness affect the amount of kinetic energy that can be absorbed, with large bones absorbing the greatest amount. When a projectile impacts bodily tissues, deceleration and transfer of energy occurs, with destructive consequences. Because laboratory abnormalities are related to the specific tissues that are injured, no pathognomic laboratory findings (serum chemistry or blood gas profile) for gunshot wounds exist. A complete blood cell count, serum chemical profile, packed cell volume, total solids measurement, and urinalysis are the recommended minimum database.4 Gathering this minimum database enables the clinician to identify and address potential sequelae of the gunshot wound. Conventional critical care techniques should be employed to stabilize severely injured patients.

    At a minimum, orthogonal view radiographs should be taken of the region(s) of the projectile’s entry, path, and exit.3 Additional diagnostic imaging modalities, including ultrasonography and computed tomography, can be helpful in determining the extent of soft tissue or bony involvement. It is recommended that easily retrievable metal fragments be removed and appropriate wound management be implemented.5 The removal of metal fragments should be based on fragment size and location and the patient’s overall status. Large metal fragments within synovial fluid have been reported to be a source of infection and lead poisoning.5

    Treatment for this case consisted of a cystotomy to remove the large metal fragment from the urinary bladder.6–9 A blood lead concentration was measured before removal of the fragment to evaluate for lead toxicosis. Aerobic and anaerobic cultures of the bladder mucosa were performed to evaluate for potential chronic urinary tract infection.10 The blood lead concentration test revealed a blood lead concentration of 21 ppb, which is within the expected normal range for cats.11 The cultures identified the presence of Staphylococcus epidermidis sensitive to cephalexin. The patient was prescribed a 10-day course of cephalexin and a 3-day course of buprenorphine. During follow-up examinations performed at MSU-VTH 2 weeks and 1 year postoperatively, the cat was noted to be healthy with no signs of urinary tract disease.

    References

    1. Gerber B, Boretti FS, Kley S, et al. Evaluation of clinical signs and causes of lower urinary tract disease in European cats. J Small Anim Pract 2005;46:571-577.

    2. Lekcharoensuk C, Osborne CA, Lulich JP. Epidemiologic study of risk factors for lower urinary diseases in cats. J Am Vet Med Assoc 2001;218:1429-1435.

    3. Pavletic MM. Gunshot wound management. Compend Contin Educ Pract Vet 1996; 18(12):1285-1299.

    4. Pavletic MM. A review of 121 gunshot wounds in the dog and cat. Vet Surg 1985;14:61-62.

    5. Dillman RO, Crumb CK, Lidsky MJ. Lead poisoning from a gunshot wound. Am J Med 1979;66:509-514.

    6. Fossum TW. Surgery of the bladder and urethra. In: Fossum TW, ed. Small Animal Surgery. 2nd ed. St Louis: CV Mosby; 2002:572-609.

    7. Greenberg CB, Davidson EB, Bellmer DD, et al. Evaluation of the tensile strengths of four monofilament absorbable suture materials after immersion in canine urine with or without bacteria. Am J Vet Res 2004;65(6):847-853.

    8. Osborne CA, Kruger JM, Lulich JP. Feline lower urinary tract diseases. In: Bojrab MJ, Monnet E, eds. Mechanisms of Disease in Small Animal Surgery. Jackson, WY: Teton NewMedia; 2010:393-402.

    9. Waldron DR. Urinary bladder. In: Slatter D, ed. Textbook of Small Animal Surgery. 3rd ed. Philadelphia: WB Saunders; 2003:1629-1637.

    10. Burrows CF, Bovee KC: Metabolic changes due to experimentally induced rupture of the canine urinary bladder. Am J Vet Res 1974;35(8):1083-1089.

    11. Puls R. Mineral Levels in Animal Health: Diagnostic Data. Clearbrook, BC: Sherpa International; 1994.

    References »

    NEXT: Equine Laparoscopy: Abdominal Access Techniques

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