Loobani AcademyAbstract
The urinary system plays an vital role in excretion of the waste products and maintenance of electrolyte balance.The urinary disease can cause metabolic disturbances and derangements of fluid, electrolyte, and acid-base balance by any changing of pathology of the urinary system.It is too important to have a right diagnosis in the clinical.Radiography examination include Ultrasound (US) and X-ray are the most usually used clinical method for diagnostic urinary tract disease in dogs, as they are easy to perform to owners, inexpensive and provides excellent contrast resolution in clinical. Ultrasound is furthermore useful for guiding interventional procedures,which is more useful than X-ray some time.The urinary bladder is ideally suited for sonographic examination,we will also take urethral catheterization by it. In the urinary system It may have various differential diagnosis such as cystic neoplasm，cystic calculi and cystitis. Urinary tract infection is common in dogs especially in females,which is most often reporting the result of ascending fecal bacterial contamination of the vulva, perivulvar skin, vestibule.Treatment is easily to be taken under a right diagnosis and the prognosis can be depended on the ultrasonography which can judging the abnormalities of urinary bladder either in its wall or in the density of urine.
Key words: cystitis,cystoliths,diagnosis，
1.Basic information
Name: DA MA
Breed: Maltese
Sex: Female (castrated)
Age: 1.5 years old
Body weight: 14.7kg
History: regular vaccination and deworming on time
2. Before therapy
Upon initial presentation，the dog started to appear lethargic and weak.The pollakiuria and hematuria was noted in recent days.Regular vaccination and deworiming are giving on time，and eat commercial foods for DA MA.Without any changing with the symptoms，owners took her to the hospital.
3. Physical examination
The physical examination revealed a moderate distended and mild painful in the abdominal palpation.Heart rate was 110bpm.Respiratory rate was 30 per min.Temperature was 38.6℃.a prolonged（>2s）capillary refill time(CRT),and the presence of white foam on the tongue.It’s seemed to be no evidence of of foreign body in the abdomen.
4.Laboratory examination
4.1 Complete Blood Count（CBC）examination
Table 1 The result of the CBC examination
Project | Result | Reference Range |
WBC | 20 | 6-17×109/L |
RBC | 6.28 | 5.5-8.5×1012/L |
HGB | 145 | 120-180g/L |
HCT | 42.8 | 37-55% |
MCV | 66.7 | 66-77fL |
MCH | 21.5 | 19.9-24.5pg |
MCHC | 342 | 300–360g/L |
PLT | 496 | 200-500×109/L |
LYM% | 6.0 | 12–30% |
OTHR% | 82.5 | 60-77% |
EO% | 3.8 | 2–10% |
LYM | 1.9 | 1.5-4.8×109/L |
OTHR | 21.6 | 3–11.5×109/L |
EOS | 1.0 | 0.1-1.25×109/L |
4.2 The result of the CRP examination
Project | Result | Reference Range |
CRP | 91.2 | <20mg/L |
CBC examination showed a obvious elevated of the white blood cells in patient,preliminary with the neutrophilic granulocyte.It may suggesting the highly possible existence of infection and inflammation.
The result of the CRP infer there was acute sever inflammation in the body,which was consistent with the result of CBC examination.
4.3 Idexx Catalyst biochemistry CHEM15
Table. 3 The result of the biochemistry CHEM15
Project | Result | Reference Range |
GLU | 5.31 | 3.89-7.95mmol/L |
CREA | 566 | 44-159umol/L |
BUN | 28.4 | 2.5-9.6mmol/L |
BUN/CREA | 5 |
|
PHOS | 2.31 | 0.81-2.2mmol/L |
CA | 2.12 | 1.98-3mmol/L |
TP | 75 | 52-82g/L |
ALB | 28 | 22-39g/L |
GLOB | 45 | 25-45g/L |
ALB/GLOB | 0.62 |
|
ALT | 233 | 10-125U/L |
ALKP | 200 | 23-212U/L |
GGT | 5 | 0-11U/L |
TBIL | 12 | 0-15umol/L |
CHOL | 6.13 | 2.84-8.26mmol/L |
Biochemistry CHEM15 examination findings showed significant azotemia and hyperphosphorus, combined with physical examination and the symptom of the patient, suggested the possibility of urinary disease which was trigger by the pre or postreanl azotemia.Alanine transaminase was significantly increased,it may infer there was cells injury in the body.The result of ALKP，GGT and total bilirubin were not significantly increased.Cholesterol was normal.
4.4 X-ray examination
Picture 1.Moderately to markedly radiopaque markings were found in the abdomen of patient.（VD radiograph）
Picture 2. Moderately to markedly radiopaque markings were found in the abdomen of patient. – lateral radiograph
4.5、Ultrasonic examination
Ultrasonic findings：
- The bladder was fullin the examination, with the size of 3.37cm*1.41cm*2.43cm. The echo of the bladder wall was decreased with a low echo performance, thickness was about 0.19cm. There were high echo gritty suspended objects in the bladder, and several high echo liner with posterior acoustic.
- The bilateralof kidneys outline wereclear, with a length of 2.62cm (left) and 2.67cm (right). The cortex showed moderate echo, the medulla showed low echo, and the cortical medulla was clearly demarcated. Doppler flow signal was distribution visibly in the image. No obvious dilatation was observed in renal pelvis and ureter.
Ultrasound diagnosis:
1.The decreasing of echo of bladder wall was indicating the cystitis;
2.High echoic suspension in the bladder, which were suspected of bladder crystallization;
3.Bladder stones (approximately at least three, the size of the largest one was about 1.31cm*0.85cm)
5.Diagnosis
Urolithiasis, cystitis
6.Treatment
6.1. Physical Urolith Removal
6.2. Antimicrobial Therapy:Ampicillin 25 mg/kg PO, IV, SC q12h
6.3. Calculolytic Diet Therapy:Hill’s Prescription Diet s/d.
In this case, the urinary obstruction did not happen.But it was necessary to remove the stones by surgical method to prevent urinary obstruction especially considering the size of stones (obstruction position can be found in renal pelvis, ureter, or urethra); when medical dissolution therapy fails; and for unacceptable clinical signs associated with urolithiasis.Antimicrobials are essential for treating infection-induced struvite uroliths.
Canine diets available for struvite dissolution include Purina Pro Plan Veterinary Diets UR Urinary St/O, and Royal Canin Veterinary Diet Urinary SO.Hill’s s/d is not intended for long-term maintenance nutrition. It must be used cautiously in young patients (i.e. because of reduced protein); in patients with hypertension and cardiac disease (i.e. because of increased sodium content); and in patients with history of pancreatitis (i.e. because of increased lipid content).Decreased BUN and albumin as well as increased ALP can occur in patients receiving Hill’s s/d.
After the physical removal，the patient was recovery and its urination was normal，but the diet therapy must be insisted at least 3 months and according the result of the symptom and urine examination.
7.Conclusion
Definition
Urolithiasis is one of a urinary disease which means one or more stones (uroliths) in the urinary tract. Uroliths can be found in the upper urinary tract (i.e. renal pelvis, ureter) and/or lower urinary tract (i.e. urinary bladder, urethra). Approximately 97% of uroliths occur in the lower urinary tract.
The most common of urolithiasis is struvite uroliths，which are composed of magnesium ammonium phosphate hexahydrate.Struvite uroliths occur most often in the urinary bladder and urethra, but they can occasionally be found in the upper urinary tract of dogs and rarely in cats.
Etiology and Pathophysiology
According to research, uroliths form with sustained alterations in urine which promote supersaturation of certain substances. Eventually, crystals form, which can become an organized stone.There is a Possibility that the factors involved in urolith formation consist of pH, mineral concentration of urine.Besides,inhibitors and promoters of urolith formation，complexors and macrocrystalline matrix are the factors too.Struvite uroliths can be infection-induced or sterile. In dogs，the most common form that inducing struvite urolithiasis is infection, whereas sterile struvite urolithiasis is more usual to be found in the cat.
Prevalence
According to various studies, struvite uroliths are currently either the most common urolith isolated from dogs or are a close second to calcium oxalate uroliths.Struvite uroliths accounted for 53.4% of canine uroliths submitted over a 19-year period in a report from the USA.Struvite uroliths accounted for 43% in a study from the UK and 32.9% in a study from Spain and Portugal.One study from Canada reported that 35.8% of all uroliths submitted from 1998-2014 were struvite uroliths.In a report from the Netherlands, struvite uroliths made up 40.9% of all submissions.Struvite uroliths accounted for 41% of all uroliths submitted from dogs to the Minnesota Urolith Center in 2007.Note that over time, incidence of canine struvite urolith submissions have declined, while calcium oxalate submissions have increased.Struvite uroliths accounted for approximately 75% of canine submissions in 1985.
Signalment
A Single struvite urolith is the most commonly diagnosed in young and adult dogs. They are also the most common type of urolith diagnosed in dogs <1 year of age.1 Struvite uroliths are more likely to form in female dogs than males. Approximately 71-85% of struvite uroliths submitted are from females.Small and toy breeds are more likely to be affected than large breed dogs.Breed predispositions include the cocker spaniel, miniature poodle, miniature schnauzer, shih tzu, lhasa apso, Pekingese, dachshund, and bichon frise.Some studies have also reported increased prevalence in the golden retriever, Labrador retriever, Bernese mountain dog, Saint Bernard, and rottweiler.Clinical Signs in some patients with struvite urolithiasis are asymptomatic. Hematuria, pollakiuria, stranguria, urinary incontinence, dysuria, vomiting, fever, dehydration, lethargy, depression, abdominal pain, vocalization, and/or collapse may be noted.
When to Suspect Struvite Stones？
Bladder stones come in several mineral compositions. The most common stone types are oxalate and struvite.Because of the treatment is different for each type, it is crucial to determine the stone type. The stone type can be confirmed by stone analysis if a sample stone is available (either passed naturally or obtained via surgery). Laboratory analysis is a easily way to determine the content of the stone and even determine what the stone consists of. Without a sample stone, there are still some hints which can be obtained through other tests like microscope examination.As mentioned, struvite stones in dogs are almost always formed because of the nature of urinary changes occur with specific types of bladder infection: Staphylococcal is the first commonly infection bacterial but occasionally a Proteus infection. If a urine culture from a patient with a bladder stone should grow either staph or proteus, this would make struvite more likely than oxalate. Also, struvite requires an alkaline pH environment to form while oxalate requires form in an acid pH; urine pH is a key part of any urinalysis and thus provides another clue as to the stone’s identity.An well educated infer is better than nothing but does not replace the analysis of a stone. Do not forget that a stone of one type forms around a stone of another type occasionally . So a complete urinary or stone analysis is needed to effectively prevent recurrence.
The choice of the treatment
Struvite stones can be removed surgically with a technique called Cystotomy，and the other way is voiding urohydropropulsion in some cases; removed with a cystoscope (if they are small enough); or dissolved by diet. Stone dissolution with diet is the least invasive compared with the other ways and probably the best option unless the patients needs a faster treatment, considering if there is risk of urinary obstruction in a male dog in the future.
Dietary therapy is a medical treatment to prevent new struvite stones is of secondary importance in dogs (except the English Cocker spaniel, for which this is reported a hereditary metabolic problem rather than infection). The focus is on preventing infection. If the dog has a history of struvite bladder stones, we should discuss long-term monitoring to the owner and understand what schedule of testing is best for their dogs. During the time,we will expect periodic urine cultures.And emphasizing therapeutic diet must be the only food fed till the stone is completely dissolved. Antibiotic drugs are always needed as long as stones are in the bladder because of the existence of the bacteria in stones. Every 4 to 6 weeks, new radiographs should be taken to evaluate the stone size and if is at least 20 percent smaller than initial size, the process can be continued. A urinalysis is checked to be sure the proper urinary conditions for dissolution are being created by the dietary therapy.In the reported that the average are needed to dissolve the stone is 2 to 3 months, but the therapy should be continued for a month after the stones are no longer visible on the radiography examination since small stones may not be large enough to find.Microscope examination can be taken to check in this situation to have a more accurate result.If the infection has been controlled ,small stones can be dissolved in as short a time as a few weeks.
What should we pay attention after the treatment？
Many pet owner will focus on the recurrence of their patients.After stones are removed one way or another, the focus shifts to prevention. Usually the patients are predisposed to a bladder infection somehow, means they are also inclined to form more struvite bladder stones. A stone can form as quickly as two weeks after infection if a urease-positive bacterium sets in.After surgery, antibiotics must be continued until the infection is confirmed to have cleared (i.e. a negative urine culture is obtained). After this, a follow-up schedule of radiographs and/or urine testing is recommended. For a single stone episode in some dogs , only follow-up visits for many times may be necessary. Realize that some individual dogs are exactly predisposed to recurring infections in bladder and they may form new struvite stones again and again. Obviously, if the stones recur, a more regular monitoring schedule would have to be revised.Dietary therapy in the prevention of struvite stones is of secondary importance in dogs. The main focus is on preventing infection. If your dog has had a history of struvite bladder stones, make sure to discuss long-term monitoring and understand what testing schedule is best for your dog. Expect periodic urine cultures to be needed.
