scott@vtx-cpd.com
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Replying to Liz Bode 29/11/2024 - 08:09
Thanks for your thoughts!
I probably think more about albumin than I should!
Scott x
Replying to Jenny G. 29/11/2024 - 12:25
Thank you again Jenny.
Scott 🙂
Hi Valeria,
Thanks so much for your question! You’re absolutely right that diazepam has been used successfully in some cases to address functional obstructions, likely caused by urethral spasms. When administered intravenously as a single dose, it can be a helpful tool, especially in resource-limited settings where catheterization might not be an option. That said, the risk of idiosyncratic hepatotoxicity in cats, although rare, is a real concern, particularly with oral or repeated dosing. The key is selecting cases carefully, discussing the risks with owners, and limiting its use to short-term scenarios.
It sounds like your experiences align with situations where diazepam has been effective in addressing spasm-related obstructions. For these cases, it’s likely not just luck, as relaxation of striated muscle in the urethra can definitely make a difference. However, when true physical obstructions like plugs or calculi are present, diazepam alone won’t solve the issue and could delay necessary intervention, like catheterization or flushing.
In cases where catheterization isn’t possible, there’s a validated alternative protocol you might find interesting. A study by Cooper et al. (2010) found success using a combination of acepromazine, buprenorphine, medetomidine, decompressive cystocentesis, and a quiet environment to manage urethral obstruction without catheterization. This protocol allowed 73% of cats to urinate spontaneously within 72 hours. While it’s not perfect, as some cases did experience complications, it’s a great option to consider, especially in low-income settings.
As an alternative to diazepam, have you considered midazolam? It offers similar muscle relaxant properties but has a shorter duration of action and may present a lower risk profile in certain cases. Its use could be worth exploring, especially in situations where you’re cautious about diazepam’s hepatic side effects.
I hope this helps! Let me know if you’d like any more info or references.
Best regards,
Scott
Replying to Valeria Bergomi 27/11/2024 - 15:20
No problem!
I am looking at you post about diazepam in cats now!
Let me know if you have any other questions.
Scott 🙂
Thank you so much for sharing!
Scott 🙂
Replying to Talia C. 24/11/2024 - 20:40
Dear Talia,
Thank you for your reply! It sounds like you have a very systematic and thorough plan in place, which is great for these tricky cases. You’re absolutely correct in your understanding of the response to desmopressin (synthetic ADH). The diagnostic utility of a DDAVP trial lies in its ability to differentiate between central diabetes insipidus (CDI), nephrogenic diabetes insipidus (NDI), and psychogenic polydipsia (PD), as you outlined. A marked increase in urine concentration, with a urine specific gravity (USG) above 1.025 or a rise of over 50% from baseline, strongly supports CDI. In contrast, only minimal improvement in USG is expected with NDI because the kidneys are unresponsive to ADH. Dogs with psychogenic polydipsia may show a mild reduction in urine output and water intake as plasma osmolality normalizes, but this response is often subtle.
The morning USG of 1.028 does introduce some complexity. While it suggests some ability to concentrate urine, it doesn’t entirely rule out CDI, as partial CDI cases may show intermittent concentrating ability. Similarly, primary polydipsia can also present with variable USG patterns, making it challenging to differentiate between the two based on USG alone.
If there is still concern about being “stuck” between NDI and primary PD, adding SDMA testing and advanced imaging are excellent next steps to rule out subtle renal disease or structural abnormalities. Iohexol clearance testing could also be considered, as it provides a precise measure of glomerular filtration rate (GFR) and might uncover early renal dysfunction not evident on routine tests. Monitoring USG at different intervals, particularly during periods of water restriction if feasible, may also help establish a clearer pattern of water handling and concentration ability.
The planned full abdominal ultrasound is an important step and will help exclude other systemic causes, particularly structural or functional abnormalities that could impact water balance. Chronic conditions, such as low-grade inflammation or mild endocrine issues, could also contribute to her clinical signs and would benefit from this thorough evaluation.
If you proceed with a DDAVP trial, I recommend carefully monitoring water intake and USG over several days before and after administration. While this won’t definitively distinguish between all potential causes, it often provides enough diagnostic clarity to inform further management or investigations. Please let me know how she progresses following the ultrasound and any additional testing.
Best regards,
Scott
This is so helpful!
Thank you for sharing. I hope everyone is having a wonderful (ulcer free) weekend!
Scott 🙂
Replying to Lesley M. 22/11/2024 - 22:36
Thank you so much and thank you again for sharing via email.
I will make sure to post here!
Scott 🙂
Replying to Lara Brunori 18/11/2024 - 13:36
Hi Lara,
Thank you again for your response. I wanted to provide an update with additional details. We checked ionized calcium, and it was marginally increased at 1.40 mmol/L (reference: 1.13–1.38 mmol/L). This might be age-related as Siichba is still a growing kitten, but we’re keeping it in mind. To help manage this and potentially reduce calcium excretion into the urine, we’ve recommended adding 1 gram of bloomed chia seeds daily to Siichba’s diet.
Based on the findings and concerns for stone formation, we suspect struvite stones as the most likely culprit given Siichba’s age (<6 months). We’ve initiated a therapeutic diet starting with feline c/d for two weeks, transitioning to feline i/d, which is nutritionally complete for kittens and designed to manage urinary health while preventing recurrence. We’re monitoring closely for any signs of worsening hydronephrosis or ureteral obstruction, as these could progress to renal insufficiency or failure. Currently, the blood work does not suggest renal dysfunction, but we are being proactive in case this changes.
Pending the repeat urine culture results via cystocentesis, we’ll decide on whether to continue antibiotics or adjust based on sensitivity findings. Regular rechecks, including imaging and urinalysis, will help us track changes in the stones’ size, position, and composition.
Your point about considering minimally invasive techniques like lithotripsy is well-taken—it would certainly be ideal if dissolution fails or calcium oxalate stones are confirmed. I’d love to hear your thoughts on this plan and any further suggestions you might have!
All the best,
ScottReplying to Talia C. 18/11/2024 - 07:46
Dear Talia,
Thank you for sharing your experience and for providing such a detailed breakdown of cystinuria genetics! The case of your miniature Bull Terrier is a great example of how combining chemical and surgical castration with dietary management can lead to excellent outcomes. It’s encouraging to hear that voiding hasn’t been needed for over a year—a testament to the success of the combined approach!
The information you found on the genetic aspects of cystinuria is fascinating and adds depth to our understanding of the condition. The distinctions between different types of cystinuria (e.g., Type I, II, III) and their inheritance patterns really highlight how diverse and complex this condition can be, particularly when androgen dependency comes into play.
Thanks again for sharing this!
Best regards,
Scott 😊
Replying to Talia C. 18/11/2024 - 07:25
Dear Talia,
Thank you for your thoughtful message and for sharing your experiences! It’s always fascinating to hear perspectives from different regions, and it seems cystoliths are a universally challenging topic! I’ll do my best to address your points below:
Mixed Cystoliths
Your example of the pug with a history of PSS and mixed struvite-urate stones highlights just how unpredictable these cases can be. Mixed stones are particularly frustrating because they defy straightforward dissolution protocols and often require multifaceted management. In these cases, I try to focus on minimizing recurrence through individualized dietary and urinary pH strategies, though success can be limited by the complex interplay of factors.Retrograde Hydropropulsion
I completely agree—retrograde hydropropulsion is a fantastic tool, especially for managing small stones and avoiding repeated cystotomies. I’ve found it to be particularly useful for recurrent cases, provided the stones are small and accessible. Your point about timing the procedure when stones are very small is critical to its success, and it’s great to hear it’s working well in your practice.Calcium Oxalate (CaOx) Stones
CaOx stones are indeed a challenge, especially in dogs, as there’s no effective dissolution strategy. I sympathize with the frustration of recurrent cases, particularly in compliant owners doing everything right. For these patients, I emphasize regular monitoring with imaging (as you already do), ensuring a low urine specific gravity (USG <1.020 ideally), potassium citrate is often helpful if tolerated, though I understand the dilemma with diarrhea in some cases. In such instances, exploring alternative alkalinizers might be worth a try. Hydrochlorothiazide as a diuretic may help in reducing urinary calcium excretion, though it requires careful monitoring for side effects. It’s always a balancing act, but I find client education about the likelihood of recurrence helps manage expectations.Cystoscopy and Antibiotic Use
Cystoscopy can be invaluable in chronic or refractory UTI cases, as your example demonstrates. The narrowed urethra you found is a great illustration of how underlying anatomical issues can perpetuate UTIs. Whether to repeat cystoscopies is a really interesting question. I think a lot of the time we don't get to repeat these procedures because of financial constraints for the owners. It also depends on what we’re looking for. If we’re just visualizing generalized inflammation, I’m not sure a repeat cystoscopy is always warranted. On the other hand, if we’re biopsying inflammatory areas and the problem isn’t resolving with our treatment, that might justify repeating the cystoscopy. In many cases, I think we’re addressing the inflammation we see and ruling it out as the cause of the problem.UTI and Prednisolone
Chronic immunosuppression is always a tightrope walk in these cases. For patients like your Frenchie with recurrent UTIs due to incomplete bladder emptying, I often consider the following: bladder management, encouraging manual expression or intermittent catheterization if incomplete emptying is severe; antibiotic stewardship, regular cultures to guide targeted therapy, and I sometimes use prophylactic low-dose antibiotics if the recurrences are frequent and clinically significant; corticosteroid dose, if possible, I aim to taper to the lowest effective dose. In combination with leflunomide, it might be worth evaluating whether the steroid dose could be reduced further; adjunctive measures, cranberry extract, D-mannose, or other supportive therapies. Regarding urinary tract infections and steroid use, I think it really depends on the case. With the French bulldog you’re describing, could you consider interventions to help the dog empty the bladder better? Residual bladder volume is definitely an issue in cases like this. Could you consider a drug such as bethanechol to improve detrusor muscle contractility or other medications to help with bladder emptying? Addressing incomplete bladder emptying may significantly reduce the risk of recurrent infections.Thank you again for your kind words and for taking the time to share your cases and thoughts.
Warm regards,
Scott
Replying to Laura Jones 18/11/2024 - 11:29
Thank you again pal!
We appreciate you!!!
Scott 🙂
Replying to Talia C. 18/11/2024 - 16:53
Thing is…
This case is doing really well! I suppose it is challenging as it is very expensive and there is not a huge amount of evidence out there.
The owners are very dedicated and happy to continue with the treatment. It is not a treatment I would have started, but if the patient is doing well, it is hard not to justify continuing for now.
Scott 🙂
Replying to Talia C. 18/11/2024 - 17:06
Dear Talia,
I hope you are well!
Thank you for your detailed case description—this is indeed a challenging situation, and it’s great that you’ve already ruled out hyperadrenocorticism.
Primary Polydipsia vs. Other Causes:
Primary polydipsia (PD) can be difficult to confirm, especially in a multi-dog household where water intake cannot be accurately monitored. The USG variation in this case is interesting—morning concentration suggests some renal concentrating ability, but the subsequent low values during the day raise concerns about inappropriate diuresis.
While the morning USG of 1.028 shows some concentrating ability, it is still not maximally concentrated (e.g., >1.040).
The marked decrease in USG during the day suggests either significant water consumption or a potential inability to concentrate due to an underlying cause.Given she is intact, consider whether hormonal factors related to her recent heat in May 2024 could play a role. While pyometra seems unlikely based on your ultrasound findings, conditions like oestrogen influence on the kidneys may contribute to altered water balance? It might be worth repeating the ultrasound. Could there be something more subtle happening in the uterus.
To further investigate the cause of her PU/PD, advanced imaging such as an abdominal ultrasound and thoracic radiographs would be logical next steps. These could help identify any occult disease or structural abnormalities contributing to her clinical signs, particularly given her history of recurrent UTIs. Alongside imaging, a desmopressin (DDAVP) trial would be a non-invasive way to explore the possibility of central diabetes insipidus (CDI). If her urine becomes concentrated after desmopressin administration, this would support a diagnosis of CDI.Additional diagnostic options include measuring SDMA (symmetric dimethylarginine) to detect early renal dysfunction, which may not be apparent on routine biochemistry. Iohexol clearance testing could also be considered as a precise method for assessing glomerular filtration rate (GFR) if renal insufficiency remains a concern. Evaluating her renal function through a urine protein-to-creatinine ratio (UPC) would provide further insight into any subtle renal disease not evident on bloodwork or routine urinalysis.
Even though a water deprivation test is often used to differentiate between primary polydipsia, CDI, and nephrogenic diabetes insipidus (NDI), I would avoid this in her case due to the risk of dehydration and the availability of safer diagnostic approaches. This combination of imaging, targeted renal assessments, and a DDAVP trial offers a systematic and minimally invasive pathway to better understand her condition.
Does that make sense?
Scott 🙂
Replying to Lesley M. 18/11/2024 - 23:03
This is really helpful!
Do you have the link for the article? I am not able to find it.
Super helpful though, thank you for sharing. It does seem high no? Especially when we are often just talking about the ingestion of one or two grapes?
Scott 🙂
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