The Stone’s Story

D. E. Larsen, DVM

Raymond came through the door with little Sophie cradled in the crook of his arm. Sophie was a really small Chihuahua, and Raymond, her owner, was a large man. It was one of the things that I always found a little odd. Some of the largest men were attached to these tiny dogs.

After he stretched a towel out on the exam table, Raymond placed Sophie in the middle of the towel. Sophie, at four and a half pounds, was overweight. Her spindly legs looked undersized for her round body.

“She has blood in her urine, Doc,” Raymond said. “And she pees a little puddle every 5 or 10 minutes. The wife is getting upset with all the cleaning up after her.”

I looked at Sophie, her gray muzzle told she was past middle age. She should probably weigh two and a half pounds, not four and a half. Her membranes were normal, with normal capillary refill time. Heavy tartar on her teeth and some chronic periodontal disease suggested that she was a good candidate for a heart murmur. That was confirmed when I placed the stethoscope on her chest.

Chronic periodontal disease leaks bacteria into the bloodstream. These circulating bacteria take up residence on the heart valves, in the kidneys, and the liver. Poor dental hygiene, most common in small dogs on pampered diets, leads to all sorts of significant health complications.

She was heavy enough that it was difficult to palpate her abdomen accurately. But when my fingers reached the posterior abdomen, I bumped a hard firm bladder. Sophie immediately squatted and peed a small puddle of bloody urine onto the towel.

“Raymond, we are going to have to pick up the towel so I can get some urine off the tabletop,” I said as I lifted Sophie up so Raymond could remove the towel.

I sat Sophie down and felt her bladder again, more carefully this time. There was a large stone in the bladder. I could feel some movement in the stone, probably a couple of stones. They were large, making the bladder feel full, but there was little room for urine. Sophie squatted again, depositing a small puddle of bloody urine on the exam table.

I drew the urine into a syringe and placed a small drop on a microscope slide. A quick look at the slide under the microscope showed the blood but also many bacteria and struvite crystals.

Struvite stones were the most common type of bladder stones in the dog at that time. Struvite stones in the dog are caused by a urinary tract infection that leads to acidity changes in the urine, crystal formation, and then the development of stones. These stones grow with time. In male dogs, they often cause urinary tract obstruction as the small stones try to pass down the urethra. That seldom happens in the female.

Today there are diets that can dissolve struvite stones in the bladder. That was not the case in the 1970s and 80s. Stones as large as Sophie’s, are best removed by surgery, even today.

“Raymond, Sophie has a large stone, or more likely 2 or 3 large stones in her bladder,” I said. “These are caused by an infection in the urinary tract. She has a lot of bacteria in her urine. We need to do several things. We need to do a culture on her urine, and while we are waiting for the culture results, we will get her started on a good broad-spectrum antibiotic. We need to get an x-ray, so we can see how many stones we are dealing with, if there are stones in the kidneys, or a bunch of little stones also. We need to do some blood work to make sure Sophie’s kidney function is normal. These stones are going to have to be removed with surgery.”

“Doc, you sound like you are talking about a lot of money,” Raymond said. “I don’t have a lot of money. Are there some short cuts we can take.”

“We can shortcut some of the things if that is what you want to do,” I said. “You need to understand, shortcuts are great if everything works out fine. But if things don’t go just right, we end up spending more money than we would have doing things right in the first place.”

“What kind of things are you talking about, Doc?” Raymond asked.

“Looking at her urine, her kidney function is probably okay,” I said. But if it isn’t, and a random urine sample is not the best indicator of kidney function, we might be delayed in finding that out, and we could lose her. If she happens to have an infection that requires a particular antibiotic, we might not know that without a culture. If we have a bunch of little stones along with the big ones I can feel, we could leave a stone behind and have to do a second surgery.”

“She is sort of long in the tooth, Doc,” Raymond said. “Let’s put her on some antibiotics and do the surgery. If things don’t work out, at least we tried.”

“That is fine, just as long as you remember this conversation,” I said as I shook Raymond’s hand.

“Will I be able to take her home tonight?” Raymond asked.

“We are early enough that she should be able to go home tonight,” I said. “We will have her on c/d diet for a time. That will be important, nothing else.”

“You are going to ruin her life and make mine miserable,” Raymond said.

“You know, you are killing her slowly with kindness, don’t you,” I said.

“What do you mean, Doc?” Raymond asked.

“Look at her, Raymond,” I said. “She weighs twice what she should, her teeth are a mess. She should have those cleaned, and there will be many teeth that are not savable. The infection in that mouth could have been what started this bladder thing, and her heart valves are leaking a little. She needs to be eating dog food, period. But we can work on those things after we get this bladder thing fixed.”

I gave Sophie an injection of Amoxicillin and Gentocin. I planned to send her home on Clavamox. We gave her 80 ccs of fluids by subcutaneous injection and placed her in a kennel while we got the surgery room ready. Sophie was unhappy in the kennel, how dare we treat her like a dog.

After anesthesia was induced and the abdomen was prepped for the last time, I draped the incision site, first with towels and then a surgery drape. I made a short incision over the bulge in the posterior abdomen caused by the large stones in the bladder. I was able to squeeze the bladder out of the incision. It was the size of a full bladder but hard as a rock. 

I placed a couple of stay sutures to hold the bladder in position when I incised it and removed the stones. Then I made an incision into the bladder. The bladder wall was thickened from the chronic infection and the mechanical damage from the stones.

I popped the first stone out, then the next. Amazingly large stones for such a small dog. The bladder lining was burgundy red and almost bubbly from the chronic inflammation. I flushed the urethra in both directions and carefully explored the bladder to make sure no small stones were hiding.

Then I closed the bladder in two layers with Maxon and returned it to normal position. I was careful to remove a couple of drops of urine from the incision and flushed the area liberally. Then the abdomen was closed with a standard 3 layer closure.

Sophie recovered quickly and was probably more comfortable than she had been in months. Raymond was pleased with how lively she was when he picked her up.

“I want to see her in a couple of days, just to check the incision and feel her bladder,” I said. “If you get a chance, try to get a look at her urine in the morning. Mainly to see is the blood is cleared up. And Raymond, you have to be strong, c/d diet only for 3 weeks. No bacon off the breakfast table. You understand, we have come this far, don’t ruin it by being weak when she begs.”

“I will do my very best, Doc,” Raymond said.

“I can guarantee you, Doc,” Sue, Raymond’s wife, said. “He has spent our summer trip to the coast, and he will finish the job if he knows what is good for him.”

Photo Credit: d.e.larsen.dvm@peak.org

The Siberian Mouse Hound

D. E. Larsen, DVM

George and Smudge waddled through the door together. Smudge was some sort of a Dachshund mix. Smudge had a long body, broad shoulders, and legs that were just long enough to keep an oversized belly from dragging on the ground.

“What are you two in to see the doctor for today,” Joleen asked.

George was an older man, probably in his seventies. His description would match Smudge’s to the tee if he walked on all fours. 

“I have been treating Smudge’s rectum with Preparation H for nearly a month now, and his hemorrhoids just don’t seem to change much,” George said. “I figured I better get the Doc to get a look at him.”

“You picked a good time to walk in,” Joleen said. “Doc is just finishing up in surgery, and it is half an hour before he has an appointment scheduled. I’ll grab your chart, and we can get you ready to see Doc.”

Hoisting Smudge onto the exam table was a surprising chore. He was so low to the ground and overweight, it was like bending over to pick a bag of concrete off the floor.

Taking a deep breath from that exertion, I started a routine exam on Smudge. 

Starting at the nose and working toward the tail, I did a full exam on every patient before looking at the specific problem.

“You are on the wrong end,” George said. “We are here for you to look at his rectum.” 

“Smudge is no picture of health,” I said. “He is well past middle age and a little overweight. We just want to make sure everything is okay before we start concentrating on one little area.”

“So, what do you find?” George asked.

“I find a couple things, George,” I said. “They are easily fixable. The hemorrhoids you have been treating with Preparation H are actually Perianal Gland tumors. They are seldom malignant, but we should remove them while they are small. They do cause some local issues when they get big. He also has a tumor in his left testicle. If you look, the left testicle is large beside the right testicle that is quite small. There is likely a Sertoli cell tumor in that left testicle. These tumors are also not generally malignant, but they produce estrogens. The estrogens probably account for some of Smudge’s belly and his small right testicle.”

“What do we need to do, Doc,” George said.

“The best thing to do is to get the tumors off the rectum and to get rid of the testicles,” I said.

“Sounds simple enough,” George said. “When can we do it?”

“We need to run some blood work to make sure his liver and kidneys are up to the surgery,” I said. “If that is okay, we can schedule his surgery next week.”

George was right on time for Smudge’s surgery appointment. George was nervous and talkative. 

“I would rather have the surgery myself than to put Smudge through it,” George said to Sandy.

“You do know what they are going to do today?” Sandy says. “You know that he’s being neutered along with the rectal work, don’t you? I don’t think you would like that very much.”

“This dog means more to me than just about anything,” George says.

“We know that,” Joleen says as she leads George and Smudge into the exam room for Smudge’s pre-surgical exam. “He will do just fine. He will bounce out of here this afternoon like nothing happened.”

The surgery went well. We did the neuter first, keeping in mind to do the cleanest surgery first. The tumor in the left testicle was the size of a marble, and the right testicle was atrophied. That would be consistent with a Sertoli cell tumor. Still, just to be sure, we will send the tissues in for a pathologist to confirm the diagnosis.

In Veterinary medicine at that time, there were few options for cancer patients besides surgery. Chemotherapy and radiation were available at a couple of university clinics, namely Colorado State and the University of California. Most clients were not inclined to take such a referral.

The small perianal gland tumors were easily removed with sharp dissection, and the wound was closed with a few silk sutures. When they were this small, dogs did not seem to be bothered by the surgery.

George was anxious when he came to pick up Smudge in the afternoon. I had explained that Smudge would feel much better with the testicular tumor removed, and it should help with his weight somewhat.

“George, I want you to start feeding Smudge a reducing diet,” I said as I handed him the leash. “That means no table scraps. We want to see some space between the floor and the belly. With that tumor gone, he should feel like being more active also.”

George stopped and talked with Joleen and Sandy on the way out the door.

“Now he should be good as new in a few months,” George said. “He should be back into his old hunting shape.”

“Hunting shape, he doesn’t look like much of a hunting dog to me,” Joleen said.

“Oh, I beg to differ,” George said. “He is a purebred hunting dog.”

Joleen leaned over and looked at Smudge on the floor.

“He doesn’t look like any purebred that I know,” Joleen said. “I better get the dog book out and see if I can find him in there.”

“Smudge is a Siberian Mouse Hound,” George said flatly, not cracking a smile. “Full-blooded, he is.”

“A Siberian Mouse Hound, I have never heard of that breed before,” Joleen said. “Now I really will have to get the dog book out to look it up.”

George smiled and chuckled a little as he headed out the door, giving Smudge a pull on his leash.

“What was that all about?” I asked Joleen.

“He says Smudge is a purebred Siberian Mouse Hound,” Joleen answered.

“I think you have been had,” I said with a smile.

Photo Credit: https://pixabay.com/?ref=pexels

Benefits of Experience

D. E. Larsen, DVM

The phone jarred me awake. It was going to be another late night, and I thought calving season was over. I glanced at the clock as I picked up the receiver, 1:30.

“Doc, this is Jack. I have a llama who gave birth tonight,” Jack said in an excited voice. “They almost always birth during the morning, but this one came tonight, and she has a problem.”

“What’s going on with her, Jack?” I asked.

“I think she has a prolapsed uterus,” Jack said. “And she is not doing well. She hasn’t even looked at the baby.”

“Llamas rarely have birthing problems,” I said. “But when they have problems, it is when they give birth at night.”

“Can you come out and get a look at her, Doc?” Jack asked.

“It won’t take me too long,” I said. “You know I am in bed.”

“I know, Doc,” Jack said. “I’m sorry, but it is like when we used to have to Hoot Owl in the woods. You just got to get up and go.”

“Don’t do anything with her until I get there,” I said. “If she is not feeling well, she might be in shock. We don’t want to add any stress. Where do you have her, Jack?”

“She is in the little barn up here by the house,” Jack said. “I will have all the lights on for you.”

I have seen very few birthing issues with llamas. One with a prolapsed vagina that I ended up delivering the baby, and that was about it. If this is a prolapsed uterus, it will be a first for me. Unlike a cow, this llama is probably worth about $30,000.

Jack was waiting at the barn door when I arrived. He was having trouble standing still.

“I am glad you could come so quick, Doc,” Jack said as I stepped out of the truck. “She doesn’t look good to me at all.”

I gathered my stuff for the first trip into the barn. A stephoscope, bucket of warm water, BeI gathered my stuff for the first trip into the barn: a stethoscope, bucket of warm water, Betadine scrub, and a dose of Oxytocin. Jack had the cria under a heat lamp. Mom was paying no attention to the baby. That in its self was an unfavorable sign.

She did have a prolapsed uterus. The membranes had already passed. This did not look bad, just one horn of the uterus was prolapsed. But Momma did not look good. Her oral membranes were ghost white and she was resting on her sternum and not responsive to my attention.

“Jack, there was a day that I would blame her condition on blood loss but I think she is in shock,” I said. “Let me run back to the truck and I will get a couple of bags of fluid and some medication and we will see if that helps her before we do anything with this prolapse.”

“Is she going to be able to breed after this?” Jack asked.

“We have to worry about her surviving the night before we worry about her breeding again,” I said. “Actually, Jack, I doubt is there is much data on fertility in the llama following a prolapse. Most of the time they breed back in the first month or so following delivery. I would think that is not going to happen, but I have no data or experience on the top of my head to support any opinion.”

I hung a bag of fluids from a nail on a nearby support post for the barn and placed a 14 gauge needle in her jugular vein. I ran the fluids as fast as they would flow and added 20 mg of Dexamethasone Sodium Phosphate to the first liter.

Halfway through the second liter, Mom was looking for her cria and acting like she would live. I slowed the flow and gave 10 mg of Oxytocin IV. Then I turned my attention to the prolapse.

This was a fraction of the size of a bovine prolapse and the oxytocin was already contracting the uterus. I scrubbed it vigorously with Betadine Scrub. Then I lubed it with J-Lube, a powdered lube that, when wet, became as slick as anything I knew.

A couple of pushes and the uterus popped back into its normal position. I ran my hand through the cervix and made sure the uterine horns were completely returned to normal. At the same time I put a couple of grams of Oxytetracycline powder in the uterus. Then I sutured the vulva closed with several sutures.

I have never experienced a prolapse that came out a second time. Especially if Oxytocin was given to contract the uterus. But, be it training, or just making myself and the owner happy, I always sutured the vulva for a 1 – 3 days.

I cleaned up Mom and removed the IV. A gave good dose of long acting antibiotics and she jumped right up, looking for her baby.

“My guess is we are home free, Jack,” I said. “I will run by and recheck her in a couple of days and get those suture out. You just need to check her over real well in the morning. Make sure is eating and taking care of the baby. You call if you have any questions about how she is doing.”

The trip home at 3:00 in the morning gave me time to ponder. Would I have been so quick to give fluids to this gal if had not been able to peek inside of the belly of Ag’s cow a couple of summers before? I am not sure of the answer to that question. I guess once you know the correct answer, it is hard to think of another solution.

Photo Credit: https://www.pexels.com/@belen-rubio-1986517