Urinary and Bladder Problems in Dogs

Urine Specific Gravity - considerations when evaluating

Question: Dr. Richards-- What would a dog's urine SG that is NOT the first urine of the day have to be before you were concerned, and do other findings such as ph factor into that decision as well? If there is no protein in the urine, how often would you recommend a urine protein/creat reading on a dog with renal aplasia but normal renal values? Thanks. Shanna

Answer: Shanna- There is no truly abnormal value for specific gravity of urine when looking at the results of a single sample. Since one of the functions of the kidneys is to either conserve fluid when necessary or to excrete it when necessary it is possible for the urine specific gravity to vary widely due to completely normal functioning of the kidneys. If I was worried about a specific disease that tended to make urine stay in a particular range for specific gravity then a value in the range might cause me to recheck further samples. I tell my clients whose pets have disorders that I think are affecting specific gravity to bring me as many urine samples as they get over the course of a day, starting from the first one in the morning until the one right before they come to the office. If all of them stay in the range I am worried about then I would proceed with further testing. I don't worry about the pH when I'm interested in specific gravity testing since it doesn't any effect on specific gravity that I am aware of. There is a relationship between protein levels and specific gravity. Some protein (trace to 1+ reading) is normal in concentrated urine ( > 1.035 generally for dogs) but protein in more dilute urine makes me suspicious. This is especially true as the protein level in the urine increases into higher ranges when the urine is dilute, so a trace reading in very dilute urine would be highly suspicious while a 1+ reading in urine with a specific gravity of 1.030 might just make me retest the protein level in a different sample rather than running a test to quantify the protein loss, which is what the protein/creatinine ratio does. This ratio gives an approximation of the amount of protein that is lost in the urine in a 24 hour period. Protein/creatinine ratios are not supposed to be a very good way to monitor kidney disease over time because the values vary over the course of the day to some degree and there aren't studies correlating whether changes in the ratio are meaningful in kidney disease. The ratio is useful in determining if protein loss in the urine is significant when there is some question of this -- which is usually the case when there is increased protein in a concentrated urine sample. Once it is established there is a disease that causes protein leakage into the urine I don't see any further need to run this test. The best currently available test to monitor for kidney disease early is probably the measurement of microalbuminemia. Albumin is a protein that has many functions in the plasma and the body tries to preserve it. There is a test kit for this from Heska Laboratories and several commercial labs offer this service, as well. Albumin is spilled into the urine in microscopic amounts before protein levels are measurable, so it is possible to catch kidney diseases that result in protein loss earlier when routinely testing for microalbuminuria. This is also a non-specific test in many ways, though. Albumin spills into the urine due to inflammatory diseases (possibly from anywhere in the body), glomerulonephritis and amyloidosis. It is important to note that this test is only useful for dogs who start out with no measurable protein in their urine -- if you can measure protein this test doesn't serve a useful purpose as you already know a problem exists. I hope I haven't been too confusing in this note. If you need clarifications please feel free to ask for them. Mike Richards, DVM 02/05/2007

Urinary lab testing - monitoring albumin and protein

Question: Dear Dr Richards, I have been a subscriber for almost a year now, and find your information very helpful. I have a 2 year old neutered Bull Terrier, and kidney problems are quite common in this breed, so I have been monitoring his urine at home for about 1 year now. In July 2001, he had surgery to remove undescended testicles. At that time his blood results showed a BUN of 20 mg/dl and Creat of 1.2 mg/dl. His urine showed a moderate amount of inflammatory cells and trace amount of bacteria, and suspected a urinary tract infection, they also found fine granular casts in it. They said these are usually seen when there is injury to a part of the kidney called the tubules. However, since he is not having trouble concentrating his urine and the blood tests they used to monitor kidney function were not elevated, they said to monitor. I did have another urine culture done within several months, and no casts were seen. I had his blood checked again in 9/01 and BUN was 19 mg/dl, Creat was 1.2 and BUN/Creat ratio was 16. I am able to monitor his urine on my own, and have been recording specific gravity , protein(mg/dl) and also microalbumin/creat ratio(this test is specific for low levels of albumin) always using a first morning void. At first, I was seeing trace to 30mg/dl levels of protein, and microalbumin/creat results were always normal. Within the last several months, I have seen intermittent proteins of 100 mg/dl and several microalbumin results of 150mg/L(which I understand is the definition of proteinuria) creat results of 300 mg/dl and ratio was abnormal on several occasions. I asked my vet to do a urine protein/creat ratio, this was done in 4/02,, and the ratio was 0.1, normal. I forgot to mention that his specific gravity results have always been >=1.030. My vet does not seem concerned by the 150 mg/L microalbumin results specifically, and the abnormal microalb/creat ratios that I have been getting , and has pretty much dismissed them with the normal result from the protein/creat ratio we just got. What do you think, I would hate to miss an early diagnosis of kidney problems.

thanks alot sincerely, julie

Answer: Julie- There is a new test for microalbuminuria in dogs ( E.R.D.-Screen by Heska) that may make veterinarians more aware of the potential benefits of monitoring albumin levels in the urine. At the present time there is some question about the meaning of various albumin levels in the urine. Hopefully this problem will be resolved in the near future, too. At the present time the "worry points" for protein and albumin levels in the urine are reported to be: Urine protein level of 2+ or more in dilute urine (SG 1.010 - 1.025 ish) should prompt monitoring of urine protein levels. Urine protein/creatinine ratio of > 1.0 (so less than 1.0 is considered normal, although most dogs have urine protein/creatinine ratios of less than 0.5). Microalbuminuria is considered to be present in dogs when the urine albumin level is between 10 and 300mg/dl ( I am pretty sure I converted this correctly, the value in Dr. Grauer's review "Diagnostic Testing Offers Early Detection of Renal Disease", in an April supplement to DVM Magazine was 1.0 to 30.0mg/dl ). However, this is a definition based on experiences in human medicine and it is unclear at this time how well they will relate to predicting canine renal failure. However, Dr. Grauer believes that it will work out to be an accurate early warning test for progressive renal failure based on his research. In a colony of soft-coated Wheaton terriers with familial kidney disease that he maintains, microalbuminuria shows up as long as two years prior to the onset of proteinuria. (from the Heska supplement to the March 2002 Compendium on Continuing Education). So, with this in mind, I think that it is best to consider the possibility that your dog is at risk for later development of kidney disease, based on your findings so far. However, this is new territory for veterinarians and I am not absolutely certain that I am interpreting the numbers correctly. This, along with the fact that isn't a definitive answer to the meaning of microalbuminuria in dogs at this present time, makes it reasonable to consider the possibility that the lab values really will turn out to be nothing to worry about over the long run. It would be reasonable to try to be certain that there is not an inflammatory or infectious process going on that is being missed. Microalbuminuria consistently occurs in dogs with heartworm disease, is present with pyelonephritis, inflammatory bowel disease, cancer and other conditions that continually disturb the immune system. Ultrasound examination of the kidneys to help rule out some forms of kidney disease might also be reasonable, especially since there were inflammatory cells and bacteria in his urine. A culture and sensitivity test run on urine extracted directly from his bladder (cystocentesis) would probably also be justified given the past history. The odds are probably good that these tests would not reveal a specific problem but that is the nature of testing. If your vet doesn't want to pursue this further given the otherwise normal lab work so far but it continues to worry you, it is reasonable to ask for referral to an internal medicine specialist for a second opinion. It does appear that intervention to control hypertension, elimination of any sources of chronic excessive immune stimulation and the use of enalapril (Enacard Rx) all can help slow the progression of kidney disease in some patients. If your vet subscribes to DVM Magazine and/or the Compendium, these supplements are recent enough that he or she may still have them. Calling Heska for information on their new test would probably be a good way to get some of this same information, as well. Personally, I hope your vet is right and this all turns out to be unnecessary worry -- but I really do think it is reasonable to go ahead with a search for potential sources of albuminuria and to keep track of the situation as you have been. I am not sure if the Heska test would be more accurate for microalbuminuria in a dog than the method of testing you have available to you but it might also be worth trying this test to see if it agrees with your findings so far. Good luck with this. Mike Richards, DVM 5/26/2002

Urine specific gravity and disease process

Question: Dear Dr. Mike:

Thanks again for another prompt response. Kori's urinalysis results came back normal except for the Sp. Gr. was 1.015. With this result, the facial paralysis, excessive drinking of water, and slight balance issues, does any other possible cause come to mind? I am taking her back tomorrow for a follow up appointment. Thanks again for your suggestions and information.

Lori

Answer: Lori-

There are several recognized ranges of urine specific gravity that can be helpful in determining if a disease is present and what the disease might be.

Urine in the range from 1.008 to 1.012 is considered to be isothenuric, or approximately the same specific gravity as the serum that filters through the kidney (the glomerular filtrate). This means that the kidneys are not concentrating the urine, nor are they diluting it. Since the only way to be sure that the kidneys are able to perform these functions is to have urine samples outside the isothenuric range, it is important to get serial urine samples to see if this happening when a urine sample falls in the isothenuric range. Consistently isothenuric urine may indicate that kidney failure is present and can be seen with hormonal disorders in some cases.

Urine in the range below 1.008 in specific gravity indicates that the kidneys are diluting the urine. This happens with disorders like diabetes insipidus. It is an indication that the kidneys can function, since they are actually making the urine dilute, though.

In dogs, urine specific gravity above 1.030 indicates that the kidneys are able to adequately concentrate urine and values above this level are reassuring, due to this. Specific gravity ranges between 1.012 and 1.030 are indicative of some kidney function but are not high enough to say that the kidneys are functioning fully.

There is a broad range of urine specific gravity that can be found in any individual urine sample. It is not at all uncommon for the specific gravity to be low when a dog is drinking normally and the sample is taken during the day. Dogs tend to be urinating more frequently during the daytime and there isn't much need for the body to concentrate urine. If the first urination of the morning, which should be more concentrated, falls into the lower ranges of specific gravity there is more reason to be suspicious of a problem.

So at this point I think you have to look at this sample as being unhelpful in ruling in or out any of the possible disorders that affect urine. However, it is a good indication of the need to continue to monitor urine specific gravity until it can be determined that samples are going to stay in this range or until a sample is concentrated enough to indicate you can stop worrying or dilute enough to make it necessary to look for problems that cause urine dilution.

Balance problems in conjunction with facial paralysis are a stronger indication of a problem affecting the inner ear than facial paralysis alone.

Mike Richards, DVM 10/29/2001

Calcium oxalate stones

Question: Dear Doctor,

I have a female Japanese Chin, eight years old, 15 pounds (large for the breed but not overweight). She has a collapsing trachea, a heart murmur, and her heart is enlarged. Of most immediate concern, though, she has calcium oxalate bladder stones. We discovered the stones because one has almost totally blocked her urethra so she had a great deal of difficulty urinating.

She had unsuccessful surgery on June 29; some stones were removed but some remain, and her urethra is still partially blocked. I understand that the stones cannot be dissolved by diet or medication. She is not a candidate for urohydropropulsion, and I don't care to subject her to more surgery since it would probably be no more successful than the first.

We have changed her diet, and plan to start her on calcium citrate, to prevent more stones forming, or existing stones enlarging. However, my main concern at the moment is the one stone that is partially blocking her urethra. If that stone shifts even slightly her bladder will be totally blocked and we will have an emergency.

I understand that sonic shock wave treatment can disintegrate existing stones, but I haven't been able yet to locate a treatment source within reasonable driving distance of my home (central Alabama), nor do I know any details.

Please tell me if you would recommend the shock wave treatment, and any details you may have. I am especially interested in the success rate because I don't care to put the dog through an extremely painful (and undoubtedly expensive) treatment with little chance of success.

I would also appreciate any other comments and suggestions you may have.

Thanks in advance, Wayne

Answer: Wayne-

You are correct that calcium oxalate stones are not easily dissolved through dietary means, as struvite stones sometimes are. So usually it is necessary to remove these stones. It is supposed to be possible to remove many stones through voiding urohydropropulsion but surgical removal is probably still the most common method of removing these stones.

The University of Tennessee has a lithotripter that they use on dogs and they are reporting good success with this procedure. Purdue University is the only other place that I know of that is doing this procedure, but there may be others, as this sort of thing changes frequently. In addition, there are some people around the country who are experimenting with laser fragmentation of bladder stones but I don't know where they are, as this was just mentioned as a possibility in a seminar we attended on lower urinary tract disease this spring. I know that the Virginia-Maryland Regional College of Veterinary Medicine (Blacksburg, VA) has done the laser procedure on horses but I haven't seen anything about small animals that I can remember.

At the seminar we attended, Dr. Osborne from the University of Minnesota showed some pretty amazing slides of stones they had managed to retrieve through voiding urohydropropulsion, but if this has been tried by someone who is good at it and it didn't work, then this may not be an option. Also, in some cases it is just obvious that a particular stone is too large to be removed in this manner, so if that is the case then it isn't an option, either. There is an article in the September 1, 1993 issue of the AVMA Journal with good diagrams of this procedure and I think it is covered in one of the Clinics of North America issues, too.

Your vet should be able to arrange a referral to the University of Tennessee if that isn't too far to go.

Mike Richards, DVM 8/23/2001

Jaundice in Border CollieX - bilirubin/bile acid levels

Question: Dear Dr Richards,

Please advise me. Over the past two months I have noticed on occasion that 10 year old border collie x looked very slightly jaundiced. I then look again and his collar looks absolutely fine and I'm left feeling that I imagined it. I work as a student vet nurse and two weeks ago, as I was leaving work, I again thought my dog looked as though he had the 'merest hint of yellow'. All of my colleagues have assured me that his colour is fine but I decided to catheterise him and obtain a urine sample. A quick dipstick test confirmed that the bilirubin levels were moderate to high (all other parameters were fine), his urine was very yellow + slightly cloudy but as our refractometer is inaccurate I was unable to take a specific gravity. I then carried out a microscope sample (then sample was not spun down as we have no centrifuge) which revealed a number of mucus threads. By the following morning numerous bilirubin crystals had formed under the coverslip.I sought the opinion of the vet but he is a new graduate and was not certain (he thought the crystals were probably parasites). Although my dog is not showing any clinical signs (other than the disputed 'hint of yellow'!) I was worried and decided to take my dog to a veterinary hospital and seek the advice of a more experienced vet. The clinical examination revealed nothing but he agreed to carry out a blood test for my own piece of mind. Unfortunately the results have done anything but. The results were as follows: Haematology - all normal Biochemistry - Total bilirubin - within normal parameters - Partial bilirubin - 3 (norm: 1-2) - Bile acids - 15 (norm: 0 - 5) I have been advised that 'something is going on in the liver but at this stage we don't know what' and, provided no clinical signs develop before, I'm to take him back for retesting in one month. What concerns me is: why should the bilirubin levels be normal in a serum sample yet 5 days earlier they were moderate-to-high in the urine sample? I'm assuming he must have fluctuating levels of bilirubin, but the vet rejected this and said that it was probably a problem with the urine testing. However, I tested the urine 3 times and the result was the same. Also, doesn't the presence of so many bilirubin crystals confirm the results of the dipstick? I suggested carrying out serial urine testing, but this was rejected as un-necessary. What do you think? Should I be worrying as much as I am? What tests should I be asking for?

Answer: Louise-

It is important to remember that in male dogs it is normal for there to be detectable bilirubin in the urine, especially if the urine is concentrated. The levels should be low to moderate, though. I find myself looking at border collies, shelties, collies and schnauzers and wondering about whether or not they are icteric (jaundiced) more often than I have this feeling in other breeds, so perhaps you will find that you have the same problem over time. Most of the time when I check blood or urine values for causes of icterus I find out that the dogs don't have this problem. Once in a while, though, they do have a detectable problem.

If there is a problem with persistent rises in bilirubin levels in the urine (bilirubinuria) then there are two major causes of this problem, internal bleeding and liver disease. Both of these can cause bilirubin to increase in the urine. These are the two major causes of bilirubin rises in the serum (bilirubinemia) as well. So the thing to do is to look for a problem with one of these conditions. The first thing we try to determine is whether there is a bleeding problem, so we check for anemia, platelet numbers and signs of rbc damage on blood smears. If there is no evidence of a bleeding problem, then we look for liver disease or for something that might cause blockage of the bile ducts outside of the liver. A bile acid test is a good way to determine if there is a liver problem but the bile acid level would be normal for a sample taken within a few hours of a meal (the test is supposed to be a fasting test but many times that is not the case). If the other liver values were normal, I would not be too worried about liver disease.

I don't see any reason not to monitor the bilirubin levels in the urine. It is easy to do and if you can figure out a way to test for specific gravity at the same time as bilirubin, you could determine whether or not the problem only occurs in concentrated urine, which would be normal for a male dog. I don't think that you can tell much by bilirubin crystal formation in a urine sample that has sat for a while. There are too many changes in urine when it sits for a while for a sample to be much value to you if it is not reasonably fresh.

It is easy to worry too much about our own pets. Sometimes I feel sorry for my pets because I test them much more frequently and often more extensively than I test most of my client's pets. It is a hazard of life for a pet owned by someone who is trained to look for problems!

Mike Richards, DVM 2/19/2001

Sharpei urinating irregularly and retaining urine

Question: Dear Dr. Richards:

Our Sharpei, about five years old, seems very irregular in its urination, and it will not urinate or defecate close to home (say less than one block).

Given the weather (deep freeze, blizzards, etc), the dog may urinate once in 24 hours, and at times, once in 48 hours. No unusual signs or symptoms have been noted.

However, other dog owners have indicated that the urine retention could cause a urinary tract infection.

Is such a specific risk significant??? What has been your expeience???

Thank you for your attention.

Howard

Answer: Howard-

I think that urine retention is not the ideal situation. It probably does predispose dogs to urinary tract infections, although I actually can't find much supporting evidence for this theory.

Based on your description of the situation it seems more likely that the urine retention is behavioral rather than medical in origin. In this situation, if the dog does not have incontinence, the increased risk of urinary tract infection is probably not very high but it probably would be higher than the risk in a dog that does not retain urine. Despite that, if you can think of some way to encourage urination it would be a good idea to do so. Trying to encourage urination at a regular spot, even if it has to be a couple of blocks from home, would be a good idea. Some dogs can be taught to urinate when asked to, if you practice a command, like "go pee" when your dog does urinate and then give him or her a small treat, you might find that you are able to encourage regular urination.

I hope that this helps some.

Mike Richards, DVM 12/28/2000

Michal Response: If your Sharpei is male - you might try just jaming stick upright in the snow about a block or so from home. Sometimes dogs can't find the usual uprights they urinate on and a stick in the deep snow helps. Can't hurt.

Retaining urine

Question: Dear Dr. Mike,

I am a subscriber. For the couple of months, Maude (5-year-old epileptic Australian shepherd) has been retaining urine for up to 18 hours at a time. This usually starts in early to late afternoon, then she doesn't urinate before bedtime, only to wake me up at 5:00 a.m. or so.

She had a urinary tract infection last December (when she wanted to run out to urinate day and night), so this is like the total opposite. This year, as last year, the infection source is e-coli (confirmed via transabdominal cystocentesis, I believe it's called). Last year, her vet put her on Ditrim; this year, her neurologist offered to run the test, and has her on Sulfamethoxazole/TMP SS. She's only been on the medication for a couple of days, so it's probably too soon to tell anything, but I haven't seen any improvement. I might also add that her neurologist TRIED to get a urine sample two months ago, but we ended up with a pee-in-the-cup sample. It did show an infection, which was treated with Cephalexin, but apparently the infection has recurred, or never cleared up.

She doesn't seem ill or out of sorts. She's currently taking 500 mg. of KBr/BID and 60 mg. of Pb/BID. She's been seizure-free since May 18 (after cluster seizures of at least three every 21-24 days from November-May).

I know that incontinence is often a problem with epi dogs but wonder if retention signifies anything and warrants further testing. She was also hospitalized in October 1999 for pancreatitis, but I doubt that this is relevant. Just thought I'd mention it.

Thanks for your insights. Linda

Answer: Linda-

Ditrim (Rx) and sulfamethoxazole/trimethoprim SS are approximately the same medication (or possibly the same medication - I can't remember if the sulfa portion is the same or not). It is not unusual for the same medication to be used more than one time for bacterial cystitis, if the bacterial culture and sensitivity results indicate it is still likely to work.

It is unusual for cystitis to cause urine retention. As you found on the last episode, it usually causes an increased urge to urinate, resulting in frequent attempts to urinate that often produce only small amounts of urine. There are always going to be some patients that don't have the typical signs for an illness, though.

Urine culture results can sometimes be misleading. E. coli and other normal bacterial inhabitants of the body can be found when doing urine cultures. Counting the colonies on a bacterial culture plate can give an indication of whether the bacteria is a contaminant. Low colony count numbers are more likely to be the result of contaminating bacteria. This is sort of judgment call and it is possible that your vet, or the neurologist, have taken this into account already.

There are two reasons that bacterial urinary tract infections recur. The first one is that they were never cured in the first place. This happens when antibiotics are not used long enough, or an inappropriate antibiotic is chosen and the pet can not clear the infection on its own. The second reason is that there is an underlying cause for the cystitis that wasn't addressed when the first infection was treated. If this is the case, the neurologist may be the best person to be addressing the problem, because neurologic problems cause a lot of the cases of urine retention and bacterial infections related to urine retention. It can take some time to work through this type of problem, so you may have to make several attempts at diagnosis or treatment before a way to cure or manage the problem is found.

I can not find any indication that phenobarbital or potassium bromide, or the combination of the two, causes urine retention. It still wouldn't surprise me if they had some effect on this situation, though.

I have to admit that I don't think you are going to see improvement in the urinary retention as the result of antibiotic therapy. I think that you are going to have to find a separate cause for that problem and appropriate treatment for it. My inclination would be to refer a patient to a neurologist who had this problem, so you are already working with the right specialist, at least for the initial attempts.

Good luck with this.

Mike Richards, DVM 12/27/2000

Struvite stones, chronic urinary tract infections/pet diets and PH

Question: Dr. R--

Thank you for the thorough explanation. It makes alittle more sense now. However, mine is more cooincidental because two of the three dogs kept increasing in ph and develop struvites. My current vet sounds more like you, not as concerned but, I came to him after many attempts of trying to figure out why they kept getting sick. My aussie, Abby, 18mos., is the most sensitive one. It sounds like the next step is to see if something else is going on other than her "butt tuck". Interestingly enough, Abby does seem to hold her bladder much longer than I would like her to. She's always been that way though. She's getting better about going, but it may also be that she is getting another uti because her ph was up again last week. I'll take her back in tomorrow to check her status. Then, we proceed to Plan B from there.

Further, does this means that you don't see any direct relationship to food relative to higher ph? My other questions relating are: 1- Is there any relationship to a higher protein content in food relative to the ph? The food CD has a lower protein content but, it has the other "junk" that the nutritionists say to avoid. 2- Is it more prudent to feed CD to keep her ph down rather than feed her a more nutritious food with ammonil supplements? 3- Best case scenario obviously would be to find the ultimate cause, which I will continue searching for. 4- If ph doesn't cause struvite stones, what does?

I hope this helps explain my problems with my sweet babies. Thanks for your help and explanations.

Margal

Answer: Margal-

I am not sure of the exact effect of excessive protein on urine pH. In general, I would guess that it usually causes more acidity in the urine because the major protein breakdown product is uric acid. However, there may also be a higher level of ammonia in the urine due to the protein breakdown and this could get much higher if there are bacteria in the bladder capable of urea breakdown which would produce ammonia in the urine. So my guess is that it usually causes acidity in the urine to have excessive protein but that in some circumstances excessive protein can lead to basic urine. This is just my interpretation of the situation, because I couldn't find a clear explanation of the effect of protein on urine pH in the books that I have on hand.

I am somewhat at a loss in advising you about the second part of your question. In my opinion, c/d (tm) is a nutritionally complete food and therefore there is no reason to look for a more nutritionally complete food. Now, whether or not it is the correct food in this situation is much more debatable. I don't think a reasonable person can argue that the commercial pet foods generally support life and they contain the ingredients known to be necessary to sustain life and that many pets live long and healthy lives while fed these foods. People making these arguments are ignoring a huge number of pets doing very well. Sure there are pets that do better on one diet than on another, but there is not one diet available commercially, or through home production, that is optimum for each and every pet alive at the present time.

Are the commercial diets like c/d (tm) optimal? That is much harder to figure out, especially for diets that are made to manipulate normal physiologic processes, like serum and urine pH maintenance. There are patients that do better on diets that acidify urine. There is very little concrete evidence to show that keeping urine pH low actually decreases the risk of urinary tract infection, though. There is pretty good evidence that doing this reduces the incidence of struvite bladder stone formation but it increases the likelihood of formation of other bladder stones. We almost never use or recommend use of c/d (tm) diet in our practice, for dogs, and we have managed to control most cases of recurrent urinary tract infections without long term use of c/d. We do not routinely use urinary acidifiers in pill or powder form, in dogs, either. The only exceptions in our practice are patients who we have obtained a bladder stone from, had it analyzed and it was determined to be struvite.

I just have to ask, who are the nutritionists referring to "junk" in the food that you are referring to? If there are references from actual nutritionists, not just people claiming to have nutritional knowledge without having data to back their claims, that specifically refute the use of certain ingredients in pet foods, I would really like to have copies of the references or directions to where I can find them.

Struvite stones used to be referred to as "infection stones" in pets. The great majority of struvite stones occur due to the presence of bacteria in the urine. Finding the reason that the pet's normal resistance to bacterial infection is compromised and fixing that problem, if possible, is the best long term solution to controlling recurrent struvite bladder stones -- and also recurring bladder infections. In pets in which this is not possible, manipulating the pH of the urine is a reasonable second choice.

Most veterinary general practitioners lack the expertise or are not able to devote the time and effort necessary to discover the underlying causes of chronic bacterial infections. This is a situation in which it is really helpful to live near a veterinary school that has a faculty member interested in this problem or a veterinary internal medicine specialist in private practice, with similar interests. Your veterinarian may be the exception to this rule, especially since it may have been a really good move to try to eliminate problems with vaginal anatomy that may have been contributing to the problem and recognizing that urine retention may be contributing to the problem is also good.

There are some good explanations of chronic urinary tract infections available. The newest "Kirk's Current Veterinary Therapy (XIII)" has some good information and the book "Small Animal Clinical Nutrition, 4th. edition", also has some good information on bladder stone formation and dietary influences. Your vet might have one of these texts and I'm sure there are others with good explanations, as well.

Mike Richards, DVM 9/12/2000

Urinary tract infections in Aussie and different urinary stone formations

Question: Dr. R--

The high ph levels lead to contiual UTIs. My aussie had what I call a "butt tuck" to give her more air circulation to help prevent the build up of bacteria. I don't recall the proper vet name for it, but, she had too much excess skin between her anus and her vagina keeping a fold over which was harboring bacteria. It made a huge difference, for awhile. She and the other two continue running high which without the ammonil to address the acidic factor and grows, we then have other UTIs or as the vets tell me, will or can lead to other complication; crystals, etc., which they have had on previous occassions. I'm also seeing more additives in vet catalogs for acidifiers, which leads me to believe there are more and more cases continuing and growing in numbers. My aussie has a much lower tolerance of feeling ill when her ph runs up. She acts nasty when she feels bad.

I hope this helps. I wonder why you aren't concerned with the ph running high 7-8-9. This doesn't mean anything to you? I'm very curious for as many ideas and perspectives that I can get. I'm still in search of the "right" vet for me since my favorite vet moved out of state awhile back. I keep finding too many problems at every turn. Much of my research has had to be on my own because the vets here don't know anything but to put them on CD or keep them on ammonil.

Thank you for your help. Margal

Margal-

I don't worry very much about urine pH in dogs or cats that do not have recurrent problems with bladder infections (cystitis) or with stone formation in the bladder or urinary tract. There are a number of possible crystal types and stone compositions and they respond differently to urine pH. Struvite stones and calcium phosphate stones are less likely to form in acid urine, but calcium oxalate stones are much more likely to form in acid urine, so manipulation of the urine pH can lead to problems that did not previously exist in a patient.

Sometimes, when it is hard to tell if a bladder infection is present, the pH of the urine can help in the diagnostic process, since bladder infections are more common in urine with a pH of 8 or greater. However, this is not a sure sign of problems.

In all honesty, I think that you have the order of events wrong. I think that it is more likely that persistent urinary tract infection is leading to increased pH in the urine. If this is the case, it is important to look for other things that might lead to persistent urinary tract infections.

In dogs, persistent urinary tract infections sometimes occur when a difficult bacterial infection is not treated long enough with antibiotics or has found a protected spot in the urinary tract where it is hard for antibiotics to reach it. In this case, there really isn't a time when the dog is free from infection, so the urinary tract infection is persistent, not recurrent. In this situation, identifying the bacteria through culturing the urine and then testing to see which antibiotic will work against it and using it long enough should work to stop the problem. It may take two or three months of antibiotics in some cases, though.

More commonly, the problem is due to recurrent urinary tract infection that is occurring because there is something wrong with the normal mechanisms that prevent urinary tract infection. This can be a problem with anatomical abnormalities of structures like the vulva or prepuce that allow urine pooling or urine retention. Internal portions of the urinary tract that are not working properly, such as a misplaced ureter, can also contribute to this type of problem. It can occur when dogs are unable to fully empty their bladder due to neurologic problems or painful conditions. It can occur when immune system disorders or hormonal diseases such as hyperadrenocorticism or diabetes. Crystal formation in the urine as a contributing cause doesn't seem to be as common in dogs as it is in cats but it can still contribute. Some types of crystals are more common in acidic urine and some types more common in basic urine. It can be very difficult to identify the exact problem in these situations but sometimes it is possible to identify and treat an underlying problem.

This is one situation in which it really can help to refer a patient to a veterinary school or internal medicine specialist. Most general practices can do most of the work-up, with some effort, but they don't do it often enough to be really experienced at identifying the more subtle problems.

The demand for a health product is based on perception of value, not actual value, unfortunately. An example of this is lamb and rice dog food. For some time, when dogs had skin problems, veterinarians put them on a lamb and rice diet. This wasn't done because there was some direct benefit of lamb for skin disease or even skin health, it was done because lamb was not a common ingredient in dog food in the past and vets were trying to figure out if a dog might have a food allergy. Putting it on a protein source it had not eaten before, in this case lamb, was a good way to figure that out. Over time, people began to make the association that dogs with skin disease were put on lamb and rice food without understanding why and they began to demand lamb and rice food from sources other than their vet. So lamb and rice foods appeared everywhere. If urinary acidifiers are being promoted as beneficial to urinary health, the same sort of mistake is occurring. Urinary acidifiers have a place in the treatment of specific urinary tract disorders. They are harmful when given to dogs in which other specific urinary tract disorders exist. For most pets they are probably neither helpful nor harmful but it isn't a good idea to count on that.

I hope that this explains my initial question as to why urinary acidification would be necessary for three dogs. While it doesn't seem unlikely that one dog out of three might need this therapy, it seemed unusual to me that there would be a situation three out of three dogs in a household would benefit from urinary acidification medications.

Mike Richards, DVM 9/7/2000

High ph in urine

Question: I'm a dog lover from childhood. I continue to learn with my dogs and try to do better by them all the time. This means learning as much information as I can to make their lives better and healthier. The more I learn about the commercial dog foods on the market, the more interest I have in the more natural foods. I'm not industrious enough or have the time to cook for them, so I lean towards the "natural" foods on the market. My problem is that all three of my dogs continue to have high ph in their urine. No one seems to know what really causes this specifically. I'm hoping you have some insight. When I put them on CD, their ph levels out. The CD has several ingredients that all the natualists or holistic vets say to avoid. In lieu of a definitive answer, which is better, having the dogs on a good nutritious diet and supplement with acidifiers (ammonil) or have them stay on CD forever with the negative ingredients and less beneficial nutrients?

I'm at a total loss for an answer. I hope you can help send me in a positive direction. The dogs are not kin. I have 2 Samoyeds and an Australian Shepherd mix. I've also researched the avenue of filtered water as a culprit to the ph to no avail.

I greatly appreciate any ideas you have to offer. I look forward to hearing from you soon. Thanks. Margal

Answer: Margal-

I think that I would be able to help you more if I understood why you are worried about the pH of the dog's urine.

Mike Richards, DVM 9/6/2000

Urate urinary tract stones in Dalmatian

Question: Dear Dr. Mike,

I have a question with a complex and lengthy history concerning my 3 1/2 year old Dalmatian, Mr. Bojangles. I will try to keep it as brief and informative as possible.

August 1998- Mr. Bojangles shivers some during day and awakens in the evening only able to sit and yelping in pain. We took him to an emergency clinic where they did blood tests, x-rays and I think a urine test. His bowels were backed up and he had a high white blood cell count. The vet concludes the dog has psychological and/or allergy problems and "nothing" is really wrong. He gave Bojangles a prednisone shot, and 2 weeks prescription of an ulcer medicine (I believe SMZ-TP?) and antibiotic(sulphrocate and a home made modify diet of chicken, rice and eggs for a month.

August/September/October 1999- Mr. Bojangles seems to be feeling uncomfortable after a full year of good health. He cannot go up and down stairs well. I began home made diet of rice, turkey and eggs. Bojangles does not get worst but doesn't get better. Took him to vet and the vet says because he is a Dal sounds like hook worm even though they are not common in our area and he has not been in a hook worm area. Bojangles seems to feel okay the next two days and then starts getting worst. We were given an additional worm medication because the vet feels it has to be worms and so with the two worm medicines he will be fine. Bojangles gets worst and my husband asks vet why we are not using an antibiotic like last year. Sulphrocate is prescribed. Bojangles goes into a severe yelping episode. Vet prescribes Rimadyl (without informing me on anything except it is an anti inflammatory) and Bojangles responds to Rimadyl. When prescription over with, Bojangles gets worst. Vet then wants to prescribe three Rimadyl tablets daily and after using your sites and other I questioned how Bo's health was going to be monitored and why no tests or have been done. Vet has blood test done and we are told everything is normal, white blood cell count is slightly elevated but nothing significant. Bojangles goes into excruciating pain and starts holding left front leg up. Vet says it is a spinal disc problem and we need to go to surgeon. Surgeon looks at Bojangles and says she feels before pursuing disc problem, we should do stone testing. Urinalysis, Urine culture, ultrasound and x-rays taken and show nothing at all. Bojangles is still taking a maintenance dose of Rimadyl through this because it was all I had to offer him to keep him from pain. Bojangles begins to shiver and surgeon/internist at referral clinic feel it must be arthritis. Joint taps done and results are negative. Bojangles begins pain episode and internist says she is able to pin point spinal pain spot just below Bojangles shoulder blade (and says palpitation on kidneys never had a pain response). Bojangles through all this continues to have no neurological deficits, can shake his head and no head posture or holding problems and does the "praying position." They do another urinalysis and all is negative. Surgeon feels must be cancer tumors then in the front left leg.

I take Bojangles to a specialist for a bone scan and bone scan is completely normal. Surgeon/Internist say then it has to be a disc or nerve problem. VERY RELUCTANTLY I allow Bojangles to have a myelogram be completed. Myelogram is negative but the CSF shows inflammation (White cell count somewhere between 14 and 28 since had blood contamination). Put on cephalexin. CSF culture grows nothing until 4th or 5th day and it could be a bacteria but they feel it is most likely a contaminate. Titers are done and all are negative. Internist says he has auto immune meningitis then and after one and half days after last Rimadyl tablet and four days after myelogram, prescribes 60 mg of prednisone daily with an ulcer medication and taken off of cephalexin. Bojangles responds to the prednisone within 6 hours and acts like our playful dog again, appetite, water consumption and urine producing all increased.. Four days later, Bojangles becomes sluggish. Internist says just muscle fatigue from steroids. Sixth day, Bojangles still sluggish, not moving well, does not want to eat and still continued high water consumption and urine production. Seventh day, Bojangles throws up food he ate Friday night and is hospitalized. Tests ran and Bo's BUN is 171 and creatinine 6.0 and Bojangles has gone from a 58 lb dog to 50.4 lbs. Next day after one day of dieresis BUN 170 creatinine 7.4. In ultrasound one of his kidneys is dilated. Second Day, we are told everything is stable (no change) but kidney still dilated and dog very uncomfortable and urine test comes back negative. Bojangles continues to produce over 500 ml of urine every four hours and now weighs 48 lbs. Third day internist says ureter tube has been dilating the last few days and they now (after four days) can see a stone causing complete blockage of the one kidney, BUN is at 161 and creatinine is 9.4. Even though they say he is a bad surgery candidate, I have surgery done on Bojangles and he has six stones and puss removed from kidney and ureter tube on left side and begins to pass urine immediately and right side and bladder have no obstructions or problems found. Now five days after surgery Bojangles BUN and creatinine significantly dropped each day and is at a BUN of 49 and creatinine of 2.4. The stone analysis shows the kidney (not bladder) stones are uric acid stones and we are still awaiting the tissue sample tests to come back and the urine cultures before diereses started are still negative.

This leads to my question:

Was Bojangles problem all along the stones? Even though blood, urine and urine culture were always negative until now? He had a positive CSF?

What should I be doing about the right kidney? It was passing urine fine but Bojangles was still in renal failure and there seems to be no answers or information why this kidney seems to be in failure?

I have been told by the vets that his kidney condition may be difficult to maintain or pin point and still might have to put him down. Are there tests available to tell me if this was just an insult to both of the kidneys by the stones and/or mylegram, anesthesia, rimadyl and/or prednisone and if repair is possible for Bojangles' kidneys?

I know I can put him on a modified diet and medication for the uric acid but don't know that I can believe it is just stones since the pain yelps had always been associated with movement, never had positive tests for stones or urinary infection the entire two plus months until now? Finances are starting to become a concern since the last few months have cost over $14,000 to date.

Any insight, hope or enlightenment you can provide will be immensely appreciated and used to keep our best friend, true fighter and love our lives, Mr. Bojangles with us.

S. and B.

Answer: S.

Urate urinary tract stones are very common in dalmatians. I think that they are the cause of difficult to pinpoint pain fairly frequently in this breed and it wouldn't surprise me too much if the urate stones were the cause of the pain seen. It is obviously difficult to ask our patients about specific pains but my friends who have had kidney stones describe referred pain (pain felt in other places) and definitely sometimes have pain associated with certain positions or certain ways they move.

The worst part of the history you provide is that the first surgeon thought of these stones and even tested for them -- and sometimes they are hard to find so they can be looked for and missed even though a good effort was made to find them. So it is hard to tell if the stones weren't there then (they form pretty quickly, so that is also possible) or if they were but just didn't show up in testing.

It is possible for dogs to have more than one problem and it is possible for a problem like kidney stones to cause enough pain to produce other problems --- I have a friend who used to get really good muscle spasms in his back when straining to pass kidney stones. He described the situation as something akin to double hell.

I'd be really hopeful for the right kidney if the ureter is patent (if urine can flow through it) postsurgically. Kidneys can recover from pretty significant damage, at least to an acceptable level of function. If secondary infection is a continuing problem that lowers the probability of recovery but your vets are probably doing their best to monitor both of these things. In a worst case scenario that kidney could be removed and the other one can provide enough filtration for a normal lifestyle, just like in people.

It is easy to get side tracked when looking for pain in a pet since it isn't possible to ask them questions. You have been extraordinarily dedicated to Mr. Bojangles and that may have resulted in finding the solution to the problem at this point. I sure hope so.

Mike Richards, DVM 11/6/99 p.s. -- just in case this becomes important in the future, smz-tmp is the antibiotic (Bactrim, Tribrissen, Ditrim Rx) and sucralfate is for ulcers. A minor point, but a mix-up could be a problem so I thought I should point that out.

Difficulty urinating - Boxer

Q: Dear Dr. Mike,

I have a 4 year old, 65 lb. male boxer who was neutered at 4 months of age due to undecided testes. We travel allot due to my husband's work and currently live in Bosnia-Herzegovina.

Five weeks ago, Samson showed difficulty when urinating. He would get unusually uncomfortable when he had to "go out" and then when we took him out, would take a full 5 minutes to vacate his bladder. Standing there, sometimes only drops would come out, then a trickle, light stream, drops, etc. These symptoms are sporadic, sometimes happening several times a day, sometimes not at all for several days. Since we had just traveled on a longer plane journey (18 hours with no toilet relief as he's crate trained), I decided to observe and make sure he was getting plenty of water and time outside.

Five days ago, I noticed a thick, yellow discharge from his penis (after exercising) which I've never seen from him before. I took him to the vet (who speaks no English, I speak no Bosnian). He said Samson was fine (i.e.: no temp. no lumps, no enlarged areas, no infection) but gave him an injection of antibiotics. The next day, symptoms grew slightly worse, I took him back and asked for two more days of injections (which he complied with, giving them every other day) in case there was an infection. He said Samson might have "crystals" in his bladder, put him on some herbal tea (no other water allowed) which I finally managed to get him to drink, making him urinate approximately every 30 minutes all day long. The ingredients of the tea are listed below. I have since stopped giving the tea (even though it contains many healing properties for the urinary tract) and have changed back to water since he drinks this more frequently and I feel it's more importent for Sam to have continuous water than sporadic tea.

The discharge is gone but the trouble urinating is still present along with more frequent urination (needing to go out every 1-2 hours) and the other night, just after a 30 minute walk, where he vacated his bladder twice, came inside, lay down and leaked urine. He also, "lost control" going out to urinate on the stairs, 2 days ago.

After looking information up on the Internet, called and asked if the vet could do a urinalysis and/or x-rays to determine if and what kind of stones are present. He does not have the facilities. Samson has an appointment tomorrow to go to another vet who is supposed to be very good, speaks English and is as I write, searching the city for an infant size catheter. There are no x-ray facilities in Bosnia for animals.

Other than this problem, Samson is healthy, active, has a shiny coat, clear eyes, alert beautiful.

Here are my questions:

1) If a urinalysis determines that there are "calcium" stones, is surgery the only solution?

2) If a urinalysis shows "crystals" (or anything other than calcium) how can we be assured that any diet or medication will dissolve them, or whether they are too big to dissolve without an x-ray? (There are x-ray facilities in Croatia, 6 hours away and I can drive there if recommended)

3) What medications do you recommend if they are the dissolvable type?

4) If the dissolvable type, have you found cranberry extract to be effective? If so, in what dosage?

5) Samson's diet, while not consistently the same has always been the best quality I could provide while living in the US (Science Diet) Africa, (homemade diet similar to below) and Bosnia (homemade food as described below). Do you have any recommendations to alter his diet to prevent this from recurring?

6) Any other thoughts that might help Samson's situation?

Thank you so much for your consideration and reply. It's exciting living in different countries but sometimes, medically challenging.

Best regards,

Laura

SAMSON'S DIET: Once a day in morning....

16 oz lean cooked beef 24 oz cooked millet or barley 12 oz raw green leafy vegetables or squash (usually spinach) 2 heaping teaspoons "Peak Condition" (ingredients listed below)

In the evening....

A snack of one hard boiled egg, or cup of yogurt or homemade dog biscuit (made of corn flour, beef broth and sunflower oil)

INGREDIENTS OF "PEAK CONDITION": (Per 4 heaping teaspoons)

INGREDIENTS: Pro-Carb™ (complex carbohydrates from glucose polymers), ProGest™ protein mix (enzymatically digested chicken, poultry liver, brewers yeast, whole egg.) Poultry fat (preserved with Natrox), pure yucca, MCT’s, Flax oil, Creatine monohydrate, R-Aginine, L-Histidine, L-Isoleucine, L-Tyrosine, L-Threonine, L-Tryptophan, L-Valine, Ascorbic acid, Mixed Tocopherols, Electrolytes, Vitamins ( A, D, E, K, Thiamin (B1), Riboflavin (B2), Panothenic acid, Niacin, Pyridoxine (B6), Folic, Biotin, B12, Choline Inosiol, P.A. Benzoin acid, C), Minerals (Calcium, Phosphorus, Potassium, Sodium, Chloride, Magnesium, Iron, Copper, Manganese, Zinc, Iodine, selenium, Chromium, boron, Vanadium). Nature Min™ (over 40 trace minerals as naturally occurring in Colloidal Polysicates), Omega 3, 6 fatty aids (from 0 fish body oils).

Nutritional Info. per 4 heaping tespoons:

Vitamins: A 250 iu C 26 mg (Calcium Ascorbate) D 250 iu E 25 iu K 1.4 mg Thiamin (B1) .70 mg Riboflavin Pantothenic Acid 7 mg niacin 15 mg Pyridioxine (B6) .75 mg Folic Acid .125 mg B-12 .00125 Choline 85 mg Inositol .255 mg F.A.B.A. .25 mg

Minerals: Calcium 500 mg Phisphorusa 400 mg Potassium 375 mg Sodium 35 mg Chloride58 mg Magnesium 300 mg Iron 3 mg Copper 55 mg Maganese .58 mg Zinc 2.4 mg Iodine .04 mg Selenium .004 mg Boron .000005 mg Chronium 5 mcg

Amino Acids L-Arginine 484 mg L-histidine 366 mg L-Isoleucine 736 mg L- Leucine 1256 mg L-Lysine 1776 mg L-Methionine L-Cistine 514 mg L-Phenlyalanine L-Tyrosine 483 mg L-Threonine 514 mg L-Tryptophan 161 mg L-valine 895 mg

Nutritional Yield: Calories: 144 Protein: 6.58 gram Fat: 6.58 gram Carbohydrate: 13.16 gram Fiber: .56 gram Ash: .56 gram Moisture: .56 gram

Ingredients of Tea:

Achillea millefolium Agropyrum repens Arctostophylos uva ursi Betula alba Equisetum arvense Mayidis stigma Malva silvestris Ononis spinosa Plantago maj. lanc. med. Prunus avium Rosa canina Thymus serpillum Urtica dioica

A: Laura-

It is going to be very hard to make a diagnosis of your boxer's condition without the availability of X-rays. The thick yellow discharge is probably smegma, which is a normal lubricating fluid produced in male dogs. It looks a lot like pus exuding from the prepuce. It doesn't always leak from the prepuce and the amount produced seems to vary a lot from dog to dog. It is not at all unusual for an owner to notice it for the first time when a dog is mature. There is a possibility of an infection when there is an exudate from the prepuce but your vet is probably right that this is not a problem if a physical exam is otherwise normal.

The other signs do point strongly towards bladder or urethral stones. Sometimes it is possible to palpate bladder stones and less frequently urethral stones on a physical exam. Sometimes vets don't try to do this because it is also possible to feel imaginary stones when there is hard stool in the colon or to get the impression that a stone may be present when there is gas in the intestine (the movement of the gas on palpation can feel a lot like grating from small bladder stones, even though that sounds strange). I still like to palpate for stones, though. Sometimes they are so obvious on palpation that X-rays are almost unnecessary.

The only bladder stones that dissolve readily, in my experience, are struvite stones but there are protocols for dissolving other types of stones. Struvite is the most common type of stone found in the lower urinary tract of dogs (somewhere around 50 to 60% of urinary stones are struvite in dogs) so it is a strong candidate. The only way to know for sure what type of stone is present is to have it analyzed. The stones are very