Feline Perineal Urethrostomy

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Article Written by Dr. Daniel A. Degner, Board-certified Veterinary Surgeon (DACVS)

Animal Surgical Center of Michigan

5045 Miller Road

Flint, MI 48507

www.animalsurgicalcenter.com

Phone: 810-671-0088

Key Points

A warning sign of urinary obstruction is frequent visits to the liter box and straining during urination without production of urine

Emergency veterinary attention is needed to treat this potentially fatal condition

With treatment, the prognosis is favorable


Anatomy

The urinary system is made of the kidneys, the tubes (ureters) that pass urine from the kidneys to the bladder, the bladder which is a reservoir for urine, and the urethra, which is the tube that drains urine from the bladder to the outside. The urethra in males is fairly long and a portion of it runs through the tissue of the penis. The urethra narrows within the penis, which makes it prone to developing obstruction.

 

What is feline lower urinary tract disease?

An inflammatory, typically noninfectious disease of the bladder in cats, is called feline lower uinary tract desease (FLUTD). Affected felines can have plugs of mucous, crystals, and bladderstones. These can pass from the bladder and into the urethra. The result is urinary obstruction which results in failure of kidney function with a build up of toxins (uremia), acids, and potassium within the blood stream. Left untreated, death ensues within 24 to 48 hours.

 

Signs

Intitial signs of urinary obstruction includes straining to urinate without producing any urine. The bladder becomes distended to the size of an orange, which is typically easily palpable through the abdominal wall. Crying, moaning in pain, anorexia, vomiting, and seclusion from the family are common nonspecific signs. As toxins build up in the body, the cat will become progessively more depressed until the patient dies.

 

Diagnosis

Upon physical examiantion, the veterinarian will find a very firm, painful bladder and urine cannot be expressed from the bladder. Radiographs (x-rays) are essential to see if the obstruction of the urethra is due to stones. Blood testing is done to check kidney function (BUN and creatinine), to check for accumulation of acid in the blood and make sure that the potassium levels are not elevated.

 

Preparation for surgery

Typically cats that present for surgical treatment of urinary obstruction need emergency treatment, therefore, preoperative preparation is usually possible. Prior to surgery, your pet will receive a sedative, have an intravenous catheter placed for the administration of intravenous fluids and intravenous medications, be induced under general anesthesia with medication(s), and have a breathing tube (endotracheal tube) placed to allow delivery of oxygen and gaseous anesthesia. The surgical site will be clipped and cleansed with an anti-septic solution in preparation for surgery. While under general anesthesia, your pet's breathing will be assisted with a ventilator and vital parameters such as heart rate, respiratory rate, core body temperature, blood pressure, oxygenation of the blood (pulse oximetry), exhaled carbon dioxide (capnography), and heart rhythm (EKG) will be monitored to ensure your companion's well being. Pain will be controlled both during and after surgery with analgesics (pain-controlling medication).

 

Treatment

Immediate treatment of urinary blockage is essential. At the veterinary hospital intravenous fluid therapy will be initiated to correct dehydration. Elevated blood potassium levels must be addressed, as this could cause abnormal heart beats and could stop the heart from beating; this is treated with administration of insulin and intravenous dextrose (sugar). A urinary catheter is used to flush the obstructing mucus plug, crystals, or stone back into the bladder. After the obstruction has been relieved, a urinary catheter is placed and the bladder is flushed with saline. The catheter is left in place for about 24 hours and then it is removed. An additional 24 hours of hospitalization is essential to ensure that the cat is urinating well. Reobstruction of the urethra again require repeating the process of unobstructing the urethra again.

Surgery is indicated if the cat has bladder stones (cystotomy). If the patient has repeated urethral obstruction (typically 3 strikes and your out) with mucous plugs or crystals, then a perineal urethrostomy is performed to remove the narrow terminal part of the urethra located within the penis.

 

Aftercare

Patients that have a perineal urethrostomy are usually released from the hospital the day after surgery or after the toxins (BUN and creatinine) have been eliminated from the blood stream. An analgesic will be prescribed for about 4 days after surgery to keep the cat comfortable at home. The incision should be checked twice daily however, should not be washed or disturbed as this may cause bleeding and delay healing. Compressed paper litter such as “yesterdays news” litter should be used. Clay litter is not recommended, as it can become caked around the surgical site and cause urinary obstruction. An Elizabethan collar is kept on the patient for about 10 days. Antibiotics typically are continued for about 2 weeks after surgery. When the cat returns to us for suture removal, a very short anesthesia will be needed.

 

Complications

Complications associated with the urinary obstruction may include an atonic bladder. Complications from surgery include bleeding from the surgery site, infection, urinary or fecal incontinence and stricture of the urethra. The atonic bladder is due to chronic overstretching of the bladder muscle, which results in a bladder that can no longer contract and expel urine. This problem is treated with mediations and urinary catheterization and usually resolves within 7 days after surgery. Bleeding is typically self-limiting and rarely needs treatment other than ensuring that your cat does not disrupt the incision by licking. Bladder infection is the most common complication following surgery and may be due to a shortened urethra. Signs of a bladder infection include blood in the urine, straining to urinate and frequent visits to the litter box. Some cats may have no visible signs of infection; therefore, a urinalysis and urine culture should be done very 3 months by the pet’s veterinarian. Fecal and urinary incontinence are very rare complications that may be a permanent problem; signs of this include involuntary dropping of stools and leakage of urine. Stricture of the urethra at the surgery site is the most devastating complication that occurs within the first 6 weeks after surgery. Warning signs of this complication are the same as those seen with urinary obstruction. Additional surgery attempting to correct this problem is usually successful only 50% of the time.

 

Prognosis

Most cats that have perineal urethrostomy go on to live a normal and healthy life.

 

Suggested reading

Degner, DA. Procedures Pro: Urinary obstruction: treatment measures. Clinicians Brief. 9(9):70-75, 2011. (click here); please note that Clinicians Brief is the publisher and copyright holder of this article and they have given permission (11/2911) to share it on www.vetsurgerycentral.com.  

 

rev 10/2/11

Frequently Asked Questions After Surgery

When should my dog have the first bowel movement after surgery?

  • Many dogs will not have a bowel movement for the first 4 to 5 days after surgery
  • Reasons that a dog will not have regular bowel movements after surgery include:
    • The dog has been fasted prior to surgery
    • Dogs do not eat well during the hospital stay
    • They frequently do not eat well when they go home
    • They are fed highly digestible food that produces little stool
    • Pain medication that contain narcotics (such as morphine, fentanyl patches, and tramadol) can be constipating
  • If a pet does not have a bowel movement on the 5th day of being home, a stool softener such as metamucil can be fed
    • Dose of metamucil is 1 tsp per 25 Kg mixed in with each meal (canned dog food); feed immediately after mixing, as the metamucil will gel the food and may make it less palatable

My pet had surgery and will not eat.  What can be done?

  • Dogs
    • Most pets will not eat their regular dog food after surgery, especially if it is kibble.
    • Offer a cooked diet having a 1:1 ratio of a protein source and carbohydrate source.  The protein source can be any meat (example: chicken breast, turkey breast, lean hamburger) that is low in fat and should be cooked (drain off all fat after the meat has been cooked).   The carbohydrate can be pasta, potato or white rice.
    • Try canned dog food; to enhance the flavor sprinkle a very small amount of garlic powder or chicken or beef broth (Chicken-in-a- MugTM or Beef-in-a-MugTM products)
    • Try Gerber strained meats for babies such as the chicken, beef, turkey, or veal
    • Try Hill's A/D diet available at most veterinary hospitals
    • Hand feeding: place a small amount of food in the mouth so that your dog gets the flavor
    • Warm the food slightly in a microwave, as the food will be more aromatic; stir the food before feeding and test the temperature on the bottom side of your wrist; it should only be luke warm.
    • Remember that most pets will not eat the first day or two after they get home from surgery
  • Cats
    • Offer smelly foods that contain fish such as tuna or smelly cat foods
    • Try Gerber strained meats for babies such as the chicken, beef, turkey or veal
    • Hand feeding:  with your finger place a small amount of food on the roof of your cat's mouth; use a syringe to get soft food into the mouth
    • Warm the food slightly in a microwave as the food will be more aromatic; remember to stir the food before feeding and test the temperature; it should be only luke-warm
    • Some cats will only eat dry food, try kibble if your cat normally has been fed that food
    • Petting and stroking your cat frequently will help to stimulate appetite
    • Remember that most pets will not eat the first day or two after they get home from surgery
    • Appetite stimulants such as cyproheptadine may be helpful
    • If your cat refuses to eat anything for 7 days a stomach tube or nasogastric tube should be placed to provide nutrition so that a serious liver problem (hepatic lipidosis) does not develop

My pet is vomiting.  What can be done?

  • The first thing for you to discern is whether your pet is vomiting or regurgitating.  Both will result in fluid or food being brought up.  Vomiting always will have heaving or retching of the abdomen prior to expulsion of the vomitus.  Regurgitation is not associated with heaving and the pet usually just opens the mouth and fluid or food will be expelled.  Usually the regurgited material will be clear or brown colored fluid. 
  • Next is to identify the cause of the vomiting or regurgitation.
  • Causes and treatment of vomiting after surgery
    • When some pets return home after a stay in the hospital they may drink excessive amounts of water at one time and then vomit; if this appears to be the case, the water should be limited to frequent smaller amounts.
    • Medications such as antibiotics, narcotics or nonsteroidal anti-inflammatory medication commonly cause vomiting after surgery.  In order to see which medication is causing the problem, the administration of each drug should be separated 2 hours apart.  Usually the pet will vomit or appear nauseated (drooling and sick look) within 1 hour of administration of the medication that they are sensitive to.  The antibiotic in some cases may be changed to a different one, or may be discontinued. 
    • Stomach upset from anesthesia is a potential cause of vomiting and will pass within a couple of days. 
    • An uncommon cause of vomiting after surgery is internal organ failure.  Blood testing will confirm this problem. For this reason vomiting should not be ignored if it persists for more than 24 hours.
    • If your pet had surgery of the bowels or stomach, vomiting is always a concern, as it may indicate that infection of the abdominal cavity, called peritonitis, is present.  Do not ignore this sign.
    • Symptomatic treatment of vomiting involves withholding food for 12 to 24 hours, then introducing small amounts of bland food such as rice and lean cooked hamburger, if your pet does not vomit after that then gradually wean him/her back onto the regular diet after 3 days.  In order to decrease the acidity of the stomach, Pepcid AC 0.5 mg/kg can be given by mouth twice daily for 5 days.  Metoclopramide and Cerenia are good anti-vomiting medications for dogs and cats.  You should always consult a veterinary healthcare professional before administering medication.
  • Causes and treatment of regurgitation after surgery
    • The most common cause of regurgitation is reflux of acid from the stomach into the esophagus while your pet is under anesthesia.  Acidic fluid from the stomach can cause a chemical burn of the esophagus and result in a bad case of heart burn, called esophagitis.  This results in poor motility of the esophagus, therefore water and food will accumulate in this structure.  In most cases, esphagitis is self-eliminating and will resolve within two or three days. 
    • If the esophagitis is severe the esophagus may develop one or more strictures.  A stricture is a narrowing or stenosis of the esophagus and does not allow passage of food down the esophagus, in regurgitation that lasts longer than one week.  This problem should be brought to the attention of your pet's doctor within the first two weeks so that it can be treated by ballooning the stricture (minimally invasive procedure, as it is done with the aide of an endoscope).  If an esophageal stricture is chronic surgery is needed.
    • Symptomatic treatment of regurgitation caused by esophagitis includes feeding bland food, and administering a coating agent (sucralfate) and an acid blocker (omeprazole or other).  Consult a veterinary health care professional if the regurgitation continues for more than a couple of days.

How do I know that my dog is in pain following surgery?

  • Signs of pain include
    • crying
    • biting if you get near the surgical site
    • grimacing (lips are pulled back and the the dog looks anxious)
    • tragic facial expression
    • panting
    • restlessness and unable to sleep; pacing
    • if abdominal surgery was done the pet will not lie down on the incision, or will continually sit up in spite of appearing very tired
    • the worst pain will be for the first 2 to 3 days after surgery

What can I do to control my dog's pain?

  • Narcotic medications that control pain: tramadol, butorphanol, Duragesic (fentanyl patch)
  • Anti-inflammatories used to control pain: Deramaxx, Rimadyl, Previcox, or Etogesic
  • If an orthopedic surgery has been done cold packing the surgical site may be helpful
    • A cold pack may be a pack of frozen peas, crushed ice in a Ziploc bag, or a cold gel pack; place a thin barrier between the skin and the cold pack.  An alternative to a cold pack is to freeze water in a styrofoam cup; after frozen cut the bottom of the styrofoam cup out. Cool the surgical site around the incision by rubbing the exposed ice directly on the skin in a circular pattern.  Cooling the surgical site helps to numb the area.

How do I know that my cat is in pain following surgery?

  • Pain is more difficult to assess in cats versus dogs, as signs can be more subtle and they usually do not vocalize when in pain
  • Signs of pain in a cat include the following:
    • biting if you get near the surgical site
    • growling or deep cry
    • not wanting to eat
    • hiding and not wanting to be near owner (remember that this could also be caused by the cat just being upset about leaving home and coming back)

What can be done for pain at home for my cat?

  • Pain medication such as buprenorphine or a Duragesic (fentanyl) patch
  • Tylenol will kill a cat as they lack abundant glutathione enzyme in the liver
  • Anti-inflammatories can be used, but the dose is much less than dogs

Is it okay for my pet to lick the incision?

  • If a dog licks the incision, the healing process may be delayed.
  • Licking can remove stitches and cause the incision to open
  • Licking can become a severe habit that is difficult to break
  • Licking can cause infection as the mouth has many bacteria
  • Dogs will frequently lick the incision when the owner is not watching such as at night time; if the skin looks red or excoriated the most common cause is from licking.
  • To stop your pet from licking the following can be tried:
    • Elizabethan collar can be placed on the neck; this will not help stop your pet from scratching at the region
    • Cervical collar (bite not collar) is a less awkward device and can be effective at stopping a pet from licking the surgical site
    • A tee shirt can be used to cover an incision on the chest or front part of the abdomen; gather the waist of the shirt up over the dog's back and wrap an elastic band around this part of the shirt.
    • A bandage or sock can be used to cover an incision on a limb; fasten the top of the sock to the dog's limb with tape.
    • Bitter apple can be applied around the incision; many dogs will continue to lick  after application of this topical
    • Bitter Apple and Liquid HeetTM (obtain this from a drugstore...it is used for sore muscles) mixed in a 2:1 ratio can be applied around the skin incision
    • Antipsychotic medication in some cases is needed

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  • Experience in the development of new surgical treatments

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