Feline Perineal Urethrostomy

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

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 bladder collects urine from the kidneys and contracts to expel its contents during urination via a tube called the urethra. The end of the urethra in a normal cat is relatively narrow. Early neutering of male cats may cause the urethra to fail to develop to a normal diameter.

Feline lower urinary tract disease

Feline lower urinary tract disease in cats commonly will only produce signs that mimic bladder infections. In some of the affected cats, mucous plugs, crystals and stones can become lodged in the terminal part of the urethra of a male cat, which results in urinary obstruction. Over a period of 24 hours of obstruction, toxins build up in the cat’s body and can cause death.

Signs

Shortly after urinary obstruction occurs, the affected cat will go to the litter box and attempt to urinate without success. As the bladder becomes more and more distended, signs of pain may be evidence by the cat secluding himself and crying out or growling. Upon palpation of the abdomen, the bladder will be painful, firm and the size of an orange. As the toxins accumulate in the blood, the patient develops signs of vomiting, abnormal heartbeats, depression and in severe cases, coma. These toxins can be fatal to the patient.

Diagnosis

Finding a very large and firm bladder upon physical examination makes the diagnosis of urinary obstruction most probable. X-rays of the abdomen are necessary to rule out obstruction caused by small stones in the urethra and bladder (arrows). Blood is tested to evaluate for accumulation of urinary toxins and high potassium levels. Abdominal ultrasound can also be used to evaluate the urinary tract, but may not be necessary in every patient.

The day of surgery

Our anesthesia and surgical team will prescribe a pain management program, both during and after surgery that will keep your companion comfortable. This will include a combination of general anesthesia, injectable analgesics, epidural analgesia, and oral analgesics.

Treatment

Urinary blockage is an emergency; therefore, it is essential to have this condition treated immediately. Your veterinarian will start intravenous fluid therapy, as these patients commonly are dehydrated. If the potassium level is very high, glucose (a type of sugar) and insulin are administered intravenously to lower the level of this electrolyte. The urethral obstruction is relieved by flushing the material out of the urethra and passing a urinary catheter into the bladder. If present, stones are surgically removed from the bladder once the patient is stable and the toxins have been eliminated from the blood stream. Most patients will have a urinary catheter left in place for at least 24 hours after the obstruction has been relieved. After the catheter is removed, the patient is carefully monitored for urination. In the event that the patient becomes obstructed again, the obstruction will need to be relieved again. If the patient becomes repeatedly blocked, a perineal urethrostomy is recommended. The perineal urethrostomy essential removes the narrow terminal portion of the urethra, which is located within the penis. During the procedure, the urethra is cut open for a length of about ½ of an inch, to a point where the urethra enlarges. The edges of the urethra are then sutured to the edges of the skin using very fine sutures (see photo right).

Aftercare

Most patients that have a perineal urethrostomy can be released from the hospital one day after surgery or once the toxins have been eliminated from the blood stream. An analgesic will be prescribed to keep your companion 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. At home compressed paper litter such as “yesterdays news” litter should be used. Clay litter is not recommended as it can become caked around the urethrostomy site and cause obstruction to urination. 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 surgery may include an atonic bladder, 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.

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- Mug^TM or Beef-in-a-Mug^TM 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 Heet^TM (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

Board-certification by the American College of Veterinary Surgeons

What does it mean?

• Four years of advanced training in surgery beyond the Doctor of Veterinary Medicine Degree

• Experience in the development of new surgical treatments

• Rigorous examination by the American College of Veterinary Surgeons to ensure competency in advanced surgical techniques

• Assurance that a veterinarian is a surgical specialist