Retrograde Cystography Michelle Hervey Tarleton State University

“Domino” 3 year old Male /Castrated Dalmatian 72 lbs Patient Signalment “Domino” 3 year old Male /Castrated Dalmatian 72 lbs http://www.bydlenijerabek.cz/wp-content/uploads/2013/04/laminatova-podlaha.jpg

Patient History Domino has presented to the veterinary hospital for dysuria, pollakuria, and hematuria. Clinical signs have been occurring for one week.

Patient Physical Exam Findings General appearance: Patient ‘s overall appearance is normal. BCS 5 out of 9. Temperature: 101.1 ᵒF Skin/coat: No abnormalities noted Eyes/fundic exam: No abnormalities noted Ears/otoscopic exam: No abnormalities noted Oral cavity: Pink mucous membranes, CRT < 2, mild dental tarter Musculoskeletal: No abnormalities noted Cardiovascular: Normal rate/rhythm, no murmurs, and a pulse rate of 105 beats per minute (bpm). Gastrointestinal: No palpable abnormalities Respiratory: Panting, thoracic auscultation no abnormalities. Genitourinary: Urinary bladder is painful when palpated. The tip of the penis around the urethral opening is erythematus, and a small amount of red tinged urine at the urethral opening. Nervous system: No abnormalities noted Lymph nodes: No palpable lymphadenopathy

Diagnostic Plan CBC Chemistry Panel with Electrolytes Urinalysis with sedimentation Quantified urine culture (QUC) Two view abdominal radiographs http://www.biyokimya.vet/sites/default/files/docs/Klinik_Biyokimya_Giris_Biyolojik_Materyaller_Analitik_S%C3%BCrecler.pdf http://amrls.cvm.msu.edu/images/feline/feline02.jpg/image_preview

Digital Imaging Digital Imaging – Recording radiographic images as a numerical data (Brown, & Brown, 2014). Digital data is collected and sent to the digital processor (the computer) as an electronic signal (Brown, & Brown, 2014). The software numerically puts together pixels that create the image that is able to be examined on the computer screen. https://castlevetsreading.files.wordpress.com/2013/03/berties-xray.jpg

Examination of Radiographs Upon examination of the digital radiographs the veterinarian is able to see uroliths. The amount of uroliths within the bladder cannot be determined. The veterinarian requests to perform a retrograde cystography study to determine the full amount of uroliths.

Retrograde Cystography The veterinarian suspects ammonium urate uroliths. The Dalmatian is predisposed to these uroliths due to “the hepatic and renal metabolic pathways in this breed results in a secretion of excess uric acid from the kidneys (Summers, 2007). Ammonium urate uroliths can be visualized by digital radiography if they are greater than 3mm, but to visualize the full amount a retrograde cystography must be performed. Retrograde cystography is the study of the bladder via the retrograde infusion of contrast media through a urinary catheter (Brown, & Brown, 2014). Ammonium urate uroliths can be seen with a double contrast retograde cystography. The double contrast media is water soluble organic iodide diluted to 150- 200 mg of iodine /mL (Brown, & Brown, 2014).

Retrograde Cystography Supplies Sedation for the patient. Sterile gloves. Sterile drape. Povidone Iodine swabs. Sterile male urinary catheter. Sterile lube. 20 to 60 mL syringe. Three way stop cock. Bowl to place urine. 2-5 mL total of 2% lidocaine without epinephrine. Broad-spectrum antibiotics. http://www.ec21.com/co/p/paulko/img/oimg_GC00034069_CA00036840.jpg Supplies list was retrieved from Brown, & Brown 2014

Retrograde Cystography Process The survey radiograph has already been performed to assess the bladder. The patient is sedated and the prepuce is saved around the tip, and flushed with a 1:40 dilution of chlorhexidine solution and sterile saline. Then the penis is extruded and swabbed with povidone iodine. The urinary catheter is placed in the bladder, and the urine is emptied from the bladder. The amount of urine is recorded, and the bladder is infused with the 2-5 mL of 2% lidocaine without epinephrine to reduce pain within the bladder and bladder spasm. The negative contrast is infused into the bladder. While infusing the bladder with contrast the bladder is palpated to note when it is distended enough for viewing on the digital radiograph. Three view abdominal radiographs are performed (right/left lateral views, and a ventrodorsal view. Then the organic water soluble contrast is infused into the bladder. The patient is rotated from side to side to coat the bladder with iodide. Another set of three view radiographs are performed. After the radiographs are viewed, and the study is complete the contrast medium. The patient’s bladder will then be flushed with a broad spectrum antibiotic, and then the urinary catheter is removed.

Retrograde Cystography Images https://www.mypacs.net/repos/mpv3_repo/viz/full/0/12/101/12686560.jpg

Diagnosis The patient has been diagnosed with ammonium urate urolithiosis, and crystaluria. These were identified by using the urine sedimentation, but the Dalmatian breed is predisposed to ammonium urate urolithis. http://www.cliniciansbrief.com/sites/default/files/attachments/AskE_Ammonium%20Urate%20Urolithiasis.pdf

Treatment Plan The patient will be placed on the Hill’s Science Diet u/d. The diet will dissolve the ammonium urate uroliths within the bladder. Hillspet.com Hillspet.com

Benefits of the Diet Decreases purine intake and uric acid excretion, which lowers risk of forming urate crystals and uroliths. Protein low enough to dilute urine by decreasing urea production and urinary concentrations of stone-forming materials. Added Taurine to help maintain normal heart muscle function. Low sodium supports kidney health. Added antioxidants to promote healthy immune system.

Treatment Regimen Feeding Regimen for last 6 weeks. Distilled water all he wants. Recheck WNL UA/CBC/Chemistry Panel/Radiographs Should have recheck every 6 months Check protein for deficiencies Fasting serum chemistry profile Echocardiogram https://s-media-cache-ak0.pinimg.com/236x/d3/9b/c9/d39bc940bc30a84e5f650fbd1acfcf80.jpg

References Brown, M., Brown, L. C..(2014).Lavin’s Radiography for Veterinary Technicians (Fifth Edition). Saunders Elsevier. St. Louis, MO. Summers, A..(2007).Common Diseases of Companion Animals (Second Edition). Mosby Elsevier. St. Louis, MO.