Two weeks ago, we welcomed back a former client who had moved to Kentucky about nine years ago. They moved back to our area and Winston the Scottie came to see us before his bags were unpacked. Prior to leaving the Bluegrass State, he had begun to pass blood in his urine. His previous veterinarian had assumed a urinary tract infection was responsible for the problem (a common enough explanation, to be sure), and prescribed a broad-spectrum antibiotic. Unfortunately, after two weeks of medication, there was no improvement, so it was time for a re-evaluation of the situation.
Now a lot of different explanations are possible here. There’s an old saying in the medical field: "If you hear hoofbeats coming around the corner, it could be a zebra, but it’s probably a horse." Hence the use of "zebra" to refer to uncommon diseases. In the case of bloody urine, there are a lot of horses before you ever start to think about the zebras. First, the previous doctor may have been right about a bladder infection causing the bleeding, but just didn’t pick a drug that would kill the germ. That’s why the urologists recommend that you always culture the urine before starting treatment. Sometimes we don’t do that because so many of our patients respond to our favorite antibiotic, and that’s so much cheaper than a urine culture. It’s not a very scientific approach, but it seems practical. When it works, you look like you know what you’re doing. When it doesn’t, you go back to what you should have done in the first place.
"Bring Winston back in five days, which will be seven days after his last dose of medicine. That way the old antibiotic won’t interfere with our culture. Don’t let him empty his bladder outside. We need a full bladder so that we can put a needle into it for an uncontaminated sample."
Since Winston was neutered long ago, I didn’t have to worry much about the blood coming from a prostate problem. The prostate gland pretty much goes away after neutering. He seemed to feel pretty good otherwise, so I didn’t think the kidneys themselves were very high on the list. If they were producing much blood, they probably wouldn’t be working all that well, and waste would be accumulating in his blood, making him feel bad. Of course, he could have a bladder stone rattling around and causing the bleeding. His previous doctor also hadn’t X-rayed the bladder.
Winston’s pretty fat, so it would be really hard to feel his bladder from the outside. Fortunately, we have a diagnostic ultrasound machine. This makes it easy to locate the bladder and get your specimen needle in place, even when the bladder doesn’t have much in it. Ultrasound also gives you a look at the thickness and texture of the bladder wall, where an X-ray only gives you a silhouette. Stones also are easily detected with the ultrasound, including some that won’t show up on X-ray.
When we examined Winston’s bladder with the ultrasound, it was obvious that we had a different problem. There were two obvious lumps on its lining, one as big as a golf ball. Exploratory surgery revealed two tumors, and we removed as much as we could while still leaving him a bladder. We also cultured the urine during the surgery, finding a nasty bug that had set up shop, and that was not sensitive to the previously prescribed antibiotic. The pathologist confirmed that Winston had transitional cell carcinoma, and Winston has a good chance of enjoying a couple of more years with a very mild oral chemotherapy administered at home. Since he’s already eleven years old, that sounds pretty good.
Hindsight being 20/20, it seems obvious that Winston’s previous doctor should have ultrasounded his bladder on day one. That’s where I have "deja vu all over again". Today, another neutered male Scottie came in with blood in his urine. His urinalysis doesn’t really support bladder infection. We X-rayed him and no stones showed up. So when is he getting his bladder ultrasound and culture? He will get that when and if his broad-spectrum antibiotics don’t work.
What’s the difference between "Previous Doctor" and me here? Only this: I laid out all the possibilities and recommended the ultrasound and culture today. What’s the difference between Winston’s people and today’s client? Winnie’s folks would do anything for him and today’s client is gambling on a quick fix. Will the quick fix work? We’ll know in a couple of weeks.
The bottom line is this: when your veterinarian recommends a full diagnostic workup instead of "just giving him some medicine", there’s a good reason for it.