Estimated reading time: 7 minutes
Subedited by Dr Phil Tucak
This case study discusses an unusual find in a feline patient. The patient presented as a traumatic uroabdomen found to be due to a urethral tear. This case proves that you can never predict the cases you’ll encounter working in regional Australia as a GP veterinarian.
Tinkles is a two-year-old male neutered domestic short hair cat who presented for hiding, urinary incontinence, inappetence and suspected pain after slamming his abdomen against the corner of a table when jumping off a bookshelf.
On clinical exam, Tinkles was found to have a painful abdomen on palpation, exhibiting signs of dehydration and was very quiet/dull with an altered demeanour. Hospitalisation, intravenous fluid therapy (IVFT), pain relief and an initial work-up including blood work of biochemistry, electrolytes and haematology, together with abdominal radiographs and an A-fast ultrasound were recommended to the owner.
Tinkles had an intravenous catheter placed and was given methadone IV at a dose rate of 0.37mg/kg for pain relief. IVFT with Hartmann’s was commenced at a rate of 9ml/kg/hr but only once cystocentesis had been performed.
Blood tests showed a moderate to severe azotaemia, a mild elevation of glucose, hyponatreamia and a stress leucogram. Three view abdominal radiographs showed ventral displacement of intestines away from the retroperitoneal space on lateral views with no bladder discernible on all views.
On ultrasound, a large amount of free fluid was identified extending from the cranial bladder to the caudal edges of the liver. This free fluid was sampled via ultrasound guided abdominocentesis. A cystocentesis was also performed into a small but visible bladder on ultrasound. No other abnormalities were found on A-fast ultrasound and a clinical suspicion of uroabdomen was formed.
The fluid found on abdominocentesis was analysed and creatinine was measured. The abdominal free fluid’s creatinine levels were much higher than the patient’s blood levels of creatinine and thus a uroabdomen was confirmed.
Tinkles’ owner was called and an exploratory laparotomy recommended. The owner was given an estimate and warned of the possibility of irreparable damage to the bladder and/or other abdominal organs, post operative complications such as infectious peritonitis, acute kidney injury and wound dehiscence.
Surgery
Tinkles was given 25mg/kg Cephazolin at induction of anaesthesia and this was repeated every 90 minutes during surgery for a total of two doses. Surgery was commenced with a xiphoid to pubis celiotomy. A large amount of free fluid was suctioned to establish visualisation of the abdominal cavity. Intestines were noted to be very hyperaemic likely due to exposure to urine/a sterile peritonitis.
All other organs not pertaining to the urogenital system were examined and found to be grossly normal on visual and digital examination. The source of the urine was hard to determine. The bladder showed no clear tears, a small rent was visible in the dorsal portion of the bladder wall but was not full thickness with no fluid leaking out.
Each kidney and ureter were closely examined with no obvious damage visible. The urethra was then examined and it seemed that the source of the free fluid was originating from this region. Cranial traction was placed on the trigone of the bladder and the celiotomy incision extended further distally to expose the urethra and pelvic inlet fully.
A small area of bruising was visible in the mid portion of the urethra and surrounding tissue. A veterinary nurse was then required to place a temporary urinary catheter into the urethra externally with aseptic technique. The nurse was guided verbally by the surgeon to advance to a point just distal to the area of bruising, and saline was flushed through this catheter. This helped clearly identify the tear which was approximately 2cm long and longitudinal/midway along the urethra length and sitting within the pelvic inlet—only visible with traction on the bladder.
The surgical team at High Street Vet Surgery’s closest referral veterinary hospital (located seven hours away) were consulted over the telephone and a plan was made to repair the tear and then place a urinary catheter for a minimum of seven days to bypass urine past the surgery site and allow healing.
The tear was repaired with six simple interrupted sutures using 4/0 PDM. The urinary catheter was gently advanced past the tear so that the catheter allowed guidance on suture placement and ensured the urethra was not accidentally occluded. A gentle leak test was performed by flushing the urinary catheter—withdrawn to just distal to surgery repair site, with digital occlusion of the proximal urethra.
The temporary urinary catheter was then replaced with an indwelling urinary catheter, placement and advancement was observed closely to ensure that no damage to the urethra and repair site occurred. An omental patch was placed over the repair site.
The abdomen was flushed with two litres of warmed sterile saline and the abdominal contents were inspected one last time and then new gloves, drapes and kit were opened. The abdominal wall, subcutaneous tissues and skin were closed routinely, an indwelling urinary catheter and closed system collection kit connected, and the patient recovered uneventfully.
Post-operative management
A 25 microgram Fentanyl patch was placed on the patient’s right hindleg and an additional dose of 0.2mg/kg methadone was given IV. 1mg/kg of Cerenia was given S/C to help with visceral pain. In the 24-hour period prior to the fentanyl patch working, 0.5mg/kg Bupredyne was given PRN and Cephazolin administration was continued for another 24 hours at 25mg/kg TID.
Twelve hours post-surgery, the patient was very bright, alert and responsive, and eating well. Repeat biochemistry was run and the patient’s electrolyte abnormalities and azotaemia were found to have completely resolved. On confirmation of adequate renal function, oral meloxicam 0.05mg/kg PO SID was commenced as well as Amoxyclav 125mg BID PO.
The following seven days of hospital care with an indwelling urinary catheter were uneventful. Tinkles was an excellent patient who seemed very comfortable and had a great appetite. Urinary output was monitored and ranged from 1-4ml/kg/hr. IVFT was discontinued 48 hours post operatively as the patient was eating well. At eight days post-operatively the indwelling urinary catheter was removed, and that evening the patient urinated a large amount independently and was discharged from the veterinary hospital the following day.
While a successful and rewarding case, questions remain on the aetiology and cause of the patient’s injury. A traumatic urethral tear with no other evidence of trauma due to a minor household mishap is unusual to rare. Tinkles is scheduled for a six-month case review and the owner is aware of the risk of a long-term stricture forming.
Dr Kirsty Downing, BVSC (Hons) Clinical Director, High Street Vet Surgery
Veterinarian Dr Kirsty Downing spent most of her childhood in South Africa. In 2007 her family decided to migrate to Australia.
Due to her love of interacting with animals and supporting the human-animal bond, Dr Downing pursued a veterinary career.
In 2014, Dr Downing graduated from the University of Queensland with a Bachelor of Veterinary Science with honours.
After spending time in Western NSW and Northern QLD working in mixed animal practices, Dr Downing joined the High Street Vet Surgery family in December 2017.
Dr Downing has tackled some major trauma cases including traumatic diaphragmatic tears, extensive de-gloving injuries, traumatic injuries penetrating into abdominal and/or thoracic cavities, prostatic abscesses, GDVs, and the standard intestinal foreign bodies.
Dr Downing loves the challenges and variety that being a veterinary general practitioner brings.
