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Initial Presentation
A 5-year-old neutered male boxer was presented for a 24-hour history of lethargy and panting as
well as 12 to 24 hours of straining to urinate. The patient, owned since he was a puppy, is an
indoor/outdoor dog with a tendency to dig among backyard plants, and is current on
vaccinations. He was neutered one year ago. He has no travel history. The owner reported that in
the past the dog has had bouts of dietary indiscretion with concurrent lethargy and panting,
usually resolving in 12 to 24 hours. However, this time the owner failed to see any improvement,
was concerned, and brought him to the clinic.
Physical Examination
A large firm bladder (~10–15 cm) was palpated in the caudal abdomen; pulses were
weak/synchronous. The prepuce was moist with a bloody red tinge. Other findings were
relatively unremarkable.
Management
The patient was hospitalized for urinary catheterization/unblocking procedure.
8:30 am
Blood work
Compensated respiratory alkalosis
Azotemia (blood urea nitrogen: 33 mg/dL [range 6–31], creatinine: 3.0 mg/dL [range, 0.5–1.6])
Lactate: 1.2 mmol/L (range, < 1.5)
Abdominal radiographs: large distended urinary bladder with evidence of a small radiopaque
calculus within the bladder
Treatment
General anesthesia was administered for urinary catheter placement and possible calculus
retropulsion. Prior to anesthetic induction, patient vomited once (foul brown material). A 14
French red rubber catheter was difficult to place due to narrowing of the penile urethra proximal
to the os penis. Dark, bloody urine (1.5 L) with a foul odor was obtained, with a sterile sample
collected for analysis/culture and sensitivity testing. A 12 French Foley indwelling urinary
catheter with a sterile closed collection bag was then placed. Patient was slow to recover from
anesthesia. Abdominal ultrasound was elected to determine the cause of urethral narrowing.
5:10 pm
Imaging
Ultrasonography: moderate amount of anechoic fluid within abdomen; urinary bladder wall
mildly to moderately thickened with no obvious tears or fluid flow into the abdomen when the
bladder was actively distended. The prostatic/penile urethra was evaluated and showed no
obvious lesions; full evaluation was limited by presence of urinary catheter.
Contrast cystogram: mildly distended bladder with irregular luminal wall; no stones, masses, or
overt rupture/leakage
Urethrogram: narrowing of the penile urethra roughly 10–13 cm proximal to urethral orifice,
consistent with area of difficulty when passing urinary catheter
Abdominal fluid analysis
Creatinine: 7.6 mg/dL (range, 0.5–1.6)
Potassium: 4.1 mEq/L (range, 3.6–5.5)
Blood work
Lactate: 4.0 mmol/L (range, < 1.5)
Progressive azotemia (blood urea nitrogen: 45 mg/dL [range, 6–31], creatinine: 4.1 mg/dL
[range, 0.5–1.6])
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Treatment
Fluid therapy: lactated Ringer’s solution (7.5 mL/kg/hr)
Enrofloxacin: 10 mg/kg IV q24h
Ampicillin/sulbactam: 30 mg/kg IV q8h
9:35 pm
Clinical decline continued; acute onset of seizure activity, which responded to bolus
of diazepam (0.5 mg/kg IV). Blood glucose too low to read; administered dextrose bolus (0.5
gm/kg IV), followed by a 2.5% dextrose CRI in fluids. Hypoglycemia deemed most likely due to
sepsis, potentially from leakage or rupture of the bladder.
10:20 pm
Patient became recumbent, minimally responsive, with poor femoral pulses and injected mucous
membranes. Began blood pressure and blood gas monitoring. A coagulation profile was
indicative of hypocoagulability.
Treatment
Nasal cannula oxygen therapy: 5 L/min
Continued enrofloxacin and ampicillin/sulbactam
Metoclopramide: 0.01 mg/kg/hr CRI
Pantoprazole: 0.7 mg/kg IV q24h
Fresh frozen plasma: 6 mL/kg IV
10:50 pm
No clinical change
Blood work
Potassium: 3.95 mEq/L (range, 3.6–5.5)
Glucose: 50 mg/dL (range, 70–138)
Lactate: 7.4 mmol/L (range, < 1.5)
Blood urea nitrogen: 41 mg/dL (range, 6–31)
Creatinine: 4.3 mg/dL (range, 0.5–1.6)
pH: 7.221
Packed cell volume: 61% (range, 37–55)
Total protein: 4.0 g/dL (range, 5.0–7.4)
Treatment
Dextrose: bolus (0.5 gm/kg IV), 2.5% dextrose CRI continued
12:15 am
Outcome
Patient experienced cardiopulmonary arrest. Intubation and cardiopulmonary resuscitation (15
minutes) produced no response. Urine culture 12 hours after plating showed abundant bacterial
growth. The sample was not submitted for evaluation due to the outcome.
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amount and appropriate type of contrast agent. If there is a tear near the trigone, the inflated area
of the balloon catheter can plug the leak, making it look like an intact bladder wall.1 Be sure to
deflate the balloon and shoot an additional image. It’s critical to have a familiarity and comfort
level with any contrast imaging that is being performed. In addition, a bladder wall leak can seal
itself with a fibrin clot. In cases such as these, although all tests are negative, there is urine in the
abdomen with no active leakage.
Uroabdomen Diagnosis
An abdominal fluid to peripheral blood creatinine ratio of >2:1 was predictive of uroabdomen
with a 100% specificity and 86 % sensitivity according to at least one study.3 Abdominal fluid
potassium to serum potassium can also be used (the critical ratio here is 1.4)3 but we do not have
the serum potassium in this case. If we look at our case, the numbers for creatinine are 7.6 mg/dL
abdominal fluid/4.3 mg/dL blood, which calculates to a ratio of 1.8 (rounded). With these
numbers, a definitive diagnosis of uroabdomen cannot be made. With a sensitivity of 86% we
can only say that most of the time (86% of the time) a dog with these numbers would not have a
uroabdomen but we can’t rule it out, either.
Cytology of the fluid was not performed and would have been helpful in the diagnostic process.
In addition to aiding to confirm uroabdomen, cytology helps guide surgical decisions for any
cause of free abdominal fluid.
Treatment
This patient likely would have benefitted from some form of peritoneal lavage. Whether
uroabdomen was present or not, there was free fluid in the abdomen. Even if the dog had a septic
peritonitis from other causes, flushing the abdomen would have been of benefit. Abdominal
lavage can be done surgically or with a peritoneal lavage catheter (not something available in
most general practice settings).
Looking back at this case, an early surgical intervention may have helped. An abdominal
exploratory would have been a high risk procedure but would have provided the benefit of a
definitive diagnosis as well as the ability to effectively lavage the abdominal cavity. At 5:30 pm,
the lactate had increased from 1.2 to 4.0 mmol/L. Increasing lactate is associated with a
worsening prognosis.4 Even so, the dog might have been stable enough to undergo a surgical
procedure at that time. By 9:35 pm he was clearly in no condition to be taken to surgery. In
general, any patient with a suspected bladder leak needs to be stabilized prior to any anesthetic
procedures.5
Stabilizing the Patient
The clinicians in this case did a good job of trying to stabilize this dog. Enrofloxacin and
ampicillin provided a complete spectrum of antibiotic coverage. It was noted that during initial
catheterization the urine had a foul odor. A sample was obtained for analysis and culture but the
antibiotics were not initiated at that point. While it is not generally indicated to start a
catheterized patient on antibiotics immediately, this case may have been an exception: Foul-
smelling urine usually indicates a UTI, and if there was an extravasation of urine into the
abdomen it could have contributed to the development of sepsis. The culture did indeed grow
bacteria but that was after the fact.
Alterations in Intervention
Additional interventions that could be recommended in hindsight are cytology of the abdominal
fluid and starting earlier aggressive antibiotic therapy and earlier peritoneal lavage either
surgically or via catheterization. We don’t know if any of these interventions would have made a
difference: The patient decompensated in the course of 1 day. That sort of progression can be
hard to stop, and it’s quite possible that, no matter what intervention was undertaken, this dog
would not have survived.