Expressing a large atonic bladder

[drakonka]

Hello,

We are at our wit's end here. Our 7 month old Maine Coon kitten was perfectly happy and healthy until his neutering surgery two weeks ago. During the surgery the vet thought that his bladder looked abnormally large and put in a catheter to check for blockage and test his urine for infection, and drained 200ml! They found no problems - no blockage, no infection. The surgery apparently went well, they stitched him up and sent him home. By all accounts it looked as if he just had a large bladder - up until then he peed normally (very big pees, 2-4 per day in the litter box).

After the surgery he couldn't pee. We took him back. They suddenly found a raging infection in his bladder and he's been in and out of hospitals ever since. We switched to a different vet who has been treating him for almost 2 weeks now. They've tried various meds throughout the weeks and he has had several days of staying with them. They've put in a catheter numerous times to drain him, drained him with a needle, but haven't been able to express him manually.

For the past 3 days they've been waiting for his bladder to fill up completely hoping he will pee on these new meds they have him on. He did not pee. They drained him with a needle this afternoon - 350ml. They said the bladder did not compress properly, so I guess he is now atonic. I have a diary of details that we've been sending to the breeders with updates if anyone asks for more details, and journals from the vet.

Right now he is on the following medications:
* Alfadil - every 8 hrs
* Mestinon - ever 8 hrs
* Stesolid - every 8 hrs
* Synulox - twice a day
* Metacam - once a day dosed to 4.5kg (his weight)

I just brought him home. At this point both vets (vet A and vet B) seem to have screwed up several times and we don't know who to trust anymore. We called another vet (Vet C), 70km away, who supposedly has their own specialists and is very well equipped. Vet B seems to be starting to give up - their next step is to put in an "internal catheter" surgically, which we would take him home with, hoping that this will allow his bladder to rest (they have tried cathetarizing him normally but he ripped it out twice). If this doesn't work, they said, we should start thinking about putting him down. We want to consult with Vet C before doing another surgery on a kitten who's already been through so much and in the meantime, while his bladder has just been emptied, see if we can learn to express it ourselves over the weekend. All the journals from both vets have been sent to Vet C, but their vet likely won't actually be able to talk to our vet until Monday. Our cat's bladder is very big - when they drained him today it was full but has only just started going a little harder so they said he should be ok through the weekend. If Vet C can't offer any other insight or alternatives we will go through with the surgery, but at this point Vet B seems to be just taking stabs in the dark hoping something will work.

We read the articles here about expressing the bladder, also found this useful page on JustAnswer and watched videos. However, being totally new to this we have no idea if this is possible with an atonic and very large bladder. Is some technique better than others, do we need to wait for the bladder to be much more full or is it ok to try in a few hours or so?

We could use any advice we can get, because the vets can't seem to give us anything practical. The vets at Vet B have been unable to express it manually themselves or show us how to do it - his bladder is very large and elongated and they just can't seem to do it. They have started bringing up running out of options, but he is otherwise such a happy and active kitten. Even as his bladder is filling up he loves playing with our other kitten, eats very well, runs around, etc. He's very tired of all of the vet trips and procedures but he is not a sickly cat - even the vets say he's perfectly healthy and happy EXCEPT for this bladder. We refuse to give up now and could use any advice we can get about how to best express him at home. I'm sorry about the wall of text - we're just very worried and feel like we're running out of time, as the vets seem to be close to giving up on him, our insurance is running out (but we'll of course spend every cent on him if we have to), and at this point it seems like we need to try something on our own here to express him.

[drakonka]

I am also noticing that now our cat is drinking frequently again, as if he still has an infection (or _again_ has an infection). He is on Synulox, but we've also heard some people say that mixing Apple Cider Vinegar with water has helped them with infections in dogs, cats, and humans. Does anyone know if it interacts badly with any of the medications I listed above? We're afraid to try it before making sure, but I can't find any concrete info online yet.

[Bobbie]

Have you checked to make sure none of those drugs can cause urinary problems? Metacam can. Sometimes these aren't known to cause urinary retention but might. (Previcox did in my paraplegic dog so that I could not express him).

[drakonka]

Have you checked to make sure none of those drugs can cause urinary problems? Metacam can. Sometimes these aren't known to cause urinary retention but might. (Previcox did in my paraplegic dog so that I could not express him).

I have read a bit about Metacam side effects but haven't noticed anything about not being able to pee. Our cat hasn't had any visible reaction (diarrhoea, vomiting, lethargy) after metacam yet that we could see and those are the ones we've been watching for. However I might try to call the emergency vet now and ask them to consider switching him to another pain killer and anti inflammatory (this is what Metacam is currently being used for - both pain killer and anti inflammatory).

He DID have a bad reaction to another pain killer that a nurse injected into his IV when I was visiting a few days ago after they tried to put in a catheter (the one he ripped out) - he went unresponsive and totally limp, couldn't even hold up his head. The nurse didn't seem to know what to do except try to shake him and get a reaction. After a minute of this I was starting to panic and was about to yell at her to find a vet who knows what they're doing, but then he came to all of a sudden and seemed fine. She checked his heart and it seemed fine. Since then we've been sure to mention the incident to every vet we speak to before every procedure so that they know what happened - they seem to know what drug it was that caused this and won't be giving it to him again, and it doesn't seem to have been Metacam.

He tried to go to the litter box this morning and wasn't able to. Part of me thinks this may be a good sign, that he's trying to go even with his stretched/non-contracting bladder. We're going to try to find the bladder now to express him.

[drakonka]

Still no luck expressing I also noticed that his penis isn't even coming out of the sheath. In the past even before this whole thing started his penis would sometimes be protruding when he was relaxed, and during the first few days of the infection it would protrude even more and he would lick it as it was irritated. Should the penis be coming out while I am trying to express the bladder? A couple of times it _seemed_ like the sheath may have twitched and I thought maybe I at least found the bladder, but the opening didn't get any larger. Maybe it's sensitive after all the cathetarizations he's been through over the past 2 weeks. Is it worth trying to pull the sheath back by hand to make sure his penis _can_ extend? I don't want to hurt him.

[critters]

Phenoxybenzamine (PBZ) was a godsend for my Buddy, who had a spasm at the neck of his bladder from spinal cord injury. Another surgical possibility is urethrostomy, which Buddy eventually had done. It allowed me to drain his pee through his belly wall.

[CarolC]

These comments are from Claudia, who did the video showing how to express Krümel.
http://www.youtube.com/watch?v=QQyHrjfBzsA
She is also asking some friends if they have any comments.

now I read everything and first of all I have to say - I would refuse to give up too with such a young cat.
First of all, I think it is no problem trying to express the bladder. The more they try the earlier they will learn
I think it will be better not to wait until the bladder is too full. Did they see my Video expressing Krümel's bladder?
For express the bladder they first have to locate it. It feels like a balloon which is filled with water.

I'm wondering, that the cat doesn't have a bladder infection, when the urin stays in the bladder such a long time???
This is very risky because the kidneys could be involved.

Did the vets exclude guanite and oxalate crystals? This is often a problem for male cats, because the urethra is
much longer and more slim than females.

I know there is a drug for bladder muscle relaxion but unfortunately I don't imagine the name. I already send a mail
to my cat-girls and will inform you as quick as possible. With this drug it should be easier to express the bladder.
To tell the truth - I have never heard about an "internal catheter This should be the last option.
Didn't the Vets show her, how to express the bladder?

[drakonka]

These comments are from Claudia, who did the video showing how to express Krümel.
http://www.youtube.com/watch?v=QQyHrjfBzsA
She is also asking some friends if they have any comments.

now I read everything and first of all I have to say - I would refuse to give up too with such a young cat.
First of all, I think it is no problem trying to express the bladder. The more they try the earlier they will learn
I think it will be better not to wait until the bladder is too full. Did they see my Video expressing Krümel's bladder?
For express the bladder they first have to locate it. It feels like a balloon which is filled with water.

I'm wondering, that the cat doesn't have a bladder infection, when the urin stays in the bladder such a long time???
This is very risky because the kidneys could be involved.

Did the vets exclude guanite and oxalate crystals? This is often a problem for male cats, because the urethra is
much longer and more slim than females.

I know there is a drug for bladder muscle relaxion but unfortunately I don't imagine the name. I already send a mail
to my cat-girls and will inform you as quick as possible. With this drug it should be easier to express the bladder.
To tell the truth - I have never heard about an "internal catheter This should be the last option.
Didn't the Vets show her, how to express the bladder?

Thank you very much, CarolC. We had actually seen that video before, watching it again now. I don't know what to do anymore. on Sunday night we took him to a large university animal hospital, we're told if anyone could help him it's them. They've also been unable to express and since last Sunday they've been keeping his bladder empty with a needle and had him on a new drug (on the phone sounded like Myocholine). I went to visit him last night after work, ended up being a 6 hour trip there and back. He is so happy and energetic. He purred for the first time in a week and a half and licked my face, and we fell asleep together on the floor.

However, the vet nurse there said that the situation is very serious and nobody knows what to do. No one's been able to express him manually and the drugs don't seem to be having any effect whatsoever - his bladder is just a flaccid "bag" in his abdomen. They now have to sedate him completely to drain him with a needle because otherwise they can't get it in properly - the bladder starts shaping around it instead of being easily punctured. I expected to hear news about his prognosis in today's update from the specialist, I didn't expect to hear my cat, who was playing next to me, was dying from a nurse during the visit.

All the vets we've spoken to are very very clear that expressing him is "impossible" - the nurse said with how misshapen and loose his bladder is you just end up with pockets of urine floating around in the bag. He kept saying that he wants me to realize "how serious his condition is". Thanks, genius. I didn't know that my cat had a serious condition. We just happened to stumble into what is meant to be the best veterinary hospital in the country two hours away from home for the heck of it. I came home and cried all night.

I am waiting to hear from the specialist today - we discussed surgical options yesterday but now with the update from the nurse I'm afraid I know what they will say.

If they tell us to give up and put him down we would definitely want to find someone who can do it at home. This means that he'd have at least a day with us and his little sister to be happy at home, and then go in the comfort of a safe environment. I am hoping that maybe, maybe that would be time enough to figure out how to express him even though the vets keep saying we can't. I'm also afraid that doing this will just make his last day painful and worse than it needs to be if this doesn't work. Also he's been jabbed with needles so much - is expressing him by pressing on his bladder even safe anymore?

He is such an amazing kitten, so full of life and curious about everything. I wish we could trade places - they'd never suggest that an othewise healthy human who can't pee be put down.

[drakonka]

Also, if there's anyone in Sweden (or anywhere) who has a lot of experience expressing such a bladder and feels that they may be able to help /teach us, please let me know. We are ready to fly someone over here if it would save our kitten.

[CarolC]

There is a German message board that is extremely good, and a bunch of the people there speak English. I do not know any in Sweden but I'm thinking maybe at least they would know the European drugs.

http://handicats.forenking.com/index.php

That has been part of the difficulty for me when you have posted, as I am familiar with North American names of drugs, not Eurpoean. I only recognized one of the 4 medications you mentioned when I looked it up, I recognize the chemical name of it, it has a different trade name in the U.S. The combination of drugs you listed, at least according to their effects, is different than what they would do here. Normally here they would give one drug to relax the sphincter (phenoxybenzamine) and another drug to help tone and contract the bladder (such as bethanecol chloride, "urecholine"). It is not safe to use bethanecol chloride without something to relax the sphincter as you do not want the bladder trying to contract and push out urine through a sphincter that will not relax. I believe critters said bethanechol made her cat impossible to express. Other medications that are sometimes used would be a muscle relaxant to help prevent spasms. The following link is about a cat with a broken tail, which is not what your cat has. However they were in Europe and treating with European meds and possibly (I don't know) something in it might help you.

http://www.kestrel.ws/erasmus.html

I assume they have checked him for stones or crystals? Stones can sometimes move around, blocking the passage of urine at times, then not blocking at others.

You can see posts by other people who got surgery for their cats by searching under urethrostomy. Here is a link that search:

http://handicappedpet.net/helppets/sear ... mit=Search

It is mentioned here:

http://www.marvistavet.com/html/urinary_blockage.html

[drakonka]

There is a German message board that is extremely good, and a bunch of the people there speak English. I do not know any in Sweden but I'm thinking maybe at least they would know the European drugs.

http://handicats.forenking.com/index.php

That has been part of the difficulty for me when you have posted, as I am familiar with North American names of drugs, not Eurpoean. I only recognized one of the 4 medications you mentioned when I looked it up, I recognize the chemical name of it, it has a different trade name in the U.S. The combination of drugs you listed, at least according to their effects, is different than what they would do here. Normally here they would give one drug to relax the sphincter (phenoxybenzamine) and another drug to help tone and contract the bladder (such as bethanecol chloride, "urecholine"). It is not safe to use bethanecol chloride without something to relax the sphincter as you do not want the bladder trying to contract and push out urine through a sphincter that will not relax. I believe critters said bethanechol made her cat impossible to express. Other medications that are sometimes used would be a muscle relaxant to help prevent spasms. The following link is about a cat with a broken tail, which is not what your cat has. However they were in Europe and treating with European meds and possibly (I don't know) something in it might help you.

http://www.kestrel.ws/erasmus.html

I assume they have checked him for stones or crystals? Stones can sometimes move around, blocking the passage of urine at times, then not blocking at others.

You can see posts by other people who got surgery for their cats by searching under urethrostomy. Here is a link that search:

http://handicappedpet.net/helppets/sear ... mit=Search

Thank you! I will check out that site asap.

I know that one of the drugs was definitely to relax the sphincter and one to contract the bladder. However, they doubt there is any blockage. The problem seems to be that the bladder isn't contracting even a little - it's just flaccid. BUT the vet just called me and said that the next thing they can try is the following:

- They know the medicines aren't working, but they don't know why
- They don't know if there is now some blockage in the urethra on top of the bladder damage (he was checked early on a couple of times with catheter, but not recently, and he did rip his catheter out twice about a week ago which could have resulted in scarring. They doubt it, but they don't know for sure)
- He was tested for crystals at the other hospital, where they found none, but this one has been doing their own tests as well.
- Their next suggestion is to do a surgery to physically observe his bladder inside and out, take tissue samples, try to express it by hand during this time, try to see why he isn't responding to the meds. They would also put a catheter in at this time via the bladder in order to check for blockage at the same time. They want to get as much information as possible.
- Depending on the state of the bladder and what they find they MAY put in a surgical catheter, like a Foley catheter, at the same time.
- I asked about urine redirection or some sort of bladder bypass. She said she would need to talk to the surgeons about possibility of anything like this, but this would come after they get all the information they can and find out what is actually happening in there.

So, they aren't giving up yet. It's grim, but the nurse last night made me think that they were going to tell me to put him down today without any further attempts to help him. Thankfully they are not doing this just yet. I know our time is running out, as jabbing him with a needle each day to drain the bladder causes its own damage (which is why they will be considering the cathetarization), but at least there is still hope.

In the meantime, I think his insurance is running out. We're going to use my savings to pay for it, but I also already have a loan lined up if that isn't enough. Just waiting for the contract paperwork now, so hopefully shouldn't be too long.

The vet commented that he's chirpy and bright as ever. Again said that he's very strong and healthy except for this stupid, unfortunately major, peeing problem. Every day I dread the call where they tell us to just give up, so even though they're still trying I can't help but be afraid of what kind of a call I'll get tomorrow. But I think they see that he isn't ready to die yet - he's been through so much and recovered and managed to stay happy and energetic through all of it. He's still just a big kitten who loves life, I saw it in him myself yesterday.

EDIT: I've brought up urethromstomy to them, but they're afraid that if the issue is with his atonic and distended bladder that surgery won't help much if at all. They say that this is valid in case of urethral problems or obstruction, not so much for bladder damage, which seemed to make sense. Is this not the case?

[CarolC]

Well, I'm not a vet but if 1) the urethra is not blocked and 2) the sphincter is relaxed enough, you should be able to express his bladder. Through experimentation you will find a method that works. Your hands will provide the compression that his muscles are no longer providing, but you have to ensure the urine can exit easily when you do it. With a flaccid bladder he might not be able to empty it himself, or at least not completely, but I would ask them if you could treat him by expressing several times daily if he has surgery to ensure the "exit" is not blocked. Possibly they are looking for the perfect solution where he can urinate independently, but if you are willing to express him then he does not have to be able to do it independently. Think of a balloon filled with water. If it is tied shut you can squeeze it and nothing comes out. But even if a balloon has a lot of water and has been sitting there for a while and is stretched out, if you untie it and give a little squeeze, water is going to come out.

This is the best article I know about incontinence. It does mention bethanecol for the atonic bladder.

http://www.vin.com/VINDBPub/SearchPB/Pr ... R00442.htm

They said none of the meds worked to tone his bladder. Can you confirm whether they tried it? (But again, they have to ensure the sphincter is open before using this med.)

This is what my Pill Book Guide to Medication for Your Dog and Cat says exactly:

"Bethanechol should only be used when the urethra is open, as when a catheter is in place, or with urethral relaxants because bethanechol can cause contraction of urethral smooth muscle as well. Theoretically, the bladder could rupture if bethanechol is given when the urethra is blocked, or in spasm."

In reference to the question of whether it is safe to express him after so many cystocentesis punctures, please see the part circled in red in the image in this link.

http://handicappedpet.net/helppets/view ... ure#p83798

[CarolC]

Please excuse the double post. I got another email from Claudia. Here is what she said:

I found the drugs: Myocholine and Dibenzyrane (don't know if you know them in US). These two drugs usually will be used in combination.
Myocholine is the one which causes contractions of the Detrusor muscle. Dibenzyrane is relaxing the sphincter.
Myocholine probably won't be very productive with spasms - as you already mentioned. But Dibenzyrane could help to empty the
bladder manually.

When I looked up myocholine, which I think you also mentioned, it turns out that is another name for bethanecol chloride. So I guess your vet has already tried it.

[drakonka]

Well, I'm not a vet but if 1) the urethra is not blocked and 2) the sphincter is relaxed enough, you should be able to express his bladder. Through experimentation you will find a method that works. Your hands will provide the compression that his muscles are no longer providing, but you have to ensure the urine can exit easily when you do it. With a flaccid bladder he might not be able to empty it himself, or at least not completely, but I would ask them if you could treat him by expressing several times daily if he has surgery to ensure the "exit" is not blocked. Possibly they are looking for the perfect solution where he can urinate independently, but if you are willing to express him then he does not have to be able to do it independently. Think of a balloon filled with water. If it is tied shut you can squeeze it and nothing comes out. But even if a balloon has a lot of water and has been sitting there for a while and is stretched out, if you untie it and give a little squeeze, water is going to come out.

This is the best article I know about incontinence. It does mention bethanecol for the atonic bladder.

http://www.vin.com/VINDBPub/SearchPB/Pr ... R00442.htm

They said none of the meds worked to tone his bladder. Can you confirm whether they tried it? (But again, they have to ensure the sphincter is open before using this med.)

This is what my Pill Book Guide to Medication for Your Dog and Cat says exactly:

"Bethanechol should only be used when the urethra is open, as when a catheter is in place, or with urethral relaxants because bethanechol can cause contraction of urethral smooth muscle as well. Theoretically, the bladder could rupture if bethanechol is given when the urethra is blocked, or in spasm."

In reference to the question of whether it is safe to express him after so many cystocentesis punctures, please see the part circled in red in the image in this link.

http://handicappedpet.net/helppets/view ... ure#p83798

Yeah, I'm also not sure why they claim it is impossible. I guess they'll see if there is blockage during this surgery and then I will bring it up again. Vets here in general haven't been very supportive of this idea - they just kept saying that they've tried, and if they can't do it we surely can't do it. If they do find a blockage there I will ask again, but if they don't I have a feeling they won't be willing to show us how because it doesn't work even for them.

However, I am seeing another vet with our second kitten tonight (I am now paranoid about her health since this whole fiasco - she may have a bit of a cold). They seem to have some alternative therapies available for animals, so maybe they'd be more open to trying to help us express.

As for bethanecol - I believe this is what he's currently on. The vet said they are giving him a drug that sounded very much like Myocholine (I'm pretty sure that's exactly what she said, which is when I first Googled it, but I will get written records as well), which I think is bethanecol: http://www.veterinarypartner.com/Conten ... ID=3001644

Regarding the urethra being open - this is what they'd confirm again with this surgery. However, you would think that even if it's not, if the bethanecol was working you'd see some sort of -change- in the very flaccid bladder (according to them). So it would get tighter or contract somewhat, no? And then it would start pressing against the obstruction, which would be bad, but right now the bladder has had no change at all according to them with or without obstruction.

Thanks very much for your advice. We will do everything we can to get him through this.

[CarolC]

I have a feeling this might not make a big difference with your cat, but am quoting it anyway because it is such a simple thing to try, almost ridiculously simple. Then when that does not work, you have ruled one more thing out.

make sure that your baby is warm. Jaime my cat with posterior paresis needs her enviroment kept at 78 to 80 degrees or she shakes and is nearly impossible to express. I use a radiator heater with a temp control on it. I couldn't adequately express her if she wasn't warm.