urethra and intestine connected possibly?

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alicston
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urethra and intestine connected possibly?

Post by alicston »

Hi! I have a spina bifida/Manx syndrome kitten (7 months old) who is unable to control bladder and bowel movements. She is in a diaper about 60% of the time, and let free to roam diaper-free the rest of the time.

I've noticed, when she has not worn her diaper, and I go express her, that urine will come out of her anus (or both anus and urethra at same time). It is not liquid with her stools, it is urine. And then sometime she will secrete feces from her urethra.

While I am in the midst of finding a new (better) vet who is willing to explore her issues (I only recently adopted her), I was wondering if anyone else has come across this issue. At first I thought she might have absorbed stools into her urethra when diapered, or liquids weren't absorbed properly in her intestines, but this is not the case.

As she is less than 4 lbs, I am concerned that they may not be able to operate on her due to her size. I have also never heard of this type of malformation before.

Any insight would be welcome.
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BendyMom
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Re: urethra and intestine connected possibly?

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Wow. that is uncommon. You get a lot of strange abnormalities in these cats, usually things like no anus at all, or one that has no tone, but this is a new one for me. The one issue that jumps out to me is that this opens the possibility of fecal contamination in the urethra, which is a huge risk for urinary tract infections, which is the biggest risk to our incontinent kids.
I don't know any regular vet who would tackle such a problem, are there specialty vets in your area? Finding one who is willing to do the correction could be a challenge. Four pounds is at least a decent weight to handle anesthesia. If there is a vet school in your area that might be a place to look to help, most have clinics associated with them.
Where are you? If it's in NC, I can tell you where you need to go.
Because of the increased risk of urinary tract infections I would keep her out of the diaper as much as possible, and make sure to express her bladder fully at least twice a day.
If you see any bloody urine, or cloudy urine, or you have any trouble expressing her, she needs help ASAP. Urinary tract infections can cause blockages and can, and do, kill these guys :(
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critters
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Re: urethra and intestine connected possibly?

Post by critters »

A fistula connection is certainly possible. Has anybody done x-rays? I'd think it would show up, especially if the fistula were air-filled. Is there a cats-only vet in your neighborhood? They tend to be really good with the species, even wonkers. :whale:
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CarolC
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Re: urethra and intestine connected possibly?

Post by CarolC »

I am not a vet and have no medical background. I do not have a fraction of the experience with cats that BendyMom and critters do.

I agree with critters' suggestion that you might be dealing with a fistula. I agree with your comment about finding a vet with more expertise. I agree with BendyMom's suggestion of a veterinary college, or perhaps ask the veterinary college if they can recommend a veterinarian within a reasonable distance who has done successful RVF surgery to close a fistula. You could probably call them. If you are near a large city, you could also call the regional veterinary specialty hospital and see if they have experience with this.

If you want to research the condition, here are some search terms to get started.

Rectovaginal fistula is an abnormal connection between the rectum and the vagina.

The abbreviation in veterinary literature is RVF. You are talking about RVF surgery.

Most of the veterinary reports of RVF I found online are about cats or dogs with a deformity of the anus (like BendyMom said) as well as an RVF opening between the rectum and vagina.

The term for the deformity of the anus is anal atresia, also called atresia ani. There are different kinds. One is an imperforate anus (like BendyMom mentioned, no b*tthole, so waste exits the body through another opening). Three other kinds of atresia ani are described here. One is anal stenosis where the anus is present but the anal canal is narrow. Since your cat is eliminating through her anus but apparently has a fistula, I think they would want to check whether her anus is normal.

Like BendyMom, at the moment I do not remember a kitten here with this exact situation. But I will look some more today. The case I do remember very well was a puppy with an imperforate anus (no b*tthole).
https://handicappedpet.net/helppets/viewtopic.php?f=29&t=13347
A rescue was lining up surgery for her, which involved fundraising and then scheduling. She became septic (massive infection) before surgery. They managed to get it under control and did the surgery to give her an anus, but she did not survive. I have always saved her photo on my computer. Her name was Juniper. I don't think they ever said what caused the sepsis, but retaining feces for too long is unhealthy, or having fecal contamination of the urinary system (as BendyMom said) can cause infection and sepsis. It seems like they just didn't quite get to her in time, though they were trying.

Here was another story of an imperforate anus with a happier outcome. You may want to read it.
https://handicappedpet.net/helppets/viewtopic.php?p=68591#p68591 wrote: Am trying to "get custody" of a 1-month old poodle with imperforate anus. She basically has no tail at all (not even any sign of one) and no anus. Her poop is evacuated via the vulva...
This article from the Canadian Veterinary Journal is about surgical repair in 5 dogs. 4 did well and 1 died.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1914316/

It shows 2 other interesting things. It shows the weight of the dogs was from less than a pound to up to 16 lbs. And it shows they did 2 separate surgeries during the surgical procedure. One to fix the wall of the rectum and one to fix the vagina. If the dog had no anus, that is a third part of the procedure. (And notice 3 of the dogs had no tail, like a Manx.)
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1914316/ wrote: Rectovaginal fistula with anal atresia in 5 dogs
Abstract

Five dogs with rectovaginal fistula and atresia ani that had been treated by surgical correction of the malformations were studied retrospectively. Ages at presentation varied from 1 to 3 months and weight from 350 g to 7.5 kg. The histories included voiding of feces through the vulva, with or without tenesmus, usually observed after weaning. Atresia ani, presence of feces in the vaginal canal, abdominal distention, and discomfort on abdominal palpation were observed during clinical examination. Also, 3 dogs had partial tail agenesis. In all dogs, the rectovaginal fistula was isolated and transected, the vulvar and rectal defects were closed separately, and the atresia ani was repaired. Normal defecation was restored, but 1 dog had fecal incontinence that subsequently resolved. One dog died 2.5 months postoperatively, and follow-up was done on the others for periods ranging from 1.6 year to 7.7 years. Surgical correction in dogs with rectovaginal fistula and atresia ani may result in a favorable outcome, if it is done early.
This facebook post about a rescue kitten may interest you. They did surgery to correct a rectovaginal fistula in Ottawa, had a complication, had to have it repaired 3 hours away in Michigan, but in the end the kitten did well.
https://www.facebook.com/donate/496618970909518/

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critters
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Re: urethra and intestine connected possibly?

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Nice research, CarolC!
alicston
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Re: urethra and intestine connected possibly?

Post by alicston »

You guys are AMAZING. I have been going to a cat-only hospital but we are critical short on veterinarians in this area and more so after the pandemic. They’re staffing up but all with new and general practice vets. Their protocol has been to address the easiest problems first - I was sent home with chlorahexide cleansing solution and the suggestion of probiotics in her diet. Not very confidence building. I’ve booked yet another appointment for this week armoured with new knowledge and vocabulary you have all supplied and I will be insistent on receiving care and action. If anything, there is one board-certified feline specialist on staff who they can pull from retirement to weigh in. I’m in Canada where there are only 5 of them available.

I’m 2 hrs away from one vet college and 6 hrs away from another, I hope they will at the very least be able to refer me if they don’t have the capability to further diagnose!
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CarolC
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Re: urethra and intestine connected possibly?

Post by CarolC »

That's great. I hope you will post back about how it goes. Your information will help future people with this situation.

It seems like what you need is a place that can do imaging with radioactive contrast. I keep reading that they get a picture of the plumbing (visualize the fistula) by squirting radioactive dye up the rectum and/or vagina and taking x-rays.

Here are some more links, if you want to read up. They give a better idea of what to expect. They are mostly pdfs. (They don't open automatically on my computer, have to download them, but they're worth it.) The last article opens online. Will quote some highlights.

This one may be of interest as it describes a dog with an RVF (fistula) that actually had a normal anus. They did surgery, but the wound split open 3 days later (dehiscence is splitting open). So they redid it a different way and it went well and the dog was fine at follow-up.
Rectovaginal fistula in a dog with a normal anus: a case report
https://www.agriculturejournals.cz/publicFiles/177928.pdf wrote:ABSTRACT: A one-year-old, 2.6 kg, spayed female Maltese dog was referred with passage of faeces coming from the vulva, repeated vaginal discharge and vaginitis. Through physical examination, contrast radiograph and vaginoscopic exploration, the dog was diagnosed with rectovaginal fistula which was surgically corrected. After midline perineal incision, the rectovaginal fistula was isolated and transected. The vaginal and rectal defects were closed separately, but dehiscence of the surgical region took place three days after surgery. For the second opera-tion, the rectal segment containing the fistula was removed by transanal rectal pull-through, and anastomosis was performed. Total follow-up time was 10 months and no sign of recurrence was reported. Early postoperative complications included perineal soiling and wound dehiscence, but the long-term outcome was good. This case is the first report of surgical correction of a rectovaginal fistula in a dog with a normal anus.
This one is helpful because it's a 6-week old kitten with no anus. There are pics of the surgical site showing stitches, but no blood (if you're sensitive).
Successful treatment of type III atresia ani and rectovaginal fistula in a kitten
https://openjournals.ugent.be/vdt/article/75441/galley/199554/view/ wrote:A six-weeks-old, female kitten presented with dehydration, depression, atresia ani and a dis-
charge of watery feces from the vulvar opening. On radiographic examination, the blind-end of
the rectum was determined to be >1 cm cranial from the anal dimple, classifying it as type III
atresia ani. Atresia ani combined with a rectovaginal fistula is an uncommon congenital defect
of the terminal rectum and anus that can occur in kittens. After supportive medical treatment
for three days, the patient was strong enough for surgical correction. The distal rectal pouch was
connected to the unperforated anus and the rectovaginal fistula was closed. The kitten recovered
uneventfully and was able to defecate normally at 38 weeks follow-up. In this case report, the
importance of early surgical correction to avoid potential life-threatening complications from
this congenital abnormality is demonstrated.
Here is another quote from that article, which says that 2 things that can develop with these cases are severe constipation, and a urinary tract infection (cystitis) like BendyMom mentioned. Not surprising when fecal germs come in contact with the urinary area.
As the kitten grows up, clinical symptoms become evident due to ascending cystitis or fecal obstruction.
I like this one because it talks about all the meds they used for the dog. It also has pictures, but almost no blood.
Anal Atresia with Rectovaginal Fistula In a female Afghan Hound Puppy
https://www.sid.ir/fileserver/se/481e20140436 wrote:Surgical treatment should be prompt and performed before colonic atony or megacolon associated with chronic and prolonged distention or possible urinary tract infection ensues 6. Postoperative complications may include tenesmus, fecal incontinence, wound dehiscence, stricture of the anoplasty, colonic atony or megacolon and rectal prolapse. Fecal incontinence, a common complication after surgery, may be transient, intermittent or permanent and related to a congenital absence of functional external anal sphincter or surgical trauma to the sphincter muscle innervation during dissection. After surgical correction, antibiotic was administered for 5 days (ceftiriaxone 30 mg/kg, sid), dexamethasone and laxative were also administrated. Postoperatively analgesia through opioid administration for a week’s time, cisapride to promote colonic motility and stool softeners as lactulose to combat constipation are provided. After 1.5 year the dog is completely healthy and the only complication was fecal incontinence.
This is a 2-month old kitten. They created an anus and held it open by suturing a plastic syringe tip in place for 5 days. Has photos, but nothing upsetting.
Rectovaginal Fistula and Atresia Ani in a Kitten: A Case Report
https://www.e-jvc.org/journal/view.html?uid=2689&vmd=Full wrote:A 2-month-old, 740 g intact female domestic shorthair was admitted for evaluation of vaginal discharge. The owner observed that the kitten was dripping feces and urine together from the vagina. {SKIP] Postoperatively, meloxicam (2.2 mg/kg, PO; Metacam®, Boehringer Ingelheim, Mexico), cefadroxil (25 mg/kg, PO; Cefaxil®; Koruspharm, Jecheon, Korea), famotidine (0.5 mg/kg, PO; Famotidine®; NELSON, Korea), and lactulose (0.5 mL, PO; Duphalac, JW Pharmaceutical, Seoul, Korea) were administered twice a day. Since the surgical area was difficult to keep clean due to the feces and syringe port, the syringe tip was removed from the surgical area after 5 days. Furthermore, to keep the surgical area clean, a lavage was performed twice a day with 0.9% normal saline using an 18-gauge needle.
You mentioned the vet suggested probiotics. I have an 8-lb female dog with a condition like spinal bifida, partially paralyzed and dual incontinent (poo and pee). I can't express her bladder because she dribbles herself empty 24/7 so there's nothing in it to express. She hasn't had a problem with urinary infections, but she was getting female vaginal infections. She wears a diaper with a large tail hole to catch urine but let the stools fall out, so they don't contaminate her girl parts. But she was still getting infections, possibly because she sleeps without a diaper at night and bounces around on her blankets on her little bare bottom. Anyway, the vet told me to give her acidophilus. I asked how long. He said for life. So I've been doing that for several years and for whatever reason, she hasn't been getting the vaginal infections. She's a dog, not a cat, but I buy acidophilus capsules and at every meal I twist one apart and sprinkle the white powder on her food. The kind of acidophilus I have doesn't have to be refrigerated. The probiotics might be beneficial, I don't know, but I agree that's kind of minor compared to the information you really need from a vet at the moment...
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CarolC
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Re: urethra and intestine connected possibly?

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critters wrote: Tue Apr 25, 2023 8:08 am Nice research, CarolC!
:thankyou: :blush: :oops: Amazing what kind of information is on this board, isn't it? :D

There was another case, but there was little info on it, and the owner did not have money to pursue treatment.
ruth wrote: Sun Jun 20, 2004 7:00 pm Thanks to all your great sharing of info, I made some cloth pants to hold a pad and then put on an altered preemie onesie which the kitten had off in less than an hour since it is so playful and active. Sad to report that I have discovered it is actually pooping out the genital area instead of the anus. Has anyone heard of this?? This does not sound good to me. The kitten is so precious but I do not like the looks of this: I was giving the kitten time to hopefully gain control of its bowels because it is walking better and better every day but now I am not sure if that is even an option. I am just being honest in saying that spending megadollars at the vet is not an option for me. Very sad about this...
I also found another special kitten, Ariel, the kitten shown on the Diapers and Male Wraps article. Her urethra was attached to her anus. Debbie rehomed her and there is no long term follow-up.
Debbie wrote: Mon Oct 24, 2005 11:18 pm Thank you guys so much for all your help and encouragement. I took my little paralyzed kitten to the vet today and got a lot of feed back but nothing I already didn't expect. She can't use her back legs not because of an injury or infection, she was born that way. She is deformed in more ways then one. On top of not being able to use her back legs, she has 7 toes on each of her front feet and her urethra is attached to her anus. We aren't even possative (she) is a girl because of no external sex parts. Her quality of life depends on if I can keep her back end clean enough and if she isn't prone to chronic bladder infections. The vet isn't sure if there is anything between her bladder and the outside world. She pees through a little hole right in front of her anus. Do you believe someone just dropped this little one off in an apartment complex??
I also found a very :smart: post regarding another female kitten with mixed up plumbing and a fistula.
critters wrote: Mon Jun 13, 2005 4:25 am I guess you can't even use the DSS pet enemas since you don't know where they'll end up. :(
:shock: That makes sense.
alicston
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Re: urethra and intestine connected possibly?

Post by alicston »

All these posts have been incredibly helpful. So after months of waiting, I was referred to a neuro specialist and a surgical hospital. The neuro consult answered my questions re nerve damage that may affect the incontinence - no impact there, as any further deterioration of the spine or nerves would not impair further urine or bowel control.

I met with the surgical vet today and (hallelujah) she has seen a canine patient with a similar issue in the last 4 months - where the German Shepherd mix had no anus but was able to control her bowel movements. There was a colo-urethral fistula that they tended to, and created an opening for the feces to exit.

In my cat's case, things are a little weirder. The fact that urine is exiting through the anus, and feces exiting through the urethra means there's something a bit different in her wiring where the vagina fits in between. Surgery is possible, with a scope, attend to the fistula, with possible complication that the sutures could open after surgery. In other situations, incontinence could be a risk, but she already is incontinent.

The surgery costs about 5K CDN. But what's really odd is that my cat shows no distress. She may or may not be experiencing UTIs, as the vet suspects she may either be (a) fine, or (b) asymptomatic of infection. The last time I thought she had an infection, her results were clean.

So we can either do the surgery now, do the surgery later, or don't do the surgery at all since she seems to be unperturbed by the situation. The vet is going to share some articles with me (that I will share here) and suggests I do bi-monthly tests to keep an eye on infections.
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CarolC
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Re: urethra and intestine connected possibly?

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Hi alicston,

That's really good that the surgeon has some actual experience with a fistula in a dog. I don't know what I'm talking about here, this is 100% a layperson talking out loud. I was trying to see how they image a fistula in humans and got 3 different answers. One said an MRI, one said a CT, and one said an x-ray. So that wasn't much help. I'm just quoting these to show how different they are.

Google search : how do they image the urinary tract in a fistula
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9809915/ wrote: The preferred imaging modality is pelvic MRI. For patients unable to tolerate MRI scans, CT cystograms can also be used to identify fistulae, and cystoscopies are often necessary to evaluate bladder outlet dysfunction.
https://emedicine.medscape.com/article/442000-workup wrote: CT scanning of the abdomen and pelvis is the most sensitive imaging test for detecting a colovesical fistula, and CT scanning should be included as part of the initial evaluation of suspected colovesical fistulae.Oct 5, 2022
https://www.urologyhealth.org/urology-a-z/b/bladder-fistula wrote: Bladder fistula is diagnosed with an x-ray study. The type of x-ray used may be a CT scan or a pelvic x-ray. A dye that shows up well in x-rays (called "contrast") will be put into your bladder, either through a vein or a catheter.
Do you see on that third one, it explains how (in humans) they get dye into the urinary system so they can see where it goes on an x-ray, and it didn't take a CT? Anyway...

I never heard of this kind of test in cats, but I found a list of vets under American Society of Veterinary Nephrology and Urology, which includes Canadian vets. Canada is huge, and I think you already drove a long way to see the specialty surgeon. But it doesn't hurt to see if any urology facilities are within a reasonable distance.

If any are close enough to drive to, it lists what kind of tests they can do. Maybe an idea (if you can afford it...none of this is cheap it seems) is to pick the closest one and ask the surgeon if s/he sees any type of imaging done at the urology specialty place that would give you better info to either decide if surgery is needed, or (if it is) help the surgeon plan what is going to be done in the procedure ahead of time, kind of a roadmap.

I only say this based on a tiny bit of experience with spinal surgery, where they do imaging ahead of time to help the surgeon plan. Spinal may not even apply to something like this. Perhaps the GSD-experienced surgeon feels fine going in, seeing how things are wired, and making logical choices at that time. No doubt there's a degree of that in any surgery anyway. But I'm thinking, would there be any additional tests your surgeon might like, if s/he thought they were possible. Sometimes I think they hesitate to suggest additional tests, as they don't know if their client is already breaking the bank to see them, or if it would be possible for their client to afford additional testing.

That's really good that she doesn't seem to be getting UTIs. I would kind of think if she was, you'd know. I'm wondering about the possibility of vaginal infection, too. I'm guessing she's not fixed yet?
:thinking:
I hope you will post the articles. More information would be a very good thing! :D
:thankyou:
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critters
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Re: urethra and intestine connected possibly?

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"Watchful waiting" is perfectly valid, especially since nothing is bothering her.
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