Blanche, a 12-year-old Labrador mix, first came to see me for an emergency last December, when her owner noticed the old girl exhibiting stranguria. That’s the technical term for slow, painful straining to urinate. The most common cause in adult female dogs is bacterial cystitis, a.k.a. a urinary tract infection (UTI). Bacterial cystitis usually occurs when bacteria on the external genitalia sneak backward from the outside to the inside, up the urethra and into the bladder. It is more common in female dogs than males. Symptoms range from none at all to a long list of fancy words. Hematuria — bloody urine. Pollakiuria — frequent urination. Periuria — urinating in inappropriate places. Polydipsia — excessive drinking. Polyuria — production of excessive quantities of abnormally dilute urine. Urinary incontinence — involuntary leaking of urine. And Blanche’s presenting sign of stranguria — straining.
“Let’s get a urine specimen,” I suggested. The gold standard in these cases starts with collecting a sterile urine sample via cystocentesis. That means passing a sterile needle through the body wall into the bladder. It’s not as bad as it sounds. We do it routinely without sedation in many animals. But Blanche was a zaftig old lady. (Look it up, or ask a Jewish friend.) She was also a very high-energy dog, despite her weight and age. There was no way I was going to safely perform a cystocentesis on her, especially since I don’t have ultrasound at my little old country practice.
We had to settle for taking Blanche for a walk and collecting a “free catch” sample when she squatted. Because this was not sterilely obtained by cystocentesis, it was not an ideal specimen for culturing to determine the exact bacteria involved. Besides, Blanche’s owner hoped to keep costs down if possible. So we simply did an in-house urinalysis, determining that there was blood in her urine, as well as an increased number of white blood cells, consistent with bacterial cystitis.
Treatment is simple. Antibiotics. In the old days, we rarely ran cultures. We would just prescribe something like Amoxicillin for seven to 10 days. Most cases cleared right up. Things are trickier nowadays. There are more bacterial infections with multidrug resistance. There is more understanding of the need to practice good antibiotic stewardship. There is a whole treatise from the International Society for Companion Animal Infectious Diseases called “Guidelines for the Diagnosis and Management of Urinary Tract Infections,” which I try hard to follow. But I will admit I am an old dog, so I prescribed the other old dog a course of antibiotics and sent her home, with the caveat that if things didn’t improve, we should do further diagnostics.
Eight months later, Blanche came back. Her UTI in December had responded well to the medication, but she was showing signs again of pollakiuria and stranguria. (Were you paying attention? That means frequent urination, with straining.) This time her owner had brought a urine sample. Again we found blood and increased white blood cells. “When we see recurrent infections,” I said, “we have to look for other underlying causes.” We discussed things like bladder stones and tumors, but her owner opted for empirical antibiotics, since it worked so well before.
Now things got trickier. Blanche started not eating well, making it difficult for her owner to give the antibiotics. He thought maybe the medication was upsetting her stomach. He said Blanche was grunting and straining when urinating, and there was visible blood in the urine. I was increasingly concerned, and advised radiographs or, better yet, referral for ultrasound to rule out bladder or urethra tumor. We were swamped with emergencies, but scheduled Blanche to return the following week for X-rays. In the meantime, I prescribed a three-day course of a different antibiotic to cover for a resistant bacterial infection, and hoped her appetite would improve.
Blanche was not excited about having her picture taken. We were able to get her to hold still (almost) for one view, but unable to take a second. There was no obvious stone visible on the film, but the bladder itself looked abnormal to me. As I walked Blanche outside to talk with her owner, I was able to observe for the first time the straining and grunting he had mentioned. This was beyond the stranguria we see with a typical UTI. Blanche was much more hunched, and straining hard. I brought her back inside, double-checked there was no evidence of intestinal obstruction, then looked at the sediment portion of her latest urine specimen analysis. This time, I thought I could identify large numbers of abnormal-appearing cells.
The most common form of lower urinary tract cancer in dogs is transitional cell carcinoma (TCC). The tumor can be in the urethra or bladder, and can metastasis to many locations. Signs are primarily related to the mass, varying depending on the size and location of the tumor. But all of Blanche’s symptoms could indicate such a tumor. Hematuria, pollakiuria, stranguria, and that excessive straining as though she were constipated, called tenesmus. In addition, those unusual cells noted on the latest urinalysis were consistent with a diagnosis of TCC. Blanche needed a much more aggressive workup. Ultrasound. Possibly sedation for multiple X-rays. Maybe a cutting-edge test called Cadet BRAF, which starts with collecting a very large urine specimen into a specialized container provided by Antech Laboratory, and which then looks for cells containing a genetic mutation commonly found in dogs with bladder (or prostate) cancer.
Blanche is being seen off-Island soon by a larger practice, for further diagnostics. We hope she will get a definitive answer. Sadly, if it is the cancer I suspect, prognosis is guarded at best. Chemotherapy may help. Surgery, usually not so much. Palliative care may improve her quality of life. I am hoping I am wrong, and waiting to hear the outcome of these next tests. The moral of the story for this old dog is that what looks like a simple UTI is not always as simple as it seems.
