Contrast Radiographs

Question 1

Case Flossie

• 5 month old FE cross breed bitch: bright and energetic with a good appetite. No history of vomiting or diarrhoea.
• Difficulty with house training- tends to urinate in the house and owners occasionally find her bed is wet. No problems with defaecation.
• Seemed to improve after a 5 day course of clavulanate amoxicillin
• Now urination in the house is happening more often and Flossie is licking around her vulva all the time.

Discuss this case?

Answer 1

•Normal IVU & RVU showing no evidence of

–ectopic ureter

–megaureter

–hydronephrosis

–bladder hyoplasia

–urethral anomaly

–uroliths

• Reviewing the history might clarify if this puppy is truly incontinent
• PLAN: consider cystocentesis for urinalysis including culture-UTI likely

Question 2

Case Chewbacca

• 3 year old MN DSH cat: bright and playful with a good appetite
• He occasionally urinates in the bath and his owners have noted the urine is pink tinged at times. He passes a good stream of urine and does not seem uncomfortable.
• Urinalysis has confirmed the presence of haematuria.
• There was no improvement after a course of clavulanate amoxicillin.

Discuss this case?

Answer 2

• IVU and pneumocystogram
• Persistent finding of proximal right ureteric dilation

–visible on the lateral and VD views

–visible at different time points during the study

• No hydronephrosis (but possibly mild pyelectasia) makes complete ureteric obstruction unlikely
• Differentials include partial ureteric obstruction (radioloucent urolith/stricture) or pyelonephritis
• PLAN: cystocentesis for urinalysis and culture, ultrasound guided pyelocentesis (challenging!)

Question 3

Case Nutty

• 8 year old FN Border Collie: bright and playful with a good appetite
• 4 recurrent episodes of dysuria, stranguria and haematuria over the last 3-4 months. In the past she has responded very quickly to a 5 day course of calvulanate amoxicillin but this time there was no improvement. Her owners report that she licks her vulva a lot but she always has done.
• Nutty is one of 6 Border Collies that live with this owner

Discuss this case?

Answer 3

• Pneumocystogram, DCC and +ve contrast retrograde vaginourethrogram
• Intrapelvic bladder which can be associated with USMI (urinary sphincter mechanism inconitence)

–loss of the normal tear drop shape of the bladder

–urethra relatively short/kinked

• No evidence of bladder wall thickening or uroliths
• PLAN: (likely UTI 2ry to incontinence)

–urinalysis including culture

–treatment trial with phenylpropanolamine +/- estriol

Question 4

Case Joss

• 9 year old MN Cocker Spaniel: bright and playful with a good appetite
• Recurrent episodes of haematuria which have become increasingly severe. He has increased urgency associated with his urination and occasionally cocks his leg but nothing is passed.

Discuss this case?

Answer 4

• DCC and retrograde study
• Multifocal abnormalities in the bladder wall
• No evidence of thoracic metastases
• Differentials include polypoid cystitis
• PLAN:

–catheter biopsy hopefully to confirm a benign/inflammatory lesion

–focus on identifying a UTI and managing with a prolonged course of antibiotics (?6-8 weeks minimum)

–surgical curettage of the bladder

Question 5

What is Polypoid cystitis?

Answer 5

Polypoid cystitis is a rare disease of the urinary bladder in dogs characterized by inflammation, epithelial proliferation, and development of a polypoid mass or masses without histopathologic evidence of neoplasia.

Question 6

What bacteria are/have been isolated in polypoid cystitis?

Answer 6

Proteus spp were the most common bacterial isolates (12/52 or 23.1%) identified when all urine samples obtained for culture at any time during the course study were considered. Other commonly isolated organisms included Escherichia coli , Staphylococcus spp, and Enterococcus spp. Several dogs (7/17) also had cystic calculi at some time during the course of their disease.

Question 7

Where are most of the masses found in polypoid cystitis?

Answer 7

Most of the masses (11/14) were located cranioventrally in the bladder as opposed to transitional cell carcinoma, which has a predilection for the bladder neck or trigone area. It is unknown whether persistent or recurrent UTI predisposes to polyp formation or if polyps predispose to UTI.

Question 8

What is the treatment for polypoid cystitis?

Answer 8

Surgery and removal of all polyps was the most efficacious treatment in dogs of this study. The question of whether or not polyps represent preneoplastic lesions remains unanswered and constitutes an area for future investigation

Question 9

Case Beaver

• 5 year old MN DSH cat: off food for 24 hours
• Beaver was hospitalised for 3 days 2 weeks ago after an episode of urethral obstruction. This has happened a couple of times in the last year or so. He was fine when he was discharged but his clinical signs recurred. He was admitted during morning surgery because he has not been urinating at home.
• He is always a hugely bad tempered cat and was especially angry when you admitted him. Your colleague has been dealing with him while you finish the morning consultations but she has just been called out to a horse with colic.

Discuss this case?

Answer 9

•DCC and retrograde urethrogram

–poor quality urethrogram, poor filling of urethra, air bubbles ++. This study is important to rule out strictures, urethral plug, calculi.

•Bladder has identical appearance on both films

–small (likely not possible to distend further or at least not safely)

–thickened wall

• No uroliths
• PLAN:

–repeat retrograde to rule out stricture/urolith but doesn’t seem obstructed

–urinalysis especially for urine culture in case UTI following recent catheterisation during last episode of clinical signs

•Diagnosis: likely to be FLUTD, idiopathic cystitis

Question 10

Case Teal

• 10 yr old ME cross breed: bright with a good appetite
• 4 recurrent episodes of dysuria, stranguria and haematuria over the last 3-4 months. In the past he has responded very quickly to a 5 day course of clavulanate amoxicillin but this time there was no improvement.
• His owners report that he licks his prepuce a lot but he always has done. Over the weekend they saw what they thought was a blood clot after he had urinated.

Discuss this case?

Answer 10

• Pneumocystogram and DCC
• Nice example of how contrast studies seem to change the opacity of structures
• Large bladder mass mid to cranial abdomen

–not typical position for a TCC, consider other tumours such as leiomyoma might be possible

–consider other differentials such as haematoma esp if more acute history

• cogaulopathy/angiostrongylus
• PLAN: met check, catheter biopsy

Question 11

Case GRACIE

• 10 year old FN cross breed: quieter than she used to be, reluctant to jump in to the car
• Progressive problems with haematuria and stranguria/dysuria. The signs initially responded to a 5 day course of clavulanate amoxicillin. She has been on this treatment for 7 days now and is still straining to pass small quantities of blood stained urine. Sometimes she squats for minutes at a time and may not be passing anything.

Discuss this case?

Answer 11

• +ve contrast retrograde vaginourethrogram
• Proximal urethra shows irregular margins extending caudally from the bladder neck
• Multiple small filling defects along the ventral bladder wall
• Thoracic radiographs: multiple pulmonary nodules
• Diagnosis: likely urethral tumour (carcinoma) with seeding to ventral bladder wall and pulmonary mets
• PLAN: palliative? (NSAIDs), catheter biopsy if would stent or consider chemo

Question 12

Case Lucky

• 12 year old ME Labrador: bright and eating well until this morning when he refused breakfast.
• Early this morning Lucky‘s owners saw he was very quiet and noticed he was standing to urinate but only passing small dribbles of urine. He sometimes seems uncomfortable when defaecating but has never had problems urinating before. They thought he was just getting old. When he wouldn’t eat either they brought him straight to the surgery knowing you run a 24 hour service.

Discuss this case?

Answer 12

• +ve contrast retrograde urethrogram
• Retroflexed bladder in perineal region consistent with perineal rupture
• PLAN: usually secondary to prostatic or large intestinal disease causing straining.

–review clinical history with owners regarding further diagnostics

•eg ultrasound scan of the prostate?

–rectal exam to assess pelvic diaphragm

•uni or bilateral rupture?

–surgical repair

Question 13

Case Mutley

• 7 year old ME cross breed: good appetite and quite bright but less playful than he used to be
• Mutley has been seen several times over the last few months with a history of recurrent episodes of stranguria, dysuria and haematuria. The clinical signs have got progressively worse.
• Initially there was a response to clavulanate amoxicillin. He was seen by a colleague at the weekend and started on enrofloxacin as well. After 3 days his clinical signs seem worse not better.

Discuss this case?

Answer 13

• Pneumocystogram, DCC, +ve contrast retrograde urethrogram
• Prominent prostate but no mineralisation, symmetrical in appearance
• Irregular mass with contrast filling defect in the trigone region of the bladder
• Irregular and ragged appearance to the urethra extending in to the prostatic urethra
• Differentials include neoplasia (likely TCCa) or much less likely inflammatory/granulomatous disease
• PLAN: catheter biopsy, met check (thoracic radiography, ultrasound medial iliac LNs)

Question 14

Case Chester

• 11 year old ME Springer Spaniel: bright but less active than he used to be and less keen to eat
• Chester has been treated at your practice for recurrent episodes of haematuria. He has also had a preputial discharge which seems to be getting more copious.
• His owners have seen every vet in the practice but really just want to collect some more antibiotics because sometimes these seem to help for a while at least.
• They have been persuaded that Chester should have further investigations.

Discuss this case?

Answer 14

• Pneumocystogram and +ve contrast retrograde urethrogram
• Prostate:

–enlarged and asymmetric

–diffuse mineralisation

–some contrast extravasation in to the prostate

•Urethra:

–narrowed in prostatic region

• Possible LNs visible ventral to L7 (site of the medial iliac nodes)
• Differentials include chronic prostatitis and prostatic adenocarcinoma
• PLAN: met check, catheter biopsy, ultrasound & FNA prostate, urine culture

Question 15

Case Bobby

• 11 year old ME Collie cross: a bit quiet & less keen to eat over for 6-8 weeks but generally well.
• Bobby’s owners are concerned he has some abdominal discomfort although (if anything) he seems to have put on weight.
• They have noticed a creamy discharge from his prepuce and he sometimes shows faecal tenesmus.
• He has also had signs of dysuria - in the last 24 hours they have seen him stand to urinate but only dribbles of urine were passed.

Discuss this case?

Answer 15

• Pneumocystogram and plain film
• Large caudal soft tissue/fluid opacity mass with some mineralisation
• Contrast study shows bladder is dorsally displaced by the mass and confirms the normal position of the prostate
• Diagnosis: large paraprostatic cyst with some mineralisation of the wall
• PLAN: met check? (some link with prostatic neoplasia), surgical exploration for resection of the cyst & biopsies for histo

Question 16

Why we might (mistakenly) avoid contrast studies….

Answer 16

• time consuming
• when not done regularly they are outside our “comfort zone”
• patients require GA/sedation
• patient preparation requires organisation
• are we over confident in what ultrasound can tell us about our patients

** Remember:

1. these are not always good reasons if the study actually needs to be done!
2. cases with significant bladder disease would generally now have ultrasound as the first diagnostic imaging test but those with urethral or ureteric disease are often best investigated with contrast studies. Films can be sent for a 2nd opinion more easily than ultrasound images