As some of you guys know from my facebook page, my cat Shadow has been having some issues. He had a UTI that did not get cleared up with a round of antibiotics, and got progressively worse to the point that he blocked. We had such a difficult time putting a catheter in him that the vet recommended a perineal urethrostomy should he ever reblock. I tried to research PUs on the web and had a hard time finding personalized accounts; thus, I am going to chronicle our experience with this procedure here, should anyone else need to know what to expect.
1.19.15 – Shadow jumped up on the loveseat, meowed at me, and peed. This is very uncharacteristic behavior of him. I kind of “huh’d” and followed him into the bathroom where he then proceeded to try to pee in the bathtub. I then recognized this behavior as the onset of a urinary tract infection and rushed him to the vet. Back in 2010, Storm had a UTI that nearly killed him. Since then I have become very aware of the signs, and Shadow was exhibiting classic UTI behavior. Male cats in particular are at danger of having their urethra blocked by urinary crystals or mucus plugs, and this can kill them very quickly as their kidneys go into failure. Blockages are emergencies.
Dr. H felt his bladder and said it was small, which meant he was still peeing and was not blocked. She prescribed him a 10 day course of Clavamox, which is what I am used to giving Storm for his UTIs. She did not think he needed Prazosin (to relax the urethra) or Buprenorpherine (for pain) at the time.
1.24.15 – I had Meemaw’s dog Chewy at the vet for another issue, and I mentioned to Dr. F that Shadow still seemed to be licking his crotch and going in the box a lot. He told me that was normal behavior, and offered Prazosin and Buprenorpherine because it was obvious Shadow was still in some discomfort.
At some point in here, Shadow had a followup urinalysis that CB took him to while I was working. Dr. F did not get any urine from him. I took this to mean that Shadow was empty. What I would later find out was that he was “fractious” and they were unable to draw some from him.
1.31.15 – Shadow looked at me and squatted on the floor. Nothing came out. It was afternoon on Saturday, which meant the vet’s office was closed. Rather than call in an emergency, I sequestered him in a room by himself with a clean litterbox. He had not produced any urine by Sunday morning, 2.1.15. I called the emergency line and Dr. H answered. We arranged to meet at the clinic, Animal Hospital.
I have been present for a couple of different emergency procedures – once when Dr. F had to cath Storm over the weekend, and once when Meemaw’s dog Cookie mauled her other dog, Chewy, after hours. Try as she might, Dr. H could not get a catheter inserted into Shadow. That was a prospect I had never even considered, since Storm had always been cath’d fairly easily. We worked on him for a couple of hours, to no avail. At that point she began to talk to me about a “PU,” or perineal urethrostomy. I’d never even heard of the procedure, but occasionally male cats will get blocked so badly that they cannot have a catheter inserted. A PU “fixes” that problem by removing the penis and rerouting the urethra to make it wider, effectively changing the plumbing of the male cat to mimic a female. Dr. H said they had just had another patient who had to undergo one.
We agreed to withdraw the urine from Shadow (they insert a syringe straight through the stomach to remove the urine – it’s rather startling the first time you see it, but apparently only causes mild discomfort), and try again in the morning.
2.2.15 – Dr. H called me to tell me that she and Dr. B had successfully cath’d Shadow! They wanted to keep him overnight to thoroughly flush him with fluids.
2.3.15 – We picked Shadow up. He had a urinary catheter in and had to wear a cone to keep him from picking at it. Urinary catheters drip constantly, so many places offer to keep the cats while they are in. In my experience (and my vet encourages this), my cats do better at home in a familiar territory. We have a collapsible dog crate that we set up when Storm has to have a cath, so we set it up for Shadow. It keeps the urine contained, keeps the other cats from messing with him, and keeps him in a restricted environment where he cannot be too active.
Typically, a cath is only kept in for 2-3 days. They make it easier for cats to catch infection, and they are also apparently incredibly irritating (Storm always seems to get sicker on the 2nd or 3rd day of having his… it’s just him moping and refusing to eat). Shadow’s was supposed to be pulled on Friday. Dr. H wanted to leave it in longer because she was afraid his urethra wasn’t really blocked, but was forming a “stricture,” which is where it narrows.
At this point, Shadow is on a diet of wet s/d (dissolution prescription diet food) when he will eat it, and wet c/d and dry c/d (prescription urinary tract health food) when he turns his nose up at the s/d. He is also on a round of Baytril, since the Clavamox did not kick the infection on the first go around. I am giving him Prazosin 3x a day, which is a new experience for me as Storm only got it 2x a day. He is also now on Amitriptyline for inflammation and anti-anxiety, and Buprenorpherine for pain.
Shadow was reluctant to eat while hospitalized. We theorize it’s because he’s away from home, and also possibly because the pain med dosage was too high (1.5mL – we drop it to 1). At home, he regains a hearty appetite.
2.5.15 – On my way home from work, I call Dr. H to discuss my concerns about Shadow. I am worried that if we pull the catheter tomorrow, Shadow may block again over the weekend. I have already racked up an ungodly bill from the attempted insertion and the actual insertion (basically twice the cost of normal, plus emergency fees). I ask if it would be possible to leave the cath in over the weekend and pull on Monday, because if Shadow does stricture, we can then have the PU surgery performed. She does some research and agrees.
2.9.15 – The catheter is pulled. Shadow is sequestered in my bedroom with a clean litterbox to ensure he is peeing. He does pee, in the box, and sometimes inappropriately on my bed. I think he must feel weird after having the cath in for a whole week. I let him out with the others during the day, but during the night he stays shut up with me so I can monitor his output. I wonder why he still sometimes pees inappropriately. I try to encourage him to play with his favorite toy, the feather-on-a-stick, but he mostly ignores it. Other than that, he is acting normal.
2.13.15 – I have a bad night. I have been plagued by nightmares about Shadow. I spend the night tossing and turning, alternating between burning hot and freezing cold. I think I am sick and I call into work. I try to sleep it off. I wake up at about 10am and feel somewhat rejuvenated. Shadow halfheartedly plays with the feather-on-a-stick and I think, “Hey, I need to have another urinalysis done to make sure we have kicked this infection.” I have also noticed that he seems to be straining some, but I have written it off as a side effect of having the cath in that long. I call Dr. H and ask. She does not think he should still be straining and asks me to bring him in right away for a urinalysis. She has a half day but will wait for me. I rush Shadow in.
His bladder is “moderately full,” and the vet tech brings a litter box out. He squats. Nothing happens. He stays in that position for 15 minutes. Fuck. Dr. H looks at me and I ask about the PU. See, my vet does not perform the PU. It’s not exactly a rare procedure, but it’s not really common. There are two other vets in town who perform it, both of them at another location. Dr. H recommends them wholeheartedly and says they do great work. They also charge around $700. The other vet she could recommend is in Nashville and charges around $2500. I ask her to make the arrangements.
Dr. H calls and fortunately, Dr. S is able to perform the PU that afternoon. She gives me copies of Shadow’s records to take, along with a dosage list of the drugs he is on. I take Shadow home for an hour to cuddle with CB while I gather his meds and food and cone. I deliver them all to the surgeon, where I briefly meet Dr. S. He tells me I should be able to pick Shadow up in the morning. He will have stitches and a catheter for two weeks, and must wear the cone the whole time. If he pulls the catheter out, it could be “disastrous.” I describe how I will contain him in the crate and Dr. S agrees that it seems like a good deal. He advises me to pick up some Yesterday’s News litter, as Shadow will not be able to use regular litter for some time while recovering. I leave Shadow there, pick up some litter, and head home.
I receive a call that afternoon saying the procedure went well and that Shadow is waking up and is comfortable.
We celebrate with Mexican food and margaritas.
2.14.15 – I call at 9am to see about picking Shadow up. I am told that they want to keep him “for observation” over the weekend. This is crushing, since I expected to bring him home. Later I call back because I have been worrying, and am reassured that he is peeing okay and is acting fine, but he is not eating and they just want to make sure he is okay.
2.16.15 – It’s the snowpocalypse. Schools are cancelled. My work is closed. I call and the vet’s office is closed. WTF!! I call the emergency line and get through to a different Dr. H, who is at the clinic trying to take care of the animals by himself. He told me Shadow had not eaten anything and he did not want to send him home if he wasn’t eating. I told him that Shadow does not do well away from home and I was certain he would eat when I brought him back. We had observed that same behavior in the two nights he stayed at his vet’s. I ask about the pain med dosage – he’s getting Buprenex 1.5mL. I advise Dr. H that he wouldn’t eat on that high of a dosage before, and he agrees to drop it to 1mL. He tells me he will feed Shadow without the cone and call me back to tell me whether or not I should come get him.
An hour later, he calls and tells me to come get him if I can safely do so. I’m married to a damn Canadian. We take over a half hour to clear the car off and make it safely there. He is discussing taking the animals home with him because he is afraid the power will go out. Shadow is not properly discharged, but I get the gist of aftercare and get some pain meds to administer along with another round of Baytril. The Prazosin is discontinued.
Post-Op, Week 1 – We get 6 inches of snow and I am damn glad that my mother’s intuition led me to stay home on Friday and deal with Shadow. Everything is closed and I dread thinking of what could have happened if I hadn’t noticed / had waited to get the PU.
All goes well for some time. I discover that the catheter after a PU is not like a normal cath… it doesn’t just drip constantly. Shadow actually controls it and urinates out of it. I begin to let him out of the crate some. I am off work on Monday and Tuesday and get to stay home with “Conehead.” We also wind up working from home the rest of the week, so “Shadowlite Dish” gets to spend his days outside of the crate, acting somewhat normal.
I have him in a smaller cone than they one they sent him home with. That one was so big he could barely move in it. We are confident he cannot get to the stitches or the catheter with the smaller cone. I begin to notice that sometimes he tries to wedge the cone against the catheter. I am vigilant in stopping him when he goes to attempt to lick his crotch.
Shadow has his one week followup visit. He is doing well and Dr. S plans on removing the catheter in a week. At this appointment he removes a couple of stitches. He also clears some scabs that are starting to form.
2.23.15, Day 10 – I go back to work in the office. CB texts me updates on Shadow. I know he spent a good part of the day laying in my computer chair. CB crates him before he heads to school at 4pm. I get home at 6pm. The first thing I notice is that the catheter is gone.
I rush Shadow to the vet in a panic. Dr. S is not there, but another vet sees Shadow. She expresses his urine and says it is coming out okay and I can take him home… or they can keep him overnight and let Dr. S look at him in the morning. I decide to let them keep Shadow overnight for Dr. S, his warning of early catheter removal being “disastrous” playing through my brain.
2.24.15 – I receive a call around noon from the surgeon. Dr. S is concerned that Shadow’s urine is not expressing easily. He wants to reinsert a cath to prevent Shadow from stricturing and has to receive my permission to do so. I give it. They call when I am leaving work to tell me the insertion went fine, and I can pick Shadow up tomorrow.
2.25.15 – Shadow is home again, this time with a “less irritating” catheter. We plan to leave it in for another 7 days. I make him wear the larger cone and give him a firm talking-to about needing to leave this one in.
2.26.15 – Shadow twists violently, rams the seam of the cone into the catheter, and pops it out. It’s 10:30pm. I don’t panic, but am filled with despair.
2.27.15 – I wake up early and take Shadow back. Dr. S wants to keep him to see if he will pee. By the time late afternoon rolls by, he has not peed, and Dr. S wants to keep him overnight. He expressed his bladder earlier and it expressed easily, so he thinks maybe Shadow just hasn’t felt the urge to go. I agree to this plan. Then I have misgivings. I talk things over with CB and we basically decide that Shadow is so damn contrary and hates being hospitalized so much, he’ll probably withhold it because he’s not home. I drive to the vet and ask to see Shadow and Dr. S. I discuss my misgivings with him and promise to sequester Shadow. Dr. S says to bring him back in if he fails to pee, but just call if he pees okay.
As soon as we get home, Shadow goes straight for the litter box and pees!
2.28.15 – By the time morning goes around, Shadow has only peed a little bit more. I see him jump into the box and nothing happens. I take him back in.
Dr. S says his bladder is “moderate” and expresses him, but it is a little more difficult than it was yesterday. He says I can take Shadow home because he is peeing, but he would prefer to do a minor procedure to open the urethra even more. It involves making three small incisions and stretching him. After thinking it over, and feeling uncomfortable about having Shadow home all weekend in case he does close up, I agree to the procedure.
Dr. S calls two hours later to tell me things went really well. He shot liquid into Shadow’s bladder and it flowed out quite easily. He was worried about a small flap of skin that he couldn’t get to, but didn’t think it would be a problem. He has a new catheter in Shadow, but that is just a precaution over the weekend, and will be pulled Monday when I pick him up. The cone must stay on for two weeks while the stitches stay in. He does not expect that he will need to see Shadow again until that time. I am overjoyed.
3.2.15 – I pick Shadow up. I love watching him pee freely.
3.5.15 – Snowpocalypse 2. I work from home. I don’t know what happens, but I start to get worried about Shadow. I watch him closely. He seems to be peeing frequently, but not very large amounts. I talk myself down – he’s acting fine. He’s eating A LOT. He’s cuddling and being adorable. I still feel like something is wrong. The vet’s office is closed and I don’t feel like it’s an emergency, but I start to think about taking him back in for a recheck, even though it’s a week early.
3.6.15 – I work from home again, and only a half day this time. I make up my mind to take Shadow in for a recheck since I got off early. At the least, it’ll calm my nerves. I call, and Dr. S is out. I make an appointment to see another vet but am told I may be charged for it because it’s not Dr. S (all of his rechecks have been free, covered under the original surgery). I call my original to see about having another urinalysis done, and Dr. H says we should do that in another two weeks. I cancel Shadow’s appointment and decide he’s okay. I go run some errands. When I get home, I see Shadow jump in the box. This time, he keeps a leg propped up on the side, so I can clearly watch him urinate. He pees a great deal… but he pees very slowly. It drips like a tap that’s barely turned on. I don’t think that’s right. We go to the surgeon.
Shadow is seen by the other Dr. H, the other vet who performs PUs. Dr. H says the bladder is small, but there is some urine in there, and he expresses it. He is concerned that Shadow is starting to stricture again. I nearly have a damn breakdown. Dr. H tells me that this is not uncommon. PUs have a fairly high complication rate – about 30% – and the primary complication is stricturing. The urethra just keeps trying to heal itself beyond what we want it to. He does not want to make a judgement call on Dr. S’s patient without his input, so he calls him. Dr. S will be in the office tomorrow. They think that they may have to open Shadow back up, clear the stricture, widen the urethra a bit more, and put a catheter in for a full two weeks.
Dr. H is a really, really nice guy. He tells me that we are nowhere near the point where Shadow would need to be euthanized. He says that this is fairly normal, and that things turn out all right in the end as long as we “have some patience and work together.” Shadow may need a couple of more surgeries to fix things, but as long as we are vigilant and stay on top of things, he will recover fully. I am incredibly stressed out because now this has been ongoing for 6 weeks. Really, though, what are my options?
A PU is performed basically as a last option. Your cat is blocked and cannot be cath’d. They have a PU, or they die. Shadow is not even two years old. I’ll be damned if he dies from this. He is not even sick anymore… that’s what’s so distressing. His urethra is just trying to heal itself shut against this surgery. Do I regret him having the PU? Meemaw observed that he wouldn’t have all these problems if we hadn’t had it done. No shit, but he would be dead, and that is a far bigger problem. Our only choice right now is to continue with these procedures, or have him put down. And I will NOT put down a cat that can be healed.
As it stands right now, as of 10pm on 3.6.15, I have Shadow at home. I have watched him pee again since we got here… again, a large amount, but at a trickle. Shadow seems to be comfortable. He ate a large dinner and is cuddling in bed. I plan to take him back to Animal House at 8am when they open so Dr. S and Dr. H can look at him again. I am hoping they think he is okay and nothing else needs to be done, but I am planning on them having to open him up for a second round at the PU. If that is the case, I will not see him again until Monday morning, and we will somehow have to make him keep a catheter in for two whole weeks. I have taped the seam of his cone shut so it cannot be used as leverage, and Dr. H is hopeful that if we keep him constantly on Buprenex this time that he won’t really feel the catheter and therefore won’t mess with it.
To say that I am worried about my son is an understatement. But I am very happy with the care he has been receiving. I think we can get through this, but we seem to have hit every damn possible complication. I look forward to the day that everything is alright again… maybe a month or two down the line. To be perfectly honest, I’m not sure I’ll ever be completely at ease again. I am going to constantly worry about Shadow’s tiny urethra. But I am keeping my fingers crossed and trying to stay hopeful that everything is going to work out okay.
3.7.15 – Shadow and I arrived at the vet’s office at 8am. It was kind of heartbreaking to take him in, because he was rowdy and playful and acting otherwise like he felt good. Dr. S felt his bladder and said that while there was urine in there, there wasn’t much. He had a hard time expressing more urine, and said that he thinks Shadow might just be a difficult cat to express – some are. He said that Shadow’s behavior was good, that it shows that he’s not building up too much urine and poisoning the kidneys, making him sick. He hypothesized that perhaps Shadow wasn’t stricturing, but rather that there was a plug near the opening that was composed of mucus, cruddy urine, and hair. He was hopeful that Shadow would not need to be opened back up, but he wanted to run a catheter just to make sure – he said that would let him “really clean him up and see what was going on.” If there were no issues, I could bring Shadow home at noon. I left him there and waited for a phone call.
At around 11am, Dr. S called to update me. He said that as soon as he sedated Shadow, urine began flowing out of him. That made him suspect that the problem is not physical; rather, Shadow is just holding his urethra shut. He gave him an injection of Valium to help him relax.
He said he debated and debated, but since there was a bit of the surgery he was unhappy with last time, he decided to open him up and clean that out. He said he went in “a little more aggressively” this time and widened the urethra a little bit more, removing that “little flap of skin” just in case it became problematic
Right now the game plan is to keep a catheter in Shadow for 2 weeks, if possible, and maybe longer – he said he’s successfully kept them in for up to a month before to let the urethra heal and relax around it. The challenge is to keep him from pulling it out.
We are putting Shadow back on Prazosin to help the urethra stay relaxed. He wants to discontinue the amitriptyline for now.
Dr. S was very positive and reassured me several times that “we will fix this” and Shadow will heal up fine, but that we need to remain patient and go through the steps. “The bladder and the urethra are not communicating very well to each other,” but he thinks this surgery would have fixed any potential physical problems and now we will focus on medicating Shadow so that they “begin talking to each other properly again. And they will.”
More good news is that they are not charging us for any of these corrections. I’ve had comments made like “Wow, that must be really expensive!” and such. Fortunately, the PU itself was just under $700, and all of this is considered “continuing care” and part of that original procedure.
Some interesting things I learned… I asked Dr. S about putting Shadow on Buprenex, as per Dr. H’s suggestion. Dr. S said we could, but said that there have been new studies that have determined that Buprenex is not absorbed very well and is not very effective on cats. He said that in his opinion it would just be money I would be throwing away. I asked about other painkillers, thinking of Metacam, and he told me that he could put Shadow on Metacam, but it is not recommended with kidney issues because if Shadow withholds urine, it can exacerbate kidney failure. He does not recommend using it in urinary tract cases. He thinks the best bet is to just try to be hyper vigilant about keeping Shadow calm and keeping him away from the catheter.
Dr. H asked me out of curiosity how old Shadow was when I had him neutered. I told him about 4 months. He said he has noticed a correlation that many cats with blockages seem to have been neutered young, and he has read some studies that suggest the urethra is not fully formed by that age and that neutering stunts its development. He says he always recommends waiting until 6 months of age or older – the downside is by then you start dealing with marking behaviors like spraying. I found that fascinating, because both Storm and Shadow were neutered young, while I waited for what I thought was far too long for Rain – just over a year. Rain’s recovery was more difficult, but he has not yet had a single UTI issue *knocks on wood* I can say with certainty that now in the future I will wait to neuter any male cats I adopt.