Diagnosing Bladder Stones in Pets: What You Need to Know

Sometimes, diagnosing urinary bladder stones in dogs and cats is simple: one set of x-rays and the mineral-dense uroliths glow bright white on your viewing screen.

Other times, it’s not so straightforward… especially for small or radiolucent stones.

Here’s how radiographs and ultrasound can be used to help you find pesky, hard-to-view bladder stones.

Are bladder stones on your differential diagnosis list?

Bladder stones may be at the forefront of your mind if you see a dog or cat who’s…

• Having blood in their urine.

• Urinating more frequently, and in short streams.

• Having urinary accidents in the home.

• Straining or experiencing pain during urination.

• Excessively grooming around their genitals.

Usually, a client will bring their pet into you for these concerns, and your physical exam will help to determine that there’s no urinary obstruction.

With urinary bladder stones, you may notice some discomfort on palpation of the caudal abdomen. On a cat or small dog, you may even feel stones or crepitus in the area of the bladder. 

Some patients, on the other hand, may exhibit minimal symptoms and their physical exam may be normal (sometimes bladder stones are an incidental finding).

Either way, most pets will need some type of imaging to confirm that bladder stones are there. Radiographs are a great place to start…

Finding uroliths via radiographs

In addition to any other needed tests—such as a urine analysis or bloodwork—radiographs are often recommended for pets with urinary symptoms, in order to look for uroliths or other abnormalities.

Typically, you’ll start with two simple views of the abdomen—a lateral and a VD. 

Take a close look at the urinary bladder to look for radiopaque stones, which should show up as a white opacity relative to soft tissues thanks to their mineral composition.

Stones can range in size from small sand-like grains to more than two inches across. There may be just one or two stones present… or a small group… or even more than 100.

Remember to check the urethra for small stones that could be stuck—especially if the patient is straining or in pain during urination.

For better visualization of the entire urethra in male dogs, consider taking another lateral view with the hindlimbs pulled forward.

Also, check the kidneys and the areas of the ureters. While much less common in pets than in people, occasionally uroliths may be seen higher up in the urinary tract.

If you see stones now—you have your answer.

If you suspect urinary bladder stones but still don’t see them, a contrast study may allow better visualization.

For finding bladder stones, a double-contrast study is ideal.

This includes using both a positive contrast agent (soluble iodinated contrast medium) and a negative contrast agent (room air, or ideally carbon dioxide to reduce the risk of an air embolus) in the bladder together.

Anesthesia or sedation may be needed for the patient’s safety and comfort since the contrast agents are administered via a urinary catheter.

In addition to radiographs, an ultrasound is a useful tool…

Finding uroliths via ultrasound

An ultrasound study is another great option for finding bladder stones, especially radiolucent ones.

The fluid-filled bladder provides contrast for the ultrasound waves so that stones can be found (and often emphasized by acoustic shadowing). 

Besides radiolucent stones, you may also see…

• Bladder stones (radiopaque or radiolucent) that were too small to visualize radiographically (smaller than 1-3mm).

• Other problematic issues in the bladder, such as ‘sludge’ buildup in cats with crystalluria.

• Damage to the urinary bladder itself, such as inflammation.

• The condition of the upper urinary tract—the kidneys and ureters.

• Unexpected findings, such as tumors or anatomical abnormalities of the bladder.

Because of this, ultrasound imaging is a valuable tool for helping you diagnose and treat problems of the bladder, including urinary stones.

Follow-up

Depending on your findings, you may recommend a diet change for dissolvable stones, or a cystotomy to remove the stones.

For dissolution, follow-up imaging can help to track the patient’s progress and see whether or not the stone is dissolving.

When a cystotomy is recommended, remember to use imaging on the day of surgery…

Take pre-op radiographs to confirm the stones are still there, and that your urinary catheter is in place.

Include post-op views to confirm and document that all stones were successfully removed.

Since most stones are radiopaque, standard radiographs are a good option for follow-ups—and typically the imaging choice on the day of surgery.

But ultrasound can also be used in conjunction with other diagnostic tests to monitor the health of the urinary system long-term and to look for early signs of a problem such as a reoccurrence of stones.

Catching stones early, when they’re small, may allow less invasive treatment options such as voiding urohydropropulsion.

With the right combination of imaging modalities, you can help your clients stay on top of treating, monitoring, and preventing urinary bladder stones in their pets.

Written by: Dr. Tammy Powell, DVM

Disclaimer: This article is for general informational purposes only, and not intended as a guide to the medical treatment of any specific animal.

Buy Veterinary Digital X-ray Equipment with Confidence

How to Buy Veterinary Digital X-ray Equipment without Experiencing Buyer's Remorse

Have you ever bought something and regretted the purchase?

I think I have at one time or another. However, it’s one thing to regret ordering a cheeseburger and fries, but quite another when I regret buying a $50,000 car or truck.

When I make a big purchase, I want to feel good about my decision. I want to make sure that I made the right choice.

I want you to feel great about buying from me! I understand it is no small thing for a Veterinarian to spend $20,000 or $30,000 on digital x-ray equipment, and I want you to feel great about buying from us.

So, here is my “purchase without buyer's remorse” plan:

The 30-day satisfaction guarantee, or your money-back offer. When you make a digital x-ray system purchase, I will give you 30 days so that you feel comfortable and confident that you made the right choice.

And if you are not satisfied, return your digital x-ray equipment for a full refund.

Yes, that is correct! A FULL refund!!

I know that after the vet digital x-ray equipment is installed in your clinic, and once you learn how to use the software, you will be very happy with the results you get.

I can offer this guarantee because I am very confident with the quality of the digital x-ray equipment we sell, and I want you to be completely satisfied.

Here is the fine print:

• Equipment must be returned in original packaging.

• Equipment cannot be returned if damaged by the user during your 30 days.

• The buyer pays the cost of shipping/packing/insurance of all returned equipment.

• You must give us a reasonable chance to correct any dissatisfaction.

The main reason I am offering this “30-day satisfaction guarantee or your money back” is to give you peace of mind.

I understand I’m not as big as Idexx, Cuattro, or Sound-Eklin. Perhaps that makes you think twice about trying us out.

But I am confident that our equipment is as good, if not better, and now we have a “30-day satisfaction guarantee or your money back” - which the big boys do not offer!

The bottom line is simple:

• I am offering quality digital x-ray equipment for the veterinary industry at an amazing price, with a great warranty, and now a 30-day guarantee.

• I want to do the right thing, treat you with respect, and help you be successful in your veterinary practice.

Call or text me - Brad Haven, Jr. - 530-355-5886

Diagnosing Tumors of the Heart in Dogs and Cats

Cancers of the heart are uncommon in dogs and cats. When they do occur, it’s important to differentiate a tumor from other conditions that could cause generalized or focal enlargement of the heart and cardiovascular symptoms.

Which cancers occur in cardiac tissues?

A cancerous lesion based at the heart could be a primary tumor, or due to metastasis. 

Primary tumors that occur at the heart include:

• Hemangiosarcomas—the most common heart cancer in dogs, usually occurring at the right atrium. These occur most frequently in larger dogs with longer noses, such as Golder Retrievers, Doberman Pinschers, and German Shepherds.

• Chemodectomas, also known as aortic body tumors or heart base tumors. Generally thought to be slow-growing, these tumors occur most commonly in brachycephalic breeds like Boxers, Bulldogs, and Boston Terriers.

• Myxomas.

• Sarcomas.

• Ectopic thyroid tumors.

• Lymphoma/lymphosarcoma—the most common heart cancer in cats.

Other cancers are possible, but these are the most commonly diagnosed types. Breeds may vary as noted above, but most pets with tumors of the heart are middle-aged or older. 

How are heart tumors diagnosed?

If slow-growing, tumors near the heart base are often an incidental finding, seen on thoracic radiographs that are taken for another reason.

Other times, diagnostics are pursued because of clinical symptoms—which are often sudden in onset.

Once a mass is large enough to push on the heart and major blood vessels, many cardiovascular symptoms are possible, such as:

• Coughing

• Ascites

• Lethargy

• Weakness

• Vomiting

• Loss of appetite

• Difficulty breathing

• Collapse

• Sudden death

Note: If a dog presents with some of these symptoms, especially sudden weakness and collapse, a quick ultrasound scan may help to identify pericardial effusion and aid in guiding a needle for emergency pericardiocentesis.

Finding heart masses early

As with most cancers and disease processes, discovering a problem earlier rather than later can allow for more treatment options.

General screening radiographs or ultrasound checks—such as with a senior wellness health check—can be a good opportunity to discover heart base tumors before they cause cardiovascular dysfunction and symptoms.

An echocardiogram performed via ultrasound can help to provide more information on the location, size, and invasiveness of the mass. 

In some cases, a presumptive diagnosis may be made based on the appearance and location of the mass on an ultrasound study, along with the patient’s signalment. If possible to perform without undue risk, an ultrasound-guided aspirate of the mass can provide more information about which type of tumor is present.

Treatment options for cancers of the heart

Treatment will be based on the type of neoplasia, how fast the mass is growing, whether metastasis is present, and whether or not the pet is symptomatic.

When a tumor of the heart is diagnosed, a good next step is to screen for metastasis and concurrent conditions via chest x-rays (if not already done), bloodwork, lymph node evaluation, and abdominal ultrasound.

Once a diagnosis is made, treatment options may include:

• Periodic monitoring with a cardiologist (especially for slow-growing chemodectomas/heart base tumors) prior to pursuing more invasive treatments.

• Surgery to remove the tumor.

• Pericardiectomy to remove the pericardium and prevent life-threatening cardiac tamponade or pericardial effusion. 

(A pericardiocentesis may be necessary on an emergency basis prior to diagnostics in a pet who presents with acute symptoms. After that, a planned pericardiectomy can help to prevent further emergency episodes of fluid buildup around the heart.)

• Chemotherapy, often in conjunction with surgery.

• Radiation therapy—either conventional, or via Cyberknife therapy.

Even though cancers of the heart are uncommon in pets, they can be scary to pet owners because of the possibility of sudden onset of serious clinical symptoms (especially with hemangiosarcomas).

By performing diagnostics, referring to specialists as needed, and giving your clients as much information as possible, you can help them make an informed decision for their pet.

Disclaimer: This article is for general informational purposes only, and not intended as a guide to the medical treatment of any specific animal.

Written by: Dr. Tammy Powell, DVM

COVID-19 and Your Veterinary Practice- COVID-19 Safety Tips

What we know right now about pets and COVID-19

Currently, pets are not considered to be involved in the transmission of SARS-CoV-2. A handful of pets around the world tested positive (compared to over 4 million human beings), and it is thought that these dogs and cats contracted the virus from a human. 

So, pets may have some risk of being infected from us, but at this time there’s no evidence of zoonosis from pets. 

Seeing patients during a pandemic

While veterinary medicine is generally considered an essential service, you’ve probably had to change the number of appointments you see—and the manner in which you see your clients and patients—during the coronavirus pandemic.

The CDC recommends using your professional judgment to provide care to pets while minimizing human-to-human exposure and conserving PPE (personal protective equipment).

This could mean…

• Seeing urgent care visits only while postponing routine and elective visits.

• Using telehealth consultations in lieu of in-person visits whenever possible.

• Requesting that clients call ahead of time to schedule their pet’s visit if possible.

• Implementing “curbside” service, where one of your team members picks up the pet from the client’s car in the parking lot. The pet owner stays outside and communicates by phone as you examine and treat their pet.

• If clients must enter the facility, insisting they wear a face mask and practice social distancing.

• If a client is ill with COVID-19 and their pet must be seen, they should have someone else (a healthy person from outside their household) bring in their pet, and also inform you that their pet has been exposed. It’s okay to ask clients while scheduling an appointment, and upon arrival at the clinic, if the pet has had any exposure to a person with known or suspected COVID-19.

• Practice frequent hand washing and disinfection of rooms and equipment.

• Have clients leave all unnecessary items (such as toys) at home to reduce the risk of spread via fomites.

In some cities or states, local regulations may have more detailed orders in terms of which visits and procedures can be performed. Check your location’s latest updates and mandates.

The same goes for telehealth consults: The FDA temporarily relaxed some of its telehealth guidelines for veterinarians as of late March 2020. However, that may change as businesses start to resume normal practices—and your state may have different rules.

Employee wellness and etiquette

The CDC recommends that staff members who are ill should stay home. Additionally, any team members who arrive at work with symptoms of illness—or become ill while at work—should be separated from others to reduce exposure, and sent home.

Staff members who are ill should not return to work for at least 10 days, until their symptoms have improved, and they are free of a fever (> 100.4 degrees) for 72 hours without using fever-controlling medications.

Social distancing should be maintained within veterinary practices. And face masks should be worn to prevent the spread of respiratory droplets.

As much as reasonably possible, team members should avoid sharing equipment and workspaces. Any shared or frequently used equipment or spaces should be disinfected often.

If a team member is ill, or sent home due to suspicion of COVID-19, other employees should be informed of possible exposure in the workplace, while maintaining confidentiality (in compliance with the Americans with Disabilities Act).

Employees at a higher risk—such as older adults, pregnant individuals, or individuals with certain underlying health conditions—should limit exposure to clients and patients with confirmed or suspected COVID-19 or a history of exposure.

Screening pets for COVID-19

As of this point in time, the CDC, USDA, and AVMA do not recommend routine testing of pets for COVID-19.

However, if you encounter a pet with relevant symptoms and known exposure to the virus, testing may be indicated after more common causes of the symptoms are ruled out. 

Contact your local or state public health official, the animal health official, or state veterinarian, who can guide you through the decision and procedures for testing.

When obtaining test samples (usually oral, nasal, or fecal/rectal swabs), strict PPE and disinfection protocols should be used to avoid exposure to the virus. 

PPE availability and usage

PPE may include face masks, gloves, eye protection, surgical caps, and gowns or coveralls. These items play an important part in protecting you and your staff from potential SARS-CoV-2 exposures.

Due to shortages of PPE in the human healthcare setting, it’s recommended that veterinarians look at CDC guidelines for PPE usage, use these resources conservatively, and consider reusable PPE where appropriate.

Limiting appointments—such as deciding to only see urgent care visits and postpone elective procedures—also plays a key role in the conservation of PPE for both human healthcare professionals and veterinarians alike.

Checking for updates

Since this is a novel virus and an unprecedented time in terms of global pandemic procedures, knowledge of the situation and recommendations are constantly evolving.

In order to stay up to date—and to stay in compliance with the latest legal requirements and safety recommendations—look for updates from your local and state authorities.

Check the CDC, USDA, and AVMA for more details regarding these recommendations—and be sure to follow them for updates. 

Also, look to the AVMA website for additional resources, such as financial and wellness strategies for veterinarians.

Written by: Dr. Tammy Powell, DVM

How to Talk to Pet Owners about Radiographs

“Does he really need an x-ray? Can’t you just give him some medicine and see how he does?

“Why is this so expensive? You just want to make money while my cat is sick!”

As a veterinarian, you’ve probably heard all of this and more.

Of course, most clients want the best for their pets, and many will understand why you want to perform certain tests like radiographs. However, even the most loving of pet parents may show some hesitation or “sticker shock” when you present the estimate…

Often, this isn’t personal. Many pet owners just aren’t prepared for a sudden expense, even if they want to do the best for their furkids. Here are some tips that may help take the conversation in a more positive direction…

Stay calm during the initial reaction

If an owner’s initial response is similar to the examples listed above, try to ignore the knee-jerk reaction to defend yourself. Get comfortable with allowing a moment of uncomfortable silence.

Often, clients will try to fill the silence themselves and offer more of their thoughts and questions. But even if they don’t do this, a quiet moment may give everyone the chance to take a breath and start over, calmly.

Don’t pile onto an owner’s guilt

Of course, you’ll need to explain why the radiographs are important for your treatment decisions, and what dangers exist for the pet if radiographs are delayed. 

However, if a pet owner understands this and is just having trouble affording the x-rays, they’re probably already feeling guilty. This causes them to lash out.

In this case, having empathy during the conversation can really help. Think about your tone of voice, body language, and anything else that may help elicit a productive conversation.

If you make an owner feel understood and accepted, they’re likely to come back to you as soon as they CAN afford the tests, rather than seeking care elsewhere.

Bundle your radiographs when possible

Often, estimates are presented as “a la carte,” with different options presented by cost, line by line. 

While this may work well in some situations, the client may try to pick and choose, asking which items can be eliminated in order to decrease the cost of treatment.

Instead, try estimates that list a total cost, with radiographs included. Some situations where this may work well include:

• Dental procedures with dental rads.

• Senior wellness testing, with bloodwork and screening rads.

• A blocked cat, with x-ray views included as part of the treatment plan.

• For three-view thoracic radiographs, bundle them together rather than listing the individual “per view” charges separately.

Of course, you can still list each item of the treatment plan, so the client knows the value they are receiving. But, list it as a total cost, rather than an itemized estimate.

Explain the benefits and limitations of radiographs

Many pet owners nowadays, especially Millennials, want to be fully involved in their pet’s care—that’s part of the reason why so many owners seek answers from Dr. Google prior to coming for a vet visit.

Those clients will want to receive answers about their pet’s condition right away—so, let the client know that radiographs will help to provide the answers they’re looking for. And since radiographs are available the same day, they can get answers to their concerns very quickly.

On the flip side, also prepare an owner that a radiograph might show normal results. If the pet is feeling well, then the client gets peace of mind. If the pet is ill, further testing may be required—by preparing the owner for this possibility ahead of time, you can avoid upset reactions as much as possible.

Ask about their biggest concern

Even though you probably already know the biggest concerns and questions clients have about x-rays, it never hurts to ask an owner why they’re hesitant. They may appreciate you listening to them, and it saves you time so you can address their biggest concern.

Some examples you may encounter include:

• Finances. In this case, you can suggest third-party financing options, such as Care Credit.

• Fear for their pet’s comfort, or having to leave their pet at the hospital. Here, discuss the procedure. If sedation is used, explain how this can minimize pain. Or, if digital radiographs are used, explain how this allows the views to be done fast so the pet can go home sooner.

Show clients the value you offer, even after the x-rays are finished

Be sure to go over the results of the radiographs with your client. Try using a quiet exam room rather than the treatment area, so they won’t be distracted.

Give the client a brief “x-ray orientation,” so they know which end is toward the pet’s head and what is abdomen versus chest, etc. Then, explain your findings. 

Whenever possible, bring a normal x-ray for comparison, so clients can really see the difference with an abnormal finding.

If you have digital images, share a copy with the client that they can look at after the visit. Offer to let them record you talking about the findings. That way, when the client goes home and shares the findings with their partner or family, everyone is more likely to understand and be on board with your recommendations.

With a little planning of the whole x-ray experience from the client’s perspective, you can make things easier on them—while at the same time, increasing compliance and getting better care for the pets you see.

Written by: Dr. Tammy Powell, DVM

Identifying Trauma in X-Rays of Hit-By-Car Patients

It’s been a slow day, and you just got back from lunch. Your first-afternoon appointment is waiting, and you look through their chart, preparing to go into the room… 

All of a sudden, the clinic doors burst open. You hear a big commotion upfront…

You walk up to see what happened and discover a distraught pair of pet owners holding carrying their Border Collie, who’s just been hit by a car.

How to avoid further surprises…

Of course, as a veterinarian, you’re probably used to something like this happening from time to time—panicked pet parents arriving at your clinic with a dog or cat in need. And you’re probably well-prepared to triage and decide what to do next…

However, you’ll want to avoid unpleasant surprises down the line—liked missed diagnoses—by ensuring that you find and plan for unexpected injuries.

For example, maybe that Border Collie has an obviously broken leg and some nasty road rash.

You’ll address those injuries, but first, you’ll explain to the owners that there are other conditions you need to check if their fur kid has just been hit by a car—conditions that could be life-threatening.

What to look for on the x-rays

Your physical exam will help direct you on what to look for. For example, if you feel a painful joint with crepitus, or hear crackles or decreased lung sounds when you auscult the chest, those will be areas you want to explore with radiographs. 

But, even if the lungs sound fine and you don’t find any other obvious abnormalities, it’s always good to evaluate the thorax and abdomen radiographically.

Sometimes, x-rays will need to wait…

For example, if the pet is in critical condition, they need stabilization first. And, you’ll use your judgment on whether sedation is needed and safe, for clearer and more diagnostic x-ray images, as well as for relief from pain and stress.

Then, when you read the radiographs, it’s important to evaluate EVERYTHING on your set of x-ray images. 

The impact of being hit by a car can cause trauma to many different parts of the body all at once, including serious internal injuries.

Here are a few things to check for on your radiographs…

• Pulmonary contusions. A strong trauma to the thorax can cause dangerous bleeding in the lungs, often visible on radiographs as alveolar or interstitial opacities.

• A ruptured bladder and uroabdomen. Look for signs of fluid in the abdomen, especially if you notice bloody urine. Try to visualize the bladder.

• Internal bleeding or damaged organs. If an organ such as the spleen has been injured, you may notice a hemoabdomen (although radiographically, this would be difficult to distinguish from a uroabdomen). In the case of ruptured intestines, you may notice spots of free air in the abdominal cavity.

• Broken bones, including the ribs and vertebrae. Visually trace along the bones one-by-one to be sure no lesions are missed. 

• Dislocations, such as a dislocated hip. Also, check for tail-pull injuries, especially in cats who may get their tail caught under a car’s wheels.

• Diaphragmatic hernia. Look for evidence of intestines or other abdominal organs in the thorax.

• Air or fluid in the pleural space. Seen as gas opacity, or fluid opacity.

• Skull and jaw radiographs if needed—in case of suspected head trauma.

Of course, other abnormalities are possible, too. As you know, pets don’t always “read the book” and clinical practice can be full of surprises! If you’re unsure of something on the films or digital images, it may be good to recheck it down the line to be sure no problems are brewing internally.

The number of views you take will vary depending on the size of the pet.

For emergency situations such as this, it may be worth having digital radiographs, for faster results without waiting for films to develop.

Also, it’s important to take orthogonal views. That way, you get the full pictures and lesions are less likely to be missed.

Re-evaluate and repeat radiographs as needed

This will depend on what you see on the first set of images, in addition to how the pet is doing in real life. Use your best clinical judgment to determine if and when repeat radiographs are needed, and keep the pet under close observation.

If there’s any doubt, consider using contrast studies to obtain more information, too.

By developing a plan for radiographs—and remembering to check everything on the images—you’ll increase the chances of finding unexpected injuries and addressing them earlier. Or, in case the radiographs are normal, you may be able to give more peace of mind to the worried pet owners.

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Disclaimer: This article is for general informational purposes only, and not intended as a guide to the medical treatment of any specific animal.

Written by: Dr. Tammy Powell, DVM