How I Diagnosed a Fur-Lined Ectopic Urethra in a Golden Retriever
Brinkley Relaxes by the Fireside
I thought Brinkley’s mom was kidding or lying when she first told me about his little problem.
“When Brinkley squats to poop, pee comes out the back of his leg.” Oh, really?
Pet mommies and daddies tell me all sorts of things.
“She lets him eat liver pate straight from her lips, is that okay?” Uh, I guess so.
“I know you’re not a shrink but, sometimes, I think he loves that dog more than me.” Probably does…
So, when a cute, stuffed-teddy-bear-looking 8 week Golden Retriever puppy comes to see me for his first vet visit, and his mom announces, “he pees out of the back of his leg when he squats to poop,” I am skeptical, to say the least. I believe pet parents have great intuitions, and they often do know something is wrong, even when laboratory tests do not show an answer, but still, I was skeptical.
I examined Brinkley’s offending leg especially closely. In the center of the swirly at the very back of his right haunch, there was a reddish-brown 4mm spot. The spot looked like an insect bite that was licked until it turned a distinctive reddish-brown color, like the tip of the paws on a white allergic shih tzu. He did want to “squat,” so I asked his mom to catch some of the alleged “urine” and bring it into the office for analysis.
The next day, she brought a tiny plastic cap from a prescription bottle, with some liquid in it. Looked yellow. Chemistry machine measured creatinine. Wow! How could this liquid come from the back of a puppy’s leg?
Brinkley stayed with me for a day of iodine-contrast radiography. I carefully injected iodine into an intravenous line. This radio-opaque iodine travels through the bloodstream and begins to be filtered through the kidneys and into the urine in minutes. This process is called an iodine contrast urethrocystogram. As the contrast agent is filtered into the urine and excreted, radiographs (x-rays) are taken to highlight the travels of urine in his system.
In Brinkley’s case, everything looked fine. I postulated that there may have been an one-way membrane, acting as a biologic valve, over the abnormal, or ectopic, opening of the pathway through which the urine travelled from somewhere inside his body , out to the swirly of the back of his thigh. I walked Brinkley outside, in case the pressure of urination would open up the pathway and iodine would flow out the back of his leg. No such luck. It seemed the pressure of squatting helped open up the extraordinary spigot, and Brinkley was much more interested in playing than squatting.
In this case, retrograde contrast should highlight the problem.
For anyone reading this who has not worked in an animal hospital, you may think this sounds hard enough. If you have worked in an animal hospital, you know that any, any contrast agent that gets on you, the x-ray table, the fur, anywhere, will show as white smudges on the x-rays and obscure the delicate structure you are attempting to elucidate.
I attached an open-end tomcat catheter to the end of a 60cc injection syringe full of iodine contrast agent, lubricated and inserted it about 1 inch into the abnormal hole in the thigh. Holding pressure around the opening to prevent flow-back, I slowly and gently injected the agent. After about 10 cc’s and after 20 cc’s, we snapped the x-ray exposures.
Sure enough! There was a skinny white line on the x-ray extending from the pelvic urethra just after the prostatic urethra, out through the caudal-most point of the upper thigh.
If you have been paying attention, you are asking, but how did I know the ectopic urethra was fur-lined? Good question…
The board-certified surgeon to whom I referred Brinkley, told me so. Brinkley was at great risk for recurrent life-long urinary tract infections if he kept his special plumbing, and he needed it fixed. A wonderful specialty surgeon followed the path, and removed the offending tube. He stopped short of removing the part inside the puppy’s pelvis, as the surgery would have required… (gross out warning: but you’re reading a medical story, so you probably like this stuff.)…would have required sawing this puppy’s pelvis in half, finishing the surgery, and then screwing it back together. Luckily, Brinkley has remained healthy since his surgery without the pelvic surgery part!
I know I’ve discovered an unusual patient when the specialist calls and thanks me for the interesting and challenging case, gets all excited and blurts out,
“Would you believe it was lined with fur the whole way into the pelvis?”
Awesome blog!
I thought about starting my own blog too but I’m just too lazy so, I guess I‘ll just have to keep checking yours out.
LOL,
Hey “Savvy”! You are most welcome to add to the banter anytime!
Would it be possible for me to see the radiograph? I am a current vet med student and in our case this week we were presented with a puppy with an ectopic ureter This would really add to the discussion as well as help us learn to read contrast radiography.
Thanks,
Liz
Oh Liz! I would love to have that radiograph! The case was over 10 years ago. The puppy in the picture by the fireplace is the actual puppy, his parents sent me that thank you picture a year after the surgery.
The surgery was performed at Tufts Veterinary School, but I no longer have the records.
Basically, the radiography process was arduous and complex. First, I did intravenous iodinated contrast, looking for the pathways through the kidneys and the ureters and urethra. Everything looked normal. Probably, the ectopic (spellcheck just put “octopus” in there!) pathway started with a flap of membrane that prevented the contrast from finding that route.
Also you have to be careful when performed a contrast study in the urinary tract to try and get the patient to urinate normally so the muscle contractions, etc, find the path the urine takes in real life. (Tricky to do and get the patient back to radiology in time for the contrast to show in the right place!) There is, of course, some risk of anaphylaxis with intravenous iodinated contrast agent. I felt the odds of several abnormalities were high; I did not want to just go for one and miss others that would affect the puppy adversely.
Then, I performed a retrograde study through the exterior hole in the leg. This was very tricky. He was not sedated (although being a large, goofy Golden, he mostly just wagged the tip of his tail and licked our faces throughout the procedure!) NOT getting contrast agent anywhere except into that hole in the leg was challenging, but we managed it.
The retrograde study showed the channel extending all the way back to the mid-pelvic urethra. Yikes!
The surgeon actually removed as much as he could in the leg, but he and the puppy’s parents elected not to “crack the pelvis” (as the specialty surgeons say) and get the rest of the ectopic urethra out.
The last follow-up I had was the letter a year later. No recurrent urinary tract infections!
Strange to think, that puppy may have already lived his natural lifespan. I hope not; I hope he lives to be 15!
Good luck with your rounds. I apologize, I do not have a relevant rad. Please email me or comment anytime, our professional helps animals the best when we work together!
Yours,
Doc Truli