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Cushings And Urinary Incontinence In A Dog

by equinesportsmed - January 14, 2022 View Case Report

Long, complex case-- A Time to Heal recently asked you whether HRUI formula could cause vomiting. This is that dog. I just entered a 4 page history in her case file here, along with blood work.

Briefly, I was consulted for anxiety and LF lameness last June. Dog had a 3 year hx of UTIs w struvite crystals every spring, treated with AB. Major weight gain over 3 years, from 45 to 68 lb. Dog seemed to do well on Xiao Yao San and Pentagenesis (deer antler velvet with immunomodulating additions), and went from partial to full fresh (raw) food diet. At that time, pulse was weak, tongue was lavender. Dramatic positive response to acupuncture.

Early July blood work showed elevated ALT and ALKP, low normal T4. September showed all normal except ALKP, which was even higher. Suggested testing for Cushings, but nothing was done. More urinary leaking in fall, local vet started Incurin, then switched to Proin. Dog came back to me in December for weird front paw lameness that started in July: two middle toes on LF paw are flat and dropped. Did not find any chiropractic abnormalities at the time, emphasized Cushing testing (December labs even higher ALKP), suggested more full thyroid testing (levels were low normal), discussed orthopedic consult, offered HRUI instead of pharmaceuticals.

Dog began vomiting on HRUI, so asked ATTH and Dr. Heilman what could be going on. Nate gave a brilliant analysis and suggested the tonic qualities or mineral part of HRUI could be too much for her. Suggested XCHT with added Gui Zhi Tang and Bai Shao, which I formulated and sent.

Meanwhile, Cushings testing finally happened and dog had a 56 cortisol in response to ACTH. Unsure whether pituitary or adrenal-- U/S schedule in February. Orthopod (casual question) thought toe problem could be degeneration of collagen from Cushings, did not think there was a surgical fix.

So-- question!!! I generally go to Si Miao San for Cushings cases. Do I add that on? Discontinue the Chai Hu Gui Zhi Tang? See the Extended History file for Nate's full reasoning on the latter.

by equinesportsmed

January 14, 2022

Whoa-- this case is so exhausting, forgot my other question! It seems like there are multiple axes of hormonal imbalances-- cortisol, estrogen and thyroid (possibly). Is this commonly seen with pituitary adenomas? Is there some clever way to hit all three? Waiting on getting a better T4 panel from Hemopet.

by naturevet

January 17, 2022

Hi there!

The case is more consistent with Damp than with a Shao Yang disharmony, so if the XCHT does not produce any clear benefit, I'd give SMS a try. It would be weird, though, for an animal on a real food diet and no kibble or canned food to not start to improve if it was a SMS case. If there had been a slight tick downward in the ALP since using a strict real food diet, then SMS would still supported.

Damp symptoms include:

Spring time cystitis (when Tai Yin and thus Damp are at their highest)

ALP that goes up over the summer months, especially in a dog on a Blood tonic like Xiao Yao San

Vomiting on a pure tonic like HRUI Combination

Since, however, the dog is on XCHT, you might as well check the liver enzymes in a couple of weeks and see if they are improving on it first before making the switch. Either SMS or XCHT could conceivably help in an actual pituitary tumor.

As for whether the dog is truly estrogen-deficient, though, that is doubtful if incontinence occurred while on the pharmaceuticals.

The thryoid hormone disruption may not be enough to suspect problems at the regulatory level. In other words, it may be a pure Cushings case

The only other formula that could fit here is Bu Zhong Yi Qi Tang. It fits with the:

Recurrent UTIs

Incontinence worsening in fall and winter (since it is essentially a Jue Yin formula)

Seeming responsiveness to XYS (since the two formulas share several ingredients)

I would not start with that formula, though, since it is a Blood tonic and thus likely to aggravate ALP levels if the latter increased while the dog was on Xiao Yao San. Still, you should keep it in mind if the ALP increases were the same, whether or not XYS was on board. If there is a partial response to XCHT, then using BZYQT + XCHT addresses most causes of urinary incontinence from a biomedical perspective

Hope that helps

Steve

Hope

by equinesportsmed

January 17, 2022

So, from the context you talk of above, May BW had elevated ALT and ALKP. Began fresh food and XYS mid-June. Her energy and attitude improved over the summer, clients were happy. BW from early Sept showed ALT wnl, but ALKP doubled. Fall began more regular incontinence issues, not associated with UTI. Incontinence resolved with Incurin, but came back when halved the dose. Switched to Proin, mostly resolved. December BW showed ALT highest yet, and ALKP steadily increasing. January ACTH stim-- was 29, not 56 as I said above. Hemopet thyroid panel should determine whether there is any aaT4 or T3, or associated with other organ dycrasias. Will retest liver enzymes at the end of January-- that will give the XCHT a chance to work.

by equinesportsmed

February 3, 2022

Blood work was run on 2/1 to check for changes in liver enzymes (uploaded in main case file). Both ALT and ALKP were slightly lower-- very slightly, IMO: ALT 177--> 155 (10-125), ALKP 694--> 653 (23-212). Nowhere near approaching normal levels, but certainly in the right direction. SDMA slightly out of ref range, unchanged at 15 (0-14). All renal values are normal.

Interestingly, T4 has moved solidly into the normal range from what I would consider low normal: 12/17/21= 1.5-->2/1/22= 1.9. So that might indicate the pituitary axis is normalizing.

To the worse, she broke with another UTI last week, and is now on antibiotics-- again! Placid has an appointment for an abdominal U/S next week on 2/10/22, where hopefully we can rule out a primary adrenal tumor and any worse stuff causing elevated liver enzymes.

So, the question remains whether to stick with the modified XCHT, or shift to SMS, which would be my normal go-to for Cushings. Seems to me that the persistent UTIs indicate damp heat is still a big issue for her. I am also planning to do a MBRT treatment once she is done with the antibiotics for the current UTI, and see how that helps normalize her neuro-edocrine axis. Steve? Nate? Thoughts?

by naturevet

February 3, 2022

Hi there,

I'd continue the XCHT regardless. If the UTIs are very quickly improved with antibiotics, I'd wonder about pairing it with Bu Zhong Yi Qi Tang, particularly if they are relatively asymptomatic and found, for example, only on UA

If the cystitis is very asymptomatic, you could use Si Miao San along with the XCHT

The final option is to use Ge Xia Zhu Yu Tang, which addresses both cystitis as well as Blood stasis in the Liver

I use the pulses's response to acupuncture to help me figure out which one is most likely to work. Damp Heat points would signal SMS efficacy. SP 4 would signal BZYQT efficacy. Blood moving points like ST 37 and BL 17 would suggest GXZYT is the way to go

Steve

by naturevet

February 3, 2022

Might as well try BZYQT if the only sign is incontinence

S

by equinesportsmed

February 3, 2022

No, she has dramatically increased incontinence with the UTIs, but not increased drinking, according to her owner. Remember, she is also on Incurin for hormonally based UI, and had a negative reaction (vomiting) to HRUI formula. Owner is also wondering whether a higher dose of XCHT would help-- I followed your guidelines in the spiral bound textbook-- half amounts because using Natural Path product. I will see her next week when she comes to Ithaca for the abdominal U/S, and check response to pulses then.

Thanks!

by naturevet

February 3, 2022

Or SMS if there are lots of Heat signs

S

by equinesportsmed

February 3, 2022

Because of the above (edited into comments), Nate was worried about using a tonic.

by equinesportsmed

February 3, 2022

If I add on one of those other formulas, use full dosing? (in conjunction with the modified XCHT)

by naturevet

February 3, 2022

Yes, full dosing. I understand the concern about tonics, so if you want to start with SMS, go for it

S

by equinesportsmed

February 3, 2022

Thanks!

by equinesportsmed

February 4, 2022

Answers to previous queries:
1) Never hot, only chilly... except when owner tried putting turmeric on food
2) Does not respond well to antibiotics for these UTIs-- inconclusive cultures, a few times has taken several rounds. So maybe sterile inflammation?

Does this change anything?

by naturevet

February 4, 2022

I guess perhaps use GXZYT with the XCHT. It might be the best overall fit

Dosing as previously discussed

S

by equinesportsmed

February 4, 2022

Thanks. Should I be concerned about the seemingly slow response of liver enzymes to XCHT? We will know more whether there is a primary liver lesion next week after her U/S.

by equinesportsmed

February 11, 2022

Recheck with acupuncture yesterday. Owners report she is much brighter with better energy and movement since starting on modified XCHT in December. Placid had abdominal ultrasound exam yesterday and thankfully, nothing unexpected. Uploaded report into file: slight adrenal enlargement consistent with early pituitary dependent Cushings, unremarkable bladder, slight increase in liver echogenicity and slightly rounded edges. Ultrasound asks if some kind of liver storage disease?

Still having fairly significant urinary leakage. Local vet put on amoxy at beginning of her incontinence issues, but nearly three weeks later, she is worse (immediately worsened with AB( and still has a lot of blood and some bacteria in urine (see upload). If not for the blood, wondering if incontinence could be weak muscle from Cushings. Owner swears dog does not drink a lot. Owner herself had heavy metal intoxication, possibly from municipal drinking water. Could the dog also have this? How could we test for that or a storage disease without going as invasively as a biopsy?

I initiated a discussion with their local vet about the UTIs, asking for a culture. See more on full case file. Sent them home with Ge Xia Zhu You Tang. Total fail on feeling any pulse in dog whatsoever! Just a vague thrum in leg. Tried a couple of the points you suggested, and no improvement to become palpable. She kind of hates AP, but I treated BL 13, 18, 20, GV 4, 17, KI3 and SP 9.

by naturevet

February 12, 2022

If there is slight liver enlargement with cystitis, that supports GXZYT, so hopefully you will see some benefits in the leaking urine. Consider BZYQT as a back up plan, although it's tonifying nature makes it less appropriate

I'm not sure about heavy metal testing in dogs. Have to Google that one, or check on VIN. As for Copper storage, the only sure way to know is through a biopsy. If you can get a trend of improvement going, storage disease is unlikely. In the cases I've treated, the liver enzymes vacillate continually within a range, but never trend in a positive direction when on herbs

Steve

Ge Xia Zhu Yu Tang

by equinesportsmed

March 22, 2022

Placid just had her blood work after six weeks on both modified XCHT and GXZYT. Clinically she is doing well, but ALP keeps rising. Wondering if we need to either use SMS or a pharmaceutical treatment for her Cushings. Her ALT is down, almost at normal levels, but ALP continues to rise, now at 1045 (23-212). From owner: "Last week Tuesday-Friday no leaking. Sat and Sun leaking. Alertness is good. Energy is stable. Weight down to 55 last week. Chasing squirrels. Skin is having more dark spots and a few pimple like spots. Foot is bothering her again. I think the snow acted as a soft buffer for her. Still drinks a lot after eating. Some loose stool days."

by naturevet

March 22, 2022

Sounds like it's time to try Si Miao San!

S

by equinesportsmed

March 22, 2022

Thx. Keep up the GXZYT? Urinary issues not completely resolved, but improved from where she started on it in February. RV thought she got better because she was on amoxicillin for 3 weeks. Owners perception was that she got worse on AB. Started GXZYT a week into the AB.

by equinesportsmed

April 14, 2022

Latest word on Placid is that she stopped leaking for a week after starting SMS, then began again, possibly after an incident where she was physically restrained from offing a cat by grabbing her hind end. She is still taking incurrin, GXZYT, SMS. Owner says, re leaking: "Leaking is only noticed when she is laying down but no clear pattern to the timing. Sometimes it is close to waking up or right before I get home but other times it is at random. She might be awake or sleeping." She is due for a blood work check at the end of next week, to see if her ALP levels are coming down on SMS. Thoughts?

by naturevet

April 17, 2022

I guess let's see what the ALP is before changing anything. If it's better, then we are looking at modifying SMS or adding in another formula. If it's even worse, then a whole re-think is required, ideally including an exam so you can see which specific acupuncture points the dog's pulse normalizes on now.

S

by equinesportsmed

April 17, 2022

Hey Steve— happy Easter and great timing. Placid just arrived in my office. Her pulse is barely palpable, only in the softest surface, slippery, I guess— but I’ve never been very good at nailing that one. I got no change with BL 20, BL 18, BL 23 or Bai Hui. BL20 felt very deficient— I tried both sedating and tonifying. Possibly 10-15% more palpable after tonifying. Owner reports she is constantly heat seeking, has always done this, camps out in front of pellet stove. Any other thoughts of what to tear? I will treat her now for incontinence. Also, maybe another toe is collapsing.

by equinesportsmed

April 17, 2022

Hey Steve— happy Easter and great timing. Placid just arrived in my office. Her pulse is barely palpable, only in the softest surface, slippery, I guess— but I’ve never been very good at nailing that one. I got no change with BL 20, BL 18, BL 23 or Bai Hui. BL20 felt very deficient— I tried both sedating and tonifying. Possibly 10-15% more palpable after tonifying. Owner reports she is constantly heat seeking, has always done this, camps out in front of pellet stove. Any other thoughts of what to tear? I will treat her now for incontinence. Also, maybe another toe is collapsing.

by equinesportsmed

April 21, 2022

Just got off your renal webinar, Steve, and had some ding ding ding recognition on this dog-- pulses so feeble I can barely feel them, always heat seeking, drinks a ton of water, especially after meals. So is she constitutionally Yang deficient, in addition to the pituitary dependent Cushings? Bai Hui was among the points I tried to improve her pulse-- no real change. We are waiting on blood work tomorrow to see if her ALP is coming down. How would a Yang deficiency diagnosis inform her treatment plan?

by naturevet

April 23, 2022

Hi Karen

I wouldn't normally expect Yang deficiency to create high ALP or to lead to cystitis. I guess for both, the only thing I could think of would be that the dog has 'Cold Coagulation', leading to Blood stasis in both locations. For the cystitis, you'd use Shao Fu Zhu Yu Tang. I guess you'd have to modify it to address high ALP. In the meantime, find out if the ALP is truly high.

Dang Gui Shao Yao San is another formula that addresses recurrent cystitis, chills, Dampness in the face of tonics, and high liver enzymes (from Liver Blood deficiency). I wouldn't expect ALP in such a case to be through the roof, but you're running out of angles to explore, so I guess it would need to be entertained as an option

Steve

by equinesportsmed

April 23, 2022

Well, as a chiropractor told me many years ago… you are allowed to have more than one thing wrong with you! (ie pituitary tumor and constitutional imbalance) Waiting to see how the SMS affected the ALP. The dog’s general health really turned around on Xiao Yao San last summer— she’s recovered her energy and attitude and lost 15#. Of course getting her off kibble helped a ton. If no improvement maybe try Dang Gui Shao Yao San.

Thanks, and thanks for agreeing to talk to Stacey!

by equinesportsmed

April 27, 2022

Had dog in office last week, pulse very feeble, but could not get it to improve with any stimulation of points-- see above for which ones I tried. One toe on hind leg has collapsed like the two on front leg. Owner is very concerned about this ligament degeneration getting worse and wants to start Trilostane. Otherwise Placid is doing very well clinically-- lots of energy, good appetite, is now down to 53# from a high of 68 last spring. She still has the "look" of a Cushings dog, with the abdomen larger than you would expect. Still craving heat.

Today, bloodwork came back after 4 weeks on SMS and ALP is up further, and now ALT up too (last time, it was close to the reference range. Chem panel is in case notes.

Alkaline Phosphatase history

12/21= 694 (began modified XCHT the next week)
2/22= 655 (added GXZYT for recurrent UTI)
3/22= 1045 (swapped SMS for XCHT, continued GXZYT)
4/22= 1509

ALT, same dates: 177, 155, 133, 140. Maybe the 140 is not statistically different than 133?
Any thoughts on adaptation of herbs?

I was going to start her on 50 mg Vetoryl SID, which is the very bottom of the recommended range. Should I go lower than that, or wait to see if any response?

by equinesportsmed

September 22, 2022

Promised you I would update this case... I want to include Dr. Heilman's brilliant analysis too. Last entry above, symptoms and bloodwork continued to deteriorate on SMS and GXZYT. Started her on Vetoryl and changed herbs to modified (Bai Shao and Gui Zhi) XCHT twice a day and BYHWT in morning, SMS in evening her incontinence got much worse, and also didn't feel well. I had them stop the SMS and BY, and go back to just GXZYT with modified XCHT and her incontinence improved right away.

Dr. Heilman reasoned that the warming season (mid-May) may have taken that strategy in the wrong direction. Her pulse was still so weak as to be almost unpalatable, so was unable to take much direction from trying different channel points. Because of prior success with XYS, he suggested Dang Gui Shao Yao San, which has more damp-draining effects for the Cushings. Because of rising liver enzymes and spring/fall worsening, he added Chai Hu Shu Gan San. They began those herbs late May.

A week after starting the new herbs, client reported that urinary leaking decreased in frequency and quantity. But then Placid got a non-itchy rash all over her body-- some kind of exteriorization? It didn't seem to bother her and self-resolved.

At last report from client (8/27/22), after 3 months on these herbs, the dog looked (48 lb!!) and felt great, BUT still has leaky episodes every couple of weeks that last 12-24 hours. Spoke to Dr. Marsden at AHVMA and he suggested trying Wu Yao Tang, which addresses Lin Syndrome, if I am reading my notes correctly. I will offer this to client.

by equinesportsmed

October 27, 2022

So, I did not connect with this client last month, the dog is doing really well. Her local vet sent her most recent ATCH stim test, so we corresponded about that-- all good, she is maintaining on a low dose of trilostane.

The client reports closely tracking Placid's incontinence episodes--- (wait for it...)-- the dog is having leaking episodes in sync with her owner's menstrual cycle, every 27 days. She has minor leaking for a few to 24 hours on the day before or the day the owner's cycle begins. How crazy is this? Has anyone seen anything like this before?

by naturevet

October 28, 2022

That's bizarre, Karen! Did you ever try the Wu Yao Tang?

In humans, urinary incontinence tied to menstruation would probably be treated with either Wu Yao Tang or Bu Zhong Yi Qi Tang. I see we discussed the latter, but I don't know if it was ever tried.

Steve

by equinesportsmed

October 28, 2022

I had suggested it, but didn't follow through-- I think the client may have felt the problem was manageable. I think we held off on the Bu Zhong because of her strong negative reaction to HRUI formula-- we didn't want to use a tonic. I will see if she is willing to try Wu Yao Tang.

Thanks, as always! Did you enjoy the leaf peeping in Vermont? (I mean, did they let you out at all?)

by naturevet

October 28, 2022

I saw some leaves as I was driving past them anyway

Good luck

S

by equinesportsmed

June 14, 2023

Hi Steve--

Some updates on Miss Placid... overall, good news. She has stabilized on 60 mg trilostane and her ACTH stim numbers were within acceptable range when tested in early April. So that was a full year on the medication. Her weight is now normal (was 65+ when I first saw her two years ago, now stable at 48), energy good. The urinary incontinence slowly resolved, to where she stopped Incurin in November 2022. However, last summer, she had multiple UTIs which necessitated treating with antibiotics. Even her conventional vet commented that she seemed sensitive to heat and damp.

She ran out of the Dang Gui Shao Yao San and Chai Hu She Gan San in early April, and due to travel and miscommunication, did not resupply. So she has been on no herbs since April and seems to be holding fine. She has two remaining issues currently, plus concern about return of summer UTIs.

Toes: during the two years her Cushings was developing, she had two "dropped" toes on one foot-- I forget which. First one, then the other, P3 and P4. Last summer and starting again now that it is warming up, she gets wounds-- irritation? interdigital cysts?-- in-between each active (P5, P2) toe and the dropped ones. She describes it as looking like a blood blister, getting larger and larger, then bursting and draining. The dog never limps until the final stage, and she's better once it drains. Then it starts all over. Only in the summer. In the winter she is totally fine, no issues. The first problem this year became infected badly enough she had to take antibiotics.

Skin: she had symmetrical scabby lesions on her flanks, kind of near the Liver alarm points, a little ventro-caudal. They are neither painful nor itchy, seem flat and leathery. Sometimes one will fall off and a new one forms beneath it. They started in February and have gotten progressively larger since then, now are around 4 cm in diameter. Their local vet saw them in early April and was not worried.

I think I can channel you well enough to know you would want to use a moving formula to send blood to the periphery for these lesions, but given her complicated background, which one? She had some improvements on Ge Xia Zhu You Tang earlier in the treatment, and was also on some modified XCHT (Chai Hu Gui Zhi Tang). I am asking for a chem panel and T4, to see what liver enzymes are up to after a year of stability.

Thanks in advance!

by naturevet

June 17, 2023

Hi Karen,

The worsening in mid-summer and clear improvements on Trilostane suggest the dog has tendencies to Damp Heat and Blood stasis. Based on that, I would try Xian Fang Huo Ming Yin for the lesions on the toes. For the skin issues, you could look at Si Miao San again. Perhaps a low dose? You'd seen one episode of incontinence on it, but you were unclear if there might be another cause, so a low dose might be prudent

Steve

by equinesportsmed

June 18, 2023

Thanks! I presume you mean topically for the XFHMY? Might a low dose SMS address the tendency towards summer UTIs as well?

You know, this site has stopped notifying by email when there are replies to questions. Is that a new feature or a bug?

by naturevet

June 18, 2023

You can give both orally, and the XFHMY topically as well in some sort of ointment. The SMS may help with the UTIs

The site is still issuing email notifications, so there may be an issue with your email in particular. Like a security setting on your end. See if you can find the emails in your spam or junk folder, and then mark them as trusted using whatever system you use

by equinesportsmed

June 20, 2023

Weird. I checked and the last notification I got was January 2023. Nothing in spam. Maybe I can try to reset in my settings.

Thanks!

by equinesportsmed

June 23, 2023

Hi Steve--

Blood work just came back on Placid... in the 16 months since starting trilostane treatment, her ALT has come back down to the normal range (just) but her AlkPhos is still disturbingly high:
2/22 4/22 6/23
653 1509 1650

Is this something to be concerned about? Also, T4 came back at 1.4 (1-4 RR)-- wondering if borderline hypothyroidism may be underlying her slow-to-heal skin lesions. Think we should do a full panel? Any change in recommendation, based upon the numbers above? I know SMS is hepatoprotective-- think that might bring down the ALP?

Thanks!

by naturevet

June 28, 2023

It might. If the dog is not on any other herbs at present, then given the lab findings and the diagnosis, Si Miao San is the next thing to try

by equinesportsmed

July 3, 2023

OK, they started her back on SMS plus XFHMY last week, and I got some of Erin's Precious 5 ointment to mix with it. Hopefully we will see some improvements. Thanks!

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