Question Details
Dysuria In A Dog
by sophiek - May 10, 2023    View Case Report
Hi Steve,

I have a tricky case that I would love some guidance on.
Mia is an 11 year old FN French Bulldog. She has had intermittent episodes of inappropriate urination since May 2022, and dysuria since dec 2022. At this time further diagnostics were declined by the owner until recently.

2 weeks ago Mia was seen by the internal medicine specialist who found thickening of the bladder and urethral walls and also the ureters. Urine sample shows pyuria (moderate growth E.Coli) and haematuria. She has been on a 10 day course of Enrofloxacin with no improvement in clinical signs. Bloods show significant azotaemia and hyperphosphataemia which has worsened in the last 2 weeks. The thought is that the thickening of the ureters may be preventing urine from draining from kidneys from bladder so causing the kidney enzyme elevations. Ddx of the thickening is neoplasia (assuming TCC though no biopsy or FNA has been done) or proliferative urethritis (secondary immune mediated inflammation).

I saw her for the first time 10 days ago. She is in lean body condition and has lost more weight since then. She strains to urinate and passes small amounts for about 15 minutes. She also urinates inside overnight and leaks urine overnight on her bedding. Appetite is picky but steady, normal thirst, normal stools. She was quiet in herself when on antibiotics. Generally demeanour is quiet and slow, always seeks warmth. No obvious cognitive decline. She has low energy and is prone to corneal ulcers, and had cherry eye surgery when a pup. She also has hemivertebrae in lumbar spine and medial luxation of both patellas, and thickening of left stifle.

Tongue was pale lavender with slightly red tip, no coating
Pulse - deep, silk thread like thin, slightly wiry and surprisingly forceful, quite fast, right is weaker than left
I think the pulse was better with SP 6 and 9 (less wiry) and became more superficial with GB 25 and GB 29
I think there were active points BL 25, GB 27 and GB 28

My TCVM diagnosis is Kidney Qi and Yang Deficiency, Wei syndrome, global Qi & Yang Deficiency and Stagnation,
Damp Heat in Bladder (haematuria, pyuria)
Blood Stasis in Lower Burner (thickening of bladder, urethra and ureter - although not sure if the thickening could actually be Damp/Phlegm and not Blood Stasis - how do you differentiate?)
Query if this is Shao Yang Syndrome with pulse changes and 'cold below'
I guess there's probably underlying Blood Deficiency too with tendency to corneal ulceration.

The initial management was Enrofloxacin to see if improvements with treating the E.Coli infection - no change in dysuria / incontinence and renal values have worsened.

I started her on SFZYT 75% with Si Miao San 25% (with the thought of berberine content possibly being helpful for antimicrobial and anti-inflammatory effects, plus the haematuria) 1/4 teaspoon BID (she is 8kg) - she's now been on this for 2 weeks with no improvement.

She has been on kibble all her life, but a few weeks ago transitioned to a balanced home made diet with veg content 15-20% and a broad spectrum probiotic.

I am wondering if
- I should add GXZYT in addition to SFZYT (and stop SMS) - not quite sure what kind of cases need the addition of GXZYT?
- I can increase dose of SFZYT to see if better effect?
- and / or I should add XCHT for anti-cancer effect, vs azotaemia (though no UPC is done, it seems like the kidneys need a decongestant effect) and possibility of an immune mediated inflammation. Or would CHJLGMLT be more appropriate? Is it worthwhile adding Yu Jin to the XCHT?
- would LJZT be helpful for appetite / weight loss / cachexia?

Thanks so much for your help!
by naturevet
May 18, 2023
Hi Sophie

That is a bizarre and challenging case! I like your ideas. I would suggest combining the Shao Fu Zhu Yu Tang with Xiao Chai Hu Tang and Bu Zhong Yi Qi Tang. Given the dog's affect, hematuria, difficulty gaining weight, poor appetite, incontinence and amazing degree of ascendance of the infection up the urinary tract without a lot of symptoms to show for it, I'm thinking Qi deficiency is the primary problem. Wei Qi deficiency in particular. The pulse tells us there is a significant Liver Qi stagnation component as well. Putting those two together, we end up with the notion of Spleen Qi sinking, for which I prescribe BZYQT. It excels at dealing with recurrent or refractory UTIs.

I would continue the Shao Fu Zhu Yu Tang, since it appears stagnant sunken Qi has led to Blood stasis. Shao Yang disharmony can entrap the Qi in the lower burner, so I would rectify that with XCHT.

Hopefully this helps the dog out. Please let us know how it goes!!
by sophiek
May 18, 2023
Thanks Steve,

The dog has since had another ultrasound which confirms thickening of the bladder neck, urethra and ureters. Due to the locations affected, the specialist thinks this is now more likely to be neoplastic rather than immune mediated urethritis secondary to chronic infection.

I saw her again last week - fairly similar findings, pulse deep, thin and slightly wiry but this time it also felt a little choppy/erratic. tongue very pale lavender and small, pale mucous membranes.

I continued the SFZYT and added Hua Shi
I added XCHT with added Qin Jiao and E Zhu

Owner reports she is brighter and more energetic in herself, but no change yet to the dysuria (she strains over about 15 minutes passing small amounts of urine at a time) and is still incontinent overnight on her bedding. Appetite varies from day to day, some days she needs to be handled, some days appetite is reasonable.

Would you still add in the BZYQT given it is now more likely neoplastic than infectious?
Would there be anything else you would recommend given now the ureters are also involved - GXZYT?

Thanks again for your time and advice!
by naturevet
May 19, 2023
Hi Sophie

BZYQT can aid dysuria. It's the next thing I would add. I don't really trust the cancer diagnosis, myself. Hopefully she feels better soon!

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