[puglover]

Hi everyone -
I have a 10 year old pug female (Cricket). I took her to the vet last week, as she had been licking her genital area, and drinking and peeing excessively.
Thay diagnosed a UTI, but the vet stated that she was shedding an abnormal amount of epithelial cells, over and above what is normal for a UTI. She is on antibiotics( 7 days so far), but she is still up to 9 cups a day of water. ( I measured the amount of water her bowl holds) When I googled excessive epithelial cell shedding, dogs, most answers went to transitional cell carcinoma of the bladder.
I took her back to the vets today for boarding for the holiday weekend, while we will be away, and told them about the excessive water intake. They stated that they usually do not do a retest on urine until 3-5 days post antibiotic treatment.

Should I have insisted for bloodwork, or a diabetes test, or would diabetes have shown up on the initial urinalysis?

Any advice appreciated -
Thanks- Debbie

[Corky/Max]

Originally Posted by puglover

Hi everyone -
I have a 10 year old pug female (Cricket). I took her to the vet last week, as she had been licking her genital area, and drinking and peeing excessively.
Thay diagnosed a UTI, but the vet stated that she was shedding an abnormal amount of epithelial cells, over and above what is normal for a UTI. She is on antibiotics( 7 days so far), but she is still up to 9 cups a day of water. ( I measured the amount of water her bowl holds) When I googled excessive epithelial cell shedding, dogs, most answers went to transitional cell carcinoma of the bladder.
I took her back to the vets today for boarding for the holiday weekend, while we will be away, and told them about the excessive water intake. They stated that they usually do not do a retest on urine until 3-5 days post antibiotic treatment.

Should I have insisted for bloodwork, or a diabetes test, or would diabetes have shown up on the initial urinalysis?

Any advice appreciated -
Thanks- Debbie

No expert here for sure but in answer to the diabetes check (and I myself have diabetes), I doubt they checked for diabetes as a bloodwork would be the main/best way to go for that diagnosis. The excess water drinking (and peeing) happens with a urinary tract infection--not just with diabetes. Is your Cricket overweight--I know Pugs like to eat and can gain weight easily!?

Sounds like the biggest concern is 'excessive' epithelial cell shedding---And I sure can't help you with that. I imagine when you go back for the final testing (3-5 days after the antibiotics are done) you will find out more. I hope there is no cancer involved and it is just a UTI. If they do a blood test-It should show the blood sugar 'numbers' in the test report.--But to be safe-if they take blood --Ask if it will tell the diabetes check!

One of the main reasons I am replying to your post---Wanted to tell you that your Cricket should be taking probiotics (pill form prob best as human yogurt may not do the trick--need dif kind for dogs!). This is to replenish the good bacteria that the antibiotics are flushing from your dog's bowels--the dog needs this good bacteria to be healthy! And I would think taking probiotics just might also help with the UTI anyhow! But don't quote me on that--I am not a vet( Although your vet may never even know that much about probiotics or think to even mention them to you as a good thing when taking antibiotics!).

Hope things work out okay! Keep us posted as we worry if we never hear back--Always afraid it is bad news if never hear from you! We all love dogs here and hope for the best news!

You may of seen this site but just in case: http://marvistavet.com/html/body_uri...infection.html

[Yogi]

Originally Posted by Corky/Max

No expert here for sure but in answer to the diabetes check (and I myself have diabetes), I doubt they checked for diabetes as a bloodwork would be the main/best way to go for that diagnosis. The excess water drinking (and peeing) happens with a urinary tract infection--not just with diabetes. Is your Cricket overweight--I know Pugs like to eat and can gain weight easily!?

Sounds like the biggest concern is 'excessive' epithelial cell shedding---And I sure can't help you with that. I imagine when you go back for the final testing (3-5 days after the antibiotics are done) you will find out more. I hope there is no cancer involved and it is just a UTI. If they do a blood test-It should show the blood sugar 'numbers' in the test report.--But to be safe-if they take blood --Ask if it will tell the diabetes check!

One of the main reasons I am replying to your post---Wanted to tell you that your Cricket should be taking probiotics (pill form prob best as human yogurt may not do the trick--need dif kind for dogs!). This is to replenish the good bacteria that the antibiotics are flushing from your dog's bowels--the dog needs this good bacteria to be healthy! And I would think taking probiotics just might also help with the UTI anyhow! But don't quote me on that--I am not a vet( Although your vet may never even know that much about probiotics or think to even mention them to you as a good thing when taking antibiotics!).

Hope things work out okay! Keep us posted as we worry if we never hear back--Always afraid it is bad news if never hear from you! We all love dogs here and hope for the best news!

You may of seen this site but just in case: Urinary Tract Infection

agree, having had a diabetic dog the blood work up would have had to been taken. The symptoms you describe are also common for a dog with diabetes.

[puglover]

Originally Posted by Corky/Max

No expert here for sure but in answer to the diabetes check (and I myself have diabetes), I doubt they checked for diabetes as a bloodwork would be the main/best way to go for that diagnosis. The excess water drinking (and peeing) happens with a urinary tract infection--not just with diabetes. Is your Cricket overweight--I know Pugs like to eat and can gain weight easily!?

Sounds like the biggest concern is 'excessive' epithelial cell shedding---And I sure can't help you with that. I imagine when you go back for the final testing (3-5 days after the antibiotics are done) you will find out more. I hope there is no cancer involved and it is just a UTI. If they do a blood test-It should show the blood sugar 'numbers' in the test report.--But to be safe-if they take blood --Ask if it will tell the diabetes check!

One of the main reasons I am replying to your post---Wanted to tell you that your Cricket should be taking probiotics (pill form prob best as human yogurt may not do the trick--need dif kind for dogs!). This is to replenish the good bacteria that the antibiotics are flushing from your dog's bowels--the dog needs this good bacteria to be healthy! And I would think taking probiotics just might also help with the UTI anyhow! But don't quote me on that--I am not a vet( Although your vet may never even know that much about probiotics or think to even mention them to you as a good thing when taking antibiotics!).

Hope things work out okay! Keep us posted as we worry if we never hear back--Always afraid it is bad news if never hear from you! We all love dogs here and hope for the best news!

You may of seen this site but just in case: Urinary Tract Infection

Thanks for the info - I'll ask the vet, and keep you informed. Just knowing that there is support out there is reassuring! :-D

[puglover]

Well, we have a diagnosis of Cushings disease - we will do another urinalysis to confirm, and put her on a 30 day regimen of denamarin ( not sure of the spelling)- the vet said that the next step was a cat scan to see what the tumor was in the pituitary gland. I know at her age,(11) surgery is probably not an option...

I will be honest - my husband is out of work,has a herniated disc, which he will be having surgery for next week, and besides taking care of his needs, this getting up to put her out to pee 3x a night is getting old ( just like an infant). I am basically sleepwalking during the day at this point....My feeling is to do the urinalysis, put her on the meds for 30 days, and see how she does.....
at that point, make a decision. I am doing the bedt that I can....
opinions?

[Mr. Vega]

In all likelyhood, this is a tumor if Cushing's was the CORRECT diagnosis. Most (90% if I remember correctly) cases of hyperadrenocorticism (Cushing's) are the result of a pituitary microtumor.

The drug you received is what's known as a Nutraceutical. It's purpose in this instance is probably to help support your little girl's liver. And btw, nobody really does surgery to get to the pituitary in dogs - just too hard to get to.

Personally, I would be concerned whether it was a correct diagnosis if only a urinalysis was done. I've never heard of anyone confirming this disease based on a simple urinalysis and well, CAT scans aren't cheap. Here is an article from this year's Western Veterinary Conference... I hope you read it well and discuss some of this with your vet.

It's super long so I'm going to paste in multiple posts and leave a few sections out.

[Mr. Vega]

Diagnosis & Treatment of Canine Cushing's I: Diagnosis of Hyperadrenocorticism (Cushing's Syndrome) in Dogs--Which Tests are Best? (V101)
Western Veterinary Conference 2009
Edward C. Feldman, DVM, DACVIM
Professor, School of Veterinary Medicine, University of California, Davis, Davis, CA, USA

18668981

History

Dogs chronically exposed to excess cortisol usually develop a classic combination of clinical signs, some of which may be dramatic. These common signs include polydipsia, polyuria, polyphagia, abdominal enlargement, alopecia, pyoderma, panting, muscle weakness, thin skin, and lethargy. It must be remembered, however, that not all dogs with hyperadrenocorticism develop the same signs. From this long list of potential signs (plus others), most dogs exhibit several (but not all) of these problems. Hyperadrenocorticism is a clinical disorder, and animals afflicted with this disease must have at least some clinical signs or the diagnosis must be questioned. Clinical signs result from the combined gluconeogenic, lipolytic, protein catabolic, anti-inflammatory, and immunosuppressive effects of glucocorticoids.

Typically, the course of the disease is insidious and slowly progressive. Owners usually report observing some alterations typical of hyperadrenocorticism in their pet for 6 months to as long as 6 years before they seek veterinary attention for their animal, since these changes are quite gradual in onset and are often believed to be a result of simple "aging." Commonly, only after signs become intolerable to the client or after abnormalities are pointed out by people who see a pet infrequently (therefore objectively noting obvious changes that have developed so slowly the owners do not observe them) that professional opinion is sought. The most common reasons that owners give for finally seeking veterinary help are usually polydipsia/polyuria, polyphagia, lethargy, panting, and/or hair coat changes. It should be pointed out that dogs with Cushing's syndrome do not have vomiting, diarrhea, anorexia, weight loss, or other signs that would cause many owners to quickly seek veterinary care.

Physical Examination

The physical examination on a typical "Cushing's" dog reveals an animal that is stable, hydrated, has good mucous membrane color and is not in distress. Veterinarians will usually observe, during the physical examination, many of the signs seen by owners. Among these abnormalities are abdominal enlargement (truncal obesity), panting, bilaterally symmetrical alopecia, skin infections, and comedones. Hyperpigmentation, testicular atrophy, and hepatomegaly are commonly identified on physical examination. Ectopic calcification (calcinosis cutis), clitoral hypertrophy, and easy bruisability are much less common. There is, however, remarkable variation in the number and severity of abnormalities noted. These dogs may have a single dominant sign or 10 signs.

Sensitivity and Specificity (Which Test Is Best?)

Sensitivity of a particular test refers to the number of patients with a condition whose test results are abnormal. Specificity of a particular test refers to the number of patients that do not have a condition but their test results are positive for that condition. Medicine would be much easier if our tests were 100% sensitive and 100% specific. Since this is never the situation, the most commonly asked question regarding naturally occurring hyperadrenocorticism is: "which test is best?" There is no doubt that the most specific and sensitive tests for this condition are history and physical examination. Therefore, all test interpretations must be done in the context of these two parameters.

"Routine" Data Base

Any dog suspected of having hyperadrenocorticism from the history and physical examination should be thoroughly evaluated before specific endocrine testing is undertaken. These initial tests should include clinicopathologic studies (complete blood count [CBC]; urinalysis with culture; and a serum chemistry profile). In addition to blood and urine testing, abdominal ultrasonography (preferred over radiography) should be completed. Finding a large percentage of abnormalities on initial screening tests that are consistent with hyperadrenocorticism further allows the veterinarian to establish a diagnosis that was initially based on history and physical examination. Typical abnormalities include dramatic increases in serum alkaline phosphatase activity, mild-to-moderate increases in ALT and serum cholesterol, low-normal or low BUN, urine specific gravity <1.020 on a sample caught by the owner at home, and bacteriuria. The more expensive and sophisticated studies needed to "confirm" a diagnosis and localize the cause of Cushing's syndrome can be recommended to the client if the dog is still believed to have this condition. Initial data base results not only ensure that the veterinarian is pursing the correct diagnosis but also might alert the clinician to any concomitant medical problems. These problems may be common for hyperadrenocorticism (urinary tract infection) or unexpected (renal failure), but in any case may require specific therapy.

[Mr. Vega]

"Screening" Tests

Background

After establishing a presumptive diagnosis of canine hyperadrenocorticism from a review of owner observations, physical examination, and laboratory data base, one usually proceeds to attempt "confirmation" of the diagnosis. When necessary, and if possible, an attempt can also be made to determine whether the pet has pituitary dependent hyperadrenocorticism (PDH) or an adrenocortical tumor (ACT). Choosing a screening test for Cushing's syndrome is important because that test result may determine whether or not a dog is treated. Routinely used screening tests include ACTH stimulation, low dose dexamethasone, and the urine cortisol:creatinine ratio. The decision to treat a dog for Cushing's syndrome should never be based solely on laboratory information. Cushing's syndrome is a clinical disorder with clinical signs. If a dog has no clinical signs of Cushing's syndrome, treatment is not recommended. This concept gains importance when it is understood that no screening test is correct all of the time, i.e., as previously stated, sensitivity and specificity is never 100%. Some dogs with non-adrenal disease and many with polyuria and polydipsia due to a condition other than Cushing's syndrome can have false positive screening test results for hyperadrenocorticism. Because false positive test results have been observed with any commonly used screening test, the definitive diagnosis of Cushing's syndrome should never be solely on screening test results, especially in dogs without classical clinical signs or in those with known non-adrenal disease. In our experience, the most sensitive, specific, and reliable screening tests for hyperadrenocorticism in dogs are history and physical examination. The most sensitive, specific, and reliable hospital study is the low dose dexamethasone test.

Low Dose Dexamethasone Test (LDDS)

The protocol utilized for this test is obtaining plasma samples for cortisol before and 4 and 8 hours after I.V. administration of 0.01 mg/kg dexamethasone. The 8-hour plasma cortisol is used as a screening test for hyperadrenocorticism, with concentrations >1.4 µg/d1 being consistent with (not confirming) the diagnosis of Cushing's syndrome. This test is relatively sensitive and specific, but not perfect. Approximately 90% of dogs with Cushing's syndrome have an 8 hour post-dexamethasone plasma cortisol concentration >1.4 µg/dl and another 6 to 8% have values of 0.9-1.3 µg/dl. The results of a low dose test can also aid in discriminating PDH from ACT, using 3 criteria: 1) an 8 hour plasma cortisol >1.4 µg/dl but <50% of the basal value; 2) a 4 hour plasma cortisol concentration <1.0 μg/dl; and 3) a 4 hour plasma cortisol concentration <50% of the basal value. If a dog has Cushing's and it meets any of these 3 criteria, it most likely has PDH. Approximately 65% of dogs with naturally occurring PDH demonstrate suppression, as defined by these 3 criteria. A dog with Cushing's that fails to meet any of these 3 criteria could have either PDH or ACT. However, if it has 2 relatively equal sized adrenals on abdominal ultrasonography, it most likely has PDH.

ACTH Stimulation (No Longer Recommended)

The ACTH stimulation test has been popular for decades in veterinary medicine. It is simple to complete and takes little time. The other significant feature regarding results of an ACTH stimulation test is that this is the only study which reliably demonstrates the effect of o,p'-DDD on the adrenal cortex. Thus, some veterinarians want results of an ACTH stimulation test, prior to initiating o,p'-DDD therapy, because the results are used as "baseline" information to objectively monitor effects of o,p'-DDD. Regardless of the protocol chosen, it must be appreciated that 20-30% of dogs with Cushing's syndrome have test results within the reference range (in our laboratory: post-ACTH plasma cortisol concentrations of 6 to 17 µg/dl). An additional 20-30% of dogs with Cushing's have test results described as "borderline" (plasma cortisol concentrations >17 but <22 µg/dl). Therefore, the test is not considered sensitive but is relatively specific, i.e., those dogs with plasma cortisol concentrations >22 µg/dl frequently have Cushing's. However, specificity of an exaggerated response to ACTH is also not perfect. Therefore, test results should never be interpreted without knowing results of history, physical examination, and routine data base testing. There are no features of ACTH stimulation test result that allow discrimination between PDH and ACT. As ACTH has become more and more expensive, this test is losing popularity. ACTH gel is effective and synthetic ACTH can be given at 0.05 mg/kg (IV or IM) instead of using 0.25 mg (one vial) per dog. Excess Cortrosyn can be frozen while maintaining potency for about 6 months. In our opinion, the lack of sensitivity of the ACTH stimulation test makes it a test that the profession should abandon. The situations in which ACTH stimulation testing would be indicated include monitoring therapy for naturally occurring hyperadrenocorticism, to aid in the diagnosis of iatrogenic Cushing's syndrome, and as the "gold standard for the diagnosis of naturally occurring hypoadrenocorticism.

Urine Cortisol: Creatinine Ratio (UC:CR)

The urine UC:CR ratio is easily performed (simply have the owner collect and deliver urine to the hospital and submit it to the laboratory) and, therefore, it is usually less expensive than other screening tests. Most dogs (~97%) with naturally occurring Cushing's syndrome have an abnormal result (the test is sensitive) but a significant percentage of dogs with polyuria / polydipsia due to other conditions and those with non-endocrine illness also have abnormal results (the test is not specific). It has be suggested that the UC:CR be routinely performed only on urine collected by an owner at home, rather than having it collected in-hospital. Since this protocol eliminates travel or hospital stress from altering test results, it seems reasonable to follow this concept. We do not utilize this test with the same degree of confidence with which we use the low dose dexamethasone screening test. However, a normal result is quite uncommon in a dog with Cushing's syndrome while an abnormal result could be used to prompt further testing. Therefore, this test can be used as a prompt to recommend abdominal ultrasonography and a low dose dexamethasone test to an owner.

17-Hydroxyprogesterone (17OHP) Testing

The use of 17OHP has been recommended as a screening test for dogs with "atypical Cushing's syndrome". The definition of "atypical" is a dog with clinical signs and routine laboratory testing consistent with hyperadrenocorticism but with normal low dose dexamethasone screening test results, normal ACTH stimulation test results, and normal urine cortisol : creatinine ratio test results. Human beings, dogs and cats with adrenocortical tumors have been reported in which the primary hormone secreted by such tumors has been 17OHP. Adrenocortical tumors have long been known to synthesize and secrete a myriad of steroids and it is not surprising to learn that some primarily produce steroids other than cortisol. Such dogs and cats, in our experience, do not have "normal" screening tests results, but their results may be relatively low in cortisol. It is extremely rare for a dog or cat with PDH to produce only 17OHP. Further, the recommendation regarding use of this hormone involves assaying 17OHP after ACTH stimulation. Our recommendation would be repeating a low dose dexamethasone test if results are <0.9 µg/dl at the 8-hour sample, since the most common explanation for such a result would be administration of 0.1 instead of 0.01 mg/kg of dexamethasone. If one is convinced that a dog has naturally occurring hyperadrenocorticism, and if that dog persistently has a non-diagnostic low dose dexamethasone test result, use of ACTH stimulation and assessment of 17OHP can be considered. This is an extremely unusual situation, however.

[Mr. Vega]

Discrimination Tests

Low Dose Dexamethasone Test

Please see previous discussion.

Endogenous ACTH

This test is relatively difficult to perform because the plasma must be handled with care, the test is not routinely available, and it is expensive. Having used this test for more than 30 years, we have found it to be highly specific and sensitive (normals: 10 to 100 pg/ml; PDH: 45 to 450 pg/ml; ACT: results are undetectable). There is some overlap in results, however. Most specifically, some dogs with PDH and some with ACT have results that range from 10-45 pg/ml. Our experience with the LDDS and abdominal ultrasonography has limited the need for assaying the endogenous ACTH concentration. This test is most commonly utilized when other discrimination test results provide conflicting information.

High Dose Dexamethasone Suppression (HDDS)

The HDDS test is relatively easy to perform (plasma obtained before and 4 or 8 hours after I.V. administration of 0.1 mg/kg dexamethasone), readily available and inexpensive. If a dog has Cushing's syndrome and the plasma cortisol, 8 hours post-dex, is <50% of the basal value, the dog has PDH. However, our experience with the LDDS and abdominal ultrasonography has limited the need and use of HDDS. Approximately 75% of dogs with PDH demonstrate suppression with the HDDS. Realizing that approximately 65% of PDH dogs demonstrate "suppression" consistent with PDH on the LDDS limits the value of this test by only identifying an additional 10% of afflicted dogs.

Abdominal Ultrasonography

In dogs suspected as having hyperadrenocorticism, abdominal ultrasonography serves three major functions. First, it is part of the "routine data base" utilized to evaluate the abdomen for any unexpected abnormalities (urinary calculi, masses, etc.). Second, the study is used to evaluate the size and shape of the adrenals. If the adrenal glands appear to be bilaterally normal sized or large in a dog or cat otherwise diagnosed as having Cushing's, this is considered strong evidence of adrenal hyperplasia due to pituitary dependent disease (PDH). If one, large, irregular and/or invasive adrenal is visualized and the opposite is small or not seen, adrenal tumor must be suspected. Some dogs with ACT have one adrenal that appears to be a "mass" and the other may be normal or enlarged. One must consider the possibility of PDH with irregular adrenals or PDH in a dog that also has a pheochromocytoma. Third, if an adrenal tumor is identified, ultrasound is an excellent screening test to identify hepatic or other organ metastasis, compression of adjacent tissues by a tumor, or tumor invasion into the vena cava or other vascular structures. It must be emphasized that interpretation of abdominal ultrasonography is completely operator dependent. Radiologists at our school routinely visualize both adrenals in healthy dogs and cats. The only limitations to successfully visualizing the adrenals are: 1) the pet's willingness to remain still and 2) air in the intestinal tract. Neither of these problems is common and both adrenals are usually visualized. In dogs and cats with PDH, both adrenals are also routinely visualized. The adrenals in PDH are usually described as relatively equal in size. Approximately 50% of dogs with PDH have adrenals that appear to be "normal" in size and about 50% have adrenal glands that appear to be enlarged. Adrenal size is best determined using the width of the left adrenal (7.5 mm represents the upper limit of normal).

Speaker Information
(click the speaker's name to view other papers and abstracts submitted by this speaker)

Edward C. Feldman, DVM, DACVIM
University of California, Davis
Berkeley, CA, United States

[Mr. Vega]

Sorry, after reading this again, I realize most of this is way too in depth. What I wanted you to take from this is that the screening tests mentioned are usually considered standard procedure before making a definitive diagnosis. Often, the screening tests are backed up by doing discrimination tests. You could print some of it out and discuss it with your local veterinarian?