Pearl Pee

Dr. Herndon,
I have a question for you regarding urinary issues. I have a 4 year old pug, Pearl, with chronic urinary issues.
History-wise, our first issue was about 8 months ago when she suddenly could not urinate one morning. We rushed her to the vet, where they surgically removed a blockage caused by struvite stones. She had shown no signs of discomfort and we had no idea she had any stones up until that day. He placed us on Hill's W/D because she needed to lose a few pounds and thought it would also help regulate her urinary issues.

A few months later, we began to see blood in her urine, and dripping out after she urinated. We went back to the vet and started Primor which, we thought, cleared up the infection. We continued to feed her the W/D and I started her on an all-natural cranberry supplement.

Last weekend, the bloody urine started again. We are back at the vet today and doing another round of antibiotics. The pH of her urine today was 8. This surprised me, as I hoped that the cranberry supplement would help acidify it. Although, if my understanding of this all is correct, the infection can cause the urine to become more alkaline- regardless of what I am supplementing her with. It seems like this pattern continues, and I am not sure where to go from here.

She always has a clean water source available to her, we get her outside very often to use the bathroom, and I am just feeling exhausted with this process. I want her to feel better, and it seems like this current diet is just not helping.

I have been uncomfortable with the Hill's diet this entire time, because the ingredients just do not seem wholesome to me. I am not necessarily insistent that she be on a grain-free diet or anything, but surely there is a more nutritious food that could work similarly. I am willing to make her food at home, if that would help.

Can you offer me any advice on food/supplementing, and any other general advice for her urinary health? She is otherwise very healthy and we are so eager to rid her of these infections.

Thanks so much for any help you can offer!

-Pearl & family in Oklahoma

Isn't it amazing what they will put up with and never complain?

Everything you have said is pretty much spot on.

Urine is what is produced when the kidneys have filtered the blood and then that filtrate is concentrated, diluted, concentrated again and various electrolytes, etc are put into and taken back out of the urine. Eventually that product is dumped down-stream in the urinary bladder. All of this amazing concentration and dilution is how the kidneys regulate things like sodium, potassium, pH, and overall hydration.

ANYWAY - There are all kinds of compounds in the urine that can precipitate out in the form of crystals. This is like what happens when you make a concentrated sugar-water solution and the sugar makes those cool crystals. Crystals form when a solution is saturated enough. pH of the urine also plays a huge role. In an acid urine, the phosphate and magnesium compounds that make a struvite stone can't form. Other stones can form in any pH urine (like calcium oxalate stones), but prefer acidic urine. It's not an entirely accurate equation but acid makes oxalate, alkaline makes struvite.

Different types of bacteria can have different effects on urine pH. Some are known to produce alkaline urine and are also capable of producing the enzyme urease that causes the struvites to form.

In nearly 99% of CANINE stuvite cases, urinary tract infection is directly to blame. Treat the infection, treat the crystals. There are those fairly rare cases where the pet is able to make struvites without infection. Keyword - RARE. Oxalate stones can "just happen" and are typically much more diet related. Bichon dogs are terribly prone to oxalate stones.

There are different approaches to dietary management of these guys. Since crystals can't form if the urine is dilute, it is important to try and address that first. Increased water intake is important. This may mean canned diet. Therapeutic diets can also be used. Now this is ENTIRELY OPINION, but I don't like Hills. Never have, never will. They have some great diets (of which w/d is one of them), but Hills and I don't get along and I don't like their attitude and approach to certain disease conditions. I'm a Royal Canin man. They aren't perfect, but I sure do like them worlds better. The goal of w/d is NEUTRALITY. It's low(er) calorie, low(er) phosphate, high(er) fiber. It is a great middle-of-the-road diet for someone like Pearl. However, it does nothing to prevent crystals and nothing to dilute the urine. Royal Canin's approach is to dilute the urine first and foremost (which I think is by far the most sane approach). Hill's other diet, c/d, is designed to acidify the urine. Doesn't dilute it. It's also higher in fat. So now I have a fat dog with acidic, soupy, concentrated urine and I haven't really gained any benefit. Can you tell how I feel about c/d?

RE: naturapathic/"wholesome" food choices. I'm a fan. I think that, in general, there is something to be said about taking a more whole-food approach to diet. I like limiting the grain content (although I'm not a grain-free advocate). Cranberry is effective, but it doesn't do much to acidify. Cranberry gets its credit because the tannins in the cranberry prevent the bacteria from adhering to the bladder wall so well. If the bacteria can't adhere, they get peed out and that's not healthy for a bacteria. HOWEVER, there are no manufacturers who are trying to develop therapeutic diets that are ALSO organic, whole-food, naturapathic. When someone does, I'll probably be right there with them. If we have a specific dietary need and a disease condition to treat - we have to resign ourselves to the more traditional diet choices. These diets are fantastic, to be sure. The argument against the "traditional nutrient" approach is more philosophical than factual at this point in our understanding about canine nutrition.

So - Pearl's case is complicated by her weight and her lack of being honest with her symptoms. Her "well-loved" stature means we have to be VERY careful of her weight. Hills c/d and Royal Canin s/o are both higher in fat. W/d is a valid choice for her. Royal Canin Calorie Contral HP is also a valid choice, and would be my first choice. It will be better for weight loss and will still have similar "stuvite preventative" effects as w/d. We must STILL INCREASE HER WATER INTAKE.

We are also going to have to be pro-active with her monitoring. This means we have to continue to get repeat urine samples after the treatment is successful and monitor her for recurrence. We're going to have to go looking for the infection and not wait for it to come to us. This may mean once monthly urinalysis at a minimum.

Why does she have so many urinary tract infections? Well, there's the BIG question since we know the stones are just a secondary player. The way I answer this question (which I get frequently) is to tell you what PREVENTS a bladder infection. Any breakdown in these preventative measures will set up the possibility of infection:

• Urethral length - it's easier for a female to develop infection than a male (in most species - cats are an exception) because the urethra is much longer in the male.
• Normal and complete emptying of the urinary bladder. Simply put - you don't pee often enough, you set yourself up for infection.
• Insufficient water intake. Soupy, concentrated urine ain't helpful.
• Normal immunity along the lining of the urethra. This is a combination of antibodies the body produces (Specifically, IgA), the mucous layer of the urethra and bladder (made up of PSGAGs, glucosamine, and other large starch and protein molecules), and the anatomy of the vulva, vagina, urethra, and urinary bladder. There are all kinds of plumbing issues that can pre-dispose to urinary tract infections. If the vulva is "tucked" up high and urine pools in the vestibule or vagina, then you are pre-disposed to issues. If you're male - having testicles pre-disposes you to problems because of that annoying prostate. Intact male dogs are at higher risk than neutered male dogs (generally speaking).

Who knows which is exactly Pearl's issue. Could be a combination of all of them. Additionally, we have the question of whether the bacteria involved are being effectively killed during a course of treatment. She may have a smoldering UTI and so culture of the urine before and after treatment may be a VERY smart thing to consider. Once we culture the bug the lab will help us determine what antibiotics are most likely to work and we can make sure we're using the right one.

So my initial recommendation to you is to finish this round of antibiotics (probably 21 days worth of antibiotic) and keep rechecking the urine. I'd consider culturing the urine when she's been done with the antibiotic for at least 5 days. Your veterinarian will get the sample directly from her urinary bladder (it sounds dramatic, but it isn't). We must make absolutely certain that the infection is gone. Start her on a joint supplement. These are only going to help the bladder. Vitamin-C containing products are nice. Dasuquin and Synovi-G3 are both good products worth considering. If we are still having problems with re-infection, then ultrasound of the bladder to look for things like a polyp or pocketing of the bladder wall is a very smart move. Be patient - we can usually get to the bottom of this and then focus on prevention alone. I'm suspicious we may not be completely and totally resolving the infection or there's a polyp or some similar problem allowing the infection to keep hiding out.

AMH