1. Urethral Stricture and Perineal Urethrostomy in a Ferret January 22, 2014 Erica Rangel Pre-Clinical Advisor: Dr. Jamie Morrisey Clinical Advisor: Dr. Andrew Cushing

2. Our Patient 3.5 year old, male castrated ferret Ferret Fun Facts! --= “mouse eating stinky thief” --strict carnivoresMustela putorious furo --Male ferret is a hob, female is a jill -- A group of ferrets is called a business

3. A Complex History 9/15/12: Presents to CUHA ER for stanguria; acidodic, hyperkalemic, azotemic Radiographs revealed mineralized opacities in the urinary bladder and urethra Cystotomy and urethrotomy surgeries performed DX: cystine urolithiasis Prognosis: Guarded

4. Pre-op OS PENIS U CATH

5. Post-op Cystotomy

6. STONE FREE !!! Post-op Urethrotomy

7. History continued… Represented for stranguria 11/1/12 and 6/23/13 Negative for uroliths and urinary infection Urinary catheter passed and clinical signs resolved with conservative management Diagnosis not obtained (but stricture suspected) Maintained on oral medications at home: prazosin 0.13 mg PO q24, diazepam 0.25 mg PO q12, meloxicam o.3 mg PO q24 and acepromazine 0.1 mg PO PRN

8. Presentation on 12/15/2013 24 hours of stranguria progressing to anuria Unresponsive to medical management PHYSICAL EXAM FINDINGS: BAR, euhydrated Vitals normal--T: 101.3 P: 200 R:32 Painful on abdominal palpation: tense turgid bladder, could not be manually expressed Mass near left kidney?

9. Ferret Reference Ranges Life Span: 5-8 years T: 100-104 degrees F P: 180-250 bpm R: 33-36 bpm Urine output: 26-28 ml/day PCV: 43-55% TS: 5.5 7.6 g/dL BG: 80-120 AZO: <45

10. Stabilization Sedation: midazolam 0.5 mg/kg IM + butorphanol 0.2 mg/kg IM Pass urinary catheter: 3.5 French red rubber  40 ml urine removed Buprenorphine 0.01 mg/kg SQ LRS 20 ml/kg SQ QATS: PCV 40 (mild anemia), TS 6.2, Glu 114, AZO 16-26

11. Photo credit: C Brown Urinary Catheterization

12. Urinary Obstruction: Our Top Differentials and Diagnostic Tests Urolithiasis  urinalysis and imaging Prostatomegaly or prostatic cysts  ultrasound Urethral Stricture (secondary to trauma: surgery and repeated catheterization)  contrast cystography Neoplasia  age rules down, blood work, imaging Neurologic (overstretched or upper motor neuron bladder?)  no other clinical signs rules down

13. Prostatomegaly: Complex Etiology Secondary to adrenal disease  affects zona reticularis  increase in ANDROGENS (not cortisol!)  prostatic hyperplasia  compresses urethra

14. Usually see other signs of adrenal disease like bilateral alopecia (60%) or increased aggression Adrenomegaly on imaging/palpation? Diagnose by clinical signs, definitive diagnosis requires sex hormone panel

15. Transfer to Exotics on 12/16/13 Bladder turgid again in AM BAR and otherwise stable OUR PLAN: Abdominal Ultrasound under sedation Continue buprenorphine 0.02 mg/kg SQ q8 Diazepam o.05 mg (up to 0.2 mg) PO q12 Place indwelling catheter Submit urinalysis

16. Photo Credits: C Brown and C Polluck

17. Urinalysis Unremarkable Specific Gravity 1.026 pH 6.5 Trace protein, 2+ Heme Sediment Exam: <5 WBC/HPF 20-100 RBC/HPF Many epithelial cells No bacteria No crystals No casts

18. Abdominal Ultrasound

19. Ultrasound Findings Possible bilateral mild adrenomegaly, but normal prostate Minuscule peritoneal fluid Top differential: perineal hernia with caudal bladder entrapment Surgery scheduled for later that afternoon

20. Preparing for Cystopexy

21. 12/16/13: Cystopexy Success

22. Or was it? 12/17/13 Stranguria + abdominal distension; 5% dehydration cystocentesis 44 ml Medications: buprenorphine 0.02 mg/kg SQ q8, meloxicam 0.2 mg/kg SQ q24, ampicillian sublactam 22 mg/kg SQ q8, diazepam PRN Suspect reherniation

23. Ultrasound Take 2

24. More Imaging: Contrast Cystography Definitive Diagnosis: penile urethral stricture with severely dilitated pelvic urethra and iatrogenic urethral tear secondary to cystocentesis

25. Another surgery 12/19/13: Microscopic Perineal Urethrostomy

28. Post-Operative Care Continue to monitor for urination Mild incontinence noted  keep abdomen and stoma clean and dry! Monitored in ICU 24 hours: IV fluids 3ml/hr, buprenophine, meloxicam, ampicillin sublactam Jugular catheter removed, transitioned to oral meds Discharged 12/20/13 --Meloxicam 0.2 ml PO SID x4 --Diazepam 0.1-0.2 ml q12 PRN --TMS 15 mg/kg q12 PO x10 days --Tramadol 5 mg/kg 0.35 ml PO q12-24 PRN x7 days

29. Patient continues to urinate well at home No more incontinence No longer on any medications Energy level off the walls Needs to come back for 3 week recheck O very thankful Outcome

30. Total Cost: $5101.35 $1507.30 9/15/12 $357.78 11/01/12 $1269.84 6/24/13 $1966.43 12/15/13 That’s LOVE!

31. Lessons Learned Don’t overly rely on one diagnostic Don’t assume what “financial” means to your client Look for horses before zebras—ferret perineal hernia never documented in literature

32. Acknowledgements Dr. Morrisey Dr. Cushing Dr. Tarbert Dr. Ash Dr. Knapp Hoch Dr. Flanders Dr. VanHatten Dr. Yeager Catrina Turner Jeff McCall My rotation mates and the Class of 2014!!!

33. References Bartlett, LW. (2002). Ferret Soft Tissue Surgery. Seminars in Avian and Exotic Pet Medicine.11 (4): 221-230 Brown C & Polluck C. (2011).Urethral Catheterization of the Male Ferret for Treatment of Urinary Tract Obstruction. Lab Animal Medicine 40 (1): 19-20. Castanheira deMatos, RE & Morrisey, JK. (2006). Common Procedures in the Pet Ferret. The Veterinary Clinics of North America. Exotic Animal Practice. 9 (2): 346-65. Evans, AT & Springsteen, KK. (1998). Anesthesia of Ferrets. Seminars in Avian and Exotic Pet Medicine. 7 (1): 45- 52. Fisher, PG. (2006). Exotic Mammal Renal Disease: Diagnosis and Treatment.The Veterinary Clinics of North America. Exotic Animal Practice. 9 (1): 69-96. Lightfoot, T et al. Soft Tissue Surgery. In: Ferrets, Rabbits and Rodents, Clinical Medicine and Surgery. 3 rd ed. St. Louis, MO: Elsevier Saunders, 2012; 141-56. Mullen, HS & Beeber, NL. (2000). Miscellaneous Surgeries in Ferrets. The Veterinary Clinics of North America. Exotic Animal Practice. 3 (3): 663-71. Orcutt, CJ. (2003). Ferret Urogenital Diseases. The Veterinary Clinics of North America. Exotic Animal Practice. 6 (1): 113-38. Pollock, C. (2007). Emergency Medicine of the Ferret. The Veterinary Clinics of North America. Exotic Animal Practice. 10 (2): 463-500. Wolf, TM. Ferrets. In: Manual of Exotic Pet Practice. St. Louis, MO: Elsevier Saunders, 2009; 345-74.

34. Questions?