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Discussion in 'Cat Chat' started by jumbu, Aug 9, 2015.
29 days post surgery
I'm so sorry you didn't have better news at the vets, what an awful situation to be in.
Huge hugs to you and Rafferty xxx
I'm so sorry things are looking so bleak Rafferty was doing so well, I can only hope things pick up again soon.
Hugs to you all xx
Oh Jumbu! What an awful situation for you all. I think you need to think about whether YOU could cope with him having the cystostomy and expressing him every 5-6 hours as well as having sleepless nights and looking after a brand new baby. The catheter and meds I think would stress him out. I'm thinking about how hard it is to medicate my dog and he is obedient! I would also be thinking about quality of life, you have said he is a fastidiously clean boy so messing himself is going to stress him out and as you gave already said, his excessive grooming is giving him sores
I think if you have exhausted all other options then your only other viable option would be number 4
People may disagree with me but I'm thinking about small, dependant humans who turn into crawling humans who are into everything.
Big hugs to you my love. We're all hear for you xxx
Oh jumbo I'm so sorry to read about Rafferty's problems. He looks such s lovely boy.
Has the vet given you any idea of the probability of him regaining control or is that now unlikely?
Rafferty is a really rare case. He has all the indicators everything should be fine but actually isn't. One study showed cats tened to regain function after 30 days or so (or at least start to) or don't. This was based on 60 cats who also had impaired tail/anal sensation (Rafferty doesn't).
This is something we are very very aware of. With the cystostemy it would be turning a tap on his side rather than squeezing him but he still would leak which would still stress him out big time.
Did you speak to the vet about possible tail amputation?
It's just so upsetting to think how brave he has been and how he has recovered so far, but that he might never actually get better.
I really feel for you, I'm so sorry you and he are going through this. Big hugs
In his case it wouldn't make a difference.
I'm so, so sorry for poor Rafferty. He's been at the vets for so long now.
If one of the HBs had been at the vets a month they would definitely be miserable, unhappy, and angry as well. They would also be incredibly bored and lonely and would probably start over grooming, especially if they were not as clean as normal. Huck over grooms at home when he is miserable, bored or jealous, as a way of comforting himself.
If he has all the indicators that he should be fine then I wonder if it's psychological that he's not…he's not happy where he is and has no motivation, stimulation to get any better. He also has no distraction from the routine of grooming himself and self comforting….whereas at home, with toys, play, love and Lyra there would be plenty to take his mind off it.
He'd also have his own litter trays and litter in familiar places as a reminder.
Can you get him on zylkene to help his mood and use other calming products?
I really think if Rafferty was in a different environment (i.e home) you may see an improvement in him mentally and possibly the physical improvement would then follow.
I am a huge believer in mental health affecting physical health.
The over grooming and misery is only when he messes himself otherwise he is very happy in himself and up for playing lots. We dont want to add anything to the mix as he has enough going on at the moment. He is a bit of a fav with the nurses and kennel team and is getting lots of fuss and playtime. He didn't attempt to groom in the visit until after he weed. Then the misery started.
He simply can't gethimself clean as he leaks continually until his bladder is then fully emptied. This last week they were trying to test how long he could go and they us thought the protesting was a sign of improvement - seems not so its back to keeping the bladder small.
We will be bringing him home at some point soon and will see how it goes. Who knows it could get better...
Zylkene is completely natural and shouldn't affect anything else he's having, but may make him feel better in himself?
It could be but the damage to his leg is purely due to nerve damage. I can't remember if I said that they couldn't do the operation the way they wanted to as the piece of pelvis was too close to the nerves and they didn't want to damage anything any more than it already was.
When he weed he tried to bury it once he recognised what had happened. Vet floors don't allow for that really.
Thanks for the suggestions HB if his bowels were ok we would try zylkene and calming stuff but until we get the balance right I don't want to throw in anything that could alter the situation
Sorry yhis is a big all over the place
I'll run it by the vet and we might give it a try when we get him home.
Could you use some grooming wipes to clean him up whenever he leaks or poos? They are really good for helping with grooming and I'm sure they would at least help. Pets at home sell them.
Yes although I'm not sure how well wipes will work on coonie fur. We are intending on keeping him well trimmed. Bit of a dilemma re the leaking cat diaper means that he would not be able poo, stud pants seem too flimsy but we willbe at work for a few hours post leak during which he can give himself sores.
I cant tell you what is best but I would try him at home to see if he can cope and is happy. If his mental health is suffering and he is unhappy both physically and mentally then you need to reflect. I went through the ringer with Iv. I was off work with him and worried hugely about leaving him. He coped. I worried about Blue accepting him again. She did. I promised myself that I would make a decision tomorrow. I didn't.
You will do what is right for him and I send you and your boy every hope that he improves.
I'm just catching up with Rafferty's thread and must say it's been a terribly sad read. I'm so sorry you're all going through this, especially the little man himself.
These cases with neurological damage following pelvic or tail pull injuries are so difficult and always upsetting, partially because they are so difficult to prognosticate. The innervation of the rectum and bladder is complex... I usually have to look at a diagram to remind me of the details when I need to as I can never seem to keep it all in my head.
This is one of my go-to diagrams:
Obviously you can see how closely the pelvic plexus (responsible for keeping the bladder relaxed in 'storage mode') and the hypogastric and pudendal nerves (responsible for emptying the bladder) are associated with the pelvis and tailbase. When the pelvis is broken, or the tail is broken and pulled from the spine as in tail-pull injuries, these nerves are at risk of bruising, stretching or even complete tearing.
Bladder function is pretty complicated and emptying one's bladder requires great neurological coordination: the sphincter muscles around the bladder neck have to relax (part of this is under voluntary control, as obviously you are normally able to control when you go for a wee), while at the same time the detrusor muscle (see diagram: it's the big muscle in the bladder wall) has to contract to squeeze the bladder empty. If one or more of the nerves isn't working, you're going to end up doing one of two things:
1. You can't hold your wee in at all, because the sphincters are paralysed and don't tighten properly. You'll have a near constant leak of wee. A milder form would be leakage under certain stresses such as coughing/sneezing (like women who have had babies!) or sleeping (like some older spayed bitches).
2. You can't empty your bladder, because the detrusor muscle is paralysed and can't squeeze, because the sphincters are locked tight, or both. In these cases the bladder is full all the time, but you do develop something called 'overflow incontinence' instead. The bladder won't burst if it can't empty, but you will get leakage of urine through even a tight sphincter and you'll drop little bits of extra wee, either constantly or at intervals.
Both cases usually require bladder expression to empty properly, but in case 1 the bladder empties easily whereas in case 2 it is very difficult. Both cases can be uncomfortable after repeated expression if the bladder wall gets sore, but usually it's case 2 which results in significant discomfort for the cat as you end up squeezing a bladder against a very tight bladder neck and, try as they might, they cannot pass urine easily.
I think taking account of what type of bladder issue we have is an important factor in deciding whether or not continued expression is fair on the cat or feasible for the owners. Ideally we try to express one to two times daily.
Lots of people successfully manage their cat's bladder paralysis at home if the bladder is easy to express and the cat doesn't mind. But for cases like example 2, expression is much more technically difficult to perform and can be painful for the cat. You say Rafferty is protesting now; have they given any indication as to whether this is because his bladder is very hard to express and it's sore for him to have it squeezed, or just because he's fed up with being manhandled?
I'm not sure if you know which case Rafferty fits into. It sounds like case 1 if he's dribbling all the time, but usually these bladders are easy to express.
I would like to point out that we can also get bladder issues secondary to 'detrusor atony' caused by stretching, even in the absence of nerve damage. This happens when the bladder has been very full for a long time; the wall stretches and then it becomes a bit flabby. It can't contract well enough to squeeze the bladder empty even though all the nerves are just fine: we see this sometimes in recently blocked cats who find it difficult to pee even after their urethra is clear.
In these cases it's important to keep the bladder as small as possible all the time so that the wall has a chance to shrink again and the detrusor muscle can recover. Repeated expression (more frequently than the usual once or twice daily) is an option, though it's not suitable for all cats as we have discussed. Medications to relax the bladder neck and boost detrusor muscle contraction can help, but there are side effects with some. Often, cystostomy tubes or urinary catheters are required for this.
Catheters are suitable for short term use but can be uncomfortable - most cats do their best to pull them out. Here's a blocked cat with one in; his urine is bloody because of his nasty cystitis.
Cystostomy tubes are for longer term use and, surprisingly, most cats seem to tolerate them quite well. They are soft tubes inserted into the bladder through the skin. They allow for frequent and pain-free bladder emptying while still allowing the cat to pee on their own if they want to, which can be helpful for their physical and mental recovery. They can also be placed long-term or permanently in some cases. Some vets recommend that cats are hospitalised if they have one of these in place; others are happy to send the cats home for the owners to manage the tube with regular checks at the vet's.
Here's one being drained with a syringe. It looks scary, but in the main part the whole thing is bandaged up around the cat's tummy and just the port is accessible to allow drainage.
Cystostomy tubes and catheters predispose to urinary tract infections, so regular urine cultures are recommended. In a 2007 study published in JAVMA, which looked at outcomes in 37 dogs and 39 cats with cystostomy tubes, complications were common (49% of cases) but usually easily resolved: bladder irritation, urine leakage, blood in the urine. In twelve cases, the tube fell out or was removed by the patient; this was considered a major complication.
It's important to note that these tubes are unlikely to help in cases where the sphincters are lax, such as in case 1 I mentioned above, because urine will continue to dribble out of the bladder regardless. Therefore patient selection is important; I assume the vets feel that Rafferty's case is appropriate if they are including it on their list of options, though from your post above it seems that they think he will still leak even with a tube in place, which might suggest he's like case 1?
Back to medications; what is he on at the moment? There are a number of drugs used in bladder cases. Some relax the sphincters and bladder neck if they are too tight (Hypovase, Dantrium, Dibenyline). Others help the bladder wall contract if it's weak (Myotonine), but won't always help in cases where the bladder wall is badly stretched because it physically just can't contract. All have potential side effects, but obviously it's a matter of risk vs benefit and many people decide they're worth a try.
It's a tough one. You need to consider logistics and his welfare both in the short term and the long term. I'm not sure in this case that the long term is clearcut and I think you'd need to experience the short term to make a fair judgement for all of you. I've written in a bit more detail about this later.
A cystostomy tube could be an option. Expressing his bladder, if you are happy doing so and he is comfortable with it (many cats get used to it provided it's really expressed and not painful), is an option too. I believe that you are concerned about Rafferty's reaction to wetting himself and keeping him clean, as well as the fact he is smelly. This is fair enough; we all know how fastidious cats are and how stinky cat wee is. Keeping his hair trimmed very short and using wipes and dry shampoo to keep him fresh will help (Ermidra is awesome for this). And of course the stud pants could be an option - what happened with those in the end?
As for the poo side of things, that can be equally complicated. In cats with faecal incontinence, poo tends to plop out as and when because their anal sphincter is paralysed (damage to the pudendal nerve in our diagram above). Bowel control in these cats is instead entirely dependent on peristalsis and how frequently the poo reaches the rectum. This varies with stool consistency.
It's important that these cats don't become constipated as it can lead to faecal retention. They may need intermittent laxatives and attention to an easily digestible diet. Untreated faecal retention leads to megacolon and this is usually an indication for euthanasia in cats with neurological issues. Another cause of faecal retention in cats with pelvic injuries is narrowing of the pelvis after healing: ie the pelvic canal is too narrow for poo to pass through and it inevitably backs up. The surgical repair will have been specifically performed in a way to avoid this complication, so I'm sure this is unlikely.
As you've found, it can be difficult to get the balance right with faecal consistency, but it is achievable in many cats.
A few people have mentioned tail amputation. I think this is often helpful in tail pull injuries, where the tail is frequently paralysed. In these cats, the weight of the tail can continue to stretch the damaged nerves and prevent them from healing. It is also prone to injury because the cat cannot feel or move it, and in some cases they'll experience a weird pins-and-needles feeling in the tail which may lead them to self-mutilate. Obviously the tail is better off gone in these cats. I think Rafferty's tail is okay, isn't it?
Overall, the prognosis for these cats is largely dependent on their urine function, as this is the factor which has the biggest impact on their quality of life and their manageability. Unfortunately, there are no hard-and-fast rules for prediction of return to function, which is why we still place so much importance on time and hope.
Obviously, the chances of damaged nerves recovering depend on how badly they were injured in the first place. Stretched nerves (neuropraxia) usually heal just fine, but it can take 2-3 months. Nerves that have been partially cut, such as nerves crushed by the broken pelvis, may heal - but it's slow. Nerve fibres can only regrow at a rate of 1-3 mm per day. Nerves that have been completely severed (neurotmesis) have a poor chance of recovering at all.
So, how can we tell how bad the nerve damage is? The answer is: not easily. There are some things that can give us an idea.
The cat can feel their tail and move it normally.
The cat can feel the skin on their bottom when it's poked/pinched.
The anal sphincter is tight and responds when poked.
The tail is paralysed and the cat can't feel it. The best place to assess is right at the top, by squeezing the tailbase. Sensation here is more important than at the tail tip.
The cat cannot feel the skin on their bottom when poked/pinched.
The anal sphincter is lax and the anus is open and loose.
It's not impossible that cats with the 'bad' signs will recover, but it's much less likely. Studies have shown that only half of these cats will regain control of their bladders, compared to virtually all cats with the 'good' signs. I've attached a table below with a summary of the findings of two of the main studies on this subject. Bear in mind these are cats with tail pull injuries rather than pelvic fractures, so there may be some difference.
The other issue when considering prognosis is how much time to give a cat. How long does recovery take, if it's going to occur at all?
The Smeak and Olmstead paper (1985) found that the average time to regain bladder function was 14 days. Some took as long as 30 days. Conversely, the Tatton paper (2009) found that all cats who regained bladder function did within a week. Importantly, in the Smeak paper, no cats regained bladder function after 30 days.
It seems that 30 days is the magical number, but remember it's not set in stone. There are plenty of (anecdotal) stories out there of cats recovering later - but we should also bear in mind that the longer a cat good without being able to wee normally, the less likely it is that they will recover. If they are still unable to feel their bottom after two weeks, the chances are even smaller.
So, cats who are still showing signs of neurological bladder damage for weeks after injury are not expected to recover. This doesn't mean that those cats should always be euthanased. Some can be given longer if their bladders can be managed via expression or cystostomy/catherisation. Some cats are even managed for years in this way if it's practical and their overall quality of life is good.
If you wish to give Rafferty a chance at home, my advice is to set yourselves a timeframe. Two weeks or a month makes sense. The aim is not to make a lifelong commitment now. The aim is to see how you all manage for a couple of weeks at home. This will help you decide if you will all be able to cope in the long term. If you can, brilliant. If not, then there is nothing wrong with deciding to call it a day for his sake. If we are lucky, we will see some improvement in those few weeks at home and the decision won't need to be made at all.
I agree with some of the others that his mental recovery will be hastened by being at home, with you and Lyra, his own stuff and litter boxes etc. While I'm sure he's adored in the hospital and the nurses are doing a great job, there is no substitute for home and I've been surprised in the past by just how much better cats tend to do in their own environment. And, of course, mental recovery can improve confidence and lower stress levels, and aid physical recovery.
I don't think managing Rafferty at home would be easy if he is struggling with his bowels and bladder, but I think it would be possible if you wanted to. Keeping him shaved round his back end and investing in some wipes and shampoo would help. Ask the nurses who have been looking after him for some tips: how have they managed? Keeping him in a large crate when you're out, or in a single room with easy-to-clean flooring, would help reduce accidents; you can let him 'out' normally when you're back home, to potter and spend time with the family. Managing his bladder will be easier with a cystostomy tube (but obviously bear in mind the potential complications), but expression is less invasive provided he relaxes at home and lets you do it. And the nurses/vets will be able to show you some simple physiotherapy moves to help his mobility and muscle strength. Remember your own vet will be on hand to help too!
If it was Bagpuss, personally I would want to make my decision having seen how he was at home, and how I (and my OH) got on with managing him. With medications and management, I would hope that he would continue to recover. If not, I would make my decision based on how happy he was and how easily I could manage his bladder. If he was content and I could easily express him a couple of times a day, I might decide to live with it; it would become a daily routine. If he was unhappy or the bladder thing just wasn't working, I would probably decide to let him go.
I am not a supporter of 'life at all costs' and I don't think it is wrong to choose euthanasia for life-changing injuries or illnesses in cats just because we as humans would continue to live with them. Cats are not humans and cannot rationalise their existence like we can. They live in the moment and care about pain, ability to groom and get about, food, and whether or not anything scary is happening to them. If we cannot help them lead a fulfilling CAT life, we should not impose our HUMAN values on them as they cannot benefit from them like we can.
I'm sorry you're in this position. Have as many chats with the vets as you need to. Discuss trialling medication if it's worth a try. It might be worth taking Rafferty home to see how you get on (start with a weekend or book some holiday so you're there with him for the first few days). Remember, by taking him home you're not making a decision to continue forever. You're seeing how you all get on. If you decide early on that it isn't going to work, you can contact your vet and talk through the options.
Equally, if you decide between you all that euthanasia would be kinder, that's not wrong. Hopefully the vets will guide you well, whatever you decide.
Fingers crossed; we're all thinking of Rafferty xxx
That might just be the longest post I've ever written on someone else's thread. Sorry!