fuzzy thinking

Few things frustrate me more than lack of a proper diagnosis.  Certainly, there are some cases where a diagnosis isn't attainable for financial, logistical, or medical reasons, but a lot of times, it's a failure on the part of the doctor.


A 10 year old great dane presented to me for a 5 week history of dribbling urine, which had progressed to not really being able to pee a full stream.  He wasn't straining, the urine was clear (not bloody) and he was otherwise acting normally.  His regular veterinarian had prescribed antibiotics 5 weeks ago, without any testing, and when those didn't help, prescribed a second antibiotic. The first error in logic is in this decision. Dribbling urine is not a common symptom of a urinary tract infection.  Antibiotics only help if a UTI is present and won't help a long list of other problems.  Signs of a urinary tract infection include frequent small urination, bloody urine, or straining to urinate.  Furthermore, male dogs are very unlikely to get a urinary tract infection without a mitigating factor, primarily due to the length of their urethra.  If a male dog indeed does have a UTI (confirmed with a urinalysis or culture), a search is indicated to look for the underlying cause (such as bladder stones, diabetes, etc.)


Medical training teaches the new doctor to start with a history (to gather a list of symptoms) and physical exam (to look for abnormalities), and then create a list of medical problems, followed by a list of most likely causes (differential diagnoses in medical terminology), which should each be ruled in or ruled out with testing.  This dog's problem list consists of dribbling urine, which could be a result of urinary incontinence, inability to empty his bladder (due to obstruction, bladder stones, mass, or spinal cord problems), or a long list of other possibilities.  The job of the clinician is to determine the cause of the symptoms, and most of the time, that requires testing.  I can't (nor can any human) be 100% sure if there's bladder stones, or bacteria, or a mass in the bladder without imaging (such as ultrasound). The treatment for each of these is very different, and so a diagnosis must be achieved to select the proper course of therapy.

Unfortunately, the regular vet did not recommend nor offer any testing, such as a urinalysis or imaging to the clients.  When their dog didn't improve after the antibiotics, the vet added pain medications to "relax" the dog's muscles, which also didn't provide any relief or ability to urinate.  When the patient still didn't get better, referral was not offered or any sort of diagnosis as to the cause of his symptoms.  The clients didn't know to ask for any other testing (as most laypeople have no way of guessing at the proper tests, and trust their doctor implicitly to do the right thing). When the clients felt their dog was simply too uncomfortable, they showed up at the ER for evaluation.

Immediately upon hearing the history I knew that this dog never had a urinary tract infection.  As I mentioned above, UTIs are rare in male dogs.  More likely, the cause of an adult/geriatric male dog to be dribbling urine is a bladder mass or bladder stones. I recommended an ultrasound, which was immediately authorized, and found the large mass with ease.

Breaking the sad news to the clients was beyond devastating.  I am frustrated at the poor diagnostic process and lack of options the clients were given; perhaps 5 weeks ago, the tumor would have been operable.