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10 April 2018

Dean's Lunchtime Clinical Club - 10 April 2018 - Vivienne Duggan

Vivienne Duggan, Associate Professor in Equine Clinical Studies and Section Head, Equine Clinical Studies, Diagnostic Imaging and Anaesthesia, spoke at the Clinical Club on 10 April on a case of Sabulous Cystitis in a Sport Horse Gelding.  Vivienne outlined how learning about such cases is important for pre-clinical students in terms of putting together everything they've learned from anatomy, physiology etc.  In this particular case, Charlie, a 7 year old gelding, dressage horse, first came to the UCD Veterinary Hospital in Winter 2014.  Charlie had developed an abnormal urination pattern, and whilst his owner was not overly concerned about this, it was proving inconvenient as he was stopping and starting when out.

A full clinical exam was carried out and all parameters were within normal limits.  The only slight abnormality was that he never really pulled his penis fully back into the sheath.  A diagnostic plan was then put in place and haematology, biochemistry, urinalysis and a rectal examination were all carried out; the latter showed no obstruction, not distended, but there was not much tone, and it was a little bit flacid.  A cystoscopy, an endoscope passed into the bladder, was then carried out and this showed an accumulation of sludge in the bottom of the bladder.  Underneath this, the team could see red and irritated bladder mucosa.  Charlie had a sabulous cystitis - a sand-like substance causing inflammation of the bladder, which was causing discomfort when he tried to urinate and this made him stop trying to go.

Sabulous urolithiasis can be neurological and Vivienne went through some examples from the literature around this.  In a study from 1990, looking at 10 cases of bladder paralysis associated with sabulous urolithiasis, all horses in the study died.  In a paper from 2008, 5 horses had the condition comfortably managed for 3 years.  Vivienne highlighted that managing this issue requires a big commitment from the owner, and there was no issue with this in Charlie's case.

Vivienne then looked at bladder innervation, neurologic disease (lower motor neuron bladder / upper motor neuron bladder) and the voiding reflex in some detail.  She then described the neurologic examination they carried out on Charlie.  This showed them that Charlie had delayed CP reflexes in both forelimbs, was pivoting on forelimbs on tight turns, and had decreased tail and anal tone and decreased perineal sensation.  This was interpreted as mild cervical spinal cord disease, which means that the horse may not be safe to ride and the owner was advised of this.  Early polyneuritis equi or other mild diffuse neurologic condition with secondary sabulous cystitis was diagnosed.  In terms of treatment, a large volume lavage of the bladder was carried out; this was a time consuming procedure.  Charlie was also put on a short course of anti-biotics as he could be susceptible to infection as a result of the scope and manipulation etc.  A short course of anti-inflammatory drugs and oral Vit E as an anti-oxidant were also recommended.  His owner was advised to monitor clinical signs and revisit in 6 – 8 weeks.  They also discussed urinary acidifiers and other drugs which could be used to relax the sphincter muscle and assist contraction of the detrusor with the owner.

When Charlie came in again, a clinical exam was carried out as before, and a bladder flush was also completed; this would continue to be carried out on a regular basis after that.  The owner noticed definite improvements, and in August 2016 advised that Charlie was 'doing amazing' and was 'stronger than ever.’

Vivienne detailed that the key message to take from this case was that whilst previously this diagnosis was considered the end of the road for horses, with a committed owner, the condition can be managed.  Charlie now comes in to the UCDVH every 4 or 5 months; the build up in his bladder is not as bad as it was during his first lavage, but the neurological disease is still the same.  Charlie is, however, still doing really well nearly 4 years on.  Vivienne advised that it's important to catch this problem early and manage it, as cases often go undiagnosed until it’s too late.

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