True VKH syndrome is a human disease, well described for nearly a century. A similar disease in dogs has been described but since we do not know the relationship between the canine and human disease, we are hesitant to call the canine version VKH syndrome as well. Until we know what is really going on in dogs, we will leave it at VKH-LIKE syndrome or, more accurately, uveodermatologic syndrome.

A syndrome is a collection of symptoms. In humans, VKH syndrome consists of the following:

1. Deep inflammation of the eye tissues (a process called uveitis) leading to at least partial blindness. Approximately 70% of people with VKH syndrome become blind and it is usually the inflammation in the eyes that appears as the first sign of VKH syndrome.
   
2. Premature whitening of the hair (present in 90% of affected people). 
   
3. Whitening of the skin (present in 50% of affected people).
   
4. Inflammation of the membranes of the nervous system (a process called meningitis). This leads to deafness in about half of the people affected with VKH syndrome.

Affected people are typically of Mediterranean, Hispanic or Asian descent. There are numerous links for more information regarding this condition in humans.

The syndrome in dogs includes:

1. Uveitis leading to blindness that, as in humans, is usually the first sign to show. The owner would notice that the eyes seem painful and/or bloodshot. The patient may bump into things and show diminished vision. The pupils are classically constricted and the eye may seem cloudy or may seem to change color from normal. 
   
2. Whitening of the coat, sometimes confined to the face (present in 90% of affected dogs) This typically begins 3 to 6 months after the eye disease has started. 
   
3. Whitening of the skin, usually most obvious on the nose, lips, eyelids, footpads, and scrotum (occurs in 50% of affected dogs).

Unlike the human disease, deafness or meningitis is not a feature. The most detrimental part of the syndrome is blindness.

What Causes this Syndrome?

Uveodermatologic syndrome is an immune-mediated disease where the body inappropriately attacks its own melanocytes (the pigment-producing cells). These cells seem most prevalent in the skin, retina, and uveal tract of the eye. It is speculated that the immune reaction is initially triggered by a virus though research is ongoing.

1. Male dogs are affected more than female dogs. 
2. Akitas and Nordic breeds are primarily affected. (Actually, 80% of reported cases involve Akitas and as many as 4.1% of Akitas are affected.)

How is the Diagnosis Made?

The best way to confirm this diagnosis is by a skin biopsy (the lip is said to be the best location). Treatment, however, is focused on the eye disease as this has the most serious outcome ‒ blindness ‒ while skin disease is generally cosmetic.

Uveitis is most literally inflammation of the uveal tract of the eye. The uveal tract consists of the iris (the colored portion), the ciliary body (the area inside from which the lens is suspended), and the choroid (the vascular coating of the inside). The treatment for uveitis due to a VKH-like syndrome is the same as for other causes of uveitis.

At the initial evaluation, 36% of dogs had glaucoma (increased eye pressure) and 57% were blind in both eyes. Some dogs were able to regain vision and 50% of subjects could see in at least one eye at the end of the study. Of the dogs that ultimately became blind in both eyes, blindness came on over 13.5 months (median). At least 10 eyes had to be removed in order to provide long-term comfort.

Pruritus, or itching, in dogs and cats, can involve scratching and licking, chewing, or biting the skin. Pruritus is the most common symptom of skin disease in veterinary medicine. Many conditions can cause pruritus, including allergies, fleas, and other skin parasites. Some skin problems are more common in younger animals, while others are diagnosed more often in older pets. 

Medications are available to manage pruritus, but unless the underlying cause of the pruritus is diagnosed and addressed, it will return once the medication is stopped. Some anti-pruritic medications, such as steroids, can result in other health issues. Providing your dog or cat’s medical history can sometimes help your veterinarian determine the cause of the itching. 

A lack of response to some medications can help your pet’s veterinarian narrow down the possible causes. Additionally, some medications can actually cause itching.

When Did the Pruritus Start?

It can be helpful to know when the itching started. If allergies cause itching, it is beneficial to know if the problem is worse at different times of the year.  

Other Health Problems 

Sometimes, skin conditions develop secondary to another health problem. Your veterinarian will ask questions about other symptoms that could point to a specific cause of pruritus. For example, pets with food allergies may have frequent bowel movements or soft stools.

Location of Skin Lesions

Some pruritic skin conditions cause skin lesions more commonly in one body region than another.

Type of Skin Lesions

Although most pruritic skin conditions look the same to pet owners, there are actually many types of skin lesions, and some skin lesions occur more commonly with specific skin conditions. However, if the pruritus has become chronic, many pruritic skin conditions look similar to each other. Your veterinarian may need to run some tests to help determine the cause of the pruritus.

What Tests are Used to Diagnose the Cause of Pruritus?

Below is a list of some common tests for diagnosing the cause. Your veterinarian will select tests based on your pet’s medical history and examination findings. 

Skin Scrapings

To look for skin parasites, a scalpel blade is used to gently scrape the skin layers to collect cells and any skin mites. The sample is then examined under the microscope.

Skin Cytology

To look for bacteria and yeast organisms, skin cells and debris samples are collected and placed on a glass slide for examination under the microscope. This test can also help determine what types of cells are in the skin.

Parasite Therapy Trial

For some parasites, the only way to determine if they are the cause of the itching is to treat the parasites. A decrease in pruritus after the anti-parasite therapy would be consistent with the parasite causing the pruritus.

Ringworm Testing

To determine if a dog or cat’s skin is infected with ringworm (a disease caused by a fungus called a dermatophyte, not actually a worm), your veterinarian may start by examining your pet under a special ultraviolet lamp called a Wood’s Lamp. If the hairs glow (fluoresce), this may mean your pet has ringworm  Those hairs are collected for further testing.

In a fungal culture, hair and skin samples are placed on a fungal culture plate. If a dermatophyte grows, the dog or cat is diagnosed with ringworm. In a dermatophyte PCR test, (a test that looks for viral diseases) the hair and skin samples are checked for dermatophyte DNA. 

Food Trial

A prescription or home-cooked diet is fed for several weeks with no other foods or treats to diagnose food allergies. Unfortunately, there is no reliable skin or blood test in dogs and cats to diagnose food allergies.

Allergy Testing

Skin or blood allergy testing is used in dogs and cats that have had other causes of pruritus ruled out through other tests. It is mainly used to select allergens for a type of allergy treatment called allergen-specific immunotherapy. There are no reliable hair or salivary tests to diagnose allergies.

Skin Biopsy

A sample of skin can be obtained through minor skin surgery. Skin biopsy is especially helpful for diagnosing some less common causes of pruritus, such as skin cancer. However, a skin biopsy cannot be used as an allergy test and cannot diagnose the cause of a pet’s allergies.

When dogs or cats develop masses protruding from their vaginas, it can be alarming for an owner. Fortunately, they are not common and are rarely seen in spayed pets.

Is it hyperplasia, swelling, prolapse, or a mass?

Many of these can look similar – a pink, fleshy mass in the cat or dog’s vaginal area. Although vaginal hyperplasia, swelling, and prolapse are similar and often related, they are not the same. Keeping it simple, hyperplasia means that there’s more tissue than there should be due to more cells being present.

Technically, this is different from swelling, which occurs for reasons other than an increase in the number of cells, such as an increase in the amount of fluid in between cells. A prolapse is where the vagina is everted (turned inside out) of the body. Imagine something from the inside of the body pushing the vagina outward, like turning a sock inside out. The tissue will often swell when combined with a prolapse.

Vaginal hyperplasia is more uniform than a mass. Think of vaginal hyperplasia as the difference between a thin cotton sock and a thick wool one. The “walls” of the wool sock (the vagina) are thicker than that of the cotton sock. If the sock couldn’t stretch outward for some reason, perhaps tight shoes, it would lessen the amount of room inside the sock for your foot, and the sock would feel tight.

Now, if that hyperplasic vagina should prolapse, a round, tongue- or doughnut-shaped mass may be easily seen; it’s often more in the neighborhood of “you can’t miss it” because the dog is paying so much attention to that area. The prolapse generally starts out smooth and shiny but eventually dries out a bit, after which cracks called fissures develop. It’s basically caused by an overreaction to estrogen and tends to occur just before she goes into heat (proestrus) or while she’s in heat (estrus).

Generally speaking, it only happens in dogs and cats who have not been spayed because spayed dogs and cats do not have enough estrogen to cause it. That said, if a spayed pet is exposed to estrogen from outside of her body, like what can happen to a dog that licks estrogen cream off her owner’s arm, there is the possibility of a prolapse developing then as well. Occasionally, difficult labor and delivery may lead to a prolapse, such as if the vagina everts outward as part of the pressure and forces involved in giving birth. Due to a slight increase in estrogen prior to the date of labor and delivery, it occasionally will happen then, too.

During delivery of a litter, if you can see any type of abnormal vaginal protrusion, it is a medical emergency.

Vaginal hyperplasia can interfere with sex while breeding; before the hyperplastic vagina prolapses outside the body, a reluctance to breed or difficulty urinating may be the only signs.

Occasionally, the discomfort continues throughout pregnancy or just recurs when the puppies are born.

Breeds predisposed to vaginal hyperplasia and prolapse include the boxer, English bulldog, mastiff, German shepherd dog, Saint Bernard, Labrador retriever, Chesapeake Bay retriever, Airedale terrier, English springer spaniel, American pit bull terrier, and Weimaraner. Because it tends to run in some family lines, it’s best not to breed dogs if they have had a prolapse even though the genetics and heritability of the condition are not fully worked out yet.

A mass is a collection of cells.  Sometimes, masses will form inside a dog’s (or, rarely, in a cat’s) vagina and grow into a larger mass that eventually pushes itself outside the vagina.  Vaginal masses, whether benign or malignant, are not common in cats and dogs, particularly if spayed.  Continuing with our sock analogy, imagine a burr inside your sock, where the burr is like a vaginal mass.  The burr protrudes into the middle of the sock where your foot sits.  You’re wearing your sock as usual.  If you stick your finger inside your sock, you can feel the burr. 

If it’s a really big burr or you turn your sock inside out, you will see it when protruding from the sock.  Masses can be pedunculated or sessile. If pedunculated (on a stalk) they are nearly always vaginal polyps, which occur more commonly in intact vs spayed bitches but can occur in both. Usually, the bitch is older. Polyps can be single or occur in groups. If the mass is sessile it is more likely a leiomyoma or leiomyosarcoma, which are differentiated by an incisional biopsy.  Occasionally, other neoplasms can occur in the vaginal vault.

Growths called Transmissible Venereal Tumors may sometimes cause vaginal protrusions in dogs.

Treatment for Vaginal Prolapses

With vaginal prolapses, unless the prolapse is extreme, it will generally resolve on its own as the dog’s heat cycle moves along or after the dog is spayed. In minor cases, the dog only needs cleaning and an ointment to keep the tissue moist, so it doesn’t dry out.

If minimal tissue damage has occurred, your veterinarian can push it back in with a gloved hand. It is first cleaned appropriately, and swelling is reduced by applying hypertonic dextrose or sugar. Sutures can then be put in to keep it in place.

If the tissue is dead (necrotic), it has to be removed surgically. Spaying her will prevent another occurrence and can be done at the same time as removing the dead tissue.

Dogs with difficulty delivering litters due to the protrusion will likely need a C-section.

Sometimes supportive therapy involving an E-collar to prevent self-trauma, a diaper with a lubricated pad, and hormone treatment can be given to make ovulation occur faster. However, dogs don’t generally have a good response to hormones, and it’s ineffective if given after ovulation, so it’s not usually helpful.

After treatment, the intact dog should be monitored in case of a relapse.

The only prevention is spaying.

Treatment for Vaginal Masses

Treatment for any kind of mass in the vagina will depend on many factors including the type of mass it is (such as a benign mass or cancer), the exact location, the extent of it, and whether or not it has metastasized to any other location.  If your pet has a vaginal mass, talk with your veterinarian to discuss treatment options.

In summary, if you notice a pink mass protruding from your cat’s or dog’s vagina, notify your vet. If your cat or dog seems to be in discomfort or having trouble urinating, contact your veterinarian or a veterinary emergency clinic right away.

Sugar substitutes are big business. Less sugar can mean weight loss, improved health, diabetic control, and even reduced tooth decay. The quest for products that can sweeten and cook like sugar is ongoing. Xylitol (also known as birch sugar) is a common sugar substitute, especially when it comes to sugarless gum, toothpaste, and more recently certain brands of peanut butter for bodybuilders. It is worth noting that even though birch sugar sounds natural and xylitol sounds like a chemical both are toxic to your dog.

Not only does xylitol offer sweetness with 40% of the calories of sugar, but it also has antibacterial properties in the mouth so it can reduce periodontal disease and has been found to have far-reaching health benefits in other areas of the body. Xylitol may help with osteoporosis, prevent ear and throat infections, and may reduce the risk of endometriosis, uterine fibroids, and even breast cancer.

Sounds wonderful and maybe it is if you are a human. If you are a dog, xylitol (birch sugar) is potentially lethal.

Two Deadly Effects of Xylitol

Hypoglycemia

In dogs, the pancreas confuses xylitol with real sugar and releases insulin to store the “sugar.” Even worse, the canine pancreas releases 3-7 times the amount of insulin that it would release to address a similar amount of actual sugar. Blood sugar levels plummet resulting in weakness, disorientation, tremors, and potential seizures.

It does not take many sticks of gum to poison a dog, especially a small dog (see below for toxic doses). Symptoms typically begin within 30 minutes and can last for more than 12 hours but, since xylitol can be absorbed into the body slowly, symptoms may not begin until 12 hours after the xylitol was eaten. Symptoms begin with vomiting and then progress to incoordination, collapse, and seizures.

Hepatic Necrosis

The other reaction associated with xylitol in dogs is the destruction of liver tissue. How this happens remains unknown but the doses of xylitol required to produce this effect are much higher than the hypoglycemic doses described above. Signs take longer to show up (typically 8-12 hours) and surprisingly not all dogs who experience hepatic necrosis will have had hypoglycemia first. A lucky dog experiences only temporary illness but alternatively, a complete and acute liver failure can result in death. Internal hemorrhage and the inability of blood to clot are commonly involved.

How Much Xylitol is Dangerous?

The hypoglycemic dose of xylitol for dogs is considered to be approximately 0.075 – 0.1 grams per kilogram of body weight (about 0.03 – 0.045 grams per pound). Chewing gum pieces have surprisingly variable amounts of xylitol depending on their flavor. (For example, most flavors of Orbit gum have about 0.009 grams of xylitol but their strawberry mint flavor has over 0.3 grams per piece). A small dog can easily be poisoned by a single stick of gum depending on the gum, how much the dog ate, and the size of the dog. It is important for you to bring the packaging for the xylitol product in question to the veterinarian’s office so that the amount of xylitol consumed can be estimated.

Treatment

Ideally, the patient can be seen quickly (within 30 minutes) and can be made to vomit the gum or candy. Beyond this, a sugar IV drip is prudent for a good 24 hours. Liver enzyme and blood clotting tests are monitored for two to three days. Blood levels of potassium are ideally monitored as well. Elevated blood phosphorus levels often bode poorly, and patients that develop hepatic necrosis usually do not survive.

What about Cats?

Xylitol toxicity appears to be limited to dogs. Cats have no significant ill-effects from xylitol.

What about Xylitol-Containing Mouthwashes for Pets?

The oral health benefits of xylitol do seem to hold true for dogs if appropriately low doses of xylitol are used.

Several products have been marketed for canine oral care, specifically for dogs that do not tolerate other methods of dental home care. These products are mixed in drinking water to provide antibacterial benefits.

Aquadent^®, for example, comes in a 500 cc (a half liter) bottle that contains a total of 2.5 grams of xylitol. It also comes in small packets to mix in drinking water. Similarly, Breathalyser Plus® from Ceva is similarly packaged. If you follow the dosing instructions on the bottle or packet, there should be no problems.

Trouble could occur if there are animals of different sizes drinking from the same water bowl or if a dog is on medication or has a disease that causes excessive water consumption.  One should dose for the smallest animal to use the bowl to be sure overdose is not possible. Alternatively, a dental water additive that does not contain any xylitol can be used. Ask your vet what he or she recommends. A dog finding the bottle and chewing it up, drinking a substantial quantity of the undiluted product could easily be poisoned, depending on the dog’s size.

Why does my pet need this medication? 

High levels of FAS can have negative effects in many ways.  It isn’t healthy for your pet.  Elevated stress hormone levels can suppress the immune system, change lab work results, and over the long term may even shorten your pet’s life.

Every time your pet is in a stressful situation such as going to the veterinarian, they learn to associate it with feeling anxious or scared.  That means that each time they go back to the clinic or a groomer, or you try to do something that they find scary, they get more and more scared.  They also anticipate something bad happening, so the anxiety starts sooner and sooner.

If they stay at a high level of FAS, your pet may learn that the only way to make people stop doing the things that scare them is to be aggressive.  This adaptation could result in a situation where your pet is sick or injured and making sedation risky but necessary because of aggression due to repeated negative experiences.  This risk can limit your veterinarian’s ability to provide necessary medical care to your pet.

My pet isn’t aggressive, can’t you just do what they need?

Physically we might be able to do these things, but it would have a negative impact on your pet’s mental health.  We don’t want them to learn to be more afraid at the vet’s office or start being afraid of strangers or you or in other situations.

He didn’t need medication last time, why are you saying he needs it now?

FAS often increases because of memories of bad experiences.  Giving medication to lower FAS also changes what your pet is learning so they don’t continue to become more and more anxious or aggressive. 

What if my pet is still fearful after taking these medications?

The medications you give at home may not be enough for your veterinarian to do full procedures but may allow injectable sedation to be given without causing undue stress.  If they don’t need urgent care, you may need to try a different combination of medications or different doses. 

What else can we do to lower my pet’s FAS?

Happy visits

If your pet travels in a carrier, use treats so they’re happy about going in and out of the carrier at home and take them for car rides in it so it isn’t a scary thing. Take your pet to the clinic when nothing is needed so they can learn that it’s a good place to be.  Start out just giving treats in your car or out in the parking lot.  Call ahead; if it’s a quiet time, staff may be able to come out and give your pet treats or have them come inside for some.

Home exams

If your dog or cat is fearful at the veterinarian’s, but is not aggressive or extremely fearful at home, you can get a pulse and respiratory rate and take their temperature at home.  You can also take pictures of their teeth in case they need to be muzzled, in which case teeth can’t be examined.

Basket muzzle training for dogs

For the safety of your clinic staff and ultimately of your dog, many fearful dogs require muzzles.   If the muzzle is introduced properly, your dog will associate it with treats and good things, so it will lower anxiety when worn.  If it is not introduced properly, putting a muzzle on a fearful dog can increase anxiety and aggression. 

A dog’s body language is often instinctive and happens naturally, such as trying to settle down a tense environment through actions or responding to an invitation to play. This form of communication can be used between dogs, during dog and human interactions, or between dogs and other animals. Knowing what your dog is communicating can help you understand his needs better and keep him comfortable in any given situation.

Below are some common types of body language that dogs use. It is important to recognize that many of these types of body language can mean different things in different settings and should be used in context of whatever is happening in the moment. A common example of this is panting, which could mean “I am nervous,” or “Gosh, it’s hot out,” or even “I’m tired.”

Diffusive Behaviors

These are types of body languages that dogs use to avoid conflict, help diffuse a potentially intense or threatening situation, and keep interactions from getting out of hand. Some refer to these behaviors as calming signals because, in a way, they signal to others things like “everything is ok,” “things have gotten a little too tense,” or “I am not a threat.” That being said, these types of behaviors indicate more than just calming; they communicate both how the dog is feeling and her ability to react and interact with others.

Be aware that some of these behaviors can be misinterpreted as signs of guilt, such as the slow, creeping walk towards or away from you when you correct your dog for doing something wrong. This behavior does not mean your dog is acting guilty for getting into the trash. It means she is trying to diffuse the situation and lessen the intensity of your correction. She honestly may have no clue at all why you are upset with her, and she just wants you to stop yelling.

Happy/Relaxed

1. Keeping the mouth open, often with the tongue lolling out, is typically a very relaxed posture for a dog.
2. Bowing down on the front legs, often known as a play bow, can be an invitation to play or a diffusive tool indicating that the dog is not a threat to someone or something else.
3. Tail wagging can often be content, happy, or excited body language. In certain settings, it’s important to know that tail wagging can indicate nervousness, anxiety, or an effort to diffuse a tense situation. Be mindful of what else is happening in the dog’s environment and remember that a wagging tail does not always mean a happy dog.

Anxiety/Fear/Worry

1. Cowering or making the body small, and crouching low to the ground can be a sign of fear.
2. Yawning frequently, especially when not obviously tired can be a sign of stress, fear, or anxiety. It can be a way to diffuse a tense situation the dog either finds himself in the middle of or in his immediate surroundings (e.g., other dogs fighting, intense talking amongst a dog’s owners, or being spoken to harshly by an owner).
3. Licking the lips or nose, even when no food or water is around, can be a sign of anxiety or fear. This is frequently used as a diffusive behavior.
4. Panting but not interested in water, or hot, can be a sign of fear, anxiety, or stress.
5. Combination of the ears positioned low and out to the side and the pet’s brows down or furrowed can be seen with anxiety or worry. This can often occur with other postures such as lowering the head and neck, and keeping the mouth closed. Be aware that lowering the head, neck, and ears can also be a sign of assertiveness or aggression in really tense situations, so assess what else is happening in the environment.
6. Creeping around or moving slowly when walking can be a sign of fear or anxiety. It is frequently a diffusive signal. This type of walking can also be a hunting maneuver, such as if a dog has spotted potential prey. Moving away quickly and darting around is also a sign of anxiety or fear.
7. Appearing on alert and trying to look around at everything quickly is a sign of anxiety or fear.
8. Unwillingness to eat or take a treat during a potentially stressful situation is a common sign a dog is anxious or afraid.
9. Pacing around and unwillingness to settle down in one place can be a sign of anxiety.  It can also be a sign of excitement and happiness.
10. Averting the eyes, turning the head away or to the side can be a sign of anxiety.  This can also be a diffusive tool as well, to avoid conflict or help diffuse a situation.
11. Pausing, holding position, or freezing can be a hunting behavior (sometimes called pointing), a sign of anxiety or uncertainty, or a diffusive behavior.
12. Tail tucked between the legs is often a sign of fear or anxiety and can occasionally be a diffusive behavior
13. Sniffing or snuffling along the ground can mean a great deal; it is often a way for dogs to get a feel for the environment, follow the trail of a recent inhabitant, discover signals left behind by other dogs or animals, or just enjoy the delights of nature. It can also be a sign of anxiety and a diffusive tool, such as when being approached by someone or something that may be a potential threat.
14. Raising a front paw can be a diffusive behavior or indicate anxiety/stress.
15. Rolling onto the back is often a sign of fear, although the occasional very confident dog may have learned to do so in order to get tummy rubs.
16. Barking or whining could be due to fear, anxiety, or excited/worked up. Growling could be assertiveness and/or aggression, or fear. High-pitched barking often means the dog is too excited and vocalizing to try to calm themselves down. Barking can also serve as a warning that the dog is too scared or too aggressive and a bite may come next.

Assertiveness and Aggression

These types of body language behaviors may occur in a dog attempting to use diffusive behavior that has been ignored, or may occur without initial signals such as in an overly excited/worked up or aggressive dog on high alert. Dogs that are too worked up or excited are said to be highly aroused. Assertive or aggressive posturing can frequently be seen in dogs exhibiting these body languages. Often the more aroused the dog, the more intensely she will respond to perceived threats or issues in the environment.

1. Direct eye contact is the most common initial body signal for displaying assertiveness or aggression, often when a dog is in a threatening situation. Assertiveness in combination with aggression is not always the case, of course, because your own dog may stare directly at you with his “sad, puppy dog eyes” when he wants something. Thus, other body signals or the situation itself should be evaluated (e.g., a new dog showing up) before determining if aggression is involved. In other words, a confident dog can be assertive, using body language to get what he wants, without demonstrating aggression, which involves behavior that can result in damage to someone else.
2. Pulling the lips back and displaying teeth can also be a signal of assertiveness or aggression.
3. As the dog’s perceived threat continues, holding the head, ears, and neck up initially may be seen (to make the dog appear bigger to the threat), but lowering the head and flattening the ears can be a signal that the dog feels the threat is worsening and the problem is escalating. This progression is an instinctive way to appear even larger and to protect important organs from attack.
4. The tail held straight up or curved over the back can sometimes mean a high alert or a threatening situation is occurring. Slow tail movements or rapid wagging that looks more like vibrating (known as flagging) can also be a sign the dog is feeling threatened and responding in an assertive or aggressive manner.
5. The dog’s weight may appear shifted toward the front of his body, which allows for quick action if needed.
6. The hair along the dog’s back may be standing on end, sometimes referred to as raised hackles. This can be an unconscious way of making the dog appear larger and more threatening. Hair standing on end indicates high alert and increased arousal, so it can sometimes be seen during intense play without any aggression.

A Note about Snapping and Biting

Bites have different degrees of severity, but a bite is still a bite, even if skin is not broken. A dog may snap at something without making contact; this is generally the dog’s effort at communicating a more intense warning. In this case, anxiety, fear, or aggression have been occurring and the signals have gone unnoticed. It is important to understand that generally, the dog is the one who has decided not to make contact or cause harm. Dogs are fast and can bite hard when they feel it is necessary, so take this warning snap seriously.

When an actual bite occurs, again, degrees of severity exist. Dogs can bite without drawing blood, bite superficially, or in more highly aroused states, give multiple and/or deep bites. Bites that occur without drawing blood are likely inhibited by the dog, meaning she held herself back from inflicting damage. It is important to understand that these bites and other superficial ones are still bites without major harm. They are likely to result in worse bites in the future if the dog doesn’t receive the help needed to move past the cause for the biting. Multiple and/or deep bites, those with no inhibition from the dog, means the dog bit without thought, acting on reaction alone.  Any snaps or bites require prompt assessment and assistance for the behavior issue.

In reality, urinary incontinence is usually one of the easiest problems to solve, so it is crucial that veterinary assistance be sought before an owner’s patience is completely worn out and before any permanent decisions about the pet’s future become topical.

Causes of Incontinence

It is important to differentiate incontinence (involuntary urine leakage) from behavioral urinary issues (submissive urination), simple lack of housetraining, territorial marking of anxious cats or unneutered males, or the senile loss of house training from canine cognitive dysfunction. Animals may urinate in the house voluntarily, and this is different from incontinence. Watch your pet closely to be sure what you are seeing is really incontinence, and if it is, the good news is that most cases are easily resolved with simple, inexpensive medications.

There are several important causes of incontinence, and most of these are ruled in or out with a urinalysis and urine culture. The urinalysis reveals cell types and biochemical elements in the patient’s urine, while the culture isolates the bacteria growing in the urine. The bacterial species grown are identified and tested for their sensitivity towards different antibiotics, the end result being confirmation of the presence of infection and a list of appropriate antibiotics.

Most cases of incontinence are due to:

1. Infection of the urinary tract (usually bladder infection)
2. Excessive consumption of water
3. Weak bladder sphincter (especially common in female dogs)
4. Spinal cord disease.

Other conditions that may need to be explored could include bladder stones and even tumors in the urinary tract.

Bladder Infection

This is a common cause of urinary incontinence in female dogs of all ages and in geriatric cats. This condition is usually easily diagnosed by urine culture, though signs of infection, such as white blood cells or bacteria, are actually visible in the urinalysis. A urine culture will confirm the infection, identify the organism, and list several antibiotics that will be effective. An antibiotic is selected based on expense, potential for side effects, and convenience of usage. After a short course (generally somewhere between 1 and 3 weeks) of medication, ideally, a second urine culture or urinalysis is done to confirm that the infection has truly been cleared up.

If a bladder infection is the cause of incontinence, most patients show improvement in their incontinence and comfort after only a few doses of antibiotics (but it is still important to finish the entire course so as to avoid recurrence). 

Excessive Water Consumption

Dilute urine is obvious on the urinalysis through a measurement called specific gravity that compares the amount of dissolved biochemicals in the urine to that of pure water (which has no dissolved biochemicals).

A urine specific gravity nearly the same as water, confirms excessive water consumption; blood tests may be indicated to go with the urine tests to determine the cause.

Causes of excessive water consumption include:

1. Diabetes mellitus
2. Cushing’s syndrome
3. Hyperthyroidism (cats)
4. Bladder infection (see above)
5. Diabetes insipidus
6. Kidney insufficiency

There are other causes as well but 90% are ruled in or out by a blood panel and urine culture.

Weak Bladder Sphincter

Aging, obesity, reduced sensitivity of neurologic receptors in the sphincter and possibly other factors all contribute to this condition which is especially common (up to one in five affected) in female dogs. Once other more serious conditions have been ruled out, the weak sphincter may be treated symptomatically with one of several medications.

Estrogens

It is not entirely clear how estrogens are helpful in this treatment. Originally, estrogens were given to post-menopausal women with urinary incontinence and the treatment was simply extrapolated to dogs. It is possible that estrogens are important in the maintenance of neuroreceptors in the bladder sphincter and without estrogens the receptors become unresponsive to the transmission of the storage message from higher neurologic centers. (In other words, the message from the brain to hold the urine does not get through to the bladder.)

In dogs, diethylstilbestrol (DES) has traditionally been the most common estrogen used, though it is now only available through compounding pharmacies. Other estrogens that have been used include estriol (Incurin®) and conjugated estrogens such as Premarin®.  Regardless of which product is used, the basic process is the same. A higher dose is utilized to begin therapy and, if it is effective, the dose is tapered to the lowest dose needed to maintain effect. For DES, dosing every couple of days is typical while with estriol most dogs end up dosed once daily.

In male dogs, testosterones seem to be more effective than estrogens, possibly through action on the prostate which sits at the neck of the bladder and incorporates the sphincter.

Alpha-Adrenergic Agonists

These medications act by enhancing release of the neurotransmitter chemicals that act on the receptors of bladder sphincter. Effectively, they turn up the volume dial on the “hold it” message from the high neurologic areas. The usual medication for canine use is phenylpropanolamine in chewable tablets, which is typically given two or three times daily.

Ephedrine and pseudoephedrine, common decongestants, are sometimes recommended alternatively. Side effects can include irritability, appetite suppression (phenylpropanolamine was the active ingredient in many human diet pills until recently), and blood pressure changes. Most dogs, male and female alike, tolerate phenylpropanolamine uneventfully. For especially resistant cases of incontinence, estrogens and alpha-adrenergic agonists can be used together.

Anticholinergics

Anticholinergic drugs are medications that work, not on the sphincter of the bladder, but on the rest of the bladder where urine is stored, relaxing the muscle fibers thus facilitating storage. An example of such drug would be imipramine, an anti-anxiety medication commonly used in humans. It has anticholinergic properties and can be used in combination with phenylpropanolamine in the treatment of animal incontinence. While phenylpropanolamine and DES are commonly used medications for this condition, imipramine is not but it does represent another option when a patient does not respond to the first two medications combined. Other anticholinergic drugs that might be used included oxybutynin or flavoxate.

Gonadotropin-Releasing Hormone (GnRH)

Several studies have been performed using analogs of this hormone (such as leuprolide) in incontinent dogs for which DES and phenylpropanolamine have failed.  More than half of the dogs tested regained complete continence while still more achieved improvement.

Surgical Therapy

Medication works for most patients with weak sphincters but when medication fails there are some surgical options to consider: colposuspension and cystourethropexy.

Colposuspension, for females only, is the most commonly performed procedure. Here, the vagina is tacked to the bottom of the belly wall entrapping and compressing the urethra. In one study of dogs that had failed on medication, there was complete resolution of incontinence in 53% with colposuspension. An additional 37% became less incontinent and 25% of those without full resolution gained complete continence when therapy with phenylpropanolamine was added. Another recent study reported that complete continence lasted for 1 year in only 14% of affected dogs, although many dogs improved.

Cystourethropexy is the modification of the above procedure that can be performed in either males or females. Since there is no vagina to use in the male, the ductus deferens are tacked down to compress the urethra. Fibers from the urethral muscles can also be tacked down (in either male or female patients). Complications include an increased frequency in the need to urinate (occurring in 2/3 of the patients in one study) and straining to urinate (in about 1/3 of patients).

Urethral lengthening works for patients for whom incontinence is caused by a short urethra. A short urethra causes a full bladder to be displaced into the pelvis and makes the urethra too short for either of the other two surgical procedures. This is a newer surgical procedure that so far has had good reports in the small number of dogs in which it has been studied. Further studies should be forthcoming.

Medications listed above are used in conjunction with surgery. Surgery alone improves approximately 50% of patients but often incontinence returns unless oral medication is restarted.

Collagen Injections: The Newest Therapy

In this procedure an endoscope is inserted in the urethra and several injections of collagen (the same kind used for cosmetic injections in humans) are deposited. In a study of 40 dogs who had failed to become continent on medication alone, 27 became continent for an average of 17 months. Furthermore, 10 dogs that experienced only partial improvement after the procedure became completely continent when oral medication was added, even though medication alone had been ineffective.

The procedure can alternatively be performed with medical grade collagen, with Teflon® (which does not last as well but is apparently considerably less costly) or with a reconstructive product called ACell®. Unfortunately, at this time there are few facilities that perform this procedure as special equipment (cystoscopy) is required.

Unusual Causes of Incontinence

The list of causes of incontinence presented above is by no means exhaustive.

While uncommon, other causes should not be entirely counted out. Some possible causes include:

1. Ectopic ureter (instead of connecting to the urinary bladder, the ureter transporting urine from the kidney connects to the vagina or rectum so that there is no storage of urine. This condition is typically noted in a puppy that simply cannot be housebroken and leaks urine. The condition can be solved surgically.)
   
2. Spinal damage, especially in the lower lumbar area. Spinal surgery may be indicated to decompress an area of nerve pressure that is interfering with the nerves of urination control.

Your veterinarian is in the best position to determine if it is worthwhile to pursue a rare disease or not. Do not hesitate to ask your veterinarian questions regarding your pet’s incontinence and the treatments or procedures described above.

Uveitis is an inflammation of the dark tissues (uvea) of the eye.  The uvea includes the iris, the ciliary body behind the iris, and the choroid in the back of the eye behind the retina.

Uveitis can be acute or chronic in onset, and anterior (iris and ciliary body) or posterior (choroid and retina) in location. Occasionally, all uveal tissues are involved (panuveitis). 

Uveitis has many different causes, including infectious diseases such as bacterial, viral, fungal, rickettsial and protozoal infections. Penetrating trauma, bleeding into the eye, long-standing cataracts, ingestion of fatty foods, immune-mediated diseases, generalized systemic diseases, and cancer of the eye are also potential causes. Occasionally, a cause is never identified.

Any age, sex or breed of dog or cat can develop uveitis. The underlying causes, however, can be influenced by the pet’s age, sex, breed, the geographic region in which it lives, and the environment.

Diagnosis

Figuring out why a pet has uveitis can be challenging. Unless the cause is obvious on the eye exam (such as a cat scratch, tumor, hypermature cataract), a thorough physical examination is required to search for evidence of disease elsewhere in the body. Numerous tests (complete blood count, biochemistry profile, serology for infectious diseases), x-rays (chest, abdomen), and possibly an abdominal ultrasound may also be needed. If the front of the eye is so cloudy that the structures in the back of the eye cannot be seen, then an ultrasound may be recommended. Ophthalmology requires specialized equipment, and your veterinarian may refer your pet to a veterinary ophthalmologist.

Treatment

The goal of treatment is to resolve the uveitis and any underlying causes.  Immediate priorities are to relieve pain, prevent glaucoma, maintain the normal internal structure of the eye and preserve vision. Treatment usually involves topical eye drops and systemic medications. Therapy is often required for weeks or months. Occasionally, treatment is lifelong. Surgery to remove the eye is rarely required; that is most often indicated for eyes that are permanently blind and painful, have a tumor, or when the inflammation cannot be controlled.

Monitoring

Because pets that have uveitis are at risk for vision problems and treatments often must be tweaked, close monitoring is important. Monitoring involves frequent ophthalmic examinations, including eye pressure measurement to check for glaucoma. Repeated laboratory tests may be required, depending upon the underlying cause and the therapy used.

Prognosis

Prognosis is good to guarded depending on the underlying cause, severity, extent of damage caused by the inflammation, duration of inflammation, response to therapy, and development of negative aftereffects. The best outcome occurs when uveitis is diagnosed early, treated promptly and aggressively, and the underlying cause is responsive to therapy.

An umbilical hernia is a condition in which abdominal contents (fat, intestines, etc.) protrude past the abdominal wall at the location where the umbilical cord was attached to the fetus. Congenital umbilical hernias are more common in puppies than in kittens.

The umbilicus, or belly button, is where the umbilical cord attaches when the puppy or kitten is in the womb. The umbilical cord carries nutrition and oxygen from the mother to the fetus, and waste products and carbon dioxide from the fetus to the mother. Normally, after the puppy or kitten is born, the cord breaks, and the connection at the umbilicus closes up.

An umbilical hernia occurs when the hole doesn’t close correctly. When this happens, skin is the only barrier between the abdominal organs and the environment.

Umbilical hernias are diagnosed on physical examination.

Small hernias do not usually cause any problems, and are often left untreated.

Large hernias should be repaired surgically, because there is a risk that the abdominal contents inside the hernia sac could become damaged or strangulated. Strangulation of intestinal loops can cause blood flow restriction to the intestine, intestinal blockage, etc. Strangulated hernias can become life-threatening; signs can include a large, warm hernia sac; vomiting; abdominal pain; lack of appetite; and depression. Radiography or ultrasonography may be necessary to help diagnose a strangulated hernia.

As long as the hernia isn’t causing problems for the puppy/kitten, the herniorrhaphy (hernioplasty, hernia repair surgery) can be delayed until the scheduled ovariohysterectomy or neuter. However, if strangulation occurs, the surgery becomes an emergency procedure.

The exact cause of congenital umbilical hernias is unknown, but it is generally thought to be a hereditary condition.

These bacteria are anaerobic, meaning that they grow in conditions where there is no oxygen (such as a deep bite wound or puncture). Clostridia are soil bacteria, meaning that they live in dirt so it should be easy to see how a puncture contaminated with dirt would be a classical tetanus-yielding wound. Such wounds are particularly common on farms where there might be nails or bits of wire on the ground, ready to pierce a human or animal foot, but there is nothing special about rusted metal in predisposing to tetanus. The puncture can come from any pointed object. The pointy object provides the puncture (an anaerobic wound) and contamination with dirt provides the Clostridia. A fight involving a bite wound and rolling around in dirt might similarly offer an opportunity for tetanus.

Different animal species have different sensitivity to the tetanus toxin. Horses, humans, and livestock are more sensitive while cats are quite resistant and almost never get infected. We will be confining our discussion primarily to dogs.

The Course of the Disease

The tetanus toxin is called tetanospasmin. It is produced by the bacterium Clostridium tetani in a wound. The toxin binds to local nerves and migrates up into the central nervous system where it interferes with the release of glycine and GABA, both of which are inhibitory neurotransmitters. The result of this loss of inhibition is painful muscle over-activity, spasms and rigidity. In severe cases, the patient cannot breathe because of the rigid paralysis of the respiratory muscles and a mechanical ventilator is required. As a human disease, tetanus has been known and described since ancient times. In the modern world, human death is unusual and is mostly limited to infants and to the elderly, but even in these groups mortality is only 10-15 percent.

Dogs with ears that hang down may actually develop ears that stand up straight, and the facial muscles pull back in such a way as to create what is called the risus sardonicus or sardonic smile. In more advanced stages, the patient can no longer walk and stands stiffly in what is called a sawhorse stance.

In an advanced state of disease, the patient cannot walk or even sit up and is at risk for aspiration of saliva or food contents. If the jaws are locked, feeding may be impossible and if the respiratory muscles become involved, the patient will not be able to effectively breathe.

In dogs, a localized tetanus is more common than the generalized (whole body form) and only the limb nearest the original wound becomes rigid or will tremor. This is an easier form to treat compared to the more generalized; however, the localized form can spread and become the generalized form.

In the generalized form, initial signs seem to pertain to the eyes and can easily be mistaken for eye disease in the early stages.

Testing

There is no test for tetanus in the way you might hope: no blood test or unique finding. The diagnosis is generally made based on the appearance of the animal and history of a wound. It is possible to measure antibody levels against the tetanus toxin but this has not been widely used in the clinical setting. Attempting to culture Clostridium tetani from the wound is generally not successful.

Therapy

The first step in treatment is antibiotics to kill the Clostridia. Happily, unusual antibiotics are not needed: penicillin works quite well for this classical gram positive rod. Clindamycin and metronidazole are also felt to be effective. Improvement is usually obvious in the first week of treatment.

Sedation is necessary to control the spasms and/or seizures. Acepromazine and chlorpromazine have been recommended to control the sensitivity to light and noise. The patient will need a darkened quiet room and may need his eyes covered to reduce stimulation. These medications can promote seizures in other sets of circumstances, but tetanus is the exception. Injectable pentobarbital, phenobarbital, propofol, methocarbamol, diazepam, or midazolam can be used to control the muscles stiffness.

Patients for whom respiratory compromise is a concern (when the respiratory muscles are affected or if there is larynx spasm) may actually need days of general anesthesia, an endotracheal tube (tube in the windpipe to keep an airway open) or even a mechanical ventilator.

The decision on whether or not to include tetanus antitoxin is more controversial. Antitoxin is an antibody solution (a blood product) generated by either a horse or human to bind and destroy the tetanus toxin. It cannot remove toxin already bound to the patient’s nerves but can inactivate new toxin not yet bound. Toxin that is already bound to nerves simply has to unbind in time on its own.

There is a risk in using antitoxin because it is a blood product of another species and highly inflammatory to the immune system. Antitoxin can be given under the skin or in the muscle but can take up to 3 days to reach a therapeutic level this way. Giving it by IV is more rapid but also more dangerous in terms of inducing an anaphylactic reaction. Skin testing is commonly used to see how reactive the patient might be. It is potentially helpful in early stages of disease only.

Tetanus toxoid is the tetanus shot most of us have had at one time or another. It is a vaccine against the tetanus toxin and it is part of a horse’s regular vaccination set, just as it is part of a human’s vaccination set. Because dogs and cats are much more resistant to tetanus than horses and humans, regular vaccination against tetanus is not recommended for them.

Nursing care requires a darkened room with minimal stimulation even if the pet no longer requires hospitalization. Clenched jaws can be problematic for feeding so expect a liquid diet or slurry to be needed. Soft bedding to prevent bedsores is a must.

Improvement is generally noted within the first week of therapy but complete recovery can easily take a month.

Some Tetanus Statistics

Most of the information in this article has been gleaned from a study by Burkitt et al published in the Journal of the American Veterinary Medical Association in January 2007 where 35 cases of canine tetanus seen at the University of California Veterinary Teaching hospital were reviewed for analysis.

Severity Classes

For the purposes of the study mentioned above, cases were classified by the severity of their signs into four groups. It is important to realize that a dog’s initial classification could easily change (in this study 17 dogs that were normal or in Group I at the beginning of the study ended in Group III or IV).

Group I	The dog was able to walk but also demonstrated constricted pupils, risus sardonicus, erect ears, inability to open its jaws, sunken eyes, and/or sensitivity to light.
Group II	All of the above plus erect tail, sawhorse stance, difficulty swallowing, walking stiffly with difficulty.
Group III	All of the above plus muscle tremors or spasms, inability to walk, and seizures.
Group IV	All of the above plus any of the following: heart rate below 60 beats per minute, heart rate above 140 beats per minute, high blood pressure, low blood pressure, or respiratory arrest.

Study Results