Struvite Info

I cribbed this off of our forum at Pugalug. Hilary put this together.

After I wrote the following, I came upon this website written by two people whose expert opinions I value very much – Christie Keith and Nancy Campbell. Much of what they say will be a reiteration of my write-up (or vice versa) but maybe some things in each article will be clarification or worded in a different way. I’d suggest you read their article first as it “cuts to the chase” whereas I sometimes get caught up in the science/research behind things:

http://vettechs.blogspot.com/2005/05/so-your-dog-has-struvites.html.

Struvites, also known as triple-phosphates, are usually caused by the Proteus mirabilis bacterium which produces urease which hydrolizes into ammonia (and hydroxyl) to elevate the alkalinity (high pH – i.e. over about 7.2) of the urine. This chemical reaction produces precipitates in the urine which lead to the formation of struvites. Proteus mirabilis is a gram-negative bacterium which means that its cell walls are such that it produces inflammation and potential toxicity. So the symptoms are painful and uncomfortable.

BTW, there are sterile/metabolic struvites which are not formed in the presence of bacteria but rather through the precipitation of excess minerals from the digestive tract but this is more common in cats and almost non-existent in dogs. More often, though, if the vet says there is no bacterial infection, the testing has not been sufficient/appropriate to detect it. Also, BTW, improper collection and storage of a urine sample can cause it to test positive for struvite crytals – crystals which formed after collection. (This is true for crystals but not, obviously, for struvite stones.)

Personally I think it’s better for the vet to do the urine capture on the spot (by cytocentesis if necessary) and then does a culture & sensitivity test. The sensitivity test will be effective only if the dog has been off antibiotics for several weeks. If cytocentesis is not done, ideally the urine should be collected mid-stream in the early morning and be analysed within the hour.

Why do some dogs get struvites and others don’t? First, exposure to the bacterium - just as some humans contract chicken pox, flu, the common cold, etc. Second, the condition of the dog’s immune system – the stronger the immune system, the better the chance of the dog’s body naturally fighting off the underlying bacterial infection. Third, structural abnormalities of the urinary tract which can harbour the bacteria rather than effectively flushing them through the system.

I have recently learned that the bacteria can clear up on its own (or rather, lay dormant) so you may encounter the presence of struvites without active bacteria - i.e. without a visible nucleoid. However, except in the one in a million example of sterile struvites, the bacteria must have been present to form the struvites in the first place and the bacteria may again be activated if the conditions in the urinary tract are suitable.

The major factors in ensuring the conditions are hostile for bacterial growth/activation are 1) adequate flushing of bacteria through the urinary system, and 2) an appropriate pH level.

What does this mean in terms of treatment and diet?

The first course of treatment is a post-culture round of antibiotics. When the sensitivity analysis comes back, you may have to change the type of antibiotic to one that is effective against the bacteria identified.

By now you will have read that changing the ingredients in a diet is useless, contrary to what most vets tell you (but you probably already know my opinion of most vets’ lack of knowledge about nutrition). Keith and Campbell’s article mentions that Royal Canin Urinary SO food has been formulated as a TEMPORARY diet to dissolve stones, but I am not as convinced. The food, by the manufacturers’ own admission, is not balanced and contains a lot of sodium to induce drinking. This is hard on a dog’s kidneys, especially in the case of older dogs. My take on a diet change is simple –
1) first, take them off kibble. Forever. Kibble, by definition, is a dehydrated food and a good amount of drinking water is needed to reconstitute the food. Even more water is needed to adequately flush the urinary tract and if your dog is not prone to drinking a lot, this can’t occur. Any bacteria that enters the urinary system will not be immediately expelled and can take hold and grow. If the dog is on canned food or cooked or raw, flood his food with water so it is of a stew-like consistency – at least until the bacteria is gone.
2) Feed a well-balanced nutritious diet, free of fillers so that the body is getting the optimum input per volume. This is to strengthen the immune system so the body can fight off infection. A corollary to this is to avoid vaccinations, surgery, stressful situations and other immune suppressants when fighting struvites.

Many people recommend acidifying supplements such as cranberries (or some form such as Berry Balance). I have used these for my own dogs to prevent struvites and frozen cranberries are a staple in my Breakfast Slop recipe. However, there is a huge controversy raging about the effectiveness and potential harm of using cranberries, cranberry juice and cranberry tablets in stone treatment. What almost everyone seems to agree on is that cranberries have some effectiveness in preventing but not treating struvites. Based on my current knowledge, I tend to favour their use and cranberries continue to be a staple in my Breakfast Slop recipe. Here are some articles dicussing the subject more: http://www.stevenfoster.com/education/monograph/cranberry.html. Here’s the scientific discussion: http://www.drugs.com/npp/cranberry.html. This last article is dead against cranberries for treating stones, but it should be noted that they are talking about calcium oxalate uroliths which form in an acid urine. However, they do make some interesting points: http://www.cranberryjuice.eu/, particularly about cranberry juice (the hippuric acid) and the use of antibiotics being contraindicated. This could explain why infections flare up shortly after finishing the course of antibiotics.

Damn. I wonder how much of this information crosses over to the cat world?

Willow was diagnosed with struvite 2 weeks ago. Has had 2 weeks of Clavamox & will be tested again tomorrow. She's allergic to every food except Solid Gold and I see that kibble should not be used if they have struvite. I am anxious to see how she tests. (would that the vet also perform brain surgery, to get her a new one that works). thanks for posting the article.

Miss Pugg wrote:Willow was diagnosed with struvite 2 weeks ago. Has had 2 weeks of Clavamox & will be tested again tomorrow. She's allergic to every food except Solid Gold and I see that kibble should not be used if they have struvite. I am anxious to see how she tests. (would that the vet also perform brain surgery, to get her a new one that works). thanks for posting the article.

I'd switch her to the Solid Gold canned, Joanne. The key is fluid and kibble is too dry in most instances.

Lisa: I don't know how transferrable this info is from canine to feline.

Here's a link to a very fine article in Whole Dog Journal on struvites:

http://www.whole-dog-journal.com/issues/13_4/features/Detecting-Urinary-Stones-Dogs_16215-1.html

Forgive me, I am trying to read this at work and I can't access the blog link. Am I to understand the crystals are the precursor to stones? If crystals aren't treated they will develop into stones? Or are they completely unrelated?

Also, if your dog gets a UTI, is that because of crystals or not? I got confused somewhere in the reading.

papaspugs wrote:Forgive me, I am trying to read this at work and I can't access the blog link. Am I to understand the crystals are the precursor to stones? If crystals aren't treated they will develop into stones? Or are they completely unrelated?

Also, if your dog gets a UTI, is that because of crystals or not? I got confused somewhere in the reading.

I'm glad I'm not the only one confused! I wonder too, if it is a UTI that causes the symptoms-where did the infection come from-stones that already exist and then not enough fluid to flush them out caused the infection?
If there isn't an infection, and there's symptoms caused from having crystals, making sure they're eating a proper diet and getting enough water prevents issues in the future?

The short short story is that bacteria get too comfy in the bladder and build skyscraper cities out of minerals which cause the stones to form. Very occassionally the bacteria become extinct before the stones cause enough trouble to be noticed and then it looks like there are stones but no infection.

There are many different types and strains of bacteria. Some dogs carry bacteria populations and never have trouble, or only rarely. There are a LOT of different variables. Short version answer is firstly work with your vet to clear the bacteria and dissolve/remove existing stones and while that is happening you can research supplements, diets etc.

ETA: I'm going to look silly after I've read the link probably!

Puggered wrote:The short short story is that bacteria get too comfy in the bladder and build skyscraper cities out of minerals which cause the stones to form. Very occassionally the bacteria become extinct before the stones cause enough trouble to be noticed and then it looks like there are stones but no infection.

There are many different types and strains of bacteria. Some dogs carry bacteria populations and never have trouble, or only rarely. There are a LOT of different variables. Short version answer is firstly work with your vet to clear the bacteria and dissolve/remove existing stones and while that is happening you can research supplements, diets etc.

ETA: I'm going to look silly after I've read the link probably!

Here's my understanding. Most often there is infection when there are crystals--either because there was an infection and crystals took hold or (sometimes with struvites) the crystals themselves irritate everything and infection develops. It's very rare for dogs to have sterile (no infection) struvites, but it can happen and we have dog in foster care now who does have them. Struvites respond well to lowering the pH level in the urine and don't form stones as readily as calcium oxalate.

Calcium oxalate are the most likely to form stones and can't be dissolved with diet or meds (or that's my understanding). The formation of calcium oxalate is encouraged in urine with too low a pH. This is where the use of things like cranberries, etc can get dicey. Too high pH--struvites. Too low pH--oxalates.

In all cases of crystals, you want to flood food with water or unsalted stock and encourage peeing as much as possible.

We see way more struvites than calcium oxalate crystals and we see a lot of crystals.

Very interesting. So you think Willow should eat canned rather than kibble? Would it help if I'd soak her food with hot water until I go back to the vet in 2 weeks? Is this possible, and I didn't go into it with her, but could she have elevated white cells and no struvite? She first said there were no struvite, then went to look at the test again and said the white blood cells were still high. Doesn't this indicate infection someplace? I never have time to go into details with her because I'm holding onto 3 dogs, trying to get things figured out, juggling purse, dogs, medicine, notes, pen, and talking to the vet about another dog's problems. Oh yes, Willow didn't get a brain transplant today, she's on the waiting list *G*. She was on a diet for the last 2 weeks and gained a pound, ouch.

Sorry I don't know how to use "multi-quote" so I'll address the posts individually:

Not Afraid wrote:Damn. I wonder how much of this information crosses over to the cat world?

A lot from what I've read (but not paid too much attention to the cat perspective). Just do an internet search for "struvites cats" and you'll get a lot of hits. Read all of them and compare/contrast as there can be some divergent opinions/recommendations. Obviously place more credence in scientifically-sourced links.

One major difference in dogs and cats is that cats are a LOT more prone to sterile struvites. Also dietary considerations may be different.

papaspugs wrote:Forgive me, I am trying to read this at work and I can't access the blog link. Am I to understand the crystals are the precursor to stones? If crystals aren't treated they will develop into stones? Or are they completely unrelated?

The terminology can be confusing but usually the term for struvites is "crystals" and the term for calcium oxalate uroliths (COUs) is "stones". Sometimes you will hear the term "struvite stones" as the aggregation of crystals can become quite large.

Struvites and COUs are polar opposites because their causes and prevention are different so when treating for one type, you have to be careful not to create conditions that are favourable to the creation of the other (i.e. pH levels).

Struvites form when pH levels are high (alkaline - over 7.2); COUs form when pH levels are low (acid - under 5.5).

Struvites are caused by bacterial infection (which raises pH); COUs are not.

Both involve the build-up of urinary minerals and both are helped greatly by the adequate flushing of the urinary system (i.e. lots of drinking water and switching from kibble to wet food).

Struvites can be dissolved; COUs generally have to be removed - by hydropropulsion or surgery.

Here's a good description from a reputable source about the different types of stones. Bear in mind that this was written about human stones but the general information translates to animals: http://www.mayoclinic.com/health/kidney-stones/DS00282/DSECTION=causes

papaspugs wrote:if your dog gets a UTI, is that because of crystals or not?

No, it's the reverse. Here's what happens.

Normal urine is sterile (free of bacteria) but does contain urea, an chemical compound formed as waste when the body metabolizes protein.

Sometimes bacteria (usually E. coli) enter the body from the outside, especially in females, and moves upwards through the urinary system (which is quite short in comparison to ours). This is when there is a UTI (bacteria = infection).

This bacteria splits the urea out into its component parts - magnesium, phosphorus and ammonium (that's what causes the strong smell) - and elevates the pH of the urine where bacteria live comfortably.

In an ideal world, these minerals are flushed out of the body with adequate hydration. However, when the urine is supersaturated with these minerals and there is inadequate flushing, the minerals will precipitate out, glob together and form struvite crystals.

UTIs can exist which don't develop into struvites, but struvites always form in dogs (not necessarily in cats) because a UTI is or has been present. So-called sterile struvites are extremely rare in dogs and are probably present only if there was a pre-existing bacterial infection that no-longer shows up.

Thanks, I think that I have a better idea of the differences and the terminology.

[quote="Tyson&LuLu'sMom"]

papaspugs wrote: I wonder too, if it is a UTI that causes the symptoms - where did the infection come from - stones that already exist and then not enough fluid to flush them out caused the infection?

See above: bacteria comes from outside (e.g. could be from fecal matter getting too close to the urinary opening).

The sequence is: bacteria ... UTI ... urea breakdown into mineral components/increased pH/insufficient water ... struvites


[quote="Tyson&LuLu'sMom"]

papaspugs wrote:If there isn't an infection, and there's symptoms caused from having crystals, making sure they're eating a proper diet and getting enough water prevents issues in the future?

There is controversy about whether diet eliminates struvites. The old research says yes but more current theory is no, that antibiotics (ABs) are needed to get rid of the underlying infection. I would agree with the need for ABs but I also think there are incidences where the infection goes away on its own* (I wouldn't count on it as a treatment, though! and would always recommend the appropriate AB). If you have a dog with struvites and no UTI, then I suspect there has been a prior infection which caused the struvites which haven't been dissolved and flushed out of the system because of lack of water.

* I used to be adamant about the need for ABs to get rid of the underlying infection but challenged this belief in October when Denver had a lot of struvites and high pH (I believe he had a high bacterial count too, but I can't put my hands on the report this morning) diagnosed on the Friday. He needed dental surgery which I booked for the following Wednesday. I intended to take in a fresh sample on the Wednesday to have a culture and sensitivity done to determine which antibiotic should be used to combat the bacteria. In the meantime, I added a lot of cranberries to his meals (to acifiy the urine) and flooded his meals with water (despite the fact I don't use kibble). When they did the in-house urinalysis on the Wednesday before sending the urine sample to the lab for the C&S, they found no bacteria, no struvites and a pH within normal range (6.0). I was astounded and asked the vet how this could have happened without the intervention of ABs. She said that I had lowered the pH of the urine sufficiently and made the environment so hostile, I had killed the little buggers off. Hey, whatever works.

Miss Pugg wrote:So you think Willow should eat canned rather than kibble? Would it help if I'd soak her food with hot water until I go back to the vet in 2 weeks?

ABSOLUTELY and ABSOLUTELY! And I'm now a firm believer that any dog who has had struvites or COUs should be switched from kibble to wet for life. In fact, I think every dog should be switched off kibble as a preventative, but I acknowledge that I'm a radical when it comes to the canine diet.

Miss Pugg wrote: could she have elevated white cells and no struvite? She first said there were no struvite, then went to look at the test again and said the white blood cells were still high. Doesn't this indicate infection someplace?

Yes, elevated WBC always indicates infection but it could be elsewhere in the body. You want to determine if there are bacteria (UTI) present through urinalysis, not by bloodwork. This will be more specific and will tell you the type of bacteria you're dealing with.

Jana, the crystals due form together to create stones. As for having crystals without infections, I can't say 100% if it is possible or not. I know that Chyna has had crystals without infection and so did Pugsly, but maybe there was infection deep in the bladder lining.

I also want to agree in the fact that crystals may be present in the urine even though an animal doesn't have them. They can form if the urine has been sitting too long, etc.... My vet told me this a long time ago which is why she always preferred me to get a sample at the vet's office verses catching it at home and bringing it to her. The more time the urine sits (even refrigerated) can produce false tests

papaspugs wrote:Forgive me, I am trying to read this at work and I can't access the blog link. Am I to understand the crystals are the precursor to stones? If crystals aren't treated they will develop into stones? Or are they completely unrelated?

Also, if your dog gets a UTI, is that because of crystals or not? I got confused somewhere in the reading.

This is awesome information!! My current foster had struvite crystals, which formed into a stone and had to be removed before she came into rescue. I am going to compile a lot of this information and put it together for her potential adoptive family, whenever she gets one.

I did take her immediately off kibble (her old owner's were feeding her Kibble's n Bits) and put her on The Honest Kitchen. I was giving her a vit c supplement, but when I put her on THK Zeal formula, which has cranberries as an ingredient, I stopped the vit c.

For sure struvites can form if the urine is not handled properly and processed promptly. At Pugalug we've had two recent cases of this and insisted our vets retest at no charge.

Please remember not to give cranberries while the dog is on antibiotics.

Great info! Zoe was just diagnosed with Struvite crystals. Her new vet immediately put her on abx and said she needed to be put on rx food...for life. I'm a bit concerned. When I talked to the vet at PetSmart, with the precursor of not seeing the urinalysis results, he said he would suggest she finish the abx first as if you start the rx food, she will be on it for life. Was this new vet quick to prescribe? He doesn't have the same bedside manner as my last vet, so I am having a hard time trusting him. Sad thing is, Zoe won't even touch her dinner. Ugh..she does that sometimes.

Mel wrote:Great info! Zoe was just diagnosed with Struvite crystals. Her new vet immediately put her on abx and said she needed to be put on rx food...for life. I'm a bit concerned. When I talked to the vet at PetSmart, with the precursor of not seeing the urinalysis results, he said he would suggest she finish the abx first as if you start the rx food, she will be on it for life. Was this new vet quick to prescribe? He doesn't have the same bedside manner as my last vet, so I am having a hard time trusting him. Sad thing is, Zoe won't even touch her dinner. Ugh..she does that sometimes.

Struvites are naturally occurring in many, many dogs. the only time struvites are of concern is when there is bacteria / infection to cause the struvites to grow and form stones.

I think many vets are quick to just say 'prescription diet for life'. I am not discounting that for some people, this is the course they need to take, but I would suggest being educated first and deciding what Zoe's needs.

Personally, I would rather do antibiotic therapy before doing a prescription diet for life.

What Renee said. Norman is on a high protein diet and probably has struvites naturally (read a lot on Whole Dog Journal about how its fairly common). However earlier this year he developed a UTI and the crystals became an issue. I actually have a nasty note in his "permanent file" at our ER because I refused the prescription diet (which I was advised he'd need to be on for life).

After 14 days on clavamox (and a med that loosened up the muscles so the crystals could be pee'd out...all was (and is) well. He still gets the same food (Honest Kitchen) and I just make sure everybody gets extra water with it. They also get HK's ice pups broth a couple times a week and if anybody is acting "off" I'll just give some sub-q's to perk 'em up. He's also not allowed to be lazy when I'm not home and is forced to go out for frequent pee breaks (formerly he'd just lounge on the couch waiting for me to get home and ignoring hubby unless food was involved, holding his urine was like putting the welcome mat out for bacteria).

The note in the file made me laugh - the vet probably didn't realize that my vet would give me a full copy of the ER report (as I'm an ocd mom and keep a copy of everything for my own purposes).