My Cavalier King Charles (CKCS) 2 year old spayed female always has white blood cells in her urine. She has been treated about 3 or 4 times with antibiotics, however, the white blood cells do not disappear. Her vet thinks that for the amount of white blood cells she has it is not a big deal and we don’t have to be concerned. Would you agree that this is not a dangerous situation and she doesn’t have to be on antibiotics?

~ Dora

Dr Sara ChapmanDear Dora,

It is good that you are seeking advice about your girl’s health issue. It seems as if you may not understand the significance – or lack thereof – of white blood cells in a urine sample. Let’s review how we diagnose a urinary tract infection, what the various components of the urinalysis mean, and options for treating problems in the urinary tract.

We say that an individual has a urinary tract infection (UTI) when they show signs of a UTI and there is laboratory verification that a UTI is present. Signs suggestive of a UTI can include: frequent and / or painful urination, urinary accidents, blood in the urine, and straining before, after or during urination. Some of these signs can also indicate other problems; for instance, animals with kidney degeneration or diabetes will urinate more and may have accidents. Animals with bladder stones, diabetes, and certain other metabolic diseases, are more susceptible to bladder infections. It is important to treat animals for problems which they actually have, rather than guessing what is going on based solely on their signs. This is why urinalysis is so important, whenever your companion has a problem involving the urinary system. A first morning urine is especially helpful, so do try to collect one before a vet appointment, and refrigerate it (for up to 12 hours) if your friend is having urinary problems.

Let’s look at the components of the urinalysis, and see what they can show us. Remember, these components are evaluated together with an individual’s physical exam, signs of illness, and other lab tests. No one component seals a diagnosis or treatment; they are all part of the full picture.

1 – Collection method: If urine is collected in a container, as the animal urinates, it collects material from all parts of the urinary tract. In a female, this is the urethra and vulva, in a male the urethra and prostate. If a urine sample is collected by cystocentesis (tapping through the body wall) it may have a few red blood cells from the process of tapping, but otherwise just collects bladder urine. Similarly, a catheterized sample (usually only done with male dogs) only collects urine from the bladder.

2 – Colour and clarity: A gross indication of the presence of material in the urine, and the concentration of the urine. More concentrated urine is more yellow, and debris in the urine makes it cloudy or discoloured.

3 – Specific gravity: The measured concentration of the urine, accurately measured with a refractometer, not a dipstick pad. Any random value can be normal; if a dog’s specific gravity is greater than 1.030, this documents adequate kidney tubule concentrating ability. All values are interpreted in light of an individual’s hydration status and other signs.

4 – pH: The measured acidity or alkalinity of the urine; this is a crude indication of acid – base balance. Animals on high protein diets tend to have urine with a lower (more acidic) pH. Animals with urinary tract infections or urinary calculi (stones) may have a higher (more alkaline) urine pH.

5 – Protein: A qualitative (a little 1+ to a lot 3 +) measure of protein in the urine. A small amount of protein in the urine can be normal, a large amount can indicate problems in the kidneys, bladder, or lower in the urinary tract. Further investigation is needed to evaluate the significance of protein in the urine.

6 – Glucose: A measure of sugar in the urine. The most common cause is diabetes, but false positive tests are possible, and kidney disease can also cause glucose in the urine. Tests for blood glucose levels are necessary.

7 – Ketone: Ketones are fat breakdown products which should not be in the urine; they can appear with fasting and complications of diabetes.

8 – Bilirubin: A small amount of bilirubin may be normal, especially in male dog urine. Bilirubin can also appear if there is liver disease or bleeding problems.

9 – Blood, RBC: Blood and red blood cells can appear in the urine for both benign (ruptured blood vessel during urination) and worrisome reasons, such as infection, tumors, kidney disease or bleeding disorders.

10 – WBC: White blood cells indicate inflammation, not infection. Inflammation can occur because of urinary tract infection, calculi (crystals or stones), or tumors. WBCs can also originate from inflammation of the vulva, prostate, or prepuce, so a cystocytensis sample should be evaluated to eliminate those sources. If WBCs persist in the urine, a sample should be obtained via cystocentesis and cultured to determine if organisms are present.

11 – Bacteria: Bacteria can be present in urine samples contaminated after they are collected, or bacteria can truly indicate the presence of bacteria in the urinary tract. Not all urinary tract infections shed bacteria in the urine, which is why cultures are needed if a urinary tract infection (UTI) is suspected.

12 – Cells: Some cells are normally present in the urine, other cells, such as ones that may shed from bladder tumours, are abnormal.

13 – Casts: These may be present when an animal has kidney disease.

14 – Crystals: Crystals form when the urine is oversaturated with substances that form crystals. Different crystals form with different disease conditions, and the pH, concentration, and temperature of the urine affect how many crystals will be present. Crystals may make it more likely for an animal to develop bladder or kidney stones, but they do not necessarily indicate the presence or type of stone.

As you have probably already surmised from this discussion, we don’t really know if the WBCs in your spayed CKCS’s urine are significant or not. I would suggest that you see if your vet can get a sample via cystocentesis to see if the WBC are truly coming from the bladder. At my hospital we collect the urine in a sterile manner, and split the cystocentesis sample between two tubes – one for the urinalysis, and one for culture if the urinalysis results are suggestive of infection. If they are, the second tube can be sent off for culture without requiring the patient to make another trip in. Culture results would then guide a sensible choice of appropriate antibiotics, if you choose conventional treatment. Holistic and homeopathic treatment is very effective with bladder infections, and would need to be individualized with your holistic or homeopathic practitioner.

If a urine sample via cystocentesis does not show WBCs, this means that the WBCs are being flushed out further down the urinary tract. In my experience, many females who are spayed when they are young have an immature vulva. This means that the vulva is small and recessed. In addition, CKCS have a tendency to be plump, and they are very hairy around their rectal and vulvar area. It is entirely possible that your girl has a low grade inflammation of her vulva which is causing her to shed WBC in her urine. If this is the case, the best thing to do is to keep the area clean, and the inflammation will typically resolve on its own. Clip off enough hair that you can easily clean the area by wiping around the vulva, and in the vulvar folds, once or twice a day. Unscented baby wipes are an easy choice for cleaning, and most dogs will allow this if you incorporate a nice belly rub into the procedure. Once the area is clean, apply a gentle cornstarch based baby powder like Burt’s Bees to the area, especially in the folds between the vulva and the thighs.

Please bear in mind that antibiotics are vastly over used in the human and veterinary fields. Overuse of antibiotics leads to more drug resistant bacteria, as well as drug reactions. Please be certain, before you start using antibiotics, that you are truly dealing with an infection which requires whole body treatment with these powerful medicines. Remember, antibiotics don’t discriminate between good and bad bacteria; they just kill all of them. Animals who are receiving antibiotics should also receive probiotics (beneficial bacteria, to replace those the antibiotics kill) for the duration of treatment and for at least a week afterward. Give the probiotics about two hours after each dose of antibiotics. Of course, if you are working with a holistic vet, you will find that you will likely be able to avoid the use of antibiotics in most situations.