Today we will meet Cinnamon, a young rabbit who one morning started looking very painful. We will learn how Cinnamon’s vet first diagnosed her problem, what treatment was needed, and the ongoing management of her condition. For anyone with a pet rabbit, Cinnamon’s case will be very important to remember.

Table of contents

Meet Cinnamon

Cinnamon is a 4-year-old female neutered dwarf lop rabbit who lives with her male neutered companion, Strawberry. She was previously a very healthy rabbit and had not visited the vets before. She lived outside in a shed with a large run. Cinnamon was sometimes moved indoors when the weather got cold. She was fed primarily forage and hay, with a handful of pellets and treats on occasion; and she had free access to water and a litter tray. She and Strawberry generally got on well.

Cinnamon’s owner noted one morning that she did not come out of her hide for feeding time, which was unusual. Looking into the shed, the owner noted Cinnamon was sitting in the litter tray and wasn’t keen to move. She was quiet and had some urine staining on her belly that wasn’t present the night before. Strawberry seemed normal. The owner was worried Cinnamon was constipated, so brought her to the vets that day.

First Visit

The vet called Cinnamon in, and her owner explained what the symptoms were, detailing the history above. The vet agreed that Cinnamon did not look like a happy rabbit, though noted that rabbits are often very withdrawn at the vets due to fear.

On examination, Cinnamon was quiet but mentally active and looking around. When placed on the floor, she wandered around. Her eyes, ears and nose looked clean. The vet checked her mouth next – they advised the owners that a detailed dental examination is difficult with conscious rabbits, but that Cinnamon’s teeth were generally healthy with no overgrowth or damage to the gums, tongue or cheeks.

Listening to Cinnamon’s heart, the vet recorded it as over 320 beats per minute. Fast for a rabbit, but it may have been partly due to stress. Her breathing rate was also elevated. She was a good weight. Her temperature was normal, but the vet agreed there was urine staining on her belly.

Finally, the vet gently palpated her abdomen – Cinnamon was very uncomfortable, especially when squeezed in the rear-half of her abdomen. She tensed and produced a few drops of what looked like very cloudy urine and she was too tense to properly palpate individual organs. She didn’t react when her spine was pressed on, meaning the pain was likely located within her abdomen.

Causes of Abdominal Pain in Rabbits

There are many causes of abdominal pain in rabbits, and the vet considered all these differentials before coming up with a plan.

One of the most common is gut stasis

This is a condition where the intestines slow down or stop, resulting in food no longer passing through the GI system. This results in pain, bloating, a build-up of bacteria and their toxins, anorexia and death if left untreated. It can be caused by many other conditions, such as dental disease, kidney disease, poor appetite, stress, injuries and more. Luckily for Cinnamon, her owner reported she was eating and pooing normally so there were no current signs of gut stasis, though the vet advised secondary gut stasis may occur.

Blockages, torsions (twisting of the guts) or bloat 

These can all cause similar symptoms to gut stasis, but tend to be more severe. The prognosis is generally worse, particularly if not identified quickly. Many of these rabbits will require surgery to correct the condition. 

Rabbits that have previously had surgery may get a condition called adhesions

This is where after an injury, usually intentionally caused by a surgeon during a procedure like an ovariohysterectomy, the healing organ sticks to another organ or the body wall. This can result in pain, infertility and blockage. This was possible in Cinnamon, since she had had her reproductive organs removed when she was 6 months old, but it seemed less likely given how long ago she was neutered.

Arthritis

In older rabbits in particular, osteoarthritis can lead to pain in the hips and spine which can present as abdominal pain. It can be tricky for vets to distinguish between abdominal and osteoarthritic pain. However, Cinnamon did not appear to be painful in her joints, and was likely too young for arthritis.  

Unfortunately, as in all animals, cancer occurs in rabbits too

When located in the abdomen, they can cause pain as well as dysfunction with the organ they are associated with. In entire females, cancers of the uterus are quite common – being spayed, this was not possible in Cinnamon. Other common cancers include lymphoma, mammary cancer, and thymomas (cancer of the thymus in the chest). Though cancers can occur at any age, they are more common in older rabbits, and the symptoms tend to not be acute. Cancer seemed unlikely to be causing Cinnamon’s symptoms. 

Finally, there can be problems with the urinary system

As with dogs and cats, these include cystitis (bladder inflammation), urinary tract infections, bladder crystals, bladder stones, kidney disease and cancer. Given Cinnamon had urine scald and was passing cloudy urine, the vet believed she was having a urinary problem.  

Initial Treatment Plan

The vet advised Cinnamon’s owner that a urinary problem was the likely cause of her symptoms. They said she may have a simple cystitis or urinary tract infection, but couldn’t rule out more serious disease like stones or cancer. They gave them three options: 1) to treat for cystitis and collect a urine sample in the meantime; 2) to trial antibiotics in case there was an infection; or 3) to perform a conscious ultrasound scan on Cinnamon to identify any possible bladder stones or signs of kidney disease.

All options had their pros and cons. Treating for cystitis may be a quick and easy fix, but if there was more serious disease it may delay treatment. In the worst case, prolonged illness could lead to secondary gut stasis or blockage. Treating blind with antibiotics is not a good use of these drugs, so was not recommended. A scan would give the vet a lot of information, but would cost the owner more and not all diseases show up on the scan.

In the end, the owner opted to take some meloxicam anti-inflammatory painkiller to help with any cystitis, and some non-absorbent litter to collect a urine sample. The vet asked if Cinnamon could come back the next day, as they were worried she might deteriorate fast. 

The Urine Sample

Cinnamon’s owner managed to collect a urine sample that day and dropped it in straight away. The urine looked very cloudy and thick, and was even too abnormal for the automatic urine machine to analyse. The vet had to look manually under a microscope. They also used a refractometer to test the concentration of the urine.

The urine specific gravity was off the chart, meaning it was very concentrated. A dipstick showed it was slightly alkaline, had a lot of protein and blood in it. Manual microscopy showed lots of non-specific sediment and some inflammatory cells, demonstrating there was cystitis. However, there were low to no numbers of bacteria, making a urinary tract infection less likely. The vet informed Cinnamon’s owner of the findings, but did advise they cannot completely rule out other diseases, like bladder stones or UTI. However, they both agreed to see how Cinnamon did over the weekend, and reassess on Monday. Again, the vet reminded the owner to look out for signs of urinary blockage or gut stasis.

Monday’s Recheck

Cinnamon represented again Monday – she was a little off her food on Saturday but picked up on Sunday, and was passing faeces still. However, she was still urinating in odd places and looked like she was straining. Clearly the problem hadn’t gone away yet. 

On exam, Cinnamon was much the same as before. When her abdomen was palpated, it was still painful, but the vet was able to feel individual organs better now. They noted her bladder was particularly painful, and felt quite hard. Squeezing it caused Cinnamon to release cloudy urine again. Feeling this hard bladder, the vet was concerned there may be a stone in it and again recommended an ultrasound scan.

This was performed conscious on Cinnamon – the scan showed a very thickened bladder wall (a sign of inflammation), with little urine inside it. There was a lot of shadowing from one or two very dense objects within the bladder. A bladder stone seemed even more likely now.

Reporting the findings to the owner, the vet explained that any stones could only be removed with surgery. Without surgery, Cinnamon would continue to be in pain, and there was a risk her bladder would completely block, resulting in a buildup of urine or even bladder rupture. However, as the owner knew well, surgery in rabbits are not simple procedures, and they are at a higher risk of anaesthetic death than other species. There were also the risks that there were not stones in the bladder and the surgery may be unnecessary, or they may find something more serious and difficult to deal with. Complications including post-operative gut stasis, cystitis, infection, wound breakdown and death were also possible.

After considering the options, the owner agreed to proceed with a surgery that day. 

Cinnamon’s Surgery

Cinnamon would undergo a cystotomy (entry to the urinary bladder) via a midline laparotomy (an incision into the abdomen) to remove bladder calculi (bladder stones). 

To prepare for surgery, an intravenous catheter was placed in Cinnamon’s ear vein – this would enable the veterinary nurses to administer fluids during the procedure to stabilise her blood pressure, as well as give a route for medications if there was an emergency. She was then placed in an oxygen chamber for 10 minutes – pre-oxygenating rabbits before surgery increases the amount of oxygen in their system, making apnoea (reduced or no breathing during surgery) less dangerous. These two steps are important for rabbits due to their higher risk of death under a general anaesthetic.

Cinnamon was then given a premedication injection of medetomidine and ketamine – these are powerful drugs that cause sedation and pain relief before surgery. Once Cinnamon was calmer, the rest of her medications were given – these were buprenorphine (pain relief), meloxicam (pain relief and anti-inflammatory) and metoclopramide (a promotility agent to prevent gut stasis).

By this point, Cinnamon was sedated enough to induce anaesthetic

A V-gel was placed over her airways – this device is an alternative to endotracheal tubes in rabbits, and allows the passage of oxygen and anaesthetic gases. This was tied to her head to keep it stable. Isoflurane vapour in oxygen was used to maintain anaesthesia. The vet nurses then shaved Cinnamon’s lower abdomen and thoroughly cleaned and sterilised it, while the vet sterilised their hands. The vet applied a small amount of lidocaine local anaesthetic to her surgical site too. Surgery could now begin. 

The vet started by incising into her abdomen. This was done slowly, layer by layer – rabbits have very thin skin and muscles in their abdomen, and going too fast could result in unwanted damage. Entering the abdomen, the vet was careful to push the large caecum (a digestive organ) out of the way to expose the bladder. The bladder was gently pushed out of the abdomen and held in place using temporary sutures. It was clearly very inflamed, so care would be taken when cutting into it.

Cutting into the bladder, almost immediately a large bladder stone was visible 

This was removed and placed in a pot for analysis later. The vet used sterilised saline to wash the bladder out repeatedly – this would remove any microscopic crystals from the stone and bacteria. Lidocaine was applied to the bladder to help reduce pain here too. Once happy there were no more bladder stones, the vet closed the bladder with two layers of suture, and then the midline incision. Cinnamon could now be woken up. 

She had a slow but uneventful recovery and was ready to go home that evening. She would need to continue her meloxicam pain relief, as well as metoclopramide to prevent gut stasis, and enrofloxacin antibiotic to prevent secondary infections. The vet wanted to see her back in 1-3 days, and the owner would need to monitor her closely at home. 

Follow-Up

Cinnamon was seen two days later for a post-op check, and was reported to be doing very well. She was still a little quiet, but eating and taking her medications well. Her wound was a little sore but holding together. She was still slightly uncomfortable in her abdomen, but given how inflamed her bladder was, this was not unexpected. She was also producing normal urine now. This was a good start. Her pain relief was increased to try and soothe her sore bladder, and a recheck appointment was made at the end of the week.

She was again doing well at her subsequent appointment, so it was decided to try and wean her off her medications. However, she started showing signs of pain a week later, so the owner and vet decided to continue pain relief for the foreseeable future until her bladder had calmed down. She was happier on the medication, so the risks of long-term use were outweighed by the benefits.

What Was the Stone?

During this time, the stone taken from Cinnamon’s bladder had been analysed – it was a calcium carbonate stone. Calcium stones are the most common stones found in rabbits, and can be caused by high dietary calcium, stress, urine pH abnormalities, low water consumption and reduced mobility. Cinnamon’s diet was generally good, but the vet and owner sat down to determine what foods were riskier and which were safe for Cinnamon.

The riskiest foods (those with high calcium) are alfalfa hay, kale, carrot tops, spinach, parsley and spring greens. The owner admitted Cinnamon often had kale and spinach, so would reduce these. To combat the formation of new calcium stones, the owner would try to increase Cinnamon’s water intake via more water bowls, giving washed greens to her still wet, and sweetening the water with a small amount of apple juice to encourage intake. She also stuck to leafier greens like celery, cauliflower, broccoli, carrots and sprouts, all of which are lower in calcium. Encouraging exercise, keeping her slim and monitoring for gut stasis and cystitis would also reduce the risks. 

Ongoing Management

Cinnamon is currently doing fairly well – she has recovered completely from her surgery, but remains on meloxicam pain relief for her sore bladder. The goal will be to eventually wean her off this once safe to do so, but she still seems sore when this has been tried. The vet has not ruled out another underlying disease causing problems, but a subsequent urine test seemed to show only signs of cystitis. Given how unwell Cinnamon was, both the vet and owner are very happy she pulled through her ordeal. 

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Key Points:

  • Rabbits with abdominal pain can go off their food, looked hunched over, strain, become withdrawn or less active
  • Abdominal pain can be caused by gut stasis, urinary disease, reproductive disease, osteoarthritis, cancer and more
  • Calcium stones are very common in rabbits, and are caused by dietary, exercise, stress and health-related factors 
  • By the time they are large, surgery is often the only way to remove bladder stones
  • Anaesthetics and surgery in rabbits are much riskier than in dogs and cats, but steps can be taken to minimise these risks 
  • To prevent recurrence of bladder stones, a rabbit’s diet should be adjusted, water intake increased, exercise increased, obesity prevented, and gut stasis prevented

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