Approach to and Management of LUT and Prostatic Disease Flashcards
Dysuria
Difficult and/or painful urination
Stranguria
Slow & painful urination or straining to pass urine
Pollakiuria
Abnormally frequent passage of small volumes of urine
Two processes cause dysuria
Mucosal irritation or inflammation (cystitis)
Narrowing or obstruction of the urethra or bladder neck
Why do we need to look at biochemistry when animal has stranguria
Obstruction or bladder rupture causes:
Post-renal azotaemia
Hyperkalaemia
Metabolic acidosis
Calcium containing uroliths can be due to hypercalcaemia
2 reasons for urine retention
Obstruction
Structural problem (more common)
Functional problem
Failure of relaxation of urethral sphincter (eg. UMN lesion)
Failure of detrusor muscle contraction (detrusor atony)
Dyssynergia
Causes of urinary incontinence
Pressure in bladder > urethra
↓ detrusor compliance
- Detrusor instability (primary rare)
↓ urethral tone
- Bladder/urethral neoplasia
- UTIs
- Prostatic problems
- Overflow incontinence (pu/pd)
Anatomical abnormality bypassing urethral sphincter mechanism
Urinary incontinence
Involuntary leakage of urine through urethra
Signs of LUT infections
Urgency, haematuria, dysuria, pollakiuria & stranguria
Urinary incontinence
(Urinary retention)
Bladder may be small & thickened
When to suspect a UTI
History & clinical signs of bladder inflammation
Protein, blood, WBCs, pH ↑ on urinalysis
Imaging – thickening of bladder wall
When to culture urine
All animals with LUT signs
All animals with renal disease
Animals with non-specific/vague signs
Sporadic bacterial cystitis
Sporadic bacterial infection of the urinary bladder with compatible LUT signs
<3 episodes of cystitis in previous 12 months
Recurrent bacterial cystitis
Animals that have had 3 or more episodes of clinical bacterial cystitis in previous 12 months OR 1 recurrence in previous 3 months
May be relapsing, recurrent or persistent
Asymptomatic bacteriuria
Animals with bacteriuria in the absence of clinical signs
Treatment – sporadic bacterial cystitis
3-5 days treatment
Ideally based on culture & sensitivity
Amoxycillin or amoxycillin-clavulanate if:
- Cocci
- Small paired rods in alkaline urine (proteus)
Not predictable if rods in non-alkaline urine
- Consider – amoxicillin, cephalexin, TMPS
Treatment – recurrent bacterial cystitis
Urine culture should always be performed
Analgesia
Investigations for nidus of infection (relapsing/persistent) or reason for susceptibility (reinfection)
Ultrasound, radiography, cystoscopy may be considered
Review previous choice of antimicrobials
follow-up bacterial culture (5-7d after tx):To help differentiate relapse, re-infection, persistent infection
Complications of UTIs
Polypoid cystitis
- Can occur due to chronic UTIs
- Consider partial cystectomy
Emphysematous cystitis- Gas in the lumen & wall of bladder
- Glucose-fermenting bacteria (usually E.coli)
- Treat cause of glucosuria
List common benign bladder masses
Polypoid cystitis – inflammatory lesion
Leiomyoma
List malignant bladder masses
Transitional cell carcinoma
Squamous cell carcinoma
Leiomyosarcoma
Rhabdomyosarcoma
Prostatic neoplasia
Metastatic neoplasia
What dog breed is predisposed to transitional cell carcinoma
Scottish Terriers
Presentation of transitional cell carcinoma
Signs of lower urinary tract inflammation
Can cause urine retention
Can cause urinary incontinence (rare)
Diagnosis of bladder masses
Diagnostic imaging (ultrasound/radiographs)
- Thickening of bladder wall & mass lesions
- Mostly occur in trigone region (dogs)
Urine sediment analysis
- Neoplastic cells may be detected
Cystoscopy
- Abnormal irregular proliferation from bladder wall
Cytology or Biopsy
- For definitive diagnosis
Reflex dyssynergia and presentation
Loss of coordination between bladder & urethral sphincter muscles
Steam initiated but not maintained, large residual urine volume, difficult to express bladder
Dog breed predisposed to reflex dyssynergia
Labradors
Treatment for reflex dyssynergia
Decreasing internal urethral sphincter tone using medications like prazosin/phenoxybenzamine
Reducing external sphincter tone with drugs such as diazepam/dantrolene, Increasing detrusor contraction using bethanecol in the management of certain urinary conditions.
Bladder atony
Bladder atony is a condition characterized by loss of bladder muscle tone, leading to a distended, flaccid bladder, weak urine stream, and may be primary (neurological) or secondary to chronic overstretch
Treatment for bladder atony
Indwelling catheter – to rest detrusor
Bethanechol – after obstruction removed
What is USMI
Urethral sphincter mechanism incompetence
Risk factors for USMI
Congenital or acquired
Female > male
Often within 3 years of spaying
USMI diagnosis
Intermittent urine leakage & incontinent at rest
Can urinate normally
Often presumptive (spayed bitches)
Summarise why diabetes can cause pu/pd
Due to elevated blood glucose levels leading to osmotic diuresis, resulting in increased urine output, and the body’s compensatory mechanism to eliminate excess glucose by increasing thirst
Name 3 drugs used for USMI treatments
Phenylpropanolamine (Propaline)
Estriol
Ephedrine
Effect of Phenylpropanolamine (Propaline)
Type: α sympathomimetic.
Effect: Increases internal sphincter tone.
Onset: Several days
Side effects: Restlessness, aggression, and hypertension.
Effect of Estriol
Type: Synthetic, short-acting estrogen.
Effect: Upregulates α-adrenergic receptors, increasing internal sphincter tone.
Contraindicated: in males, entire bitches, and patients with polyuria-polydipsia (PUPD)
Ectopic ureters
A congenital anomaly where ureters do not connect to the bladder correctly but may connect to the urethra or another part of the lower urinary tract. This condition, often seen in female dogs, can lead to urinary incontinence and recurrent urinary tract infections
Other USMI treatments besides drugs
Collagen injections
Try drugs in combination
Weight reduction
Increase opportunities to urinate
Surgery
Diagnosis for Ectopic ureters
History: young animals, especially females, may present with continuous urine leakage,
Diagnostic approaches: Ultrasound, X-ray, IVU or retrograde vagino-urethrogram, and CT-IVU.
Cystoscopy may be employed for direct visualization and identification of ectopic ureters
Treatment for ectopic ureters
Refer for surgery
Clinical presentations of prostate disease
Haematuria
Haemorrhagic urethral discharge
Tenesmus (a continual or recurrent inclination to evacuate the bowels, caused by disorder of the rectum or other illness. )
Dysuria
Recurrent UTIs
Urinary incontinence
Hindlimb stiffness
Infertility
Diagnosis of prostate disease
Rectal palpation
Haematology & biochemistry
Urinalysis & culture
Collection of prostatic fluid
Radiographs
Ultrasound (FNA)
Describe a normal prostate
Ventrally, smooth, bi-lobed, non-painful
Describe Benign prostatic hyperplasia (BPH)
Age related change
Hypertrophy & hyperplasia of secretory & connective tissues
Intraparenchymal fluid cysts
Presentation of benign prostatic hyperplasia
Often asymptomatic
Haematuria, haematospermia, haemorrhagic urethral discharge
Difficulty defaecating
Diagnosis of BPH
Palpation
Enlarged (symmetrical)
Non-painful
Mobile
Ultrasound:
Diffusely hyperechoic
Parenchymal cysts
Histology needed for definitive diagnosis
Response to treatment suggestive
Care! Multiple diseases possible
Treatment of BPH
Asymptomatic
Not necessary
Symptomatic
Surgical castration- Resolution within 4 weeks
Medical management- Osaterone (Ypozane) (inhibits testosterone uptake & receptor binding)Deslorelin (Suprelorin) (GnRH agonist) - implant
Bacterial prostatitis
Prostatic inflammation usually due to bacterial infection from urethra or haematogenous spread
Entire male dogs more likely
Presentation of Acute prostatitis
Fever
Depression
Anorexia
Vomiting
Urethral discharge
Tenesmus
Constipation
Dysuria
Abdominal pain
Gait changes
Presentation of chronic prostatitis
Purulent/ haemorrhagic urethral discharge
Recurrent UTIs
Mild haematuria
Infertility
Diagnosis of prostatitis
palpation can reveal pain (indicative of acute issues) or be non-painful (suggestive of chronic conditions), and size and shape may appear normal. Evaluation often considers signalment, history, clinical signs, consistent imaging findings, urinalysis, urine culture, prostatic fluid cytology, and culture. Bacterial prostatitis should be investigated in intact males with bacteriuria or bacterial cystitis.
Treatment of prostatis
IV antibiotics empirically (fluoroquinolones, TMP-SMX) with characteristics able to cross the blood-prostate barrier; oral antibiotics (trimethoprim, fluoroquinolones, clindamycin, macrolides if susceptible) for 4-6 weeks, and consider castration,
Presentation of prostatic abcesses
Often similar to acute prostatitis
Can cause chronic urethral obstruction
Acute abdomen or septic shock
Diagnosis of prostatic abscesses
Palpation: Enlarged/ Asymmetric
Ultrasound
Treatment of prostatic abcesses
Surgical Options:
Surgical drainage and omentalisation or percutaneous drainage may be employed.
Concurrent treatment for chronic prostatitis is recommended.
Considerations:
Due to the risk of serious complications, considering referral to specialized care is important.
Paraprostatic cysts
Large sacs of fluid adjacent to prostate & attached by stalk
Presentations of Paraprostatic cysts
Dysuria or tenesmus
Perineal mass
Occasionally systemic signs
Diagnosis of Paraprostatic cysts
Plain Radiographs
Ultrasound
Ultrasound-guided fluid aspirate
Treatment of paraprostatic cysts
Omentalisation
Castration
Presentations of prostatic neoplasias
Entire or castrated dogs
Tenesmus, dysuria, haemorrhagic urethral discharge, hindlimb lameness, chronic weight loss and/or anorexia
Palpation of prostatic neoplasia
Firm, irregular nodules
Enlarged, asymmetric, firm, fixed +/- painful
Enlarged sublumbar lymph nodes
Palpation of prostatitis
Palpation can reveal pain (indicative of acute issues) or be non-painful (suggestive of chronic conditions), and size and shape may appear normal.
Radiographs of prostatic neoplasia
Irregularly enlarged
Mineralised opacities
Lysis or proliferation on lumbar vertebrae or pelvic bones
Ultrasound of prostatic neoplasia
Focal or multifocal hyperechoic parenchyma
Asymmetry
Irregular contour
Cavitatory lesions
Radiograph of paraprostatic cysts
May have thin mineralisation of wall (egg shell like)
Describe fluid aspirate of a paraprostatic cyst
Yellow-brown
Small numbers of red & white blood cells & epithelial cells
Usually sterile
Treatment of prostatic neoplasia
Prognosis grave
No curative treatment
3 functional problems that can cause urine retention
Failure of relaxation of urethral sphincter (eg. UMN lesion)
Failure of detrusor muscle contraction (detrusor atony)
Dyssynergia
Most common bladder neoplasia
Transitional cell carcinoma
Diagnosis of TCC
U/S: Thickening of bladder wall and mass lesions in trigone area
UA: Neoplastic cells may be seen
Cystocopy: Abnormal irregular proliferation along bladder wall
Cytology/biopsy: Definitive diagnosis- Traumatic catheterisation,cytoscopically,suction biopsy, laparoscopy
Treatment for TCC
Surgery but may not be viable
Chemotherapy- Mitoxantrone/Carboplatin
NSAIDS- Meloxicm- Antineoplastic effects and antiinflammatory
Prognosis for TCC
Guarded
What drug to give to decrease internal urethral sphincter tone
Prazosin/Phenoxybenzamine
What drug to give to decrease external urethral sphincter tone
Diazepam
What drug to give to increase detrusor contraction
Bethanecol
