Approach to Management of LUT Disease & Prostate Flashcards
how do urethroliths present
LUT inflammation or urethral obstruction
how do urocystoliths present
hematuria
recurrent UTI
LUT inflammation
asymptomatic
how do ureteroliths present (4)
- azotemia/uremia
- abdominal pain
- non-specific signs
- asymptomatic
how do nephroliths present (6)
- azotemia/uremia
- hematuria
- abdominal pain
- non-specific signs
- recurrent UTIs
- asymptomatic
how are urolithiasis diagnosed
- clinical signs
- diagnostic imaging (rad, US)
- urine culture
why are radiographs better at diagnosing urolithiasis
not all stones are radiodense (may need contrast)
allows assessment of size and number of stones
what stones can cause UTIs
struvite
what are the ways to manage urolithiasis (6)
- spontaneous voiding
- catheter retrieval
- voiding urohydropropulsion
- lithotripsy
- surgery
- medical dissolution
what size of stones can be managed by spontaneous voiding
<3-5mm bladder stones in bitches
what size of stones can be managed by catheter retrieval
<3mm bladder stones in dogs
what stones can be managed voiding by hydropropulsion and in what patients
small bladder stones in female cats or dogs of either sex
what is lithotripsy used for
used to fragment bladder or renal uroliths using laser or sound
not widely available
how do you predict the urolith composition (7)
- signalment
- urine pH
- crystals in urine
- urine culture results
- serum abnormalities (calcium)
- rad appearance
- location
what pH of urine are struvite crystals in
neutral to alkaline
what is the radiographic density of struvite crystals
+ to +++
how many struvite crystals are typically in dogs and cats
dogs: variable
cats: often single
what is the pH in the urine calcium oxalate crystals are usually found in
acid to neutral
what is the radiographic appearance of calcium oxalate
+++ to ++++
what is the number of calium oxalate crystals usually found in dogs and cats
dogs and cats usually multiple
what is the urine pH of ammonium urate
acid to neutral
what is the radiographic appearance of ammonium urate
- to ++
how many ammonium urate crystals are typically found in dogs and cats
dogs usually multiple
cats usually single
what other investigations should you do if you find struvite crystals
predisposes to infections
what additional investigations should you do if you find calcium oxalate crystals
underlying causes of hypercalcemia
renal function
what additional investigations should you do if you find urate cyrstals in the urine
liver imaging and function tests (not Dalmatian, genetics)
what surgerys can be done to manage uroliths (5)
- nephrotomy (not recommended)
- ureterotomy (not recommended bypass preferred)
- percutaneous cystoscopic removal of bladder stones
- cystotomy for bladder stones
- urethrotomy (not recommended flush into bladder)
what crystals can be treated by medical dissolution
struvite, urate and cystine stones only
what should you do after removing stones
repeat radiographs +/- double contrast
quantitative analysis
+/- culture urolith
when is medical dissolution contraindicated (4)
- compound or mixed uroliths suspected
- obstruction to urine flow
- high risk of obstruction in patient that cannot be monitored
- patient uncomfortable
what area of the urinary tract is medical dissolution possible
only if the stones are in renal pelvis or bladder
what must the urine USG be for medical dissolution
urine must be unsaturated with solute so aim for SG <1.020 in dogs and <1.025 in cats
what should you not use in medical dissolution
salt or diuretics
what dietary modifications are done for medical dissolution of infection induced struvite (4)
- decrased urinary pH
- decrease secretion of Mg and PO4
- decrease urine concentration
- decrease production of urea
what dietary modifications are done for medical dissolution of sterile struvite (3)
- decrease urinary pH
- decrease excretion of Mg and PO4
- decrease urine concentration
how is infection induced struvite treated
if signs of cystitis 7 days antibiotic treatment if not culture urine and treat if Staph pseudointermedius/proteus sp isolated
how are urate uroliths treated by medical dissolution
treat liver disease if present
if not low purine, non-acidifying diet
allopurinol inhibits xanthine oxidase
how are uroliths prevented (4)
eliminate underlying causes and minimze risk factors
- increase water intake
- increase voiding freq
- +/- diet modification
- +/- drug therapy
what USG do you want the urine to be to prevent uroliths in the long term
<1.020 in dogs and <1.025 cats
how do you prevent infection induced struvite crystals
eradicate and prevent UTIs
dietary modification probably unnecessary
how do you prevent sterile struvite crystals (4)
dietary modification
- restricted Mg and PO4
- promote acidic urine pH <6.5
- risk of calcium oxalate urolith formation
- +/- methionine or ammonium chloride
how do you prevent calcium oxalate crystals (4)
- treat hypercalcemia (if present)
- treat conditions causing hypercalciuria (if present)
- diets
- +/- potassium citrate
what diet can prevent calcium oxalate (4)
- non-acidifying
- without excessive protein, calcium, oxalate or sodium
- sufficient phosphorus
- adequate magnesium
how do you prevent urate crystals
correct PSS if present and possible
diet: low purine, alkalinizing diet
which uroliths are fast growing
struvite and urate
UA weekly until crystal free then every 2-4 weeks
what are slow growing uroliths
calcium oxalate
UA monlthy until crystal free then 3 monthly
what is reflex dyssynergia
loss of coordination between bladder and urethral sphincter muscles
what dogs are predisposed to reflex dyssynergia
middle aged male labradors
what does the urine stream of reflex dyssynergia look like
stream initiated but not maintained
large residual urine volumes
difficult to express bladder
how is reflex dyssynergia treated (3)
- decrease internal urethral sphincter tone (prazosin/phenoxybenzamine)
- decreased external sphincter tone (diazepam/dantrolene)
- +/- increase detrusor contraction (bethanecol)
what are the causes of primary bladder atony (2)
- dysautonomia
- LMN disorders
what are secondary causes of bladder atony (4)
- distended, flaccid bladder after obstruction removed
- weak or absent urine stream
- incomplete bladder emptying
- overflow incontinence
how do you treat secondary causes of bladder atony (2)
- indwelling catheter to rest detrusor
- bethanechol after obstruction removed
what is urethral sphincter mechanism incompetence USMI
congenital or acquired
female > male
often within 3 years of spaying
what is the etiology of USMI (7)
- decrease tone of urethral support structures
- abnormal position/morphology of bladder/urethra
- decreased number/responsiveness of urethral a-adrenergic
- obestiy
- vaginal structural abnormalities
- genetic facotrs
- hormonal changes
how is USMI diagnosed (5)
intermittent urine leakage and incontinent at rest
can urinate normally
often presumptive (spayed bitches)
- appropriate history
- no evidence of inflammation
- urine well concentration
- no neurological abnormalities
- respond to treatment trial
how is USMI treated (3)
- phenylpropanolamine
- estriol
- ephedrine
what is phenylpropanolamine
a-adrenergic agonist that increases the internal sphincter tone for USMI
what are the side effects of phenylpropanolamine
- restlessness
- aggression
- hypertension
what is estriol
synthetic short acting estrogen causes upregulation of a-adrenergic receptors that increases sphincter tone
when is estriol contraindicated
male dogs
entire bitches
PUPD patients
how would you treat USMI if there has been no response to medication
reconsider diagnosis
try drugs in combo
weight reduction
increase opportunities to urinate
collagen injection s
surgery (artificial urethral sphincters, colposuspension, cystourethropexy)
what are ectopic ureters
ureters bypass the trigone of bladder
urine into urethra or vagina
unilateral or bilateral
what other abnormalities may be present with ectopic ureters (3)
- reduced bladder capacity
- renal dysplasia or agenesis
- USMI
how is ectopic ureters diagnosed
often continuous urine leakage young animal
animal often wet
may also urinate normally
US (renal architecture)
IV urogram (renal function, ureters)
retrograde vaginourethrogram
CT
cystoscopy
can be difficult to diagnose
how are ectopic ureters treated
surgery
- reimplant ectopic ureter into urinary bladder
- create new ureteral opening
laser treatment
what are the presentations of prostate disease (9)
- hematuria
- hemorrhagic urethral discharge
- tenesmus
- dysuria
- recurrent UTIs
- urinary incontinence
- hindlimb stiffness
- infertility
- non-specific signs (lethargy, anorexia)
how are prostatic diseases diagnosed (9)
- rectal palpation (ventrally, smooth, bi-lobed, non-painful)
- exam of urethral discharge (cytology)
- urinalysis and culture (prostatic fluid will pass back into the bladder)
- hematology and biochem
- collection of prostatic fluid
- rads
- US
- US guided biopsy
- surgical biopsy
how is a prostatic wash done (9)
- sedate dog
- pass urinary catheter in sterile manner
- empty bladder (keep sample) +/- flush bladder
- move urinary catheter to level of prostate (will need to feel per rectum for end of catheter)
- massage prostate per rectum
- inject small volume (2-5ml) of sterile saline
- massage prostate per rectum for 1 min
- aspirate fluid
- submit for cytology and culture
what is benign prostatic hyperplasia
age related change
hypertrophy and hyperplasia of secretory and connective tissues
intraparenchymal fluid cysts
increased vascularity can cause bleeding
how does benign prostatic hyperplasia present (5)
- often asymptomatic
- hematuria
- hematospermia
- hemorrhagic urethral discharge
- difficulty defecating
how is BPH diagnosed (4)
- palpation (enlarged, non-painful, mobile)
- US
- histology needed to definitive diagnosis
- response to treatment suggestive
what is the appearance of BPH on US
diffusely hyperechoic
parenchymal cysts
how is symptomatic BPH treated (2)
- surgical castration most effective, resolution within 4 weeks
- medical management
how is symptomatic BPH medically managed (3)
- delmadinone acetate (Tardak) (suppresses FSH & LH production)
- osaterone (Ypozane) (inhibits testosterone update and receptor binding)
- desloreline (suprelorin) (GnRH agonist) implant
what is bacterial prostatitis
prostatic inflammation usually due to bacterial infection
entire male dogs
breakdown of protective mechanisms
how is bacterial prostatitis spread
from urethra
hematogenous spread
what pathogen can cause bacterial prostatitis
brucellosis
zoonotic
what is the acute presentation of bacterial prostatitis (10)
- fever
- depression
- anorexia
- vomiting
- urethral discharge
- tenesmus
- constipation
- dysuria
- abdominal pain
- gait changes
what are the chronic presentations of bacterial prostatitis (4)
- purulent/hemorrhagic urethral discharge
- recurrent UTIs
- mild hematuira
- infertility
how is bacterial prostatitis diagnosed (7)
palpation
- painful (acute); non-painful (chronic)
- may be normal size and shape
- signalment
- history
- clinical signs
- consistent imaging findings
- urinalysis and urine culture
- prostatic fluid cytology + culture
how is bacterial prostatitis treated
IV antibiotics in acute
oral antibiotics
castration
what IV antibiotics would you use to treat acute bacterial prostatitis
need to be able to cross blood-prostate barrier
highly lipid soluble
not highly protein bound
ionize at pH of prostatic tissue
fluroquinolone
TMPS
what oral antibiotics would you use to treat bacterial prostatitis
min 4 weeks (acute); 4-6 weeks (chronic)
trimethoprim, chloramphenicol, fluroquinolones (clindamycin & macrolides if susceptible on testing)
what are prostatic abscesses
incapsulated purulent material
how do prostatic abscesses present (3)
- often similar to acute prostatits
- can cause chronic urethral obstruction
- acute abdomen or septic shock
how are prostatic abscesses diagnosed
palpation
enlarged asymmetric
US
how are prostatic abscesses treated
surgical drainage & omentalization or percutaneous drainage
with concurrent treatment for chronic prostatitis
risk of serious complications
consider referal
what are paraprostatic cysts
large sacs of fluid adjacent to prostate and attached by stalk
how do paraprostatic cysts present (3)
- dysuria or tenesmus
- perineal mass
- occasionally systemic signs
how are paraprostatic cysts diagnosed
rads: plain may have thin mineralization of wall (egg shell like)
US
US guided fluid aspirate (yellow-brown, small numbers of red & white blood cells & epithelial cells usually sterile)
how are paraprostatic cysts treated (2)
- omentalization
- castration
what are common prostatic neoplasia
carcinomas
what is the signalement of prostatic neoplasia
entire or castrated dogs
what is the presentation of prostatic neoplasia (5)
- tenesmus
- dysuria
- hemorrhagic urethral discharge
- hindlimb lameness
- chronic weight loss and/or anorexia
what do prostatic neoplasias feel like on palpation
- firm, irregular nodules
- enlarged, asymmetric, firm, fixed +/- painful
- enlarged sublumbar lymph nodes
what is the urinalysis of prostatic neoplasia (3)
- hematuria
- +/- atypical cells
- +/- evidence of UTI
what would the appearance of prostatic neoplasia be on rads (3)
- irregularly enlarged
- mineralized opacities
- lysis or proliferation on lumbar vertebrae or pelvic bones
what is the appearance of prostatic neoplasia on US (4)
- focal or multifocal hyperechoic parenchyma
- asymmetry
- irregular contour
- cavitatory lesions
how is prostatic neoplasia diagnosed (3)
- rads
- US
- BRAF test on urine
how are prostatic neoplasia treated
often metastazed
prognosis grave
no curative treatment (castration no benefit, palliation with piroxicam +/- mitoxantrone or carboplatin)
prostatectomy –> incontinence not recommended
