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Module 17 > Approach to Management of LUT Disease & Prostate > Flashcards

Approach to Management of LUT Disease & Prostate Flashcards

1
Q

how do urethroliths present

A

LUT inflammation or urethral obstruction

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2
Q

how do urocystoliths present

A

hematuria

recurrent UTI

LUT inflammation

asymptomatic

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3
Q

how do ureteroliths present (4)

A
  1. azotemia/uremia
  2. abdominal pain
  3. non-specific signs
  4. asymptomatic
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4
Q

how do nephroliths present (6)

A
  1. azotemia/uremia
  2. hematuria
  3. abdominal pain
  4. non-specific signs
  5. recurrent UTIs
  6. asymptomatic
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5
Q

how are urolithiasis diagnosed

A
  1. clinical signs
  2. diagnostic imaging (rad, US)
  3. urine culture
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6
Q

why are radiographs better at diagnosing urolithiasis

A

not all stones are radiodense (may need contrast)

allows assessment of size and number of stones

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7
Q

what stones can cause UTIs

A

struvite

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8
Q

what are the ways to manage urolithiasis (6)

A
  1. spontaneous voiding
  2. catheter retrieval
  3. voiding urohydropropulsion
  4. lithotripsy
  5. surgery
  6. medical dissolution
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9
Q

what size of stones can be managed by spontaneous voiding

A

<3-5mm bladder stones in bitches

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10
Q

what size of stones can be managed by catheter retrieval

A

<3mm bladder stones in dogs

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11
Q

what stones can be managed voiding by hydropropulsion and in what patients

A

small bladder stones in female cats or dogs of either sex

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12
Q

what is lithotripsy used for

A

used to fragment bladder or renal uroliths using laser or sound

not widely available

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13
Q

how do you predict the urolith composition (7)

A
  1. signalment
  2. urine pH
  3. crystals in urine
  4. urine culture results
  5. serum abnormalities (calcium)
  6. rad appearance
  7. location
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14
Q

what pH of urine are struvite crystals in

A

neutral to alkaline

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15
Q

what is the radiographic density of struvite crystals

A

+ to +++

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16
Q

how many struvite crystals are typically in dogs and cats

A

dogs: variable
cats: often single

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17
Q

what is the pH in the urine calcium oxalate crystals are usually found in

A

acid to neutral

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18
Q

what is the radiographic appearance of calcium oxalate

A

+++ to ++++

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19
Q

what is the number of calium oxalate crystals usually found in dogs and cats

A

dogs and cats usually multiple

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20
Q

what is the urine pH of ammonium urate

A

acid to neutral

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21
Q

what is the radiographic appearance of ammonium urate

A
  • to ++
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22
Q

how many ammonium urate crystals are typically found in dogs and cats

A

dogs usually multiple

cats usually single

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23
Q

what other investigations should you do if you find struvite crystals

A

predisposes to infections

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24
Q

what additional investigations should you do if you find calcium oxalate crystals

A

underlying causes of hypercalcemia

renal function

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25
Q

what additional investigations should you do if you find urate cyrstals in the urine

A

liver imaging and function tests (not Dalmatian, genetics)

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26
Q

what surgerys can be done to manage uroliths (5)

A
  1. nephrotomy (not recommended)
  2. ureterotomy (not recommended bypass preferred)
  3. percutaneous cystoscopic removal of bladder stones
  4. cystotomy for bladder stones
  5. urethrotomy (not recommended flush into bladder)
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27
Q

what crystals can be treated by medical dissolution

A

struvite, urate and cystine stones only

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28
Q

what should you do after removing stones

A

repeat radiographs +/- double contrast

quantitative analysis

+/- culture urolith

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29
Q

when is medical dissolution contraindicated (4)

A
  1. compound or mixed uroliths suspected
  2. obstruction to urine flow
  3. high risk of obstruction in patient that cannot be monitored
  4. patient uncomfortable
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30
Q

what area of the urinary tract is medical dissolution possible

A

only if the stones are in renal pelvis or bladder

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31
Q

what must the urine USG be for medical dissolution

A

urine must be unsaturated with solute so aim for SG <1.020 in dogs and <1.025 in cats

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32
Q

what should you not use in medical dissolution

A

salt or diuretics

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33
Q

what dietary modifications are done for medical dissolution of infection induced struvite (4)

A
  1. decrased urinary pH
  2. decrease secretion of Mg and PO4
  3. decrease urine concentration
  4. decrease production of urea
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34
Q

what dietary modifications are done for medical dissolution of sterile struvite (3)

A
  1. decrease urinary pH
  2. decrease excretion of Mg and PO4
  3. decrease urine concentration
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35
Q

how is infection induced struvite treated

A

if signs of cystitis 7 days antibiotic treatment if not culture urine and treat if Staph pseudointermedius/proteus sp isolated

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36
Q

how are urate uroliths treated by medical dissolution

A

treat liver disease if present

if not low purine, non-acidifying diet

allopurinol inhibits xanthine oxidase

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37
Q

how are uroliths prevented (4)

A

eliminate underlying causes and minimze risk factors

  1. increase water intake
  2. increase voiding freq
  3. +/- diet modification
  4. +/- drug therapy
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38
Q

what USG do you want the urine to be to prevent uroliths in the long term

A

<1.020 in dogs and <1.025 cats

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39
Q

how do you prevent infection induced struvite crystals

A

eradicate and prevent UTIs

dietary modification probably unnecessary

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40
Q

how do you prevent sterile struvite crystals (4)

A

dietary modification

  1. restricted Mg and PO4
  2. promote acidic urine pH <6.5
  3. risk of calcium oxalate urolith formation
  4. +/- methionine or ammonium chloride
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41
Q

how do you prevent calcium oxalate crystals (4)

A
  1. treat hypercalcemia (if present)
  2. treat conditions causing hypercalciuria (if present)
  3. diets
  4. +/- potassium citrate
42
Q

what diet can prevent calcium oxalate (4)

A
  1. non-acidifying
  2. without excessive protein, calcium, oxalate or sodium
  3. sufficient phosphorus
  4. adequate magnesium
43
Q

how do you prevent urate crystals

A

correct PSS if present and possible

diet: low purine, alkalinizing diet

44
Q

which uroliths are fast growing

A

struvite and urate

UA weekly until crystal free then every 2-4 weeks

45
Q

what are slow growing uroliths

A

calcium oxalate

UA monlthy until crystal free then 3 monthly

46
Q

what is reflex dyssynergia

A

loss of coordination between bladder and urethral sphincter muscles

47
Q

what dogs are predisposed to reflex dyssynergia

A

middle aged male labradors

48
Q

what does the urine stream of reflex dyssynergia look like

A

stream initiated but not maintained

large residual urine volumes

difficult to express bladder

49
Q

how is reflex dyssynergia treated (3)

A
  1. decrease internal urethral sphincter tone (prazosin/phenoxybenzamine)
  2. decreased external sphincter tone (diazepam/dantrolene)
  3. +/- increase detrusor contraction (bethanecol)
50
Q

what are the causes of primary bladder atony (2)

A
  1. dysautonomia
  2. LMN disorders
51
Q

what are secondary causes of bladder atony (4)

A
  1. distended, flaccid bladder after obstruction removed
  2. weak or absent urine stream
  3. incomplete bladder emptying
  4. overflow incontinence
52
Q

how do you treat secondary causes of bladder atony (2)

A
  1. indwelling catheter to rest detrusor
  2. bethanechol after obstruction removed
53
Q

what is urethral sphincter mechanism incompetence USMI

A

congenital or acquired

female > male

often within 3 years of spaying

54
Q

what is the etiology of USMI (7)

A
  1. decrease tone of urethral support structures
  2. abnormal position/morphology of bladder/urethra
  3. decreased number/responsiveness of urethral a-adrenergic
  4. obestiy
  5. vaginal structural abnormalities
  6. genetic facotrs
  7. hormonal changes
55
Q

how is USMI diagnosed (5)

A

intermittent urine leakage and incontinent at rest

can urinate normally

often presumptive (spayed bitches)

  1. appropriate history
  2. no evidence of inflammation
  3. urine well concentration
  4. no neurological abnormalities
  5. respond to treatment trial
56
Q

how is USMI treated (3)

A
  1. phenylpropanolamine
  2. estriol
  3. ephedrine
57
Q

what is phenylpropanolamine

A

a-adrenergic agonist that increases the internal sphincter tone for USMI

58
Q

what are the side effects of phenylpropanolamine

A
  1. restlessness
  2. aggression
  3. hypertension
59
Q

what is estriol

A

synthetic short acting estrogen causes upregulation of a-adrenergic receptors that increases sphincter tone

60
Q

when is estriol contraindicated

A

male dogs

entire bitches

PUPD patients

61
Q

how would you treat USMI if there has been no response to medication

A

reconsider diagnosis

try drugs in combo

weight reduction

increase opportunities to urinate

collagen injection s

surgery (artificial urethral sphincters, colposuspension, cystourethropexy)

62
Q

what are ectopic ureters

A

ureters bypass the trigone of bladder

urine into urethra or vagina

unilateral or bilateral

63
Q

what other abnormalities may be present with ectopic ureters (3)

A
  1. reduced bladder capacity
  2. renal dysplasia or agenesis
  3. USMI
64
Q

how is ectopic ureters diagnosed

A

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

65
Q

how are ectopic ureters treated

A

surgery

  • reimplant ectopic ureter into urinary bladder
  • create new ureteral opening

laser treatment

66
Q

what are the presentations of prostate disease (9)

A
  1. hematuria
  2. hemorrhagic urethral discharge
  3. tenesmus
  4. dysuria
  5. recurrent UTIs
  6. urinary incontinence
  7. hindlimb stiffness
  8. infertility
  9. non-specific signs (lethargy, anorexia)
67
Q

how are prostatic diseases diagnosed (9)

A
  1. rectal palpation (ventrally, smooth, bi-lobed, non-painful)
  2. exam of urethral discharge (cytology)
  3. urinalysis and culture (prostatic fluid will pass back into the bladder)
  4. hematology and biochem
  5. collection of prostatic fluid
  6. rads
  7. US
  8. US guided biopsy
  9. surgical biopsy
68
Q

how is a prostatic wash done (9)

A
  1. sedate dog
  2. pass urinary catheter in sterile manner
  3. empty bladder (keep sample) +/- flush bladder
  4. move urinary catheter to level of prostate (will need to feel per rectum for end of catheter)
  5. massage prostate per rectum
  6. inject small volume (2-5ml) of sterile saline
  7. massage prostate per rectum for 1 min
  8. aspirate fluid
  9. submit for cytology and culture
69
Q

what is benign prostatic hyperplasia

A

age related change

hypertrophy and hyperplasia of secretory and connective tissues

intraparenchymal fluid cysts

increased vascularity can cause bleeding

70
Q

how does benign prostatic hyperplasia present (5)

A
  1. often asymptomatic
  2. hematuria
  3. hematospermia
  4. hemorrhagic urethral discharge
  5. difficulty defecating
71
Q

how is BPH diagnosed (4)

A
  1. palpation (enlarged, non-painful, mobile)
  2. US
  3. histology needed to definitive diagnosis
  4. response to treatment suggestive
72
Q

what is the appearance of BPH on US

A

diffusely hyperechoic

parenchymal cysts

73
Q

how is symptomatic BPH treated (2)

A
  1. surgical castration most effective, resolution within 4 weeks
  2. medical management
74
Q

how is symptomatic BPH medically managed (3)

A
  1. delmadinone acetate (Tardak) (suppresses FSH & LH production)
  2. osaterone (Ypozane) (inhibits testosterone update and receptor binding)
  3. desloreline (suprelorin) (GnRH agonist) implant
75
Q

what is bacterial prostatitis

A

prostatic inflammation usually due to bacterial infection

entire male dogs

breakdown of protective mechanisms

76
Q

how is bacterial prostatitis spread

A

from urethra

hematogenous spread

77
Q

what pathogen can cause bacterial prostatitis

A

brucellosis

zoonotic

78
Q

what is the acute presentation of bacterial prostatitis (10)

A
  1. fever
  2. depression
  3. anorexia
  4. vomiting
  5. urethral discharge
  6. tenesmus
  7. constipation
  8. dysuria
  9. abdominal pain
  10. gait changes
79
Q

what are the chronic presentations of bacterial prostatitis (4)

A
  1. purulent/hemorrhagic urethral discharge
  2. recurrent UTIs
  3. mild hematuira
  4. infertility
80
Q

how is bacterial prostatitis diagnosed (7)

A

palpation

  1. painful (acute); non-painful (chronic)
  2. may be normal size and shape
  3. signalment
  4. history
  5. clinical signs
  6. consistent imaging findings
  7. urinalysis and urine culture
  8. prostatic fluid cytology + culture
81
Q

how is bacterial prostatitis treated

A

IV antibiotics in acute

oral antibiotics

castration

82
Q

what IV antibiotics would you use to treat acute bacterial prostatitis

A

need to be able to cross blood-prostate barrier

highly lipid soluble

not highly protein bound

ionize at pH of prostatic tissue

fluroquinolone

TMPS

83
Q

what oral antibiotics would you use to treat bacterial prostatitis

A

min 4 weeks (acute); 4-6 weeks (chronic)

trimethoprim, chloramphenicol, fluroquinolones (clindamycin & macrolides if susceptible on testing)

84
Q

what are prostatic abscesses

A

incapsulated purulent material

85
Q

how do prostatic abscesses present (3)

A
  1. often similar to acute prostatits
  2. can cause chronic urethral obstruction
  3. acute abdomen or septic shock
86
Q

how are prostatic abscesses diagnosed

A

palpation

enlarged asymmetric

US

87
Q

how are prostatic abscesses treated

A

surgical drainage & omentalization or percutaneous drainage

with concurrent treatment for chronic prostatitis

risk of serious complications

consider referal

88
Q

what are paraprostatic cysts

A

large sacs of fluid adjacent to prostate and attached by stalk

89
Q

how do paraprostatic cysts present (3)

A
  1. dysuria or tenesmus
  2. perineal mass
  3. occasionally systemic signs
90
Q

how are paraprostatic cysts diagnosed

A

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)

91
Q

how are paraprostatic cysts treated (2)

A
  1. omentalization
  2. castration
92
Q

what are common prostatic neoplasia

A

carcinomas

93
Q

what is the signalement of prostatic neoplasia

A

entire or castrated dogs

94
Q

what is the presentation of prostatic neoplasia (5)

A
  1. tenesmus
  2. dysuria
  3. hemorrhagic urethral discharge
  4. hindlimb lameness
  5. chronic weight loss and/or anorexia
95
Q

what do prostatic neoplasias feel like on palpation

A
  1. firm, irregular nodules
  2. enlarged, asymmetric, firm, fixed +/- painful
  3. enlarged sublumbar lymph nodes
96
Q

what is the urinalysis of prostatic neoplasia (3)

A
  1. hematuria
  2. +/- atypical cells
  3. +/- evidence of UTI
97
Q

what would the appearance of prostatic neoplasia be on rads (3)

A
  1. irregularly enlarged
  2. mineralized opacities
  3. lysis or proliferation on lumbar vertebrae or pelvic bones
98
Q

what is the appearance of prostatic neoplasia on US (4)

A
  1. focal or multifocal hyperechoic parenchyma
  2. asymmetry
  3. irregular contour
  4. cavitatory lesions
99
Q

how is prostatic neoplasia diagnosed (3)

A
  1. rads
  2. US
  3. BRAF test on urine
100
Q

how are prostatic neoplasia treated

A

often metastazed

prognosis grave

no curative treatment (castration no benefit, palliation with piroxicam +/- mitoxantrone or carboplatin)

prostatectomy –> incontinence not recommended

Module 17 (31 decks)

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