Approach to Management of LUT Disease & Prostate Flashcards
1
Q
how do urethroliths present
A
LUT inflammation or urethral obstruction
2
Q
how do urocystoliths present
A
hematuria
recurrent UTI
LUT inflammation
asymptomatic
3
Q
how do ureteroliths present (4)
A
- azotemia/uremia
- abdominal pain
- non-specific signs
- asymptomatic
4
Q
how do nephroliths present (6)
A
- azotemia/uremia
- hematuria
- abdominal pain
- non-specific signs
- recurrent UTIs
- asymptomatic
5
Q
how are urolithiasis diagnosed
A
- clinical signs
- diagnostic imaging (rad, US)
- urine culture
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
7
Q
what stones can cause UTIs
A
struvite
8
Q
what are the ways to manage urolithiasis (6)
A
- spontaneous voiding
- catheter retrieval
- voiding urohydropropulsion
- lithotripsy
- surgery
- medical dissolution
9
Q
what size of stones can be managed by spontaneous voiding
A
<3-5mm bladder stones in bitches
10
Q
what size of stones can be managed by catheter retrieval
A
<3mm bladder stones in dogs
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
12
Q
what is lithotripsy used for
A
used to fragment bladder or renal uroliths using laser or sound
not widely available
13
Q
how do you predict the urolith composition (7)
A
- signalment
- urine pH
- crystals in urine
- urine culture results
- serum abnormalities (calcium)
- rad appearance
- location
14
Q
what pH of urine are struvite crystals in
A
neutral to alkaline
15
Q
what is the radiographic density of struvite crystals
A
+ to +++
16
Q
how many struvite crystals are typically in dogs and cats
A
dogs: variable
cats: often single
17
Q
what is the pH in the urine calcium oxalate crystals are usually found in
A
acid to neutral
18
Q
what is the radiographic appearance of calcium oxalate
A
+++ to ++++
19
Q
what is the number of calium oxalate crystals usually found in dogs and cats
A
dogs and cats usually multiple
20
Q
what is the urine pH of ammonium urate
A
acid to neutral
21
Q
what is the radiographic appearance of ammonium urate
A
- to ++
22
Q
how many ammonium urate crystals are typically found in dogs and cats
A
dogs usually multiple
cats usually single
23
Q
what other investigations should you do if you find struvite crystals
A
predisposes to infections
24
Q
what additional investigations should you do if you find calcium oxalate crystals
A
underlying causes of hypercalcemia
renal function
25
what additional investigations should you do if you find urate cyrstals in the urine
liver imaging and function tests (not Dalmatian, genetics)
26
what surgerys can be done to manage uroliths (5)
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)
27
what crystals can be treated by medical dissolution
struvite, urate and cystine stones only
28
what should you do after removing stones
repeat radiographs +/- double contrast
quantitative analysis
+/- culture urolith
29
when is medical dissolution contraindicated (4)
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
30
what area of the urinary tract is medical dissolution possible
only if the stones are in renal pelvis or bladder
31
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
32
what should you not use in medical dissolution
salt or diuretics
33
what dietary modifications are done for medical dissolution of infection induced struvite (4)
1. decrased urinary pH
2. decrease secretion of Mg and PO4
3. decrease urine concentration
4. decrease production of urea
34
what dietary modifications are done for medical dissolution of sterile struvite (3)
1. decrease urinary pH
2. decrease excretion of Mg and PO4
3. decrease urine concentration
35
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
36
how are urate uroliths treated by medical dissolution
treat liver disease if present
if not low purine, non-acidifying diet
allopurinol inhibits xanthine oxidase
37
how are uroliths prevented (4)
eliminate underlying causes and minimze risk factors
1. increase water intake
2. increase voiding freq
3. +/- diet modification
4. +/- drug therapy
38
what USG do you want the urine to be to prevent uroliths in the long term
\<1.020 in dogs and \<1.025 cats
39
how do you prevent infection induced struvite crystals
eradicate and prevent UTIs
dietary modification probably unnecessary
40
how do you prevent sterile struvite crystals (4)
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
41
how do you prevent calcium oxalate crystals (4)
1. treat hypercalcemia (if present)
2. treat conditions causing hypercalciuria (if present)
3. diets
4. +/- potassium citrate
42
what diet can prevent calcium oxalate (4)
1. non-acidifying
2. without excessive protein, calcium, oxalate or sodium
3. sufficient phosphorus
4. adequate magnesium
43
how do you prevent urate crystals
correct PSS if present and possible
diet: low purine, alkalinizing diet
44
which uroliths are fast growing
struvite and urate
UA weekly until crystal free then every 2-4 weeks
45
what are slow growing uroliths
calcium oxalate
UA monlthy until crystal free then 3 monthly
46
what is reflex dyssynergia
loss of coordination between bladder and urethral sphincter muscles
47
what dogs are predisposed to reflex dyssynergia
middle aged male labradors
48
what does the urine stream of reflex dyssynergia look like
stream initiated but not maintained
large residual urine volumes
difficult to express bladder
49
how is reflex dyssynergia treated (3)
1. decrease internal urethral sphincter tone (prazosin/phenoxybenzamine)
2. decreased external sphincter tone (diazepam/dantrolene)
3. +/- increase detrusor contraction (bethanecol)
50
what are the causes of primary bladder atony (2)
1. dysautonomia
2. LMN disorders
51
what are secondary causes of bladder atony (4)
1. distended, flaccid bladder after obstruction removed
2. weak or absent urine stream
3. incomplete bladder emptying
4. overflow incontinence
52
how do you treat secondary causes of bladder atony (2)
1. indwelling catheter to rest detrusor
2. bethanechol after obstruction removed
53
what is urethral sphincter mechanism incompetence USMI
congenital or acquired
female \> male
often within 3 years of spaying
54
what is the etiology of USMI (7)
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
how is USMI diagnosed (5)
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
how is USMI treated (3)
1. phenylpropanolamine
2. estriol
3. ephedrine
57
what is phenylpropanolamine
a-adrenergic agonist that increases the internal sphincter tone for USMI
58
what are the side effects of phenylpropanolamine
1. restlessness
2. aggression
3. hypertension
59
what is estriol
synthetic short acting estrogen causes upregulation of a-adrenergic receptors that increases sphincter tone
60
when is estriol contraindicated
male dogs
entire bitches
PUPD patients
61
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)
62
what are ectopic ureters
ureters bypass the trigone of bladder
urine into urethra or vagina
unilateral or bilateral
63
what other abnormalities may be present with ectopic ureters (3)
1. reduced bladder capacity
2. renal dysplasia or agenesis
3. USMI
64
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
65
how are ectopic ureters treated
surgery
- reimplant ectopic ureter into urinary bladder
- create new ureteral opening
laser treatment
66
what are the presentations of prostate disease (9)
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
how are prostatic diseases diagnosed (9)
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
how is a prostatic wash done (9)
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
what is benign prostatic hyperplasia
age related change
hypertrophy and hyperplasia of secretory and connective tissues
intraparenchymal fluid cysts
increased vascularity can cause bleeding
70
how does benign prostatic hyperplasia present (5)
1. often asymptomatic
2. hematuria
3. hematospermia
4. hemorrhagic urethral discharge
5. difficulty defecating
71
how is BPH diagnosed (4)
1. palpation (enlarged, non-painful, mobile)
2. US
3. histology needed to definitive diagnosis
4. response to treatment suggestive
72
what is the appearance of BPH on US
diffusely hyperechoic
parenchymal cysts
73
how is symptomatic BPH treated (2)
1. surgical castration most effective, resolution within 4 weeks
2. medical management
74
how is symptomatic BPH medically managed (3)
1. delmadinone acetate (Tardak) (suppresses FSH & LH production)
2. osaterone (Ypozane) (inhibits testosterone update and receptor binding)
3. desloreline (suprelorin) (GnRH agonist) implant
75
what is bacterial prostatitis
prostatic inflammation usually due to bacterial infection
entire male dogs
breakdown of protective mechanisms
76
how is bacterial prostatitis spread
from urethra
hematogenous spread
77
what pathogen can cause bacterial prostatitis
brucellosis
zoonotic
78
what is the acute presentation of bacterial prostatitis (10)
1. fever
2. depression
3. anorexia
4. vomiting
5. urethral discharge
6. tenesmus
7. constipation
8. dysuria
9. abdominal pain
10. gait changes
79
what are the chronic presentations of bacterial prostatitis (4)
1. purulent/hemorrhagic urethral discharge
2. recurrent UTIs
3. mild hematuira
4. infertility
80
how is bacterial prostatitis diagnosed (7)
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
how is bacterial prostatitis treated
IV antibiotics in acute
oral antibiotics
castration
82
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
83
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)
84
what are prostatic abscesses
incapsulated purulent material
85
how do prostatic abscesses present (3)
1. often similar to acute prostatits
2. can cause chronic urethral obstruction
3. acute abdomen or septic shock
86
how are prostatic abscesses diagnosed
palpation
enlarged asymmetric
US
87
how are prostatic abscesses treated
surgical drainage & omentalization or percutaneous drainage
with concurrent treatment for chronic prostatitis
risk of serious complications
consider referal
88
what are paraprostatic cysts
large sacs of fluid adjacent to prostate and attached by stalk
89
how do paraprostatic cysts present (3)
1. dysuria or tenesmus
2. perineal mass
3. occasionally systemic signs
90
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)
91
how are paraprostatic cysts treated (2)
1. omentalization
2. castration
92
what are common prostatic neoplasia
carcinomas
93
what is the signalement of prostatic neoplasia
entire or castrated dogs
94
what is the presentation of prostatic neoplasia (5)
1. tenesmus
2. dysuria
3. hemorrhagic urethral discharge
4. hindlimb lameness
5. chronic weight loss and/or anorexia
95
what do prostatic neoplasias feel like on palpation
1. firm, irregular nodules
2. enlarged, asymmetric, firm, fixed +/- painful
3. enlarged sublumbar lymph nodes
96
what is the urinalysis of prostatic neoplasia (3)
1. hematuria
2. +/- atypical cells
3. +/- evidence of UTI
97
what would the appearance of prostatic neoplasia be on rads (3)
1. irregularly enlarged
2. mineralized opacities
3. lysis or proliferation on lumbar vertebrae or pelvic bones
98
what is the appearance of prostatic neoplasia on US (4)
1. focal or multifocal hyperechoic parenchyma
2. asymmetry
3. irregular contour
4. cavitatory lesions
99
how is prostatic neoplasia diagnosed (3)
1. rads
2. US
3. BRAF test on urine
100
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
