Clinical approach to the urinary patient Flashcards
Define oliguria
less than normal urine output
Define anuria
total absence of urinary output
What is the normal urine output for dogs and cats?
15-45ml/kg/day for dogs and cats (less than normal water intake d/t insensible losses which are 20ml/kg/day)
Define dysuria (often used somewhat interchangeably with stranguria)
difficult urination, characterised in animals primarily by straining to pass small amounts of urine. Pain a feature in human medicine but hard for vets to assess.
Define stranguria (often used somewhat interchangeably with dysuria)
slow and painful urination
Define pollakiuria
frequent passage (typically small amounts of urine)
Define urinary incontinence
involuntary passage of urine
Define periuria/ inappropriate urination
urination at wrong time and in wrong place, may be secondary to dysuria, nocturia or behavioural problems
Define nocturia
urination during the night
What other findings may suggest urinary tract disease?
- abdominal distension
- collapse
- halitosis
- depression
- vomiting
- suspected constipation (always be careful with owner interpretation)
- post trauma
What abnormal findings may there be on clinical pathology with urinary tract disease?
- azotaemia
- hyperkalaemia
- hyperphosphataemia
- polycythemia
- proteinuria
- others
What is the logical approach to urinary problems?
- hx, CS, PE
- is the problem related to urinary tract?
- LOCATION: upper urinary tract (kidneys and ureters), lower urinary tract (bladder and urethra), both, involvement of other organ systems
Hx to oclect
- owner main concern
- general and urogenital hx
- problem: duraiton, severity, course, response to tx
- normal for the animal?
PE points for urinary exam
- general and urogenital
- abdominal palpation (esp kidneys and bladder)
- rectal +/- vaginal (feel external urethra)
- external genitalia
- neurological (anal and perineal reflexes, tail and HL function)
What are common CS assocaited with upper urinary tract?
- PU/PD
- abnormal renal palpation
- depression
- lethargy
- halitosis
- oral ulcerations
What CS are associated with lower urinary tract problems?
- dysuria
- pollakiuria
- urinary incontinence
- abdnormal palpation of bladder and/or urethra
- abnormalities of external genitalia
What might oliguira/ anuria suggest?
upper or lower urinary tract
What might haematuria suggest?
either upper or lower urinary tract problem but usually lower urinary tract
Common upper urinary tract problems
- ARF
- CKD
- glomerulonephritis
- neoplasia
- pyelonephritis
- developmental abnormalities
- nephro /ureterolithiasis
Common lower urinary tract disorders
+++
Further investigations for urinary problems
- CLINICAL PATHOLOGY: blood, UA
What is the emergency panel for urinary problems
- electrolytes
- urea and creatinine
- PCV/ TS
- blood gas analysis
What information can you obtain from UA?
- SG
- dipstick
- sediment analysis
How can urine be collected?
- various methods
= depends on what you are primarily interested in and practicalities - free catch
- catheter
- cystocentesis
- samples may be recorded at different times (first thing in morning, random, post-prandial)
Methods - free urine catching
- easy in dogs
- plastic granules in litter tray or vet bed in bare cage - CATS
Pros - free catch urine sample
not associated with iatrogenic haematuria unlike other methods
Cons - free catch urine
not ideal to use for culture d/t contamination risk
Describe catheter sampling
- useful if being catheterised for different procedure
- technically harder in females: often resented
- need good technique
- culture should be quantitative
- risk iatrogenic trauma/ infection
- wide variety of catheters available
Name different urinary catheters
- basic polypropylene catheter: most common for acquiring samples, rigid so easier to place
- foley catheters: commonest for indwelling catheters as more flexible
Materials for catheterisation
- catheter
- sterile lube
- dilute antiseptic to clean
- speculum for female
- sterile gloves or no touch technique if catheter in sterile sleeve
- animal restraint (sedation - females, male cats very likely to need sedation)
Catheterisation - males
- extrude penis
- pass catheter gently via external urethral orifice
- stop if resistance
- once encountered care passing further (risk blood contamination or knotting in bladder)
- if possible avoid first few mls as more likely contaminated
Catheterisation - femlae technique
- need to visualise or palpate external urethral orifice
- visualisation using speculum best for urine sampling as reduced contamination
- pass catheter gently into urethral orifice and advance carefully as for male
Outline ‘blind’ urethral catheterisation
- steriel gloves
- index finger in vagina
- catheter advanced under finger
- when correctly positioned it ‘disappears’ under a band of tissue
- catheterising female cats surprisingly easy: ventral recumbency, well lubricated catheter run along vaginal floor
Outline cystocentesis
= percutaneous aspiration of urine from bladder
- ideal for bacteriology as less contamination
- better tolerated in females than catheterisation
- low risk of inadvertant penetration of other viscera
- may cause iatrogenic haematuria
- occasionally associated with complications
When shouldn’t you do cystocentesis?
- tumours (risk of seeding)
- thrombocytopaenia
Cystocentesis - procedure
- usually conscious with manual restraint
- ventral or ventrolateral site
- USG increases accuracy if bladder not palpable
- needle (22G 1-2 inch dogs, 5/8ths inch cats) attached to a syringe (5-10ml) directe at an oblique angle in to the bladder
- urine aspirated and needle withdrawn
What are the mainstays of diagnostic imaging?
radiography and utlrasound
What are important radiographic techniques?
- plain films
- contrast techniques (IV urography, retrograde (vagino) urethro cystogrpahy, cystography (positive, negative, double))
- specialist techniques (antegrade pyelograpy, renal angiography, fluoroscopy)
What is retrograde imaging?
contrast injected from caudal to cranial
What is antegrade imaging?
contrast ingected from cranial to caudal
What is ultrasound most useful for?
- imaging parenchymatous organs and bladder
- distinguishing fluid from soft tissues
- assessing bladder wall thickness
- evaluating ureterovesicular emptying
- allowing image guided centesis and biopsies to be performed
- determining origin of organ enlargement
- detecting free abdominal fluid
Define polyuria
greater than normal urine output
What is ultrasound not useful for?
- imaging intrapelvic structures
- examining a bladder containing a gas
- determining #, size, or composition of calculi
- detecting bony change
Uses - radiography
- determining presence and # of radiodense calculi
- determining presence and # of radiolucent calculi with contrast technqiues
- detecting bony changes
- contrast techniques can demonstrate extent and location of luminal abnormalities particularly urethra and ureters
- thoracic rads for detecting pulmonary metastases
Are MRI and CT useful for urinary problems?
Yes - lots of indications, especially for CT
How important is cytology/biopsy for urinary tract problem work up?
- extremely!
- USG and non-invasive methods (FNA, tru-cut, catheter, biopsy forceps, sx)
Name 3 types of uroendoscopy
- urethroscopy
- cystoscopy
- ureteroscopy
- mainstays in human med, increasing in veterinary)
- therapeutic and diagnostic
Indication - nuclear scintigraphy
quantitative measurement of GR which is kidney specific (i.e. when you suspect one kidney is worse than other and you want to determine which one). Rarely used currently in veterinary.
Define urodynamics
investigation of the function and dysfunction of lower urinary tract
Name some tests that are included in urodynamics
- uroflowmetry
- pressure flow study
- cystometry
- urethral pressure profilometry
- ambulatory urodynamics
What is urethral pressure profilometry?
- type of urodynamics
- highly technique dependent
- for research rather than clinical use
Are there inheritable urinary tract problems?
Yes - many are autosomal recessive conditions
Examples of DNA tests for urinary tract problems
- feline polycystic kidney disease *
- familial/ juvenile nephropathies
- canine hyperuricouria (excessive excretion of urate)
