Dogs and Cats 21 Flashcards
1
Q
renal proteinuria what are the main types, causes and how to know
A
- transient
- Persistent renal proteinuria and other urinalysis results
○ Glomerular disease
§ Often marked proteinuria (UPC> 2.0)
○ Tubular disease
§ Possibly also glucosuria, acidosis, electrolyte imbalances
2
Q
When to suspect glomerulopathes and the histopathological classification
A
When to suspect glomerulopathies
- Persistent renal proteinuria (UPC elevation)
- Hypoalbuminaemia
- Hypercholesterolaemia
- Persistent hypertension
- Low USG without explanation
- Normal USG but azotaemia in a hydrated animal - uncommon
Histopathological classification: glomerular disease
- Examples of subgroups recognized are:
○ Membranoproliferative glomerulonephritis - more common in dogs
○ Membranous nephropathy
○ Amyloidosis - more common especially in cats
3
Q
Glomerular disease primary and secondary causes
A
- Primary ○ Familial congenital - Secondary ○ Infectious ○ Immune-mediated ○ Idiopathic ○ Neoplastic ○ Miscellaneous
4
Q
Familial renal disease suspicion and approach
A
- Suspect familial renal disease if
○ Pet is purebred - sharpies, British shorthair
○ Pet is adolescent or young adult
○ Siblings/close relatives are showing similar signs - Approach
○ Screening tests (breed associations)
○ Search genetic disease database;
5
Q
Secondary glomerulopathies what are the 4 main causes
A
- Caused by infection
○ Dogs: bacteria causing pyelonephritis, prostatitis, orchitis - Caused by inflammation
○ Dermatitis, periodontal disease, SLE - Caused by neoplasia
○ Lymphoma, mastocytosis or histiocytic disease - Miscellaneous causes
○ Overvaccination, Trimethoprim sulfonamide
6
Q
Glomerulopathies investigation what does it involve
A
- Different degree of work-up depending on patient criteria
- Patients are categorised in 3 tiers according to:
○ Persistent renal proteinuria
○ Hypoalbuminaemia
○ Azotaemia
○ Hypertension and sequelae
7
Q
What are the potential diagnostic tests for a glomerulopathy and when is work up indicated
A
- Tests ○ Renal biopsy ○ Genetic tests ○ Antithrombin III measurement ○ Abdominal ultrasound, thoracic radiographs ○ Haematology, Biochemistry(Serology) ○ Blood pressure ○ Urinalysis, UPC, Culture - Tests may be essential, recommended or potentially helpful - If indicated, work up for: ○ Hypoalbuminaemia ○ Azotaemia ○ Hypertension ○ Infectious diseases ○ Other sequelae
8
Q
when to do a renal biopsy and when not to
A
- Do it (well prepared): ○ Disease unresponsive to standard care ○ Severe proteinuria (UPC > 3.5) ○ No overt contraindications - Leave it: ○ IRIS stage 4 renal disease ○ Biopsy unlikely to change treatment plan ○ Contraindications
9
Q
Nephrotic syndrome what is it a combination of and indication of
A
- Combination of
○ Hypoalbuminaemia
○ Hypercholesterolaemia
○ Proteinuria
○ Extracellular fluid accumulation (e.g. ascites) - Indicator of severe disease and associated with poor prognosis
10
Q
Treatment of glomerular disease what are the main factors that need to be managed
A
- Factors to be managed
○ Protein loss
§ Weight loss, hypercoagulability, hypercholesterolaemia, ascites
○ Underlying disease
§ Inflammation, immune-complex deposition
○ Progression of renal disease
§ Hypertension, azotaemia - Management may be supportive, or specifically targeting the underlying disease
11
Q
What are the 4 main things involved in treatment of glomerular disease
A
1) Supportive management of blood pressure and proteinuria
2) further supportive treatment
3) further supportive treatment in selected patients
4) specific treatment = treat underlying disease and or immunosuppressive treatment
12
Q
Supportive management of blood pressure and proteinuria in the treatment of glomerular disease what drugs involved and what do they do
A
○ ACE-inhibitor, e.g. benazepril
§ Less filtration pressure in glomerulus due to vasodilation of efferent arteriole
§ May cause reduction in renal blood flow and GFR - RISK
□ Monitoring of renal function after start
○ Further blood pressure control
§ Calcium channel blocker, e.g. amlodipine
§ Angiotensin receptor blocker, e.g. Telmisartan
13
Q
Further supportive treatments in teh treatment of glomerular disease what are the 2 main things involved and what else need to do
A
○ Protein-restricted diet
§ O3 fatty acid supplement - anti-inflammatory as well
○ Anticoagulants
§ Antithrombin III - if albumin is lost this is lost as well
□ If lose hypercoagulable -> predispose to blood cot
§ Aspirin or Clopidogrel
○ Stage and treat azotaemic dogs/cats
14
Q
What are the 3 main further supprotive treatments that may be needed in treating glomerular disease in selected patients
A
1) Drainage of ascites
§ Only recommended in cases with ascites causing respiratory distress
2) Diuretics
§ Only recommended in selected cases with ascites
§ Potassium sparing ones - spirolactone
3) IV fluid therapy
§ Crystalloids: avoid fluid overload
§ Colloids: Only in patients with hypotension that does not respond to crystalloids
15
Q
Specific treatment (treating underlying disease or immunosuppresives) for glomerular disease when to do
A
○ Immunosuppressive treatment –yes or no?
§ In 50% of dogs, glomerulopathies are associated with immune-complex deposition
§ Possible benefit for Immunosuppressives
§ Immunosuppressives are not indicated in all dogs, e.g.
□ No benefit in many genetic disorders
□ No benefit in amyloidosis
16
Q
Specific treatment (treating underlying disease or immunosuppresives) for glomerular disease current treatment guidelines
A
§ Depend progression of disease § Rapid □ Prednisolone and/or □ Mycophenolate mofetil, or □ Cyclophosphamide § Slow - in addition to above □ Azathioprine □ Cyclosporine □ Chlorambucil
17
Q
What are the 5 main treatment goals in treating glomerular disease and treat same for dog and cats?
A
- UPC:WNL or at least 50% reduction of UPC
- Blood pressure controlled
- No hyperkalaemia
- Stabilise azotaemia
- No sequelae
Cats are not dogs
- Causes of glomerulonephritis are less well established in cats.
- Very limited studies about therapy in cats.
- Thus, specific treatment guidelines are for DOGS ONLY.
18
Q
Monitoring glomerular disease what frequency and what monitoring
A
- 1 week –1 month –3 months
- Appetite, Urination
- Physical components
○ Body weight, BCS
○ Physical examination changes - Blood pressure
- Clinicopathological
○ UA and UPC, +-Ucult
○ PO4, K, Na, Ca, urea, crea, cholesterol, albumin, CBC
19
Q
Prognosis for glomerular disease
A
- Regression is possible
- Poor prognostic indicators:
○ Azotaemia (10-45 days median survival)
○ Nephrotic syndrome (51 d vs 605 d median survival) - Although MST with NS is short, survival >7 years has been reported
20
Q
What is the blood supple and lymphatic drainage from the bladder
A
- Caudal vesicular artery: ○ Major supply § Arises from uterine(female )or prostatic (male) branches of the internal pudendal - Cranial vesicular artery: ○ Terminal end of umbilical ○ Supplies cranial end of bladder. - Venous drainage: internal pudendal veins. - Lymphatic drainage: ○ Hypogastric ○ Sublumbar ○ Medial iliac lymph nodes
21
Q
Bladder innervation what are the 3 main ones and the function
A
- α adrenergic receptors in the smooth muscle of the bladder neck and urethra
1) Sympathetic innervation
○ Hypogastric nerves(L4-L6)
○ Storage (filling): detrusor relaxation & bladder neck/ urethral contraction - MAINTAIN CONTINENCE
2) Parasympathetic innervation
○ Pelvic & Pudendal nerves(S1-S3)
○ Voiding: detrusor contraction, relaxation of the bladder neck & urethra
3) Somatic innervation: -
○ Pudendal nerve(S1-S3)
○ Voluntary control of urination
22
Q
Storage stage of the bladder what innervation and function is involved
A
- Smooth mm at vesicular-uretheral junction maintained in contraction for storage (Except during micturition):
○ Mediated by α-adrenergic stimulation via the hypogastric nerve
○ B-receptor stimulation via the hypogastric nerve relaxes the detrusor simultaneously
23
Q
Voiding of the bladder what innervation and function is involved
A
- As bladder nears capacity, stretch receptors are activated:
- Results in parasympathetic stimulus to institute reflex micturition
- Depresses sympathetic outflow in the Hypogastric n and brainstem (pons-micturition centre)
- Parasympathetic nerve supply originates in pontine centre and in the sacral spinal cord(S1-3):
- Stimulates and maintains detrusor contraction via the Pelvic nerve
24
Q
Urethral anatomy where extends and anatomy in male dog and cat
A
- Extends from the trigone to the urethral meatus
- Lined by transitional epithelium
- Male dog
○ Preprostatic
○ Prostatic (within prostate)
○ Membranous/cavernous
○ Smooth muscle
§ Longitudinal, runs length of the urethra
○ Straited muscle - distal 2/3rds - Male cat
○ More distinct preprostatic urethra
○ Short prostatic section
○ Membranous (within pelvis)
25
Urethral anatomy in female dogs and cats
- Female dogs
○ Urethra shorter and wider
○ Smooth muscle: outer and inner longitudinal and middle circular, runs length of urethra
○ Straited muscle: distal 1/3
○ OHE increases collagen and decreases smooth muscle in the proximal urethra - PREDISPOSE
- Female cats
○ C/w female dogs
§ Lumen smaller
§ Less circular smooth muscle and elastic fibres
26
Blood supply and innervation to the urethral in male and female
```
Blood supply
- Female
○ Vaginal arteries from the urogenital artery
- Male
○ Prostatic: prostatic artery
○ Membranous/cavernous: urethral branches of pudendal, urethral or prostatic, urethral bulb artery
Innervation
- Striated muscle
○ External urethral sphincter
○ Pudendal nerve
- Smooth muscle
○ Internal urethral sphincter
○ Parasympathetic: pelvic nerve
○ Sympathetic: (alpha adrenergic) hypogastric nerve
```
27
Healing of the bladder, how long does it take
- Bladder undergoes rapid healing
○ Mucosal defects heal within 5 days
○ Full thickness incisions regain 100% normal tissue strength in 14-21 days
28
what are the 7 main indications for bladder surgery
1. Urolithiasis
2. Trauma
3. Neoplasia
4. Ectopic ureter surgery
5. Urachal diverticulum
6. Bladder biopsy
7. Urinary diversion - cystotomy tubes
29
Cystotomy what is it and what need to do in preparation -EXAM
- Midline celiotomy -> if removing uroliths than caudal laparotomy is appropriate
Preparation
- Stay sutures
○ In the apex of the bladder (cranial traction)
○ Lateral to the incision
- Pack off the bladder - moistened lap sponges - CLEAN CONTAMINATED SURGERY
- Empty the bladder
○ Catheter
○ Cystocentesis/suction
○ Empty bladder after incision via suction
30
Cystotmy what are the 2 main approaches, which better and how to open bladder -EXAM
○ Dorsal or ventral approach
§ No issues with adhesions
§ Ventral approach
□ Improved exposure of trigone (visualisation of ureteral orifices)
□ Decrease risk of iatrogenic urethral damage than dorsal approach
□ Avoids retroflexion and 180 degree kinking of urethra than dorsal
○ Choose avascular region in ventral midline
○ Stab incision with 15 or 11 blade
○ Extend with Metzenbaum scissors
○ Make incision from apex to trigone region
31
Cystotomy closure suture material and what is important
○ Rapid healing occurs with mucosal defects epithelialize in < 5days
○ Accurate needle placement through the submucosa is the most important aspect of closure
○ Suture material
- synthetic monofilament absorbable (PDS 3/0-5/0)
- simple continuous or interrupted
§ Ideally do NOT penetrate lumen
§ Engage submucosa only: - NO KNOTS WITHIN LUMEN
32
What is important to consider with closing bladder and synthetic sutures and which types degrade with what
□ Absorbed via hydrolysis
® Hydrolysis is more rapid in urine, particularly when infected
® Sutures with a glycolide component degrade more rapidly in a ALKALINE environment (when infected)
® Sutures with dioxanone component degrade more rapidly in an acid environment
® Short acting absorbable may not last long enough for healing infected urine
33
Urteral ectopia what are the 2 main types which species common in and what does this influence
Morphologic types
1. Intramural
○ Ureter enter bladder wall at a normal location
○ Runs sub-mucosal empty into the urogenital tract distal to the trigone
○ Most common form in dogs
2. Extramural
○ Ureter by-passes bladder completely
○ Inserts distal to the trigone
○ Most common form in cats
- Morphology influences method of correction
34
Surgical correction for intra-mural ectopic ureters what are the 2 main options and which recommended
1) Neourecterostomy - create a new opening - SPECIALIST LEVEL SURGERY
2) Cystoscopic-guided LASER ablation - RECOMMENDED - more minimally invasive
§ Catheterise the ureter and laser the section away
35
What is the surgical correction for extra-mural ectopic ureters and how occur
○ Ureteroneocystostomy
§ Re-implantation of the ureter from the abnormal insertion point into the bladder lumen proximal to the trigone
□ Difficult due to small size of ureters
§ Ventral cystotomy
§ Stab incision
§ Passage of ureter through bladder wall
§ Spatulation
§ Suturing with 5/0 - 6/0 suture
36
Surgical outcome of ectopic ureter surgical and what need to do
- Persistent incontinence is common
○ 30-70%
○ Concomitant functional bladder/urethral abnormalities (huskies)
○ USMI
○ Urethral pressure profilometry pre-op may be predictive (where available)
○ Address this problem at index surgery
○ Communicate and discuss with owners beforehand
37
Urethral sphincter mechanism incompetence predisposing factors
- Urethral tone
- Bladder neck position - if intrapelvic bladders
- Urethral length
- Neuter status
- Body size
- Breed
- Tail docking
- Obesity
38
Urethral sphincter mechanism incompetence surgical treatment when used what are the 3 main things targeting and techniques used
only if adverse effects or refractory to medical management
Surgical targeting ->
1) bladder neck position -> advance bladder neck into abdominal pressure zone
§ Use colposuspension or urethrocystopexy/urethropexy
2) Increase functional length of the urethra
§ Colposuspension
§ Urethral lengthening
§ Urethrocytstopexy/ urethropexy
3) Increase static resistance via reduction in urethral diameter - what we are moving towards
§ Submucosal injections
§ Artificial urethral sphincters (AUS)
39
What are the 3 main surgical treatments for urethral sphincter mechanism incompetence
1) colposuspensio
2) endoscopic transmucosal infection - good
3) hydraulic occlusion - good
40
Colposuspension what is it used for, what is involved and outcomes
Urethral sphincter mechanism incompetence surgical treatment
§ Sutures vaginal tissue to pubic brim which -> creates sling to put pressure on urethra
□ Advances bladder neck and proximal urethra into abdominal pressure zone
□ Increases functional urethra length
□ Compression of urethra between vagina and pubis
§ Outcomes
□ Cure 54%, improvement 36%, fail 9%
□ Complications 15%
® Dyssunergia
® Infection
® Recurrence - suture breakdown
® May require adjuvant medical
41
Endoscopic transmucosal infection what is it used for, outcomes and what use
Urethral sphincter mechanism incompetence surgical treatment
§ Restoration of continence 2-28 months in 36% -> can go back and redo due to collagen breakdown
§ Second treatment 4-25months in 41%
§ Failure mechanism - mucosa erosion and loss of agent
§ USE - glutaraldehyde cross linked bovine collagen
□ Retreatment in 30%
□ No complications
42
Hydraulic occulsion what used for what done and when is continence achieved
Urethral sphincter mechanism incompetence surgical treatment
§ Open surgical procedure but relatively straight forward
§ Device placed around pelvic urethra to add pressure and help remain continent
§ SC access port used to inject small volumes of saline -> can also remove if put in too much
§ 3-4 weeks until continence achieved
43
Options for urolithasis treatment
1) Medical dissolution possible ○ Struvite, urate, cystine
2) surgical
- cystotomy - most common
- Alternative methods
○ Laparoscopic assisted cystotomy
○ Laser lithotripsy via cystoscopy
3) Care with urinary diets post-op
○ Protein restriction may delay healing
44
What are the 8 steps in a cystotomy for urolithiasis
1. Visual inspection and palpation of entire mucosal lining
2. Check for urachal diverticulum
3. Catheter flush (urethral floss) -> retrograde flush through bladder out the urethra -> TO ENSURE WHOLE OF LOWER URINARY TRACT HAS NO STONES LEFT
4. Collect samples for C and S
○ Bladder wall mucosa
○ Urolith (crushed)
5. Submit uroliths for composition analysis
6. Radiograph post-surgery to ensure all calculi removed - IMPORTANT
7. Urethral FLOSS
8. Check for urachal diverticulum
45
Urethral surgery what are the main indications and what if cannot be repaired
- Obstruction - uroliths, neoplasia, stricture
- Trauma: rupture, perforation, avulsion
- If urethral abnormalities cannot be repaired, a urethrostomy proximal to the site of the lesion can be considered
46
Urethrotomy what is it, when performed, what should always attempt before hand and how
- Temporary opening of the urethra
- Performed mainly to remove uroliths that can't be shifted or to biopsy a lesion
- Always attempt urohydropulsion - IMPORTANT
○ Usually effective
○ Cystotomy is always preferable to urethrotomy
○ Loss of sterile lubricant
○ Largest possible catheter diameter
○ Care with bladder overdistention
47
Urethrotomy location which preferred and risks
- Location
○ Penile
○ Scrotal
○ Prescrotal: preferred position - near the os penis
○ Perineal
- Post-operative haemorrhage and urine scald are temporary issues
- Risk of post-operative stricture:
○ Uncommon
○ More likely if urethra severely traumatised
48
Urethrotomy steps
○ Dorsal recumbency
○ Place a catheter as far as possible into the urethra
○ Ventral midline incision and lateralize retractor penis muscle
○ Use a 15-scapel blade to incise into the urethra
○ Cold saline to aid haemostasis
○ The urethrotomy can be allowed to heal via 2nd intention
○ Expect post-op bleeding
49
Perineal urethrotomy what is different and therefore what need to consider
○ Urethra is much deeper
○ Need to divide the bulbospongiosus muscles to expose the corpus spongiusum
○ After obstruction relieved, pass catheter normo and antegrade to exclude other obstructions
○ Use primary closure of the urethra to avoid cellulitis
50
Closure of urethrotomy what involved
○ Simple interrupted sutures of 4-6/0 monofilament absorbable
○ Close urethral mucosa and tunica albuginea
○ Close over a catheter
○ Secondary intention closure is preferable for cases where the mucosa is damaged
51
Urethrostomy site, what doing and indications
- Sites: similar to urethrotomies
- Permanent opening of the urethra
- Indications
○ Recurrent obstructive calculi, which cannot be managed medically
○ Immoveable calculi
○ Salvage surgery for trauma or stricture
○ Neoplasia (performed proximal to site of neoplasia)
52
Urethrostomy perferred locations in cats and dogs and why
- Cats: perineal, subpubic/transpelvic and prepubic
- Dogs: scrotal is preferred
○ Urethra wider and more superficial
○ Less cavernous tissue - reduced haemorrhage
○ Reduce scalding post-operatively (hindlimbs and perineal)
53
Scrotal urethrostomy what is involved, steps and closure
○ Castration and scrotal ablation
○ Place catheter is possible
○ Dissect subcutaneous tissue and retract retractor penis
○ Can place atraumatic forceps across both ends of urethra
○ Use 15 blade to incise urethra, 2.5-4cm incision
○ Close urethral mucosa to skin
○ Post-operative haemorrhage is reduced with continuous closure vs interrupted
54
Prescortal and perineal urethrostomy in dogs technique, what isn't present and which should be avoided
○ Technique as for urethrotomy but suture urethral mucosa to the skin
○ Retractor penis muscle isn't present in the perineal location
○ In dogs - perineal urethrostomy should be avoided is possible
§ Increased risk of infection
§ Increased urine scalding
§ Increased peri and post-op haemorrhage
55
Perineal urethrostomy in cats indications and surgical technique
○ Indications
§ Recurrent urinary tract infections, previous catheterisation leading to stricture, neoplasia, obstruction
○ Surgical technique
§ Castration and penile amputation are performed
§ A new stroma is created on the perineum
§ Critical to dissect and free urethra proximal to bulbourethral glands to minimise tension
56
Perineal urethrostomy in cats post operative care
§ Shredded paper rather than a litter tray
§ Avoid a urethral catheter
§ Use a buster collar, consider hobbles
§ Remove stitches in 10-14 days under heavy sedation/GA
57
Perineal urethrestotomy in cats 4 main complications
i. Urinary tract infection - 25%
□ Anatomical alteration of the urethral meatus and the underlying uropathy increase the risk
ii. Stricture formation
□ Stoma being too small initially
□ Tension
□ Post-operative subcutaneous urine leakage
iii. Haemorrhage
□ Usually mild unless there is self-traumatisation
iv. Others
□ Complication rate is low if done correctly
□ Faecal and urinary incontinence, rectal prolapse, perineal hernia uncommon
Despite increased risk of UTI and the requirement for ongoing management of FLUTD, can be a life- saving procedure
58
Prepibic urethrostomy what is it, which species used in, outcome, issues and procedure
○ Salvage procedure mainly used in cats
○ Can be used in dogs as well
○ In males dogs need to use a parapreputial location
○ Outcome was guarded in one study
○ Peristomal inflammation can be a problem
○ Procedure
§ Ventral celiotomy
§ Blunt dissection to mobilize the urethra
§ Severe the distal end of the urethra and exteriorize 2-3cm lateral to the midline
§ Spatulate the end of the urethra
§ Ensure the urethra doesn't kink
§ Suture the mucosa to the skin
59
Urethral obstruction how important, common cause, initial management and goals
- Diagnosis important because duration of obstruction associated with chance of recovery
- Ureteroliths are a common cause of ureteral surgery in cats
○ Can also get blood clots, circumcaval ureters -> obstruction
- Initial medical management 1-4 days prior to surgery
○ Rehydration
○ Diuresis
○ Relaxation of ureteral mm
- Goal = distal migration into bladder avoiding consequences
- Drugs not commonly used or effective
60
What are the 4 surgical management for urethral obstruction and how done
1. Ureterotomy
○ Small size, stricture
2. Re-implantation
○ As for extramural ectopic ureters
3. Pig-tail catheter/stent
○ By-passes obstruction
○ Difficult to place, easier to use in dogs as larger ureters
4. SUB - subcutaneous ureteral bypass - NOW DONE MORE
○ Ventral midline laparotomy
○ From renal pelvis into the bladder -> artificial ureter
○ Leave diseased ureter -> relief of azotaemia and upper urinary tract obstruction
○ Flush every 3 months -> to ensure everything is patent
○ Can be issue with complications - urinary tract infection
61
Urethral trauma causes and clinical signs
Causes
- Mainly secondary to blunt trauma or catheterisation (iatrogenic)
- Pelvic fractures may result in urethral trauma (sharp bone edges) - NEED TO EXAMINE LOWER URINARY TRACT
Clinical signs - depends on where the trauma occurred
- Haematuria, dysuria, anuria, vomiting anorexia, depression
- Abdominal distension (proximal urethra)
- Subcutaneous swelling/celluitis, severe bruising or skin necrosis (distal urethra)
- Signs associated with azotaemia/hyperkalaemia/metabolic acidosis
- Animals may urinate normally
○ Catheterization and bladder expression may all be possible and don't rule out urethral trauma
62
Urethral trauma diagnosis and stabilisation why needed and small lacerations
Diagnosis
- Biochemistry (azotaemia, hyperkalaemia, metabolic acidosis)
- Abdominal/perineal ultrasound
- Abdominocentesis
- Positive contrast urethrocystography
Stabilisation
- Unless urinary tract injury is recognised quickly patients are often very ill when diagnosed
- Stabilisation is required to make safe candidates for general anaesthesia and surgery
○ Small lacerations will heal in 3-5 days with diversion -> Placing a U catheter to act as a stent
63
Urethral resection and anastomaosis is it done, indications and surgical approach
- not done in general practice
○ Indications: trauma, stricture and neoplasia -> complete transection
○ Surgical approaches
§ Caudal ventral midline abdominal incision: only suitable for proximal urethra
§ Pubic symphysiotomy
§ Bilateral pubic and ischial osteotomy
§ T shaped bone flap
§ Place catheter retrograde from external urethral orifice
64
Urethral prolapse signalment, recent activity, and presentation
- Young male brachycephalic dogs especially English bulldogs
- May occur after excessive sexual excitement or masturbation
- Small red pea shaped mass at end of the penis
65
Urethral prolapse treatment
- Surgical resection and suture urethra to penile mucosa is treatment of choice
○ Pass urinary catheter and remove protruding mucosa
- Urethropexy is alternative technique
- Castration is recommended particularly dogs that have prolapsed due to erection, sexual excitement
66
Bladder trauma causes, repair and main surgical treatment with indications and what can do
- Same as urethral trauma
- Debride and repair defects with sutures
- Use omentum/serosal patches to reinforce repair
Cystectomy
- Indications - trauma, necrosis, neoplasia
- About 75% of the bladder can be resected providing the trigone is intact and still have good function
- Initially urination will be small amounts frequently
○ Hypertrophy, mucosal regeneration distension and smooth muscle stretching restore normal voiding volumes within a few months
67
Bladder neoplasia how common, character, most common and history
- 1% of all canine tumours- less in cats
- 97% are malignant and epithelial
- Most common in transitional cell carcinoma
History
- Older dogs
- Female dogs at higher risk
- Neoplasia rare in cats
68
Bladder neoplasia clinical signs and diagnosis
```
Clinical signs
- Haematuria
- Pollakiruia (abnormally frequent urination)
- Stranguira (difficult)
- Urinary tract infection
- Palpable caudal abdominal mass
- Bladder distension
- Weight loss
- Signs are usually chronic
Diagnosis
- Urine analysis
○ Pyuria, haematuria, proteinuria
- Survey radiographs
- Positive contrast urography
- Thoracic radiography - mainly checking for metastasis - 14% of cases
- Ultrasound
- Cystoscopy - biopsy and definitive diagnosis
○ Not FNA -> risk of tumour seeding
```
69
Bladder neoplasia 3 main treatment options and when can do
1) Surgery
- Dogs: within the trigone - not good surgical options
- Cats: down at apex
○ Partial cystectomy -> removal grossly
§ Rare to get complete resection because generally cells left over
- Aggressive tumour but aggressive surgery hasn't increased survival time
2) Other treatment options
- Chemotherapy - cox-2 inhibitors (piroxicam deracoxib and meloxicam)
- Radiotherapy - not improved survival times
3) Palliative diversion techniques -> generally die from not being able to urinate
- Permanent low profile cystotomy tubes
- Urethral stents
○ Stricture and neoplasia an issue
70
What are common neoplasia of kidney and penis and treatments
```
- Kidney
○ Renal carcinoma
○ Nephroblastoma
○ Treatment with nephrectomy and ureterectomy
- Penis
○ Transmissible venereal tumours
○ SCC
○ Treatment for TCC chemotherapy
Other tumours may require penile amputation and urethrostomy
```
71
renal biopsy methods and indications
- Methods
○ Blind percutaneous needle
○ U/S guided needle
- Need to biopsy the renal cortex NOT THE MEDULLA
- Indications
○ Trauma to kidney, renal vessels or ureters
○ Persistent pyelonephritis
○ Persistent obstruction with hydronephrosis
○ Renal/peri - renal masses
○ Organ harvest for transplantation
72
Feline inappropriate elimination definition, prevalence and gender effect
Definition
- Urination and/or defecation in areas that are considered inappropriate by the owner
Prevalence
- Most common behavioural problem in cats
- Approximately 1/3 of cats house soil, spray, or mark
- Urine>both>faces
Gender effect
- House soiling – none
- Spraying/marking – twice as common in males
Problem cats often do not cover urine or faeces
73
Identifying the cat that is doing the inappropriate elimination
○ Confinement - not always clear cut because may remove a stressful cat so the remaining cat stops because no longer stress
○ Video
○ Fluorescein caps?
§ 0.5ml of a 10% solution orally OR 6 fluoroscein strips in a capsule
§ False negatives common - if negative not always the actual case
§ Can stain fabric
74
Inappropriate elimination what are the 2 main differentials and how to differentiate
1) House soiling
- don't want to use their little tray (disease or little box issues)
- large volume
- horizontal surfaces
- one or few areas
- sometimes faeces
2) urine spraying
- cause - stress, social sexual behaviour (controlling space)
- small volume
- vertical surfaces
- severeal specific area
- rarely faeces
75
What are the 3 main components of inappropriate elimination and what to do to assess
```
1. Medical
○ Medical history
○ Physical exam
○ Urinalysis
○ CBC, biochemistry, thyroid assessment
○ Rule out PUPD - water intake
○ Radiography, ultrasonography, endoscopy, biopsy
○ Faecal examination
2. environmental
○ Diagram of house
§ Urinating near windows -> spaying behaviour most common
§ Litter trays - all in one room -> wrong location
§ Food and water
§ Elimination
○ Other cats around the house
3. Behavioural
○ Development of problem
○ Changes – litter, location, social structure, routine, season
○ Frequency
○ Attempts to treat
```
76
House soiling differential diagnosis
```
○ Medical disease - need to rule out
○ Separation anxiety - puddle of urine outside door of bedroom - common cause
○ behavioural issues
○ soiled areas - don't want to soil (get enzymatic cleaner)
○ Lack of training - lots of cases
○ Cognitive dysfunction
○ Other age related
§ Incontinence, arthritis
```
77
House soiling behavioural causes what preferences and aversions are important
○ Litter box management - how often wash tray, change litter, scop the pop
○ Number of litter boxes
○ Type of litter box
○ Location of litter box
○ Smell of soiled areas
○ Preferences - box, litter, location
§ Litter -> Small particle size -sandy, unscented litter, clumping, carpet
§ Location -> hallways and closets, easily accessible
□ multi-cat households - guarding litter boxes
§ Box -> cleanliness, detergents, number (number of cats + 1)
○ Aversions - box, litter, location
§ Litter -> Hooded litter boxes, unclean boxes, detergents, liners, frightening/painful event, accessibility
§ Location -> basement and laundry rooms
78
House soiling what are the 5 main treatment options
1) clean soiled areas
2) make soiled areas
3) address litter box factors
4) litter tray re-training
5) pharmacolical therapy - MOST DOESN'T REQUIRE DRUG THERAPY
79
What are 2 ways to make soiled areas to prevent house soiling and what involved
```
○ Aversive: don't want to go there
§ Crushed mothballs
§ Citrus, pine, or lemon scented products
§ Upside-down plastic carpet runner
§ Foil, double sided tape
§ Water in bath
○ Attractive: so don't urinate there
§ Feliway™ spray q12-24h
§ Food
§ Bedding
§ Toys
```
80
How to address litter box factors to prevent house soiling
```
○ Accessibility of litter boxes
○ Number of boxes (n+1)
○ Fine, clumping, unscented litter - Depth
○ Litter box hygiene
§ Scoop daily
§ Clean with warm water
§ Replace all litter monthly
○ Type of litter box
§ Open (vs covered)
§ No liner
§ Size of litter box
```
81
how to litter tray retraining to treat house soiling
```
○ Retraining cat to litter box
○ Confinement and supervision
○ Change substrate preference
§ Carpet to litter
○ Reward elimination in appropriate areas
```
82
Urine spraying/marking prevalence in what situations ad the gender effect with differential diagnosis
```
Prevalence
- 25% of cats in single cat households
- Close to 100% probability one cat is spraying in households ≥ 10 cats
- Gender effect
○ Males 2 x > females
○ Intact > altered
§ 10% Castrated males continue to spray
§ 5% Spayed females continue to spray
Differential diagnosis
- Medical disease
- House soiling
- Separation anxiety
```
83
Urine spraying/marking behavioural causes
```
- Stress or anxiety
○ Other cats in the home or outside
§ Active or passive inter-cat aggression
○ Change in environment or schedule
○ Conflict related to a person
- Normal form of territorial communication
```
84
Urine spraying/marking what are the 5 components for treatment
1) surgery
2) Behavioural modification
3) Environmental modification
4) pheromones
5) pharmacological therapy
85
Surgery as part of treatment for urine spraying what is involved and how effective
○ Castration - 90% effective in eliminating or markedly reducing
§ Should check cat penis if been castrated -> if spikes present then maybe haven't been castrated properly OR getting testosterone from somewhere else
○ Ovariohysterectomy - 95% effective in eliminating or markedly reducing
86
Environmental modification as part of the treatment of urine spraying what is involved
```
○ Identify and remove stressors
§ Eliminate outside cats
□ Keep stray animals away from home
® Scarecrow™
® Mothballs
□ Prevent visual access to windows
□ Change to an indoor only cat
§ Feed ad lib (puzzle feeder)
§ Daily fresh water
§ Avoid punishment -> Verbal and physical
§ Environmental enrichment -> Rotate toys, scheduled play time
§ Predictable environment
§ Consistent schedule
§ Multi-cat households
§ Address litter box factors
§ Consistency and predictability - provide stable environment, set schedule, no punishment
```
87
environmental modification in terms of multi-cat households and litter box factors as part of treatment of urine spraying
§ Multi-cat households
□ Create core areas - IMPORTANT
® Food, water, litter box, lying area and scratching post in each cat’s preferred area
® Increase vertical living space (perches)
® Collar activated cat door
□ Address inter-cat aggression
§ Address litter box factors
□ Enzymatic cleaner, scoop box daily, clean and replace litter weekly
□ 71% female, 36% male responded with ≥ 50% ▼marking1
□ Clean soiled areas and make areas aversive or attractive (Feliway™)
88
Pheromones in the treatment of urine spraying what is a common one used, mechanism, properties, use and efficacy
○ Feline synthetic facial pheromone
§ Mechanism:
□ Induces cheek gland marking preferably to urine spraying/marking
§ Properties:
□ Anxiolytic
□ Appetite stimulant
□ Lowers aggression?
§ Use: plug in diffuser or spray on marked objects
§ Efficacy:
□ 33% total elimination of spraying
□ 74% to 97% reduction in spraying/marking in multiple studies (USA, UK, France, Japan)
89
Pharmacological therapy in the treatment of urine spraying types, what drugs types involved, drugs
```
○ Anxiolytics
§ Benzodiazepines
□ Diazepam 0.2-0.4 mg/kg q12-24h
□ 55-75% effective in reducing spraying, 75-90% resumed1
§ Azapirones
□ Buspirone
§ TCA
□ Clomipramine
® 80% responded (>75% reduction)1
® 35% cessation of spraying1
§ SSRI (preferred drugs)
□ Fluoxetine
® >90% reduction marking by week two2
® 66% cessation of spraying2
○ Antiandrogenic
§ Progestins (historically)
□ Megestrol acetate, Medroxyprogesterone
® 48% male & 13% female improved1
® Single cat homes responded 50% better1
§ Cyproheptadine
□ 55-75% reduction spraying and masturbation2
□ Cessation of urine spraying for 1 month in castrated male
```
90
Prognosis for inappropriate urination
- Previously house-trained
- Duration of problem
- Pet’s environment (e.g. other cats)
- Number of areas soiled
- Ability to control triggers
- Temperament
- Owner compliance
- Medical prognosis
91
Signalment and history
- 2YO MN DSH - CLASSIC SIGNALEMENT -> commonly young
- 2 days anorexia, lethargy and depression
- Urinating outside of litter tray
- Found collapsed
What do you want to do first and next
```
ABCs
- Patent airway
- Breathing
- Heart beat with pulses
Major body system assessment
- cardiovascular
- respiratory
- neurologica
- abdominal palpation
- body temp
```
92
```
Collapsed blocked cat
Major Body System Assessment
- Cardiovascular
○ MMs pale, CRT 2.5 sec, pulses v. weak -> severe shock
○ HR 120, cardiac auscultation OK
§ HR should be 200- ISSUE
- Respiratory
○ RR 20, effort and auscultation OK
- Neurological
○ V. depressed mentation - due to severe shock
- Abdominal palpation
○ V. large, hard bladder
- Body temp
○ 36.7C
What to do next
```
Cardiovascular status will kill first
STAY OFF THE PENIS
FIRST - place IV catheter and give fluids
93
Blocked cat what are 7 steps to do with from stabilisation to post treatment
1) inital procedures - place IV catheter, emergency database and ECG
2) IV fluids
3) hyperkalaemia treatment - MAIN THING THAT WILL KILL BLOCKED CAT
4) get history from owners
5) talking to the owners
6) unblock the cat
7) further treatment and monitoring
94
Intravenous fluids how important in stabilisation of a blocked cat, what to give and how fast
- ALWAYS stabilise before unblocking
- There is NO contraindication to rapid fluids in blocked cat (cannot make bladder burst)
- Which fluid do you want to give? -> Balanced electrolyte (less acidifying)
○ NOT -> 0.9% NaCl - acidifying, 0.18% NaCl hypertonic fluid - Na+ increase within the brain -> cerebral oedema
- How fast?
○ ALWAYS give IV fluids if the animal has hypoperfusion
○ Rate depends on perfusion status - AGGRESSIVE IN THIS CASE
§ For cats up to 40-60 ml/kg/hr
§ Often use 50-200 ml/hr/cat for first 30-60 minutes in unstable cats
○ Reassess every 5-15 min
95
Intravenous fluids benefits in stabilisation of a blocked cat
```
○ Other benefits of fluid therapy
§ Treats hypovolaemia
§ Dilutes K
§ Promotes renal excretion of K
§ Reverses acidosis (thereby reduces K) -> HCL outside cell goes down, moves outside the cell, K+ moves into cell to maintain neutrality
```
96
What is the main thing that will kill a blocked cat and the clinical effects
```
Hyperkalaemia treatment - MAIN THING KILLING BLOCKED CAT
- Clinical Effects of Hyperkalaemia
○ Depression/obtundation
○ Muscle weakness
○ Slow conduction: bradycardia
○ ECG changes - progressive
i. Bradycardia
ii. Gradual diminution then loss of P waves
iii. Tall T waves
iv. Widening of the QRS complex
○ Reduced cardiac contractility
○ Hypotension
```
97
When to treat hyperkalaemia and what are the 3 things to treat with
- Treat the patient not the number
- Hypoperfusion
- Bradycardia
- ECG abnormalities
Treat with
1) calcium gluconate
2) dextrose +/- insulin
3) sodium bicarbonate
98
Calcium gluconate what is it used for, mechanism of action, onset, duration and dose
Treat hyperkalaemia
○ Drug of choice
○ Protects the heart but doesn’t treat hyperkalaemia
○ Buys time for unblocking
○ Onset: immediate
○ Lasts: 20-30 minutes -> should get cat unblocked in this time
§ If takes longer can give another dose
○ Give at 1ml/min without ECG, faster if you have one
99
Dextrose +/- insulin what can it be used for, mechanism of action, onset, duration and who not t give to
Treat hyperkalaemia
○ Stimulates glucose uptake by cells
§ Uptake via Na/K pump so potassium shifts into cells
○ Onset: “within 1 hour” - NOT QUICK ENOUGH FOR EMERGENCY SITUATIONS
○ Lasts: “few hours”
○ DO NOT give to unstable blocked cats before fluids!
100
Sodium bicarbonate what can be used for, mechanism of action, duration, onset and side effects
Treat hyperkalaemia
○ Reduces extracellular H+
○ H+ moves out of cells
○ K+ moves into cells
○ Onset: “within 1 hour”
○ Lasts: “few hours”
○ Possible side effects - RISK BENEFIT RATIO ISN'T JUSTIFIED
§ Hypernatraemia
§ Hyperosmolality
§ Acute CV collapse if given as a rapid bolus
§ Paradoxical intracellular and CSF acidosis
