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URI2 > Equine urinary tract > Flashcards

Equine urinary tract Flashcards

1
Q

Describe the epidemiology of urolithiasis and obstructive disease in horses

A
  • Adults: mean age ~10yo
  • Foals: reported after bladder rupture repair
  • Males, mainly geldings
  • No breed predisposition
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2
Q

Describe the location of uroliths in the horse

A
  • 84% in bladder, 60% remain in bladder, 24% pass into urethra to cause obstruction
  • 16% in renal pelvis, 12% within renal pelvis, 45 causing ureteral obstruction
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3
Q

What is the most common composition of uroliths in horses and how do these form?

A
  • Calcium carbonate more common than calcium phosphate

- Form from nidus of inflammation, infection or fibrosis

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4
Q

Compare the nephroliths and ureteroliths in horses

A
  • Nephro: usually within/adjacent to renal pelvis, small passed into bladder with no signs
  • Uretero: probably nephro that moved into ureter, enlarge over time, lodge in distal ureter, may be palpated per rectum
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5
Q

Describe the clinical signs of unilateral renal/ureteral calculi

A
  • Mild clinical signs e.g. recurrent colic or none
  • Azotaemia usually absent
  • Intermittent/persistent gross haematuria
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6
Q

Describe the clinical signs of bilateral renal/ureteral calculi

A
  • Hx of NSAID use
  • Usually CKD before presentation: weight loss, PU, poor performance, reduced appetite, lethargy
  • Uncommon signs: obstructive disease leads to colic, haematuria, lumbar pain, HL lameness, chronic azotaemia (oral ulceration, excessive dental tartar, melaena)
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7
Q

Describe the diagnosis of renal/ureteral calculi in the horse

A
  • Often incidental at PM, esp. if UUT
  • Rectal exam may show turgid ureter (not usually palpable - able to feel = abnormal) +/- ureterolith, increased renal size
  • Blood biochem: azotaemia, isosthenuria in CKD, no azotaemia if unilateral
  • Urinalysis: pigmentation/microscopic haematuria
  • Bacterial culture: rule out UTI
  • Ultrasonography transabdo: nephroliths, dilation of renal pelvis, fibrosis but may miss small stones <1cm
  • Transrectally: ureteral dilation and lithiasis
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8
Q

Describe the treatment of nephroliths in the horse

A
  • Surgery: Nephrotomy/uretotomy
  • Unilateral nephrectomy if no azotaemia
  • Electro hydraulic lithotripsy for ureteroliths: electrical impulse causes shock waves to break stone, fragments flushed out
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9
Q

What is the most common type of urolithiasis in the horse?

A

Cystic calculi

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10
Q

Compare the gross appearance of calcium carbonate and calcium phosphate calculi

A
  • Carbonate: singe, large spiculated stones, fragment

- Phosphate: smooth, grey-white stone, do not fragment

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11
Q

List the risk factors for crystal precipitation in the horse

A
  • Supersaturation of urine
  • Prolonged urine retention
  • Promotors of crystal growth
  • Tissue damage
  • Nidus present
  • UTI
  • Fluid therapy containing calcium
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12
Q

Describe the clinical signs of cystic calculi in the horse

A
  • Dysuria
  • Stranguria
  • Pollakiuria
  • Haematuria esp. post exercise
  • Restlessness, grunting, tenesmus during urination
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13
Q

Outline the diagnosis of cystic calculi in the horse

A
  • Rectal palp: firm oval mass in lumen, rare to get multiple calculi
  • Transrectal ultrasonography
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14
Q

Outline the treatment options for cystic calculi in male horses

A
  • Standing or GA depending on site of calculus
  • Standing: perineal urethrotomy, pararectal cystostomy (not recommended), electro hydraulic, shockwave or laser lithotripsy
  • GA: laparoscystotomy via parapreputial or midline incision, laparaoscopic or laparoscopic assisted cystotomy, urethrotomy for distal urethral calculi)
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15
Q

Outline the treatment options for cystic calculi in mares

A
  • Manual extraction of calculi <10cm under standing sedation and epidural anaesthesia
  • Fragmentation via electro hydraulic or laser lithotripsy
  • Sphincterectomy or dorsal urethra for large stones
  • Laparoscystotomy rarely required
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16
Q

Where do urethral calculi commonly lodge in horses?

A

Ischial arch in males or distal urethra

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17
Q

Compare the presentation of cystic and urethral calculi in horses

A

Urethral tend to cause a more acute problem

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18
Q

Describe the diagnosis of urethral calculi in horses

A
  • Clinical signs: colic, frequent attempts to urinate, blood at urethral orifice
  • Palpable calulus in penis
  • Rectal examination: turgid, full bladder
  • Confirm by passing catheter and endoscope
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19
Q

In the horse, what is a possible consequence of urethral calculi and how is this diagnosed?

A
  • Bladder rupture if not recognised early
  • Signs: depression, anorexia
  • Clin path: electrolyte imbalances, azotaemia
  • Peritoneal creatinine >2x serum creatinine
  • Palpation of empty bladder on rectal exam
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20
Q

Describe the treatment options for urethral calculi

A
  • Ischial arch: standing, sedated, epidural perineal urethrotomy
  • Lower urethral calculi: retrieval with endoscopic instruments e.g. Basket forceps
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21
Q

Outline the prevention of calculi in horses

A
  • Remove calculus, and debris
  • Antimicrobials if UTI/recurrent cystitis after urolith removal
  • Dietary management: reduce calcilum absorption, avoid calcium supps, avoid alfalfa, promote diuresis (add salt to concentrate ration, warm water in winter)
  • Urinary acidification efficacy unproven, not really an option in horses
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22
Q

What conditions does cystitic occur secondary to in the horse?

A
  • Urolithiasis
  • Bladder neoplasia
  • Bladder paralysis
  • Anatomical defect in bladder/urethra
  • Instrumentation of urinary tract e.g. catheterisation, endoscopy
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23
Q

Describe the clinical signs of cystitis in the horse

A
  • Dysuria: pollakiuria, stranguria, haematuria, pyuria

- urine scalding/urine cystals (mares perineum, males HL)

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24
Q

How does bladder paralysis lead to cystitis in the horse?

A

Incomplete emptying, sediment remains in bladder leading to secondary issues

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25
Q

Describe the diagnosis of cystitis in the horse

A
  • Physical examination
  • Rectal palpation
  • Urinalysis: bacterial C+S (>10,000cfu/ml in mid-stream catch/catheter sample), sediment exam within 30-60mins of collection (10+ leukocytes/hpf, not feasible in first op. practice)
  • Ultrasonography: wall thickened, uroliths, masses
  • Cystoscopy: mucosal damage, masses
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26
Q

List the organisms commonly involved in cystitis in horses

A
  • E coli
  • Proteus spp
  • Klebsiella spp.
  • enterobacter spp
  • Streptococcus spp
  • Staphylococcus spp
  • pseudomonas aeruginosa
  • Corynebacterium renale (RARE)
  • Candida spp in sick neonates
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27
Q

Describe the treatment of cystitis in horses

A
  • Long term ABs (4-6 weeks)
  • TMPS, penicillin
  • Bladder lavage
  • Treat primary problem e.g. urolithiasis, sabulous urolithiasis
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28
Q

What is sabulous urolithiasis?

A

Aka sabulous cystitis: deposition of mucous and salts in bladder, sand-like/slurry material deposited in the badder - abnormal quantities of sediment, mostly calcium carbonate

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29
Q

Explain how sabulous urolithiasis may lead to cystitis

A
  • Constant mucosal irritation from sand
  • Prevents complete bladder emptying
  • BActerial ammonia production in the sediment
  • Stretching/inflammation of bladder wall negatively impacts detrusor muscle function leading to more crystal accumulation
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30
Q

How does sabulous urolithiasis develop?

A
  • May be idiopathic bladder paralysis syndrome
  • Or secondary to neurological disease affecting bladder emptying: EHV1, polyneuritis equi, EPM, sacral Fx, osteomyelitis, illicit tail block
31
Q

Describe the clinical signs of sabulous cystitis in the horse

A
  • Urinary incontinence (may be primary or secondary)
  • HL weakness/staxia
  • Generally urine scalding
32
Q

Describe the diagnosis of sabulous cystitis

A
  • History and clinical signs
  • Rectal examination demonstrates flaccid bladder full of sediment
  • Endoscopic examination of bladder for confirmation
33
Q

Discuss the prognosis of sabulous urolithiasis in the horse

A
  • Poor
  • Pathological changes generally irreversible
  • May be able to fix bladder paralysis depending on primary cause
  • Long term management and treatment required, may need periodic lavage of bladder
34
Q

Describe the treatment of sabulous urolithiasis in the horse

A
  • Options for end-stage neuro-myogenic bladder dysfunction same regardless of cause
  • Aim to encourage bladder emptying while hoping for improvement in bladder reflex
  • Bladder lavage: repeat with large volumes of sterile saline
  • Antimicrobial therapy based on urine C+S, intially TMPS over a few weeks (even if no UTI at this stage - high risk)
  • NSAIDs
  • Low calcium diet
  • Bethanecol suggested but not licensed in horse
35
Q

Describe the clinical signs of pyelonephritis in the horse

A
  • RARE
  • Signs may relate to underlying cause
  • Haematuria, pyuria rather than strang/pollakiuria
  • Pyrexia, weight loss ,anorexia, depression
36
Q

What conditions is pyelonephritis usually associated with in the horse?

A
  • Uro/nephro/ureterolithiasis
  • Recurrent cystitis
  • Bladder paralysis
  • Bladder neoplasia/FBs
37
Q

Describe the diagnosis of pyelonephritis in the horse

A
  • Same as cystitis
  • CBC and biochem
  • Cystoscopy to evaluate ureteral openings, catheterise and sample individually
  • Ultrasound of kidneys, bladder and ureters (may identify uroliths)
38
Q

List the organisms involved in pyelonephritis in the horse

A
  • Those as for cystitis

- Plus haematogenous septic nephritis: Actinobacillus equuli, Strep equi equi, Rhodococcus equi, Salmonella spp.

39
Q

Describe the treatment of pyelonephritis in the horse

A
  • Prolonged antimicrobials based on C+S
  • If unilateral, nephrectomy
  • Bilateral rarely treated successfully
40
Q

List the differentials for haematuria in the horse

A
  • Vascular malformation
  • UTI
  • Urolithiasis
  • Neoplasia
  • Exercise
  • Oxidation
  • Nephrotoxicity e.g. NSAIDs
  • Urethral defects
  • Idiopathic
41
Q

Explain oxidation as a differential for haematuria in the horse

A

Horse urine oxidised after exposure to air, snow bedding (due to pyrocatechin) - turns red-brown

42
Q

Describe urethral defects as a cause of haematuria in the horse

A
  • Rent at proximal urethral or ischial arch in males
  • Pathophysiology unknown, may be traumatic, iatrogenic (e.g. catheterisation)
  • Blowout of corpus spongiosum penis into urethral lumen
43
Q

Describe idiopathic haematuria in the horse (presentation, cause)

A
  • Sudden onset, potentially life threatening
  • Haemorrhage from 1 or both kidneys leads to blood clots in urine
  • Cause undetermined, may be neoplastic, arteriovenous or arterioureteral fistulae
  • No other signs of disease
  • Haemorrhage can be episodic
44
Q

Describe the diagnosis of idiopathic haematuria

A
  • Exclude other diseases
  • Signs of acute blood loss: tachypnoea, tachycardia, pale MM
  • Rectal palp shows enlarged irregular bladder
  • Endoscopy to confirm blood from kidneys
  • Ultrasonography: identification of renal pathology
  • Renal biopsy may be helpful but will cause more bleeding
45
Q

List the diagnostic methods for the investigation of haematuria in the horse

A
  • Physical exam
  • Rectal palp
  • Haem and biochem
  • Urinalysis: differentiate between haemoglobin, blood, myoglobin
  • Cystoscopy
  • Ultrasonography of kidneys and bladder
  • Assess timing of haematuria
46
Q

How can haematuria of glomerular origin be differentiated from haematuria from another origin in the horse?

A
  • Glomerular: variation in RBC size, shape and Hb content, present of Hb casts (RBC+Hb+Tamm-Horsfall protein)
  • Bleeding from other sites more uniform RBC population
47
Q

Outline how the timing of haematuria may indicate the origin in the horse

A
  • Throughout: haemorrhage from kidneys, ureter or bladder
  • Beginning of urination: lesions distal to urethra
  • At end of urination: lesion in proximal urethra or bladder
48
Q

Describe the treatment of idiopathic haematuria in the horse

A
  • Supportive care for blood loss e.g. blood transfusions
  • Haemostatic meds e.g. aminocaproicacid, formalin
  • Corticosteroids if suspect immune mediated cause
  • If unilateral: nephrectomy, but risk of other kidney being affected later (esp in Arabs)
49
Q

Describe the treatment of urethral rents in horses

A
  • Often haematuria resolves spontaneously

- If persists >1month or significant anaemia, temporary sub-ischial urethrotomy successful

50
Q

Describe the clinical signs of urethral rents in the horse

A
  • Haematuria at start/end of urinatioin
  • Periurethral accumulation of urine (rare)
  • No stranguria or pollakiuria
51
Q

How are urethral rents diagnosed?

A

Urethral endoscopy and contrast radiography

52
Q

List the differentials for pre-renal pigmenturia in the horse

A
  • IMHA
  • Piroplasmosis
  • Anaplasmosis
  • Drug toxicities
  • Oxidative damage
  • Liver disease
  • Haemolytic uraemic synrome
  • Rhabdomyolysis
53
Q

List the post-renal differentials for pigmenturia in the horse

A
  • Urolithiasis
  • Cystitis
  • Urethral rents
  • Vaginal varicoceole/genital tract disease
54
Q

What is the most common cause of PUPD in the adult horse?

A

Apparent psychogenic polydipsia

55
Q

List the differentials for PUPD in the adult horse

A
  • Psychogenic polydipsia
  • PPID
  • Chronic renal failure
  • Hepatic insufficiency
  • Diabetes mellitus
  • Diabetes insipidus
  • Physiological causes
56
Q

In a horse presented for PUPD, would would anaemia, elevated BUN (urea >15mmol/L, creatinine >300mmol/L), hypercalcaemia, isosthenuria and a low urine creatinine:serum creatinine ratio be suggestive of?

A

Chronic renal failure

57
Q

In a horse presented with PUPD, what would polycythaemia be suggestive of?

A

Dehydration, suggesting PU is primary problem rather than PD, i.e. diabetes insipidus

58
Q

In a horse presented with PUPD, what would neutrophilia be suggestive of?

A

Glucocorticoid response or inflammatory disease

59
Q

In a horse presented with PUPD, what are the differentials for low urea and creatinine and how can these be differentiated?

A
  • Hepatic insufficiency
  • Or psychogenic PD and medullary washout
  • Differentiate based on GGT, GLFH and bile acids
60
Q

In a horse presented with PUPD. what would persistent hyperglycaemia be suggestive of?

A

PPID

61
Q

In a horse presented with PUPD, what are the differentials for hypercalcaemia?

A
  • Chronic renal failure

- Paraneoplastic causes

62
Q

What causes of PUPD produce hyposthenuric urine in the horse?

A

Diabetes insipidus and psychogenic polydipsia

63
Q

What causes of PUPD may cause glucosuria in the horse?

A
  • Diabetes mellitus
  • PPID
  • Acute stress
  • A2As
64
Q

Compare the urine creatinine: serum creatinine ratio in horses with dehydration vs CRF

A
  • Dehydration: increased ratio

- CRF: lower ratio

65
Q

Describe the clinical signs of psychogenic polydipsia in the horse and how is it diagnosed?

A
  • Significant PU, often flooded stables
  • PD as a stable vice
  • May be result of excessive salt consumption
  • Diagnosis of exclusion
66
Q

Describe the management of psychogenic polydipsia in the horse

A
  • Restrict salt intake
  • Restrict water intake
  • Alleviate boredom
  • Increase feeding frequency of roughage
67
Q

Outline the mechanisms by which PPID causes PUPD

A
  • High cortisol → hyperglycaemia → osmotic diuresis
  • Cortisol antagonism of ADH in collecting ducts
  • Adenoma growth may impinge on posterior pituitary and hypothalamus leading to decrease ADH → central diabetes insipidus
68
Q

Explain the diagnosis and treatment of PPID

A
  • Plasma ACTH
  • Positive if >29pg/ml most months, >47pg/ml in Aug, Sept, Oct
  • Treat with pergolide, recheck ACTH in 4 weeks
69
Q

List the differentials for a foal that is weak, trembling, has a distended abdomen, bradycardic a few days after birth?

A
  • Bladder rupture
  • Sepsis
  • PAS
  • Persistent meconium impaction
  • Colic for other reasons
70
Q

Describe the clinical signs of bladder rupture in a foal

A
  • Normal at birth
  • First 24-36hours tranguria/pollakiuria
  • Day 2-4 dull demeanour, abdomianl distension
  • May void small amounts of urine
  • Cardiac arrhythmias e.g. bradycardia due to hyperK
  • Muscle fasciculations
  • Colic
  • Sepsis
71
Q

What diagnostic investivation findings would be likely in a rupture bladder in a foal?

A
  • HyperK, high creatinine, low Na and Cl
  • Metabolic acidosis
  • Abdominocentesis shows periteonal:serum creatinine ratio >2:1
  • Abdominal ultrasound shows large amounts of free fluid in abdomen and collapsed bladder
  • ECG shows hyperK related changes (bradycardia, wide WRS, prolonged P wave)
72
Q

Describe the treatment for a rupture bladder in a foal

A
  • Stabilise pre-op: IV NaCL 0.45-0.9% +5% glucose 1-3L
  • If hyperK (>5.5mEq/l): IV Ca gluconate 1ml/kg over 10 mins, IV NaHCO3 1-2mmol/kg over 15 mins, 50% dextrose IV 2ml.kg over 5 mins, insulin if significant ECG abnormalities or poor response to initial fluids
  • Drain urine from abdomen pre-op
  • Broad spec ABs
  • Consdier gastric ulcer prophylaxis
  • Ensure passive transfer of Abs occurs
  • Surgery to repair defect, remove enlarged umbilical structures
  • Place indwelling catheter for 48 hours to decrease bladder distension at repair site
73
Q

Discuss the prognosis for bladder rupture in the foal

A
  • If non-septic, good prognosis
  • 95% success rate if treated early and otherwise healthy
  • If concurrent infection of GI issue, 50%
  • In septic or premature, complications e.g. peritoniitis, incisional complications, adhesions more common
  • Repeat ruptures can occur
74
Q

Explain the haematological and biochemical parameters that may be abnormal in a foal affected by placental disease

A
  • Serum creatinine may be 30-40% higher in first 3 days
  • Do not worry if otherwise healthy and urinating normally
  • If does not fall after 3 days, investigate renal causes

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