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SA DX & TX II > Exam 4 - Incontinence > Flashcards

Exam 4 - Incontinence Flashcards

1
Q

the bladder is in a _____ phase 99% of the time & in an _____ phase 1% of the time

A

storage

emptying

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2
Q

what makes up the proximal & distal urethra?

A

proximal urethra - composed of smooth muscle that makes up the internal urethral sphincter

distal urethra - composed of striated muscle making up the external urethral sphincter

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3
Q

what are the components that make up the urethral sphincter mechanism?

A

internal urethral sphincter, external urethral sphincter, urethral length, & position of the bladder intra-abdominally & cranial to the pelvis such that intra-abdominal pressure is applied to the proximal urethra & not solely the bladder

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4
Q

what spinal cord segment does the hypogastric nerve originate from?

A

L1-L4 in dogs & L2-L5 in cats

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5
Q

if the bladder is under sympathetic control, what phase is it in?

A

storage

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6
Q

what is the sympathetic control exerted on the bladder from the hypogastric nerve?

A

hypogastric nerve innervates the muscle via beta fibers, so when stimulated, the muscles are relaxed & the internal urethral sphincter via the alpha fibers, when stimulate, contract

beta fibers - relaxes bladder wall
alpha fibers - contracts internal urethral sphincter

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7
Q

what spinal cord segment does the pudendal nerve originate from?

A

spinal cord segment S1-S3

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8
Q

what does the pudendal nerve innervate?

A

striated muscle of the external urethral sphincter & provides voluntary input to micturition

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9
Q

what does the pelvic nerve innervate?

A

somatic nerve that innervates the detrusor muscle, so that when stimulated, the muscle contracts

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10
Q

if the bladder is under parasympathetic control, what phase is it in?

A

peeing!!!!

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11
Q

what spinal cord segment does the pelvic nerve originate from?

A

spinal cord segment S1-S3

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12
Q

what makes up the afferent (sensory) innervation of the urinary bladder?

A

pelvic nerve - parasympathetic, senses bladder filling & the need to void

hypogastric nerve - sympathetic, senses pain & over-distension

pudendal nerve - somatic, to bladder neck & urethra

voiding is coordinated in the micturition center in the pons with cerebrocortical input

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13
Q

why is determining age of onset of incontinence important?

A

some causes are congenital & some are acquired (ectopic ureters - incontinence in puppies)

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14
Q

T/F: urethral sphincter mechanism incompetence is more common in female dogs post-ovariohysterectomy but often occurs several years after

A

true

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15
Q

what is a normal residual volume of urine in the bladder after a patient voids?

A

< 0.4 ml/kg

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16
Q

what does a large residual volume after voiding indicate?

A

detrusor hypocontractility or outflow resistance

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17
Q

what may be felt on physical exam that can help you differentiate between an upper motor neuron bladder & lower motor neuron bladder?

A

UMN bladder - often large & difficult to express

LMN bladder - often large & easy to express

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18
Q

what reflexes will you use to determine anal sphincter tone in an incontinent patient?

A

perineal reflex & bulbospongiosus reflex depend on an intact pudendal nerve & intact sacral spinal cord segment of S1-S3

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19
Q

why do you need a urinalysis in a patient presenting with incontinence?

A

important to evaluate for concurrent disorders!!!

dogs with UTIs occasionally present for incontinence

UTI can be a complicating factor in a patient with incontinence

relatively dilute usg suggests an evaluation for pu/pd is warranted

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20
Q

what do you need to do before considering more invasive methods for managing urinary incontinence?

A

need to get a negative urine culture!!

UTIs are common in dogs with disorders causing incontinence (ectopic ureters, neurologic bladders)

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21
Q

why would an abdominal ultrasound be beneficial to do when working up a patient for incontinence?

A

non-invasive way to assess a patient for structural abnormalities

sometimes jets of urine can be seen entering the bladder from the ureters - normal ureters are not usually visible

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22
Q

when would you want to do IV urography for contrast abdominal imaging in a patient with incontinence?

A

evaluating a patient for ectopic ureters!!

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23
Q

what is the purpose of doing a urethrocystoscopy?

A

allows for the identification of ectopic ureters - biopsies can be obtained

may allow intervention for ectopic ureters

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24
Q

where does a normal ureter enter a bladder? what about an ectopic ureter?

A

enters the bladder obliquely near the trigone at the ureterovesicular junction

ectopic ones enter at a more distal location in the urethra or the vagina

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25
Q

what is the most common cause of congenital incontinence?

A

ectopic ureters

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26
Q

what is the common signalment of animals affected by ectopic ureters causing incontinence?

A

females > males

usually <1 year at presentation (females younger than males at presentation possibly due to longer more effective urethral sphincter mechanism in males)

increased incidence in labs, goldens, & huskies

unilateral - 2/3 of cases & bilateral - 1/3 of cases

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27
Q

what other conditions are ectopic ureters commonly associated with?

A

concurrent hydroureter, hydronephrosis, +/- pyelonephritis, urethral sphincter mechanism incompetence, bladder hypoplasia

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28
Q

T/F: dogs with ectopic ureters urinate normally in-between episodes of incontinence

A

true

29
Q

how are ectopic ureters diagnosed?

A

urethrocystoscopy to visualize ureteral openings

contrast CT

excretory urogram

ureteral jets in the bladder seen on ultrasound make ectopic ureters less likely

30
Q

what are your 2 treatment options for a patient with ectopic ureters?

A
  1. laser ablation via urethrocystoscopy
  2. surgical transposition - only resolves incontinence in 50% of cases (patient may have coexisting urethral sphincter mechanism incompentence)
31
Q

what is urethral sphincter mechanism incompetence?

A

decreased tone of the urethral sphincter with normal detrusor function that is subdivided into hormone responsive & non-hormone responsive

32
Q

T/F: hormone responsive urethral sphincter mechanism incompetence usually occurs several years after a dog is spayed

A

true

33
Q

what animals are commonly affected by urethral sphincter mechanism incompetence?

A

common in large breed spayed female dogs

rare in male dogs & very rare in cats

34
Q

how is hormone responsive urethral sphincter mechanism incompetence treated? why does it work?

A

estrogens - estradiol increases urethral sphincter tone & may increase sensitivity of alpha receptors in the urethra of intact female dogs

35
Q

T/F: urethral sphincter mechanism incompetence is often associated with a more caudally positioned bladder (pelvic bladder) on radiographs

A

true

36
Q

how is urethral sphincter mechanism incompetence diagnosed?

A

usually diagnosis of exclusion

urethral pressure profile testing can confirm the diagnosis but is seldom done

37
Q

what is phenylpropanolamine used for? how does it work?

A

used for treating urethral sphincter mechanism incompetence in dogs (proin) - 90% of female dogs respond to it alone or it with estrogens

alpha receptor agonist that increases contraction of smooth muscle of internal urethral sphincter

38
Q

what is estriol used for? how does it work?

A

labelled for use in dogs to treat urethral sphincter mechanism incompetence - >60% of female dogs respond to estrogens alone, but dogs with non-hormone responsive USMI won’t

mimics estradiol to increase urethral tone & increases sensitivity of urethral smooth muscle to alpha innervation (possible synergy with proin)

39
Q

how are urethral collagen injections used for treating urethral sphincter mechanism incompetence?

A

bulking agent is injected into urethra via cystoscopy - usually temporary & has to be repeated

used in refractory cases

40
Q

what is colposuspension? when may this be used?

A

suturing cranial vagina to the prepubic tendon in dogs with urethral sphincter mechanism incompetence & a pelvic bladder

41
Q

what is lower motor neuron bladder? where is the lesion? how do you treat it?

A

causes loss of the detrusor reflex with decreased sphincter tone that typically causes a large bladder that is easily expressed

lesion at S1-S3 (or pelvic nerve)

diagnose & treat underlying condition - will need to do manual expression of the bladder

42
Q

what is upper motor neuron bladder? where is the lesion? how do you treat it?

A

causes loss of detrusor reflex with increased sphincter tone that typically causes a large bladder that is difficult to express (back dogs)

lesion is located cranial to sacral spinal segments

diagnose & treat underlying condition, manual expression may be difficult & patient may need to be catheterized

43
Q

T/F: in FeLV associated incontinence, you may see it with or without spinal cord lymphoma

A

true

44
Q

what is reflex dyssynergia?

A

incoordination of urethral relaxation & detrusor contraction where voiding is initiated normally but is then interrupted by involuntary contraction of the external urethral sphincter causing the patient to strain unsuccessfuly

45
Q

what is the management aimed at for treating reflex dyssynergia causing incontinence?

A

aimed at relaxing urethral sphincters

46
Q

when do we see reflex dyssynergia occur?

A

urethral disorders such as urethral spasm in an FIC cat or certain spinal cord lesions

47
Q

what is dysautonomia? what clinical signs does it cause? how is it treated?

A

rare, idiopathic polyneuropathy of the autonomic nervous system (sympathetic & parasympathetic) that occurs in dogs & cats

incontinence, constipation, mydriasis, & prolapsed 3rd eyelids

treatment is unrewarding - bethanechol can be tried

48
Q

what is detrusor atony? what does it result in?

A

occurs after the bladder becomes markedly distended due to a mechanical or functional outflow obstruction due to separation of the tight junctions of the detrusor muscle

results in a large flaccid bladder with a weak or absent urine stream

49
Q

what management is used for patients with detrusor atony?

A

treat the underlying condition & place an indwelling catheter to keep the bladder empty to try & reestablish tight junctions (can take up to 7-14 days)

bethanechol can be tried to stimulate detrusor contractions - ensure the urethra is patent first & concurrent use of prazosin or tamsulosin may relax internal urethral sphincter

50
Q

what is urge incontinence? how do you treat it?

A

involuntary bladder contractions that result in frequent, involuntary voiding of small volumes of urine usually secondary to lower urinary tract inflammation

need to treat the underlying disease

51
Q

what is paradoxical incontinence?

A

form of overflow incontinence that occurs when mechanical (uroliths) or functional (reflex dyssynergia) obstruction of the urethra impairs voiding

when intravesicular pressure exceeds the pressure at the site of the obstruction, urine will escape around the obstruction

52
Q

what are 4 drugs that are used to decrease urethral resistance?

A
  1. prazosin/tamsulosin - alpha 1 antagonists
  2. phenoxybenzamine - non-specific alpha antagonist (sympatholytic)
  3. diazepam - skeletal muscle relaxant
  4. dantrolene - skeletal muscle relaxant
53
Q

what are the indications for using drugs to decrease urethral resistance?

A

functional outflow obstruction

reflex dyssynergia

54
Q

what are the indications for using drugs to increase urethral resistance?

A

urethral sphincter mechanism incompetence!!

55
Q

what are 2 drugs that are used to decrease urethral resistance?

A
  1. phenylpropanolamine - alpha agonist (sympathomimetic)
  2. estriol - estrogen + increases sensitivity of alpha receptors
56
Q

what are the indications for using drugs to increase detrusor contractility?

A

detrusor atony after prolonged bladder distension

detrusor areflexia from UMN or LMN lesion

57
Q

what drug can be used to increase detrusor contractility?

A

bethanechol - enhances smooth muscle (detrusor) contractility (cholinergic/parasympathomimetic)

58
Q

what 2 drugs can be used to increase detrusor contractility?

A
  1. propantheline - anticholinergic
  2. oxybutynin - anticholinergic
59
Q

what are the indications for using drugs to decrease detrusor contractility?

A

urge incontinence

60
Q

what are examples of conditions that fall into the neurogenic classification of disorders of micturition?

A

UMN bladder

LMN bladder

reflex dyssynergia

detrusor areflexia

61
Q

what are examples of conditions that fall into the non-neurogenic classification of disorders of micturition?

A

anatomic abnormalities - congenital or acquired

USMI - hormone responsive & non-hormone responsive

62
Q

T/F: in dogs with an UMN bladder, urine retention is common but overflow incontinence is less common

A

true

63
Q

what are the possible side effects of estriol?

A

inappetence, vomiting, excess water intake, & swollen vulva

64
Q

what are the possible side effects of proin?

A

hypertension, restlessness, & tachycardia

65
Q

how does bladder positioning play into the development of urethral sphincter mechanism incompetence?

A

intra-abdominal pressure ends up being applied to proximal urethra & bladder in bladders that are positioned more caudally

66
Q

which ectopic ureter is extramural & which is intramural?

A

left - extramural

right - intramural

67
Q

if you want to do surgery to correct ectopic ureters in a dog, what must be done prior?

A

need to resolve UTIs if present

68
Q

which ureter is normal?

A

one on top

SA DX & TX II (62 decks)

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