Incontinence Flashcards
Causes of incontinene in dogs and cats? Which species is more commonly affected?
> dogs esp female more common > juvenile - ureteral ectopia - congenital USMI - genitourinary dysplasia - bladder hypoplasia - intersex - pervious urachus - neuro dz > adult - USMI - prostatic dz - neuro dz - urogenital neoplasia - fistulae - bladder aotny - cystitis - detrusor instability - pelvic masses
More common cause of incontinence in dogs?
> USMI (urinary sphincter mechanism incontince)
- most common neutered bitch but also in entire females and castrated makes
- most commonly acquired after neutering
- can be congenital with anatomical defects eg. Intersex, ectopic ureters
- leakage during recumbency
- severity of leakage variable (hard to monitor Tx efficacy)
Which Breeds most commonly affected by USMI? What is the aetiology
Large/medium dogs - shorter urethral length pdf - overweight - docked > multifactorial aetiology not fully understood
Risk fctors for USMI
- bitch
- breed (Irish setter, Doberman, Rottweiler, English sheepdog)
- docked
- overweight
- post neutering (within 3 years if it’s going to happen)
> cause unclear, used to think adhesions form but this has been disproven, oestrogen and progesterone levels and potential gonadotrophins
Diagnosis of USMI
- PE unremarkable
- Dx based on Hx, CS, investigtion, response to trial tx, r/o other causes
- caudally positioned bladder neck is supportive but NOT diagnostic
Is USMI common in make dogs?
- no
- but more common in neutered males
Is USMI in males similar to female form?
- similar to bitch (leak when recumbemt)
- intrapelvic bladder neck and castration risk factors
- responds to medical and surgical tx less well than the bitch
What is ureteral ectopia?
Ureters bypass bladder into urethra or vagina
- usually congenital (can be acquired)
- more common in females, dogs
- probably inherited or familial (golden retriever PDF )
- openings may be single, double or elongated (troughs)
- in dogs likely intramural ectopic ureter (joins at correct place but only opens more caudally)
- in cats likely extramural ectopic ureter
Clinical signs of ureteral ectopia?
- constant dribble
- severe scalding
- often UTIs
- may have concomitant USMI
- may have other abnormalities eg. Hydroneohrosis, hydroureter, uterocoeles
What is genitourinary dysplasia and which animals is it common in?
- rare cause of incontinence in cats (but more common than ectopic ureters cats than dogs)
- on rads no urethra seen, really wide elongated bladder straight out to vagina (very easy to catheterise!)
How may Intersexuality cause incontinence? Tx?
Rare
- urine refluxing into another structure
- concominant SMI possible
- tx dependent on underlying defect, usually surgical
What is Bladder hypoplasia commonly seen with? Px?
Rare
- usully w/ other congenital defects ef. bilateral ectopic ureters
- dx radiographically
- poorly compliant bladder -> overflow, guarded px
Cause of Bladder atony ? Tx and Px?
- 2* to bladder distantion
- tight junctions in bladder wall disrupted -> atonic bladder difficult to manage
Previous urachus
- more common farm species
- rare smallies
Is imaging useful in incontinence investigation?
Yes - if normal anatomy seen, suggests functional cause
Outline the order of further investigation for incontinence
- diagnostic imaging
- plain rads (RLR, VD)
- IVU (IV urography)
- retrograde study
- ultrasound
- others
Most useful study?
Retrograde vagino urethro cysto gram
What is ultrasound useful for?
- confirming ureteral emptying into bladder
- additional information on kidneys bladder and prostate
Uses of endoscopy
> visualising
- ectopic ureters
- lesions of the bladder neck/urethra that can cause incontinence
- subjective evaluatino of urethral tone
facilitates biopsy
laser sx for intramural ectopic ureters
- no info on urethropelvic relatinoships
not widely available UK
Tx urinary incontince
- without dx Tx is trial and symptomatic
- ensure owners understand what you’re doing , not necessarily bad
Medical Tx incontinence?
> Tx UTI - base on culture and sensitivity - confirm eradication > Tx underlying systemic dz - PUPD may exaggerate or precipitate condition > diet if obese > specific mess depend on dx
Which nerves supply the bladder and LLUT?
> hypogastric n (symp) - L1-4 - facilitates bladder filling - b fibres bladder, a fibres neck > pudendal n. (Somatic) - S1-S3 > pelvic n. (Parasympathetic) - S1-3
Give 4 drug options for Tx incontinence LOOK UP TABLE
> phenylpropanolamine - best but more expensive - less effective in males > ephedrine hydrochloride > oestrol > testosterone - prostatic hyperplasia side effect etc.
Which drugs are licenced?
- phenylopropanolamine (propalin, Vetoquinol)
- ephidrine hydrochloride (Enurace 50, Janssen)
- Oestriol (Incurin, Intervet)
- Testeosterone (Durateston, Intervet)
Side effects of phenylpropanolamine
- irritability
- hypertension
- anorexia
How does the risk of adverse effects with oestriol compare to phenylpropanolamine?
- lower
how can medical tx be escalated before resorting to surgery?
> off lic increase dose of PPA (phenylopropanilamine) - watch for side effects - combine with oestriol tx > Imipramine - a adrenergic - improves bladder storage - anecdotally helps dogs unresponsive to PPA > GnRH analogues -> v FSH and LH - successful
Further medical options
- see above
When is surgical Tx indicated?
Specific diagnosis has to be made
- not responsive to medical Tx
Which abnormalities has surgery been described for?
- ureteral ectopia
- USMI
- genitourinary dysplasia
- congenital Genito-urinary malformation
- masses
- prostatic dz
What should be managed prior to surgery?
- weight and UTIs
Are surgical procedures effective?
Not very!! No perfect techniques, many described
Which techniques have most and least support for them?
> most - colposuspension - urethropexy - prosthetic sphincter - endoscopic injection of collagen > occasional reports - vas deferens pexy - urethrocystoplasty (cats) - sling urethroplasty - cyst-urethroplasty - other transpelvic slings - other combos (2 types essentially: Own tissues v implants)
General Aims of surgery for USMI?
- improve pressure transmission to bladder neck
- increase urethral resistance
- or both
What is the oldest described surgery for incontinence?
> colposuspension
- move bladder neck into an intra-abdominal position.
- fix with non absorbable sutures from prepubic tendon to the vagina
Which 3 methods are more popular for treating female incontincnece?
> urethropexy
- similar to colposuspension (sutures urethra - prepubic tissue, bladder neck relocated cranially)
prosthetic sphincters
- currently fashionable
- ^ urethral resistacne (inflatable band around bladder neck)
- filled with saline and allows post-op tweaks
collagen or synthetic alternatives
- injected into peri-urethral tissues
- open surgery or endoscopic injector
- gets degraded over time, can accidentally cause obstruction
Is surgical Tx of males as successful ?
No bitches always do better
Surgical treatment for male SMI?
> Vas deferens pexy
- male colposuspension using deferent ducts
- results variable
Prostapexy
- male colposuspension using prostate to pull bladder forward
- better success rates, no complicatiosn
Surgical Tx of ectopic ureters?
> reimplantation of ureter
- neo-ureterocystostomy for intramural (surgery, laser)
- ureteral transaction and reimplantation for extramural
ureteronephrectomy
- good for charity setting
- providing contralateral is still functioning
Complications of ectopic ureter re-implantation?
- continued incontincnece
- UTIs -> pyelonephritis
- bladder oedema and dysuria
- stenosis or new stoma
- recanalisation of lighted distal ureter
- wound breakdown
Give egs. Of specific Tx of specific less common causes of urinary incontinence
- correction congenital genito-urinary malformation
- tx prostatic dz (omentalisation etc.)
- excision of bladder, urethral or vaginal masses
- permemenant cystotomy
Which tumour is most common in the bladder?
Transitional cell carcinoma
- not amenable to surgery
How can incontinene be categorised? Is this useful?
-
Madical tx of neurogenic atonic bladdders?
> v urethral tone - phenoxybenzamine - diazepam > ^ bladder tone/contractility - bethanecol (onl once bladder easily expressed) > physical bladder emptying - abdo pressure - indwelling catheter - permanent cystotomy
