Lower Urinary Tract Disease Flashcards

1
Q

What counts as the lower urinary tract?

A
  • Bladder
  • Urethra
  • fundamental design fault
  • males… ridiculously narrow
  • females…. Far too short and quite wide
  • Prostate
  • don’t forget the possible role of the prostate in dogs with LUT signs …. but refer to repro
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2
Q

Define stranguria

A

•difficult and slow urination +/- straining

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3
Q

Define dysuria

A

•difficult +/or painful urination

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4
Q

Define pollakiuria

A

•abnormal frequent urination (“little & often”)

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5
Q

Define haematuria

A
  • presence of blood in the urine
  • Can be microscopic (just on dipstick or something, could we have caused it?) or macroscopic (think about when the blood seems to occur)
  • Could you have caused it? (i.e. iatrogenic by cysto or catheterisation)
  • small amount of blood isn’t always significant in a urine sample
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6
Q

Define peruria

A
  • urination at inappropriate sites
  • Can be misinterpreted as incontinence
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7
Q

Define anuria

A
  • failure of urine production by the kidneys
  • end stage in AKI à no renal output
  • or just not able to pass urine??
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8
Q

Define oliguria

A
  • significant reduction in urine production
  • < 0.5 mls/kg/hour
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9
Q

Define polyuria

A
  • ­ increased urine production
  • primary (eg CKD, diabetes)
  • secondary (eg psychogenic polydipsia, increased drinking after exercise)
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10
Q

What is the difference between LUT signs and a small bladder vs a full bladder?

A

LUT signs and a small bladder: very uncomfortable but not usually life threatening

LUT signs and a full bladder: urethral obstruction much more likely and is life threatening –> AKI. Act as an emergency as if its not now, it will be very soon!

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11
Q

With dysuria, where are some anatomical sites to consider?

A

Is the problem in the:

  • Bladder
  • Urethra
  • Genital tract
  • prostate
  • vagina

LUT signs –> Discomfort/straining –> usually bladder or urethra but don’t forget about the genital tract that might be causing straining as well

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12
Q

What are some things that can cause dysuria?

A
  • Inflammation of LUT or genital tract
  • Infection resulting in inflammation
  • Narrowing/obstruction of the urethra
  • physical e.g. stricture, mass, calculus, “plug”, blood clot (can be haemorrhage from the kidney or somewhere)
  • functional e.g. urethral spasm
  • Dysuria and haematuria together are strongly suggestive of LUTD
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13
Q

If you have haematuria, what are some anatomical sites to consider?

A

Where is the blood coming from? Are we focussing on the right sight?

  • Renal
  • trauma, neoplasia, calculi, idiopathic (in dogs, sometimes a kidney starts to bleed and we don’t always know why this is)
  • Post-renal
  • inflammation, infection, calculi, neoplasia, iatrogenic
  • genital causes – oestrus, prostate disease
  • Could be a systemic disease leading to coagulopathy –> what could be causing this?
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14
Q

If you have haematuria and the blood is brown, where is it likely to be from?

A

Does the urine look red or brown? Is it fresh? Brown – idiopathic renal haematuria

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15
Q

If you have haematuria and the blood is coming towards the end of urination, where might it be coming from?

A

Does urine colour change or is it abnormal throughout urination? Is it at the end of urination, might be from prostate? Is it early on in in urination showing might be urethral

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16
Q

Is haemoglobinuria or myoglobinuria more common in small animals?

A

Haemoglobinuria - more common

Myoglobinuria - rare in small animals

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17
Q

Haemoglobinuria:

  1. What colour is the urine sample usually?
  2. What happens if you spin the sample? Urine and blood
  3. Pre-renal causes?
  4. Post-renal causes?
A
  • Pink/red urine
  • Spin a urine sample: supernatant stays pink
  • Spin a blood sample: plasma is often also pink
  • Pre renal
  • RBCs lysed in circulation e.g. IMHA
  • plasma will be pink
  • Post renal
  • RBCs lysed in hypotonic urine
  • plasma may be normal
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18
Q

Myoglobinuria:

  1. What colour is the urine sample usually?
  2. What happens if you spin the sample? Urine and blood
  3. What can cause it?
A
  • Red/brown urine
  • Spin a urine sample: supernatant stays coloured
  • Spin a blood sample: plasma is clear
  • Systemic disease causing extensive muscle destruction
  • ischaemic necrosis

rare in small animals

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19
Q

Why can haematuria cause problems on dipstick analysis?

A

Dipstick analysis can be misreading – if red urine, can stain pads on dipstick test so can make it difficult to work out if there is anything meaningful. Dipstick may give false positives

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20
Q

In dogs, what are 90% of bladder tumours?

A

~90% of bladder tumours in dogs are transitional cell carcinomas

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21
Q

Are bladder tumours more common in males or females?

Is there any increase of these tumours in certain breeds?

A
  • ­ in females cf males
  • ­ in some breeds (Westies, Scotties, Shelties)
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22
Q

What is the most common bladder tumours in horses?

A
  • SCCa is most common bladder tumour
  • SCCa: squamous cell carcinoma
  • sarcoids - urethra/external genital tract/sheath
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23
Q

How can UTIs cause dysuria secondary to other problems?

A

Secondary to other problems including

  • systemic disease
  • low urine SG
  • immune compromise
  • Think about cats with hyperT4, DM
  • anatomic defect
  • Ectopic ureter?
  • Any time anatomy incorrect, bacteria take advantage of the lack of normal! If ureter attaching in different place, more susceptible to infection and don’t have normal key mechanism to prevent infection taking hold
  • urinary calculi
  • Causes inflammation and irritation, bacteria will start to colonise wall of bladder and cause problems
  • Neoplasia
  • Ulceration of mucosa –> compromised defences
  • Bleeding and unhealthy tissue, bacteria will leap in on top
  • It’s a secondary infection and may need to look further for the underlying causes
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24
Q

What are some things that are obstructions that can caue dysuria?

A
  • M - Urinary calculi
  • N - Neoplasia
  • I - Urethral plugs
  • T - Rupture
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25
Q

What is a urolith?

A

Urolith

  • a calculus (stone) in the urinary tract
  • Can be single
  • Can be multiple
  • cystolith, ureterolith, nephrolith, urethral calculus
  • ie where is it?
26
Q

What is crystalluria?

A
  • the presence of crystals in urine
  • not always helpful in determining nature of a urolith
  • crystals not always equal a urolith
  • Crystals can be completely normal in the urine! Can appear as have old urine sample, can be because urine has been in the fridge and crystal precipitate out – as soon as urine leaves body, can be altered – so don’t assume that just because you see crystals, don’t assume it will tell you what the calculus is. Can sometimes, but don’t assume.
  • crystalluria might be seen in patients with urolithiasis but can be an incidental finding
27
Q

When can crystals be normal in the urine?

A

Crystals can be completely normal in the urine! Can appear as have old urine sample, can be because urine has been in the fridge and crystal precipitate out – as soon as urine leaves body, can be altered – so don’t assume that just because you see crystals, don’t assume it will tell you what the calculus is. Can sometimes, but don’t assume.

28
Q

What are the most common urolith types that occur in:

  1. Horses and rabbits
  2. Cats and dogs
  3. Sheep?
A
  • horses and rabbits:
  • calcium carbonate
  • cats and dogs: these are the most common but there are others!
  • magnesium ammonium phosphate (“struvite” “triple phosphate”)
  • calcium oxalate
  • sheep:
  • vary with diet
29
Q

What can struvite mean in cats and dogs?

A

Struvite (magnesium ammonium phosphate crystals)- often insignificant in dogs but may be associated with UTI if very high numbers. Cats rarely associated with UTI.

30
Q

What is the significance of calcium oxalate dihydrate crystals?

A

Calcium oxalate dihydrate (associated with hypercalcaemia, can be normal, can be associated with calcium oxalate calculi) and monohydrate (early but not very sensitive marker for ethylene glycol toxicity)

31
Q

When are ammonium biurate crystals seen in dogs?

A

Ammonium biurate: seen in dogs with portosystemic shunts and can be seen in normal Dalmatians and Bulldogs

32
Q

Which species is it common to find calcium carbonate crystals in the urine?

A

Calcium carbonate: variable size and shape, normal finding in many horses, rabbits, guinea pigs and goats

33
Q

What does it mean if you find cystine crystals in the urine?

A

Cystine: abnormal and indicate an error in cysteine metabolism

34
Q

What is the multifactoral pathophysiology of increased precipitation of excretory metabolites into the urine?

A
35
Q

What are the clinical signs of nephroliths?

A
  • Can be Asymptomatic
  • Sometimes incidental finding on x-rays
  • Be sure that if you take radiograph to look for another reason and find these, aren’t necessarily the cause of something unless you have evidence of renal disease!
  • Can be associated with pyelonephritis
  • pain, pyuria, pyrexia
  • which comes first?
36
Q

What are the clinical signs of ureteroliths?

A
  • Asymptomatic
  • incidental finding on x-rays
  • Associated with pyelonephritis
  • pain, pyuria, pyrexia
  • Renomegaly
  • uni or bilateral +/- pain
  • Renal failure if bilateral
  • acute bilateral hydronephrosis
  • “big kidney-little kidney” cats
  • save that kidney!
37
Q

What are the clinical signs of cystoliths?

A
  • True LUT signs
  • dysuria
  • pollakiuria
  • haematuria

Very rarely palpable on physical exam

38
Q

What are the clinical signs of urolithiasis?

A
  • True LUT signs
  • dysuria
  • pollakiuria
  • Haematuria
  • But also become unwell due to urethral obstruction
  • Abdominal discomfort
  • Licking at penis (or vulva)
  • Urethral obstruction
  • post renal azotaemia –> AKI
  • Don’t forget: rectal examination to palpate urethra – more applicable to dogs than cats. Can feel urethra ventral to rectal wall and might feel calculus there is that region
  • A retrograde urethrogram is the best way to assess the urethra- a catheter can sometimes get past a calculus.
39
Q

How can we diagnose urolithiasis?

A
  • Does the clinical history and/or physical exam suggest stones?
  • does the signalment help?
  • Plain radiographs?
  • Struvite – will most likely show up on plain radiography
  • calcium oxalate - will most likely show up on plain radiography
  • calcium phosphate
  • Contrast radiography:
  • what techniques and what sites?
  • ammonium urate
  • Cystine
  • Think about need for contrast radiography for these…
  • Think about whether stones are radiopaque or radiolucent. Even if radiopaque, how easy would it be to miss a small stone (in a cat for example!)?
  • Abdominal ultrasound
  • not useful for the urethra
  • why not? Can only really see abdominal portion – can miss a fair bit on the urethra if using an abdominal ultrasound. Look back at kidneys – just check what is going on
  • ridiculously easy to miss a stone!
  • look for hydronephrosis and dilated proximal ureter in cats
  • i.e. the big kidney phase
40
Q

When diagnosing urolithiasis, when is plain radiography useful?

A
  • Struvite – will most likely show up on plain radiography
  • calcium oxalate - will most likely show up on plain radiography
  • calcium phosphate
41
Q

When diagnosing urolithiasis, when is contrast radiography useful?

A
  • what techniques and what sites?
  • ammonium urate
  • Cystine

Think about need for contrast radiography for these…

42
Q

When diagnosing urolithiasis, when is abdominal ultrasound useful? When is it not useful?

A
  • not useful for the urethra
  • why not? Can only really see abdominal portion – can miss a fair bit on the urethra if using an abdominal ultrasound. Look back at kidneys – just check what is going on
  • ridiculously easy to miss a stone!
  • look for hydronephrosis and dilated proximal ureter in cats
  • i.e. the big kidney phase
43
Q

What are the most common stones found in dogs?

A
  • Signalment can predict stone type in many cases
  • sex
  • breed
  • age
  • ~50% struvite
  • ~30% calcium oxalate
  • ~8% urate
44
Q

What are the most common stones found in cats?

A
  • Calcium oxalate and struvite equally common
  • calcium oxalate ­increasing
  • nephroliths
  • ureteroliths
45
Q

How can the urine pH differ with the stones we might see?

A
  • alkaline with struvite
  • acidic to neutral with calcium oxalate
  • acidic with urate, cystine
  • One of the few situations when we are interested in the urine pH – when thinking about what type of stone might be pregnant
46
Q

Struvite - acidic or alkaline pH?

Calcium oxalate - acidic or alkaline pH?

A
  • alkaline with struvite
  • acidic to neutral with calcium oxalate
47
Q

Does the type of stone thats present matter?

When might it matter more?

A
  • Not in acute cases
  • if acute urethral obstruction - immediate treatment is the same
  • Yes, always for less acute cases – in the more chronic or once we have stabilised out acute case
  • stone composition determines treatment
  • manage the stones but you might also need to
  • treat the UTI?
  • manage hypercalcaemia?
  • diagnose the liver disease? Esp if its urate?
  • Manage the underlying disease e.g. hyperadrenocorticism
48
Q

If we need to get a stone out, how can we use voiding urohydropulsion to get it out?

A

If stones are too big, essentially fill up bladder with saline and flush it out and express it and try to force calculi out through urethra. Can be scary if you misjudge the size

49
Q

If we need to get a stone out, what are some ways that we can get it out of the patient?

A
  • Voiding urohydropulsion
  • If stones are too big, essentially fill up bladder with saline and flush it out and express it and try to force calculi out through urethra. Can be scary if you misjudge the size
  • Catheter assisted retrieval (ultrasound guided)
  • Might be able to suck stone onto end of catheter or into the catheter. Use US to guide.
  • Cystoscopy – good way of getting stones if you have the equipment
  • Cystotomy
  • therapeutic and diagnostic purposes
  • try to remove all stones – don’t want the patient to have another urethral obstruction the day after surgery because you left some behind!!
  • Urethrotomy/urethrostomy
  • if surgery required to relieve obstruction
  • don’t miss the chance of getting a stone
50
Q

What is the treatment for nephroliths?

A
  • only problematic renal calculi need treatment
  • consider dissolution diets for struvite and manage UTI
  • support the kidneys if necessary
  • avoid risk factors for AKI
  • leave well alone/benign neglect?
  • Can we dissolve them? Maybe if we manage pyelonephritis
51
Q

What is the treatment for ureteroliths?

A
  • an opportunity to save a kidney – if you suspect one:
  • think about prompt referral rather than too much wait and see..
  • often undiagnosed but this is improving
  • surgery/stenting?
  • ureteric stent
  • subcutaneous ureteral bypass
  • lithotripsy?
52
Q

What are some treatment options for cystoliths?

A
  • Cystoliths (bladder stones)
  • medical dissolution with diet +/- pH modification
  • voiding urohydropulsion
  • cystoscopy
  • cystotomy
  • avoid suture nidus for future stone formation
  • laser lithotripsy
  • Lithotripsy – fragmentation of urolith via external shock waves
53
Q

What is the treatment for urethral obstruction?

A
  • treat as an emergency unless partial obstruction
  • stabilise the patient but do not delay relieving the obstruction for too long
  • manage hyperkalaemia?
  • fluid therapy
  • decompress the bladder?
  • Therapeutic cystocentesis – rare you will do any harm… if you do it once and drain the bladder completely, these are tiny holes – at worst it will leak slightly through tiny pin prick holes. Can be lifesaving. Don’t be too resistant
  • retrograde urohydropulsion and treat as for cystolith if possible?
  • urethrotomy/urethrostomy
  • rarely an emergency procedure
  • appropriate for recurrent problems or if poor compliance with diet
  • These are better done when the urethra is not inflamed, swollen, oedematous etc.
54
Q

What is retrograde urohydropulsion?

A

Finger in rectum is crucial part of this technique

Stop off urethra, build up pressure and releasing finger helps to shoot everything into the bladder – gives you some times whilst things recover

55
Q

What are some indications for MEDICAL treatment of urolithiasis?

A
  • for non obstructive disease
  • struvite, cystine and urate stones can be dissolved
56
Q

What are the general principles of MEDICAL treatment for urolithiasis?

A
  • ­ increase water intake –> increases­ urine volume, reduce concentration of contamination in urine that are likely to form the calculi
  • manipulate urine pH
  • decreased concentration of mineral components in urine
  • treat for 1 month after x-rays show resolution
57
Q

What is significant about struvite stones in DOGS?

Treatment and prevention?

A
  • nearly always assoc with UTI
  • urease producing Staph
  • NH4 precipitates with Mg & PO4
  • HCO3 –> ­pH (very rare to need this!)
  • Treat UTI
  • Short term: low protein acidifying diet
  • Prevention
  • not required unless sterile struvite
58
Q

What is significant about struvite stones in CATS?

Treatment?

A
  • 90% of struvite in cats are sterile
  • Treat with diet only ie low protein acidifying, salt supplemented diet
59
Q

Where are calcium stones most commonly seen?

What is the recurrence rate?

What is significant about them?

A
  • Challenging, more common ?due to acidifying diets
  • Most upper urinary tract (renal/ureteric) stones contain calcium
  • No suitable means of dissolution
  • 60% recurrence over 3 years
  • Conflicting advice about prevention with diet
  • more clinical research is needed to help give appropriate guidelines
60
Q

How, overall generally, can we assess LUTD?

A
  • History
  • Physical examination
  • Urinalysis: stix, SG, sediment
  • Urine culture
  • Diagnostic imaging +/- cystoscopy
  • radiography
  • ultrasound
  • Blood tests looking for
  • consequences or cause of disease?
  • Rule out other disease?
  • systemic disease mimics haematuria?
  • repro organ involvement e.g. prostatitis – don’t forget the prostate!