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CAEM Pt. 2 > Renal: Urinary Incontinence & Uroliths > Flashcards

Renal: Urinary Incontinence & Uroliths Flashcards

1
Q

What is urinary incontinence?

A

Involuntary passage of urine during the storage phase of urination (inappropriate)

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2
Q

Musculature in bladder and urethra (3)

A

1) Detrusor = smooth m. in bladder, helps expel urine
2) Proximal internal urethral sphincter = smooth muscle
3) Distal external urethral sphincter = skeletal muscle

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3
Q

Pudendal n. innervation during micturition

A

Controls voluntary portion of urination via control of the somatic skeletal external urethral sphincter

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4
Q

Hypogastric n. innervation during micturition

A

> Helps you store urine

  • Sympathetic innervation to the internal urethral smooth m. sphincter (constriction)
  • Relaxation of detrusor m.
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5
Q

Pelvic n. innervation during micturition

A

> Parasympathetic innervation to help you PEE

- Contraction of detrusor m.

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6
Q

Innervation throughout micturition

A

1) Stretch receptors sense full bladder, send info to brain (pons)
2) Motor efferents to pelvic nerve = initiate detrusor contraction
3) Inhibition of sympathetic tone on external and internal urethral sphincter (pudendal, hypogastric)

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7
Q

Diagnostics involved with urinary incontinence

A

1) Signalment = young (congenital), large breeds more commonly
2) History = diff from PU/PD, urge incontinence, behavioral problems –> puddle size, timing, urgency
3) PE = bladder size, neurologic status, rear end anatomy
4) Minimum database = urinalysis and culture
5) Imaging = position of bladder, ureters, calculi, etc.

  • Others = CBC/chem for systemic causes, uroendoscopy
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8
Q

Number one cause of urinary incontinence

A

Primary sphincter mechanism incompetence, or estrogen-responsive incontinence

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9
Q

Common history with primary sphincter mechanism incompetence

A
  • Occurs +/- 3 years after spaying

- Urine leakage occurs when laying down (increased intra-abdominal pressure) or with increased parasympathetic tone

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10
Q

Diagnosis of urinary incontinence

A

Diagnosis of exclusion

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11
Q

Main medications for urinary incontinence (2)

A

1) PPA = alpha agonist, increase urethral closure pressure (give biggest dose at night, may be ineffective after prolonged use)
2) Estrogens (DES) = increase sensitivity of the urethral smooth muscle to catecholamines

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12
Q

Side effects of estrogen and PPA in patients with urinary incontinence

A

1) PPA = hypertension

2) Estrogens = clinical signs of estrus, bone marrow suppression

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13
Q

Surgical intervention of urinary incontinence (primary sphincter mechanism)

A

> Submucosal injections of collagen or Teflon

- Other = hydraulic occluder, etc.

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14
Q

Most common anatomic abnormality that contributes to urinary incontinence

A

Ectopic ureters, most commonly at the distal urethra, intramural, bilateral

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15
Q

Common breeds affected by ectopic ureters

A
  • Siberian huskies
  • Lab retrievers
  • Golden retrievers
  • Newfies
  • Etc.
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16
Q

Common history with ectopic ureter animals

A
  • Young animal (< 1 yr)
  • Difficult house breaking
  • Urinary dribbling - constant or intermittent
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17
Q

Gold standard for ectopic ureter diagnosis in males and females

A
  • Excretory urograph in males with CT

- Cystoscopy in females

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18
Q

Common concurrent disorders with ectopic ureters

A
  • UTI
  • Pyelonephritis
  • Hydroureters or hydronephrosis
  • Eventual urethral sphincter mechanism incompetence
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19
Q

Treatment of ectopic ureters

A

Surgical transposition - although persistent incontinence may persist

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20
Q

State of the bladder with an UMN lesion

A

Bladder is difficult to express - external urethral sphincter tone stays in place, can’t initiate urination

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21
Q

State of the bladder with a LMN lesion

A

Large and flaccid bladder, bladder is easy to express - still some internal sphincter tone, no sensory stretch

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22
Q

What is reflex dyssynergy or destrusor urethral dyssynergia?

A

Voiding dysfunction = normal initiation of micturition, followed by a decrease in and then a sudden interruption of urine flow

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23
Q

Signs of reflex dyssynergy

A

Prolonged attempts at urination (dysuria, stranguria) with only small urine squirts eliminated

24
Q

Type of dog more commonly affected by reflex dyssynergy

A

Middle aged large to giant breed dogs

25
Q

Treatment of reflex dyssynergy (2)

A

> Medical relaxation of urethral sphincter = prazosin or phenoxybenzamine (alpha antagonist)
Stimulation of bladder contraction = bethanecol (parasympathomimetic)

26
Q

Side effect of smooth muscle relaxants used in reflex dyssynergy

A

Hypotension (alpha antagonists) - avoid in critically ill patients

27
Q

Side effect of bethanecol

A

Parasympathetic SLUDE = salivation, lacrimation, urination, defecation, emesis

28
Q

What is a urolith?

A

Organized crystal aggregate of minerals in small amounts of matrix minerals (mucoproteins, protein, and other factors)

*Majority are pure (one mineral), but they can be mixed

29
Q

Steps in urolith formation

A

1) Super saturation of urine = increasing concentrations of lithogenic substances
2) Initiation phase = nucleation
3) Growth phase and aggregation

30
Q

What is the most common urolith in dogs?

A

Ca++ oxalate - esp in older male dogs

31
Q

What should you suspect when you find a struvite crystals?

A

Dog has an underlying UTI

32
Q

What urolith do we commonly see in Dalmatians and English Bulldogs?

A

Urate uroliths - impaired transport of uric acid

33
Q

What urolith do we commonly see with liver dysfunction or shunts?

A

Urate uroliths

34
Q

Diagnosis of uroliths

A

1) History and clinical signs = hematuria, dysuria, pollakuria, stranguria, abdominal pain, vomiting, anorexia
2) PE = bladder palpation, rectal to feel urethra or for stones
3) CBC/chem = hypercalcemia, decreased liver values with urate stones
4) U/A = sediment indicating inflammation/infection (pyuria, hematuria, proteinuria, bacteriuria), CRYSTALS from fresh urine?
5) Urine culture
6) IMAGING = > 3 mm, include the entire urinary tract
7) STONE ANALYSIS
+/- U/S = not good for counting stones
+/- Contrast studies

35
Q

True or false - crystalluria doesn’t equal urolithiasis

A

TRUTH - can be normal and requires no treatment

36
Q

What should you always do after urolith surgery?

A

RADIOGRAPH to ensure you got them all

37
Q

What do you not put the urolith in for storage?

A

Formalin

38
Q

What type of uroliths do female and male dogs get?

A

1) Females = struvites, because of UTI’s

2) Males = Ca++ oxalate

39
Q

What diagnostic test is most important for urolith treatment/prevention?

A

Stone analysis

40
Q

Indications for stone removal (6)

A

1) Repeated urethral obstruction
2) Clinical signs associated with recurrent bacterial UTI’s
3) Ureteral obstruction
4) Severe hematuria
5) Pain, stranguria, dysuria, pollakuria
6) Suspect stone that cannot be dissolved medically (Ca++ oxalate, silicate)

41
Q

Surgical and non-surgical options for stone removal (3)

A

1) Voiding hydropulsion = under GA, distend bladder and try and expel the stones
2) Lithotripsy = break up stones and remove them (not done in cats)
3) Surgical removal - TAKE RADIOGRAPHS

42
Q

Possible complication of voiding hydropulsion

A

Hematuria, urethral obstruction, or bladder rupture

43
Q

What stones can we medically dissolve?

A
  • Struvites
  • Cystine stones
    +/- Urate - diet can help
44
Q

Control of struvite stones

A
  • Control UTI’s

- Diet = feed 1 month past dissolution, don’t need to be kept on long term diet control

45
Q

What should you think of when your struvite stones are dissolving?

A
  • Inadequate UTI control

- May be a compounded stone that needs to be surgically removed

46
Q

What should you warn owners of with medical dissolution of stones?

A

Esp in male animals = may cause an obstruction

47
Q

How do we monitor struvite stone patients?

A

> Urine culture and sensitivity = 1 month after dissolution, then every 3-6 months thereafter even if no clinical signs are present
Consider radiographs every 6 months for animals with recurrent UTI’s or signs

48
Q

When are longer term diets necessary for struvite stone animals?

A

For sterile stones (not associated with UTI’s) = helps keep the urine acidic (< 6.5)

49
Q

Treatment of Ca++ oxalate stones

A
  • Medical dissolution won’t work
  • Tx = SURGICAL REMOVAL
  • Can do benign neglect (do nothing) but need to warn the owners of possible obstruction
50
Q

Prevention of Ca++ oxalate stones

A
  • 2/3 of stones will recur
  • Tx any underlying disease (hypercalcemia)
  • Encourage weight loss
  • Diet to keep urine < 7.5 or >6.5
  • Avoid high oxalate plants or hypercalcemic foods
  • Rx = K+ citrate = alkalizes urine, improve Ca++ tubular resorption
51
Q

Monitoring for Ca++ oxalate stones

A

U/A and imaging 1 month after removal, then every 3-6 months for life

52
Q

Treatment of urate stones

A
  • Correct any underlying causes = PSS
  • Dissolution with diet for 2/3 of cases (don’t use it for more than 6 months)
  • Rx = allopurinol = xanthine oxidase inhibitor (not in PSS or liver disease patients, metabolized by liver)
53
Q

Breeds we see cystine stones in

A

Newfies, Dachshunds, bulldogs - almost exclusively males

54
Q

Treatment of cystine stones

A
  • Medical dissolution possible
  • Low protein diet to lower the USG (medullary gradient)
  • Rx = K+ citrate to alkalinize urine
  • Rx = thiol-containing drugs like D-penicillamine or tiopronin = bind with cystine to make it soluble in the urine
55
Q

Treatment of silicate stones

A

Surgical removal

CAEM Pt. 2 (27 decks)

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