SA LUT Disease

Question 1

1. Where are LUT diseases located?
2. Define dysuria.
3. Define stranguria.
4. Clinical signs of the above 2.
5. Define haematuria.
6. Define pollakuria.
7. Define periuria.

Answer 1

1. Bladder (,prostate in males) and urethra.
2. Difficulty urinating.
3. Straining to urinate - owners may report constipation.
4. Vocalisation, licking prepuce / lower abdomen, inappetence, lethargy (similar regardless of cause).
5. Bloody urine.
6. Increased frequency of urination.
7. Voiding in inappropriate places.

Question 2

Differential diagnoses in cats.

Answer 2

Feline idiopathic cystitis (FIC); overwhelming majority of cases.
- urethral plugs.
- urethral spasm.
- behavioural.
Urolithiasis (10-20% cases).
Bacterial UTI.
Structural LUT disease; e.g. stricture, congenital.
Others, rare - neuro, neoplasia, prostatic.

Question 3

Differential diagnoses in dogs.

Answer 3

Bacterial UTI (females>males).
Prostatic disease - infectious / neoplastic.
Urolithiasis.
Neoplasia; TCC.
Others, rare:
- urethritis.
- cyclophosphamide induced sterile haemorrhagic cystitis.
- structural LUT disease; e.g. stricture, congenital.
- neuro disease.

Question 4

Diagnostic approach to LUT disease.

Answer 4

Signalment - sex, age, spp.
Hx.
CE.
- focus on genital area, rectal, testicles.
Urinalysis.
Imaging.
- US.
- Rads.
Prostatic samples.
Other lab diagnostics.

Question 5

Hx taking for LUT cases.

Answer 5

Signs of LUT disease - as described.
MOST importantly - still able to pass urine?
- urinary obstruction = emergency.
– hyperkalaemia.
- obstruction MOST common with:
– FLUTD.
– urolithiasis (males>females).
– neoplasia.
– prostatic disease.

Question 6

CE for LUT cases.

Answer 6

Abdominal/bladder palpation.
- often (not always) large if obstructed.
- painful?
Rectal exam:
- prostate; enlargement, symmetry, discomfort.
- urethra – uroliths?
- pain – often indicates inflammatory/infectious disease.
Penile/preputial/vulval/vaginal exam.
Neuro exam - indicated if HL ataxia, difficulty posturing, dribbling urine.

Question 7

Identifying urinary obstruction.

Answer 7

Hx - unproductive urination attempts.
Exam:
- tense, usually large painful bladder.
– not palpable? Ruptured? AFAST.
- Associated complications.
– bradydysrhythmias.
–> life-threatening hyperkalaemia.
IMMEDIATE vet treatment.

Question 8

LUT patient basic urinalysis.

Answer 8

USG.
- submaximally concentrated.
– appropriate vs pathological.
–> <1.030 in dog.
–> <1.035 in cat.
Dipstix analysis.
Urine biochemistry.
- NB. except some proteinuria (LUT inflammation).

Question 9

LUT patient microscopy and culture.

Answer 9

Sediment exam (plain tube).
- crystals.
– true vs storage artefact.
– normal vs abnormal.
– calcium oxalate dihydrate and struvite crystals normal in healthy cats and dogs.
–> abnormal if present with stones.
– urate, cystine always pathological.
- bacteria.
– asymptomatic bacteriuria vs UTI.
Cytology (EDTA tube).
- cells – inflammatory, neoplastic.
- do not refrigerate.
Culture.
- refrigerate if not immediate.
May see WBCs suggestive of infection or inflammation.

Question 10

LUT patient imaging.

Answer 10

US.
- for cystocentesis.
- bladder wall morphology.
- prostatic parenchyma.
- uroliths.
Radiography.
- plain.
– uroliths (radio-opaque).
– prostato/lymphadenomegaly.
- contrast, double contrast.
– uroliths (radiolucent).
– masses, polyps, strictures.

Question 11

Further diagnostics for the LUT patient.

Answer 11

Haematology, serum biochemisty.
- underlying systemic disease?
Free abdominal fluid? - analyse.
Prostatic wash/suction.
Bladder suction biopsy.
Cystoscopy.

Question 12

Concept of asymptomatic bacteria.

Answer 12

Bacteria in absence of clinical signs of a UTI.
Common.
No evidence of increasing risk of UTI, adverse urinary events or adverse systemic events.
ONLY evaluate urine for bacterial presence IF there would be rationale to treat.

Question 13

Urine collection methods for urinalysis.

Answer 13

Free-catch (mid-stream) (dogs).
Litter tray (cats) - non-absorbent.
Cystocentesis.
- preferred for culture.
Catheterisation.
- dogs vs cats.
- male vs female.
- can culture, although less sterile than cystocentesis so interpret results accordingly.

Question 14

Predisposing factors to UTI?

Answer 14

Indwelling u cath.
Nidus (‘lith, suture).
Structural UT disease.
Abnormal voiding.
Sub-maximally concentrated urine.
Immunosuppression/systemic disease.
Need to treat and manage underlying disease too.

Question 15

1. Treatment of sporadic bacterial cystitis?
2. Other treatment considerations.

Answer 15

1. Ideally treat based on C&S.
   Ideally NSAID only pending results.
   Amoxicillin OR TMPS.
   3-5d course.
2. Fresh water access.
   Enable frequent voiding.
   Keep vulva/prepuce clean and free from urine scald.
   - UTIs typically due to ascending infection.
   If alkaline pH, consider evaluating for struvite uroliths.

Question 16

1. Most common bacteria to cause UTI?
2. Possible complications of UTIs?

Answer 16

1. E. coli.
2. Struvite uroliths.
   - urease producing bacteria; staphylococcus spp., proteus spp.
   Pyelonephritis.
   Polypoid cystitis.
   Emphysematous cystitis.

Question 17

Complicated UTIs guidance referral?

Answer 17

ISCAID guidelines.
(International Society for Companion Animal Infectious Diseases).

Question 18

Managing complicated UTIs.

Answer 18

Evaluate and treat underlying cause.
Base tx on C&S.
- prostatic – ideally pend C&S.
– only TMPS, fluoroquinolones and doxycycline will penetrate.
–> 3-6w course.
– neuter entire ma;e dogs 1-2w into tx.
- pyelonephritis – treat pending C&S.
– Quinolone –> 7-14d course.
- Re-culture.
– ~1w into tx to demonstrate control.
– 1-2w after stopping tx.

Question 19

Feline idiopathic cystitis (FIC).

Answer 19

Susceptible cat in a provocative environment.
Susceptible cat:
- neuroendocrine modulation.
– adjusted sensory nerve function.
– abnormalities of the CNS stress response.
- GAG layer hypofunction.
Environmental stress manifests as FLUTD.
Similarities with human Interstitial Cystitis.

Question 20

FIC presentation.

Answer 20

Non-obstructed.
- pollakuria.
- strang/dysuria.
- haematuria.
- still able to void.
- often self-limiting.
- may experience recurrent episodes.
Obstructed.
- urethral spasm or plug.
- unproductive attempts to urinate.
- emergency.
- more common in males (non-obstructive equi-prevalent).
– high recurrence rates.
– >40% experience a recurrence within 6-12m.
NEVER ATTEMPT TO EXPRESS BLADDER.

Question 21

Managing FIC.

Answer 21

If FLUTD signs, young cat, first episode, non-obstructed:
- manage medically.
Obstructed; alleviate obstruction then manage medically.
Diagnostics (imaging) for underlying cause if:
- obstruction.
- recurrent episodes.
– if young, probably still FIC, but exclude other causes e.g. urolithiasis.
- older cat.
- exam abnormalities.

Question 22

The obstructed cat.

Answer 22

Unproductive attempts to urinate:
- owners frequently report ‘constipation’.
Urethral obstruction.
- back pressure on kidneys so post renal azotaemia.
- hyperkalaemia.
Small or large, painful bladder.
Agitated/painful vs depressed.

Question 23

Emergency management of hyperkalaemia.

Answer 23

Definitive correction requires alleviation of obstruction.
- u cath – requires anaesthesia.
Hyperkalaemia needs addressing first.
- fluid therapy.
- drug therapy – glucose, insulin, calcium gluconate.
Bladder decompression rarely required in interim.
- if cystocentesis needed; butterfly needle and drain as much as you can – small risk of rupture.
Analgesia with opioids during stabilisation, pending GA.

Question 24

Equipment for u cath?

Answer 24

Clippers, Hibi and swabs for prep.
Drapes.
Gloves.
Lubricant.
Urinary catheter.
Saline.
Suture material.
Forceps, needle holders.
Syringe.
Urine pot.
Collection bag.
Buster collar.

Question 25

U cath care.

Answer 25

Leave catheterised vs remove catheter.
If catheterised…
- closed, clean system.
– wear gloves for handling.
– keep bag off floor.
- change bag daily.
- avoid abx.
- tape collection system to tail to avoid pulling.
- BC.

Question 26

Post- cath management.

Answer 26

Monitor UOP.
- In’s vs Out’s.
- calculating UOP, assuming assess q4h.
– weight of bag now - weight 4h ago = UOP for last 4h.
– UOP for last 4h divided by 4 = UOP for 1h.
– UOP for 1h divided by patient weight (kg) = UOP (ml/kg/h).
Monitor hydration/volaemic status.
Monitor electrolytes.
- post obstruction diuresis.
– hypokalaemia.
Examine urine sediment/cytology daily for evidence of infection.

Question 27

Medically managing FIC.

Answer 27

Non-obstructed or post-obstructed cats.
Analgesia:
- opioids; bup.
- NSAIDs – consider contraindications.
- Gabapentin – useful for severe cases.

Question 28

FIC environmental modification.

Answer 28

Critical to long-term management.
Alleviate predisposing stressor.
- remove if known.
Address negative cat-cat interactions:
- provide easy exit routes from house/places to hide.
- behavioural advice.
Resource availability.
- particularly plentiful clean/varied toileting stations.
Feliway - feline facial pheromone.

Question 29

Promoting urinary health in FIC cases.

Answer 29

Encourage water intake.
- dilute inflammatory mediators/noxious substances in urine.
Dietary modification; introduce slowly.
- wet diets.
- urinary diets – anti-anxiety compounds (if chronic).
Avoid obesity.
GAG supplementation.
- GAG protects against noxious substances in urine.
- FIC cats may have reduced urinary GAG.

Question 30

FIC antispasmodics.

Answer 30

Commonly used post-obstruction.
- limited evidence.
Prazosin.
- a1 blocker.
- smooth muscle relaxant.
- may cause hypotension.
Dantrolene.
- skeletal muscle relaxant.
– external urethral sphincter.

Question 31

Other FIC therapies.

Answer 31

If chronic/relapsing cases, refractory to all other therapy.
- behavioural consultation.
- +/- psychoactive meds.
– e.g. TCAs e.g. clomipramine.
- may be required – seek behavioural advice/referral prior to use.