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Clinical Urology > SA: Uroliths, FLUTD and Urinary Incontinence > Flashcards

SA: Uroliths, FLUTD and Urinary Incontinence Flashcards

1
Q

What are the 4 main types of urinary stones?

A

1) Struvite: Magnesium ammonium phosphate hexahydrate
2) Calcium Oxalate: Monohydrate or dihydrate
3) Urate
4) Cystine

Others are much rarer: silicate, xanthine etc.

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2
Q

What is considered the gold standard to diagnosing the TYPE of urolith present?

How else can you diagnose specific urinary uroliths?

A
  • Quantitative cristallographic layer analysis (mass spectrophotometry)

Can suspect the type based on:

  • Urine pH
  • Presence of UTI + type of bacteria
  • Radiographic density
  • Signalment
  • Cristalluria
  • Shape
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3
Q

What is the cause of Struvite crystal formation in the dog and cat?

A

Dog:

  • Almost always associated with urease producing bacteria (urinary tract infection)
  • Females are predisposed (85%)

Cats:
- Almost ALWAYS sterile and dietary related

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4
Q

How can Struvite crystals be diagnosed in a clinical setting?

A

Urinalysis

  • pH > 7.5
  • Presence of crystals
  • Positive urine culture for urease producing bacteria

Radiographs:
- Radio-opaque stones: smooth and round borders

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5
Q

You have diagnosed struvite crystals in a patient, how can you treat them?

A

Non-obstructive stones:
- Appropriate antibiotherapy – based on a urine culture
- Full dose antibiotics for the full length of treatment
2-4 weeks – Small bladder stones
4-12 weeks – Large bladder stones
3-9 months – Large kidney stones

  • Dissolution/Calculolytic diet: 4 weeks beyond radiographic resolution or surgical removal

During the dissolution
- Monthly: USG

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6
Q

How can Struvite crystals be prevented from forming in the patient?

A
  • Prevention of UTI
  • Eliminating underlying causes (anatomical or metabolic)
  • USG and pH monitoring
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7
Q

What has been the most commonly diagnosed urinary urolith in cats and dogs?

A

Calcium Oxalate

  • Persian and Himalayans are overrepresented
  • Small dog breeds: English bulldogs, Schnauzers, Shi-tzus, Bichon Frises, Maltese and Poodles etc. are overrepresented
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8
Q

How can Calcium Oxalate crystals be diagnosed?

A

Urinalysis:

  • pH <7
  • Crystals (false positive with refrigerated urine)
  • Negative urine culture (secondary infections?)

Radiographs:

  • Very radio-opaque stones
  • Irregular/sharp margins, multiples and variable in size
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9
Q

How can Calcium Oxalate crystals be treated in a patient?

A
  • Surgical removal!
    Cystotomy
    Bypass (Stent, Sub-cutaneous Ureteral Bypass)
  • No medical management cure
    Can try to eliminate or manage risk factors, e.g. hypercalcemia

Note: Recurrence in 40-60% of dogs within 2-3 years
They likely will come back in for surgery- monitoring is MANDATORY

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10
Q

Why is monitoring important in dogs diagnosed with Calcium Oxalate uroliths?

A

There is a recurrence rate of 40-60% of dogs within 2-3 years, and you cant dissolve these stones, they need to be removed IF they form

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11
Q

How can Calcium Oxalate uroliths be prevented in a dog or cat?

A
  • ALWAYS post-op radiographs with entire urinary tract (perineal and penile urethra)
  • Radiographs every 3 months post-op the first year (lateral view of the entire urinary tract)
  • USG consistently below 1.020 – measured on the first urine in the morning (q3 months): want to continuously dilute the urine
  • Urine pH between 6.8-7.2
  • Potassium citrate (50-100mg/Kg BID for life) +/- Vit B6 (2-4 mg/Kg/day)
  • SO Diet – not calculolytic, but may help balance the pH of the urine
  • Treating underlying causes (e.g. idiopathic hypercalcemia in Cats)
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12
Q

What breed of dogs produces higher amounts of uric acid than other breeds, and why?

A
  • Dalmatians, English Bulldogs and Black Russian Terriers
    These dogs have a well-described alteration in purine metabolism that leads to the excretion of uric acid in the urine rather than excretion of the more soluble metabolite, allantoin

All Dalmatians excrete relatively high amounts of uric acid, however, not all Dalmatians form urate uroliths

The cause of this is due to a mutation in the urate transporter (SLC2A9 gene)

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13
Q

What are Urate uroliths made out of?

A

Salts of uric acid, this can be uric acid itself, sodium urate or ammonium urate

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14
Q

How can Urate Uroliths be diagnosed in a patient?

A

Urinalysis:

  • Urine pH <7
  • Negative urine culture, but a possible secondary bacterial infection
  • Crystals

Abdominal US: preferred
Radiographs: NON-radioopaque stones, therefore need contrast to see them

Blood ammonia levels: looking for elevations to suggest liver insufficiency

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15
Q

Why do urate uroliths form?

A
  • Genetic predisposition: as is in the Dalmatian, English Bulldog and Black Russian Terrier
  • Liver disease/ failure: leading to a disruption in purine metabolism
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16
Q

How can Urate Uroliths be treated/ managed?

A

Medical dissolution of non-obstructive stones is 30% efficient, and takes 8+ weeks
- Calculolytic diet/ low purine diet + Xanthine oxidase inhibitor (allopurinol) + alkalization of urine (potassium citrate)

Surgical:
Must surgically remove any obstructive uroliths
- Lithotripsy- if accessible
- Bypass

Long term management:

  • Fix portosystemic shunt if present
  • Investigate and monitor liver function
  • Genetic testing if no liver dysfunction
  • Calculolytic diet/ low purine diet + Xanthine oxidase inhibitor (allopurinol) + alkalization of urine (potassium citrate)
  • Keep USG <1.020 and pH > 6.6
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17
Q

What is the etiology of Cystine and Silica Urolithiasis in cats and dogs?

A

Cystine- and silica-containing uroliths are uncommon in dogs and very rare in cats (1.3% and 6.6% respectively)

Dogs and Cats: Cystinuria results from a genetic mutation in the cystine transporter, which would otherwise allow for reabsorption from the glomerular filtrate.
Dogs only: there is an androgen-dependent cystinuria reported in several breeds of intact male dogs

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18
Q

How can Cystine Uroliths be diagnosed?

A

Urinalysis:
- Colourless hexagonal crystals: refrigeration can falsely increase proportion

Radiographs: faintly dense, more than urate but less than oxalate
US: might see shadows

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19
Q

What is the treatment/ management/ prevention of Cystine and Silica Urolithiasis in cats and dogs?

A
  • Surgical removal

Medical Dissolution: (53% successful)
- Diet: high moisture, low protein, alkalinizing diet (urinary diets) or feeding a vegetarian-based diet
- The drug, tiopronin (Thiola®, 2-MPG; 15-20 mg/kg PO q12h), can also be administered to help prevent (or possibly dissolve) cystine stones
+/- potassium citrate (starting dose of 50-75 mg/kg q12h)

Prevention in the future:

  • Castration of male intact dogs
  • Dilute urine: USG< 1.020 + Alkaline pH (7.8) + Low protein/Low sodium food
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20
Q

What surgical treatment options are there for urolithiasis?

A

Depends on the location of the urolith and whether it is obstructive or not

  • Surgical: Cystotomy, Urethrotomy, Ureterotomy
  • Voiding Urohydropulsion: only possible with small stones <4mm
  • Endoscopic basketing
  • Lithotripsy: mostly used on stones that are in the urethra
  • Percutaneous Cystolithotomy (PCCL)
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21
Q

You suspect a patient has a stone in the ureter (ureterolithiasis), how can you be sure of this?

A
  • CBC + Biochem = azotemia
  • Urinalysis: will guide suspicion of type of crystal/ stone present
  • Rads + US: rads will help with only certain types of stones, US can be more sensitive
22
Q

You have diagnosed a stone in the ureter (ureterolithiasis) of a CAT, how can this be treated or managed?

A

Conservative management (13% success rate):

  • Fluid therapy
  • alpha- antagonist: prazosin
  • Steroids: reduce inflammation/ edema
  • Analgesic therapy: buprenorphine to prevent ureteral spasm
  • Diuretics: mannitol

note: animals undergoing conservative management, should be monitored regularly, including weight, serum creatinine +/- SDMA to ensure overhydration does not occur and there is an improvement
note: this is not discussed in dogs because it is far rarer in dogs to get obstructions in the ureters, in cats it is far more common. But principles can be applied to the dog.

Surgical management/ treatment:

  • Ureterotomy: high morbidity and chance of recurrence
  • Ureteral stent placement
  • Sub-cutaneous ureteral bypass (SUB): technically challenging but better prognosis
23
Q

You notice a nephrolith (stone in the kidney) while doing radiographs of a dog or cat, what is the treatment for these?

A

These are most commonly CaOx stones, but can be mixed with calcium phosphate or urate

  • Treatment may not be necessary if it is an incidental finding and not causing problems
  • Surgery
  • Lithotripsy is possible
  • Medical dissolution depending on the type of stone present in the kidney

Prognosis is good with nephrolith cases

24
Q

What is Feline Lower Urinary Tract Disease (FLUTD)?

A

This is an umbrella term used to describe ANY disorder affecting the bladder or urethra of cats

Divided into obstructive and non-obstructive forms

  • Young to middle-aged cats are more affected (2-6 years old)
25
Q

What are the predisposing factors to FLUTD?

A 
Longhaired
Moving houses
Decreased drinking
Low level of activity
Little outdoor access
Use of non-clumping litter
Multi-cat household
Obesity
Stressed owners
Changes to environment
26
Q

What are the clinical signs associated with FLUTD in cats?

A
  • Overgrooming
  • Stranguria
  • Dysuria: pollakiuria, hematuria, Periuria
  • Mucuous plugs in the urine of male cats
  • Small bladder on palpation
  • Anuria + distended bladder = blocked cat
27
Q

A cat presents with non-obstructive FLUTD, what are the differential diagnoses?

A
  • Idiopathic cystitis (FIC)
  • Urolithiasis
  • Infectious cystitis: bacterial or fungal
  • Urethral stenosis: congenital vs iatrogenic
  • Anatomical anomaly
  • Neoplasia
  • Prostatic diseases
28
Q

A cat presents with obstructive FLUTD, what are the differential diagnoses?

A
  • Urethral plug (mucous plug)
  • Urethral stone: struvite 92% of the time
  • Urethral spasms
  • Urethral stenosis
  • Urethral neoplasia
29
Q

You suspect FLUTD in a cat patient, what diagnostic investigations can be performed to narrow a differential?

A
  • CBC + Biochem
  • Urinalysis + urine culture/ sensitivity
  • Abdominal rads + US
  • Cystoscopy
30
Q

What is Feline Interstitial Cystitis (aka Feline Idiopathic Cystitis)?

A

A disease of the feline lower urinary tract (FLUTD), but with no known cause- accounting for 2/3rd of all FLUTD cases

Suspected causes include:

  • Defective bladder lining: may see areas of necrosis, inflammation/ ulceration
  • Neurogenic inflammation: an abnormal neuronal stimulation leading to chemokine release
  • Abnormal responses to stress: only catecholamines are released from the adrenals, and there is no cortisol release in cats with FIC
31
Q

What is the treatment for a cat with a urethral obstruction?

A

EMERGENCY
1) CBC + Biochem: Assess for life-threatening electrolyte derangement e.g. hyperkalemia, renal function

2) Treat dehydration and shock carefully: don’t want to overload the patient, 5ml/kg bolus if in shock, repeat until the patient responds
Mild dehydration: calculate the volume to be replaced and administer over 24 hours

3) Hypocalcemia or hyperkalemia: 10% Calcium gluconate supplement (0.5ml/kg IV over 10 mins) under ECG monitoring

Severe Hyperkalemia (>7mEq/L) = Insulin/ Dextrose:
- Regular Insulin 0.25 – 0.5 UI/Kg IV bolus
50% Dextrose (Diluted 1:4 in 0.9% NaCl) IV bolus
Dextrose CRI 2.5 - 5%

Moderate Hyperkalemia (6-7mEq/L) = Dextrose bolus alone

Mild Hyperkalemia (<6mEq/L) = Fluid therapy + volume expansion

4) Relieve the Obstruction! (description later on)

32
Q

You are presented with a cat that has a lower urinary obstruction, you measure K+ levels on biochem and notice severe hyperkalemia (>7mEq/L), what is the treatment?

A

Severe Hyperkalemia (>7mEq/L) = Insulin/ Dextrose:
- Regular Insulin 0.25 – 0.5 UI/Kg IV bolus
50% Dextrose (Diluted 1:4 in 0.9% NaCl) IV bolus
Dextrose CRI 2.5 - 5%

+ 10% Calcium gluconate supplement (0.5ml/kg IV over 10 mins) under ECG monitoring to protect the heart from the K+ levels

33
Q

You are presented with a cat that has a lower urinary obstruction, you measure K+ levels on biochem and notice moderate hyperkalemia (6-7mEq/L), what is the treatment?

A

Moderate Hyperkalemia (6-7mEq/L) = Dextrose bolus alone

+/- 10% Calcium gluconate supplement (0.5ml/kg IV over 10 mins) under ECG monitoring to protect the heart from the K+ levels

34
Q

You are presented with a cat that has a lower urinary obstruction, you measure K+ levels on biochem and notice mild hyperkalemia (< 6mEq/L), what is the treatment?

A

Mild Hyperkalemia (<6mEq/L) = Fluid therapy + volume expansion

35
Q

How can you relieve a lower urinary obstruction in a cat?

A

Relieve the obstruction:

  • Anesthesia with short-acting agents: Sacrococcygeal epidural if needed for relaxation
  • Voiding with gentle palpation: Confirm complete or partial obstruction
  • Partial obstruction can be managed medically without catheterization
  • Topical lidocaine spiked lubricant on catheter: caution toxic dose = 2mg/Kg in cats
  • Extrusion and examination of the penis = plug? Clots?
  • Advance catheter +/- urohydropulsion with saline and monitor bladder size
  • Decompressive cystocentesis may be required (butterfly, empty as much as possible)
  • Rinse the bladder to remove blood, inflammatory cells, and sand with lukewarm saline
36
Q

What is the hospitalization protocol for a cat that had a lower urinary obstruction?

A

Hospitalization:

  • 48h with a urinary catheter or until urine is clear
  • Monitoring in and outs for post obstructive diuresis and preventing dehydration
  • Analgesia: Opioids + Gabapentin oral (continue at home)
  • Urethral relaxant: α antagonists such as Prazosin or Tamsulosin, Phenoxybenzamine
  • Striated muscle relaxant: Dantrolene

Caution: Careful use of NSAIDs in a dehydrated patient or a renal injury patient

  • Discharge when voiding normally without catheter
37
Q

What is the treatment for a cat with non-obstructive FLUTD?

A
  • Treat as an outpatient ideally to limit stress
  • Analgesia + anxiolytic agent: Gabapentin oral
  • Urethral relaxants
    • α antagonists: Prazosin or Tamsulosin, Phenoxybenzamine
    • Striated muscle relaxant: Dantrolene

Caution: careful use of NSAIDs!

Antibiotics are not indicated unless urine culture specifies otherwise

38
Q

How can you prevent Feline Interstitial Cystitis (aka Feline Idiopathic Cystitis)?

A
  • Increase water intake: wet food diet has a lower relapse rate than a dry diet
    • Ice chips with tuna water
    • Water fountain
  • Urinary diet: RC or Hills
  • Stress management: increase number of litter boxes (2 for every 1 cat), and place in a quiet area of the house. Provide hiding places, toys, scratching posts, may need to rehome if there is tension between cats
  • Stress management of the owner!
  • Medical management: Feliway, Amytriptilline or Gabapentin
39
Q

The Urinary cycle is made up of 2 phases, what are they?

A

1) Filling Phase:
Sympathetic nervous system (L1-L2)- Hypogastric nerve
𝛽 receptor = relaxation of detrusor muscle
α receptor = contraction of trigone and urethral smooth muscles («internal sphincter»)
Stretching

2) Voiding Phase:
Distension stimulates stretch receptors
Conscious voiding signal through parasympathetic nervous system (S1-S3)
Pelvic nerve: detrusor contraction
Pudendal nerve inhibition: «external sphincter» relaxation (striated muscles)
α adrenergic reflex inhibition: «internal sphincter» relaxation

40
Q

You notice an animal is suffering with dysuria (pain when urinating), you palpate the bladder and it is NORMAL or SMALL, what are the possible differentials for this?

A

Anatomic abnormalities:

  • Ectopic ureters
  • Pelvic bladder
  • Ureterocoele (usually associated with ectopic ureters)
  • Vestibular strictures (urine pools in the vagina and leaks when dog lays down)
  • Hypoplastic bladder neck

Decreased bladder compliance:

  • Urge incontinence (Urolithiasis, neoplasia, inflammation
  • Idiopathic detrusor instability (Overactive bladder)

Decreased urethral pressure:
- Urethral sphincter mechanism incompetence (congenital vs acquired)

41
Q

You notice an animal is suffering with dysuria (pain when urinating), you palpate the bladder and it is DISTENDED, what are the possible differentials for this?

A

Anatomical urethral obstruction:

  • Urolithiasis
  • Neoplasia
  • Inflammation
  • Stricture

Functional urethral obstruction:
- Urethral spasm

Decreased urethral pressure:
- Urethral sphincter mechanism incompetence

Neurologic abnormalities:

  • LMN (S1-S3) – Neoplastic, trauma = large flacid bladder, continuous overflow incontinence, absent perineal reflex
  • UMN (Pons – L7) – Firm large bladder difficult to express: urethral tone increased, overflow incontinence
  • Detrusor atony (iatrogenic from over distension)
42
Q

What is the signalment, usual history and physical exam findings of a dog or cat with Ectopic Ureter(s)?

A
  • Signalment
    Puppies
    Female&raquo_space; males
  • History
    Incontinent from birth or from adoption
    Dribbling while walking, worse when lying down
    Patient is soaked, smelly
  • Physical examination
    Drip of urine in consult room
    Urine scold, perivulvar dermatitis
    Normal size to small bladder
43
Q

What are the DDx for ectopic ureters?

A
  • UTI

- Behavioral/ toilet training issues

44
Q

How can ectopic ureters be diagnosed?

A
  • Urinalysis
  • Culture + sensitivity
  • CBC + Biochem
  • DI: Rads, US, Cystoscopy
45
Q

What is the difference between an intramural and extramural ectopic ureter?

A

Most common type is Intramural (80% of cases)

  • Intramural = Ureter enters at the trigone but tunnels down the urethra
  • Extramural = distal ureter may implant into an abnormal area without tunneling
46
Q

What is the treatment for an intramural ectopic ureter, and an extramural ectopic ureter?

What is the prognosis?

A

Intramural:

  • Cystoscopic/Fluoroscopic guided laser neoureterostomy (ablation) - at the time of diagnosis, rapid recovery = gold standard
  • Open neoureterostomy

Extramural:
- Neoureterocystotomy

Prognosis:

  • Complete resolution after surgery = 50% of cases
  • Improvement will be seen in most of the rest of the cases. Delay neutering to prevent the occurrence of estrogen-responsive incontinence
  • 25% of cases require meds for USMI (Urethral Sphincter Mechanism Incompetence)
  • 25% of cases will still be incontinent, and thus may need a urethral occluder
47
Q

What is Urethral Sphincter Mechanism Incompetence (USMI)?

A

This is a disorder characterized by a decreased urethral closure pressure, which can occur because of lumbosacral disorders such as intervertebral disk disease, degenerative myelopathy, trauma, malformations of the spinal vertebrae (e.g., in Manx cats), and rare disorders such as dysautonomia.

USMI is diagnosed when all other disorders have been ruled out

48
Q

What is the usual signalment of Urethral Sphincter Mechanism Incompetence (USMI)?

A
  • Female adult dogs

Note: any cat suspected to have USMI should be tested for FeLV because associations between the two have been suggested

49
Q

What are the risk factors that may predispose a dog to developing USMI?

A
  • Large-breed dog (>20kg)
  • Tail docking
  • Obesity
  • Neutered status
50
Q

How can USMI be diagnosed in a dog?

A
  • Bladder will be normal size
  • Urinalysis
  • Urine culture + sensitivity
  • CBC + Biochem
  • DI: help rule out stones and anatomical anomalies

Gold standard = Urethral pressure profile, which documents a decreased urethral closure pressure. However, this is only done if all other causes are ruled out and medical management has been unsuccessful

51
Q

What are the medical treatment options for USMI?

A

1) Phenylpropanolamine: Non-selective adrenergic agonist (sympathomimetic) that significantly increases the urethral tone.
- Side effects include hypertension, restlessness, tachycardia, intraocular hypertension and hepatic gluconeogenesis.
- Resolution of USMI in 85% of the cases in female (44% in male).

2) Estriol: natural estrogen, exerting a permissive effect on the ɑ-receptors of the urethral sphincter thus increasing responsiveness to the sympathetic nervous system, resulting in increased urethral tone.
- Side effects are really uncommon and present as clinical signs of oestrus (swollen vulva, vulvovaginitis), even more rare are gastro-intestinal upset.

3) Combination of both: synergistic effect

Clinical Urology (8 decks)

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