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Y4 SA - urinary & endocrine disease > Urinary incontinence > Flashcards

Urinary incontinence Flashcards

1
Q

What causes urethral smooth muscle contraction & prevents leakage?

A
  • positive stimulus via alpha-adrenergic fibres
  • the sympathetic nervous system
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2
Q

What allows passive filling of the bladder?

A
  • inhibition of the detrusor muscle via beta-adrenergic fibres
  • the sympathetic nervous system
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3
Q

What nervous system predominates bladder filling?

A
  • the sympathetic nervous system
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4
Q

What nervous system allows voluntary bladder filling?

A
  • the somatic nervous system
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5
Q

What allows sudden or prolonged increases in bladder pressure?

A
  • the somatic nervous system stimulates urethral striated muscle contraction
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6
Q

Which nervous system predominates urination?

A
  • the parasympathetic nervous system
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7
Q

Describe the mechanisms that allow urination
(the detrusor reflex & micturition reflex)

A
  • when the threshold is reached, stretch receptors in the bladder wall stimulate detrusor muscle contraction = detrusor reflex
  • urethral sphincter muscles relax
  • micturition reflex = detrusor reflex and inhibition of sympathetic and somatic stimulation to bladder and ureters
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8
Q

Distinguishing between polyuria, behavioural problems and incontinence

A

Behavioural
- stress
- pain
- instinct
- cognitive dysfunction

Polyuria

Pollakiuria
= increased urinary frequency

Impaired control of bladder
- neurogenic
- non-neurogenic (anatomical or functional disorder)

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9
Q

What is true urinary incontinence?

A
  • the pt is unaware that they’re leaking urine
  • usually due to poor sphincter functionality
  • uncommon in cats
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10
Q

What is urge incontinence?

A
  • the pt is aware that they need to urinate but may have lack of control
  • can be caused by bladder irritation or seen as inappropriate urination
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11
Q

What overflow incontinence?

A
  • the pt is (usually) unaware that they’re urinating
  • occurs when urine pressure within the bladder is greater than the urethra
  • considered a ‘voiding’ rather than storage disorder
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12
Q

Causes of neurogenic urinary incontinence

A
  • sacral fracture
  • pelvic nerve or pelvic plexus trauma
  • lumbosacral disease (IVDD, lumbosacral stenosis, neoplasia)
  • sacral malformation
  • FeLV - associated incontinence
  • generalised peripheral lower motor neurone disease
  • dysautonomia
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13
Q

Other CS of neurogenic urinary incontinence

A
  • LMN signs
  • often other neurological signs
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14
Q

Causes of non-neurogenic urinary incontinence

A
  • urethral sphincter mechanism incompetence
  • urethral hypoplasia
  • lower urinary tract inflammation (bacterial cystitis, sterile cystitis, urolithiasis)
  • detrusor instability
  • ectopic ureter
  • partial outflow obstruction (uroliths, neoplasia, polyps)
  • patent urachus
  • vestibulovaginal stenosis/septum
  • primary detrusor atony with outflow
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15
Q

How does a cerebral lesion causing neurogenic incontinence present?

A
  • the bladder can empty normally but often at inappropriate times
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16
Q

How do brainstem-L7 lesions causing neurogenic incontinence present?

A
  • Absent voluntary micturition
  • Bladder is hard to express
  • Increased urethral sphincter tone
  • High volume urinary retention
  • Development of automatic bladder
  • UMN bladder
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17
Q

How to S1-S3 nerve root lesions causing neurogenic incontinence present?

e.g. damage to the sacral spine/pelvic plexus/tail pull injury in cats

A
  • LMN bladder
  • ‘paralytic bladder’
  • Absent voluntary micturition
  • Bladder is atonic, flaccid and easy to express
  • Concurrent reduced perineal reflex and anal tone, may
    have tail paralysis
  • Atonic urethral sphincters
  • Absent detrusor reflex
  • Can result in overflow incontinence when full
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18
Q

Automatic bladder

A
  • may develop over time when initial shock has passed
  • where sympathetic and parasympathetic pathways enable bladder emptying when threshold is reached
  • not under voluntary control
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19
Q

What is the most common non-neurogenic cause of canine incontinence?

A
  • urethral sphincter mechanism incompetence (USMI)
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20
Q

What is the most common presentation/signalment for USMI?

A
  • female
  • spayed
  • older
  • large breed
  • overweight
  • normally presents as intermittent involuntary leaking of urine when dog is relaxed (sleeping) or excited
  • pt may have good/back leaking days
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21
Q

What can USMI occur concurrently with?

A
  • ectopic ureters
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22
Q

Can USMI be congenital?

A
  • yes
  • less common
  • some may resolve post 1-2 seasons
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23
Q

What is an uncommon presentation/signalment for USMI?

A
  • male entire or castrated dogs
24
Q

Breed predispositions for USMI

A
  • Irish setter
  • Doberman
  • bearded collie
  • rough collie
  • Dalmation
25
Q

How can USMI be exacerbated?

A
  • intrapelvic bladder position
26
Q

Factors that affect/contribute to USMI

A
  • low urethral tone / reduced amount of smooth muscle in urethra
  • obesity
  • hormonal influence (aging or lack or oestrogens change urethral structure)
  • intrapelvic bladder position
27
Q

Medical management of USMI

A

sympathomimetic agents
- age to mimic the storage of urine phase Phenylpropanolamine; propalin (vetoquinol) and urolin (dechra)
- ~75% respond well

oestrogens
- act on oestrogen receptors in sphincters
- estriol; Incurin (intervet) and enurace (Janssen)
- takes longer to get a response
- can’t use in males/entire bitches or cats

check for UTI regularly

28
Q

Surgical management of USMI

A

All referral level surgery

Colposuspension
- for intrapelvic bladders
- reposition of the bladder neck into the abdomen and urethra is moved between vagina and pubic brim

Urethropexy
- urethra is fixed surgically in a new cranial position

Bulking agents
- for submusoca of urethra (collagen injections)

Urethral occluders
- expandable cuffs provide external pressure to urethra

Prostatopexy
- similar to urethropexy

29
Q

Congenital causes of incontinence

A
  • intersex pts (rare)
  • ectopic ureters
30
Q

How can being intersex affect incontinence?

A
  • may have combination of genital and reproductive organs resulting in different anatomy or functional problem
31
Q

When is incontinence observed in pts with ectopic ureters?

A
  • shortly after birth
32
Q

What is an ectopic ureter?

A
  • bladder is bypassed and urine may empty into vagina or urethra
  • grossly ureter could look normal but ‘brows’ along bladder submucosa into ‘intra-luminal’ position
  • can occur concurrently with other abnormalities
33
Q

What is common with ectopic ureters?

A
  • secondary infection, including pyelonephritis
34
Q

Tx of ectopic ureters

A
  • surgical
35
Q

Anatomical causes of incontinence (not congenital)

A
  • detrusor instability
    – an overactive bladder presenting as pollakiruia
    – most animals have underling cystitis, irrupting the bladder lining and over stimulating the detrusor reflex = urge incontinence
36
Q

What is urinary retention?

A
  • a disorder of urine storage and voiding rather than classic incontinence
  • pt presents with stranguria or dysuria, and may be attempting to void urine but unsuccessful
37
Q

Categories for causes of urinary retention

A
  • neurogenic
  • non-neurogenic

either:
- detrusor muscle isn’t working well
or
- bladder isn’t contracting against high outflow pressure

38
Q

Neurogenic causes of urinary retention

A
  • LMN disorder
    – sacral region pathology e.g. cauda-equine syndrome, SI luxation
  • UMN disorder
    – sacrum to brain pathology
  • Detrusor-urethral dyssynergia
  • Dysautonomia
    – rare, other neuro signs too (CV, GI, etc)
39
Q

Management of urinary retention

A
  • facilitate bladder emptying
  • medicate depending on cause
40
Q

Non-neurogenic causes of urinary retention

A
  • blockage
    – anatomical obstruction
    – functional obstruction
  • trauma to ureters and/or bladder
  • detrusor atony
41
Q

Anatomical obstruction causes of urinary retention

A
  • either within urinary tract or nearby anatomy
  • blocked cat: cell plug/crystals
  • prostatic dz
  • urolithiasis
  • tumour
  • strictures
42
Q

Functional obstruction cause of urinary retention

A
  • urethral spasms
43
Q

Causes of trauma to ureters and/or bladder

A
  • injury to abdomen (ruptured bladder)
  • iatrogenic
44
Q

What is a common cause of detrusor atony?

A
  • over distention of bladder
45
Q

What is the bladder like with detrusor atony

A
  • distended and flaccid
46
Q

Can detrusor atony recover?

A
  • yes if acute onset
47
Q

What do LMN (sacral spine segments, pelvis nerve or pelvis plexus) disorders result in?

(with respect to the bladder)

A
  • detrusor atony and sphincter areflexia
    -> loss of perineal reflexes, distended bladder that is easy to express
48
Q

Examples of LMN disorders

A
  • cauda-equine syndrome
  • sacroiliac luxation
  • IVDD
  • sacrococcygeal trauma (‘tail pull injury’)
  • neoplasia
49
Q

Tx/management of LMN disorders

A
  • Bethanecol (a parasympathomimetic) may improve bladder contractility IF there is some function left
  • nursing/home care: manual expression 3-4x daily, cleaning, monitoring for UTI
50
Q

What do UMN disorders result in?

(with respect to the bladder)

A
  • disruption between the sacral segments and the pontine micturition centre in the brain
    -> reflex detrusor contraction (trying to empty bladder)
    -> concurrent uninhibited sphincter spasticity (hard to empty past this)
  • pts often have paresis or paralysis of the hindlimbs and can’t urinate voluntarily
  • bladder is large, firm and difficult/impossible to empty early in the disease
  • automatic bladder or reflex bladder can develop = automatic emptying of the bladder when full
51
Q

Tx for UMN disorder: facilitate complete bladder emptying

A
  • urethral smooth muscle relaxants
    – alpha antagonists: phenoxybenzamine, prazosin
  • skeletal muscel relaxants
    – e.g. baclofen, diazepam, dantrolene
  • monitoring for UTIs is important
52
Q

What is idiopathic reflex dyssynergia

A
  • loss of coordination between the detrusor muscle contracting and relaxation of the urethra
  • i.e. the pt is not blocked and the nerves work fine, everything is just irritated and neuromuscular systems aren’t working in a coordinated fashion
53
Q

How does idiopathic reflex dyssynergia present?

A
  • spurting urine flow
54
Q

Ddx for idiopathic reflex dyssynergia

A
  • any cause of inflammation to the bladder or urethra
55
Q

Problems resulting from idiopathic reflex dyssynergia

A
  • bladder may not empty completely
  • can result in an overstretched bladder
  • which can become atonic
56
Q

Tx of idiopathic reflex dyssyngeria

A
  • short term: tx any underlying cause, prevent over distention (tube cystotomy/catheter)
  • help restore normal detrusor contraction (parasympathomimetic agents)
  • may improve spontaneously or require meds long-term
57
Q

Most common presentation/signalment for idiopathic reflex dyssynergia

A
  • male dog
  • large breed

Y4 SA - urinary & endocrine disease (16 decks)

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