12.7.5: Urinary incontinence

Question 1

Micturition

Answer 1

filling the bladder + emptying

Question 2

What should be you first steps in an animal presenting with urinary incontinence?

Answer 2

• Neuro exam
• Urinalysis

Question 3

How can we subdivide incontinence to create an appropriate list of differentials?

Answer 3

• Neurogenic
• Non-neurogenic
• (Urinary retention -> overflow): can further split into neurogenic and non-neurogenic. Sometimes seen as not true incontinence.

Question 4

Differential diagnoses for neurogenic incontinence

Answer 4

• 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

Question 5

Differential diagnoses for non-neurogenic incontinence

Answer 5

• Urethral sphincter mechanism incompetence (USMI)
• 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

Question 6

Which nervous system dominates during filling of the bladder?

Answer 6

Question 7

Which nervous system dominates during emptying of the bladder?

Answer 7

Question 8

1-4

Answer 8

Question 9

5

Answer 9

Question 10

6

Answer 10

Question 11

7

Answer 11

Question 12

8

Answer 12

Question 13

1

Answer 13

Question 14

2

Answer 14

Question 15

3

Answer 15

Question 16

Potential causes of neurogenic incontinence

Answer 16

Question 17

Potential causes of non-neurogenic incontinence

Answer 17

Question 18

1 and 2

Answer 18

Question 19

3 and 4

Answer 19

Question 20

5 and 6

Answer 20

Question 21

What is an automatic bladder and how does it develop?

Answer 21

Automatic bladder: may develop over time when initial shock from injury has passed. This is when sympathetic and parasympathetic pathways enable the bladder emptying reflex when the threshold is reached; this is not under voluntary control.

Question 22

True/false: when managed the neurological patient, you should wait and try to avoid putting a urinary catheter in for as long as possible.

Answer 22

False.
* Bladder care is an important part of managing neuro patients
* Catheterisation post-surgery is common in most cases
* Animals with incontinence get sore very quickly; there can be scald in the vestibule and prepuce and then issues with overgrooming
* UTI is a risk but on the whole putting a catheter in is preferable. Regular (4x daily) expression will help prevent overflow/ over-distension and UTI

Question 23

Which bladder is it fine for owners to express at home?
a) LMN bladder
b) UMN bladder

Answer 23

a) LMN bladder (flaccid)
Should not empty UMN bladder.

Question 24

Common presentation of USMI

Answer 24

May present with peri-vulvar dermatitis (why would they only have a skin issue here? Suggests urinary)

Question 25

Aetiology of USMI

Answer 25

Question 26

If you have a puppy presenting with USMI, what might you investigate, and if this is not the cause, what could you do?

Answer 26

• Puppy with USMI -> check for ectopic ureters
• Could consider leaving for a couple of seasons, may settle down

Question 27

Overall plan for USMI patients

Answer 27

• Check healthy, no neuro problems
• Check for UTI (urinalysis and microscopy)
• Try medications aimed at improving urethral resistance (PPA is first line)

Question 28

Medical management of USMI
1

Answer 28

Question 29

Medical management of USMI
2

Answer 29

Question 30

Which is more common: medical or surgical management of USMI?

Answer 30

Medical treatment is more common

Question 31

Surgical management of USMI

Answer 31

Question 32

Congenital non-neurogenic causes of incontinence

Answer 32

• Intersex patients (rare) - different anatomy
• Ectopic ureters
• Destrusor instability (=urge incontinence; overactive bladder presenting as pollakiruia)

Question 33

Presentation, cause and treatment of ectopic ureters

Answer 33

• If bilateral ectopic ureters, signs will be very early in life as no control.
• Ureter normally enters the bladder at the trigone - anywhere else is ectopic

Question 34

Presentation and pathogenesis of detrusor instability

Answer 34

• Often seen in young excited male dogs - hard to differentiate from behavioural causes
• Overactive bladder presenting at pollakiruria
• Most animals have underlying cystitis, irritating the bladder lining and overstimulating the detrusor reflex

Question 35

Broad causes and management of urinary retention

Answer 35

Question 36

Causes of neurogenic urinary retention

Answer 36

Detrusor-urethral dyssergia: detrusor and urethra not coordinating.
Dysautonomia: very rare, may see ataxia, loss of proprioception as well.
Detrusor atony: usually secondary to over-stretching of bladder; if caught acutely, we can probably reverse them. This is why we put catheters in.

Question 37

Example cause and treatment of LMN bladder

Answer 37

Question 38

Causes and treatment of UMN bladder

Answer 38

Question 39

Idiopathic reflex dyssynergia (detrusor-urethral dyssynergia) : problems and treatment

Answer 39

Question 40

Non-neurogenic urinary retention : possible causes

Answer 40

Question 41

Broad treatment approaches to urinary disorders

Answer 41