Dogs and Cats 19 Flashcards
(101 cards)
1
Q
abnormal urination important history questions
A
- Any changes to drinking or eating habits
- Passing normal faeces
- Change to frequency or volume of urine
- Straining to toilet urine or faeces
- Urine a normal stream
- Is there an apparent pain
- Any difficulties in urinating
- Does the pet know when it is urinating
- Is there bed wetting -> think urinary incontinence
- Is there any dribbling of urine -> ectopic ureters
- Abnormal colour, blood, smell
- Urinating in abnormal places
- When was this first noticed
- Any changes since first noticed
2
Q
Abnormal urination what are the 3 main things and how should be able to distinguish
A
Thorough physical examination and history
After this should be able to distinguish underlying problem
- Incontinence
- Difficulty in urinating
- Behavioural
3
Q
Dog urinary incontinence what is it and causes
A
- Loss of voluntary control of micturition, usually observed as involuntary urine leakage Causes of incontinence - Neurologic - Storage dysfunction - Urethral disorders - Anatomic - Retention - Mix of all of the above
4
Q
Urethral sphincter mechanism incontinence signalment and risk factors
A
- May affect more than 20% of female dogs
- Middle age to older
- Medium to large breed
Risk factors - Neutering: does the age this is done change the outcome
- Conformational characteristics -> bladder neck position, urethral length, vaginal abnormalities
- Obesity
- Large to medium breed
- Early tail docking
5
Q
Urethral sphincter mechanism incontinence general history, physical exam findings
A
History
- Bed wetting
- Urine dribbling - generally more ectopic ureters not really this
- Normal drinking and urinating pattern
- Smell -> urinary incontinence or anal gland
- Excess licking vulval area
Clinical examination
- Usually unremarkable
- Can observe urine scalding, perineal and ventral dermatitis
- Smelly
6
Q
Urethral sphincter mechanism incontinence diagnosis
A
1) Urinalysis
○ Specifically checking USG and sediment
§ Could be PU/PD -> due to underlying cause
§ Sediment for UTI -> would expect other clinical signs
○ Collecting the urine
§ Soup ladel work well -> free catch is fine as not doing culture and sensitivity
2) imaging
3) surgery
7
Q
Urethral sphincter mechanism incontinence treatment an combinations
A
- As the aetiology is believed to be multifactorial often treatment involves combination of drugs and or surgery
- Normal starting point is to discuss medical options and let the owners decide
- Drugs
○ Most commonly used are oestrogens and sympathomimetic/alpha adrenergic receptor agonists
1. strillbestrol
2. incurin
3. propalin (phenylpropanolamine) - PERFERRED
2) Other drugs
§ Alpha-adrenergic agonist - Sudafed (pseudoephedrine) not so easy to obtain now
§ GnrH agonists and antihistamines - Can be worse in the summer -> some only need to medicate in summer
8
Q
What drugs used for Urethral sphincter mechanism incontinence, price, how effective and side effects, which is preferred
A
1) Strilbestrol (Diethylstilbestrol) 1mg tablets
□ Cheap - approx. 30c per tablet
□ Effective in 60-70% of dogs
□ Rare side effect is irreversible bone marrow suppression
2) Incurin (oestriol) 1mg tables
□ Mild price range - approx $1.80 per tablet -> $50 a month
□ Response rates to 82% have been reported
□ At higher dose end, swollen mammary glands and vulva have been noted, plus attractiveness to male dogs
3) Propalin (phenylpropanolamine HCL) - sympathomimetic
□ Liquid - more expensive, a 100ml bottle is approx $100, which lasts a 25kg dog around 6 weeks
□ Response rate of 90% have been reported
□ Can be associated with restlessness and hypertension
□ PREFERRED MEDICATION
9
Q
Cats inappropriate urination what need to do first, presentation and 2 things need to establish
A
- The most common urinary problem is inappropriate urination
- The first step is to work out is it urination or spraying?
○ Both socially unacceptable
Presentation - Often urinate in different locations
- Notice blood within the urine
Two things to establish
1. Is the cat well in itself and still passing urine -> if urethral plus is suspected this is an emergency
2. Work out the underlying cause
10
Q
What are the 5 main causes of inappropriate urination in cats
A
- Idiopathic -> most common cause
○ Urinalysis is unremarkable expect for blood - Crystalluria -> in Australia mostly struvite crystals
- Infectious -> cystitis - not that common
- Neoplastic - older cats
- Behavioural - stress induced
11
Q
What are the 4 main things need to do in a case of cat inappropriate urination and what not do
A
1) Pain relief -> the cats are sore
○ One off injection of meloxicam 0.3mg/kg/sc
- Antibiotics NOT INDICATED
2) Collect urine -> ideally via cystocentesis but often have no urine in their bladder
○ Hospitalise to collect - not always best, or if owners feel that can get urine at home this is a better option
○ Collecting at home
§ Clean dry litter tray with non-absorbent material - polystyrene or a commercial production
§ Once collected must be analysed ASAP
§ Free following urine - not urine absorbed in the litter
3) Urinalysis
○ Result will dictate treatment
○ Further investigation may be required, that treatment can be lifelong and warm signs of a blocked cat as this is an emergency
4) In all cases it is important to encourage drinking - so wet food, water fountains
12
Q
for kidneys what need to assess in radiograph or ultrasound
A
- Size (dog kidney: aorta ratio, cat 3.0-4.3cm), shape, margination, echogenicity, echotexture, corticomedullary definition, presence of mineralisation
13
Q
Renal pelvis dilation when normal, what are some causes and when indication of obstruction in radiograph
A
- Renal pelvic dilation is seen in clinically normal dogs and cats
- Overlap between normal, diuresis, pyelonephritis, renal insufficiency, obstruction
- Pelvic width >13mm always indicated obstruction
○ Always important to look at in conjugation with blood, history and urinalysis
○ Should follow uretra -> if dilated can follow with ultrasound - NOT NORMAL
14
Q
renal degeneration how assess on radiograph
A
- Assess corticomedullary definition
○ Decreased
○ Margins often irregular - Can result in renal mineralisation
15
Q
Differentials for changes in renal echogenicity during ultrasound and differentiating
A
- Nothing is specific BUT DOESN’T MATTER FOR THE MANAGEMENT OF THE PATIENT unless ruling in or out neoplasia
○ Only way to find is the fine needle aspirate and biopsy - risk of haemorrhage and as above doesn’t change management - DON’T WORRY ABOUT - Kidney can appear normal sonographically even if diseased
- DIFFERENTIALS
○ Increase cortical echogenicity +/- loss of CM definition
○ Glomerular or interstitial nephritis
○ Acute tubular necrosis
○ Pyelonephritis
○ Leptospirosis
○ End stage renal disease
○ fat cats - especially male -> if everything else is normal put it down to this
16
Q
assessing ureters using diagnostic imaging what use and how useful
A
- Excretory urograms on the left -able to see where ureters attach to bladder
- These days if possible do CT -> easier to see where the go within
- Ultrasound -> will see when dilated, also will be able to see waves of peristalsis if trying to work against an obstruction
17
Q
what urinary calculi what important to assess in radiographs
A
- Need to include the caudal urethra within abdominal radiograph - can have a urinary calculi within - common place is at the os penis
18
Q
for bladder on ultrasound what is important to assess and common findings
A
- For bladder assess
○ Degree of distention, wall thickness, urine echogenicity, presence of mineralisation - calculi, cystitis, neoplasia especially around neck of bladder (urothelial or transition cell carcinoma)
19
Q
What occurs with caculi in the bladder with patient positioning and therefore how diagnose
A
Dorsal recumbency - dorsal wall
left lateral recumbency - calculus on left
right lateral recumbency - on the right
CALCULUS HAS MOVED WITH THE POISONING -> how to confirm it is a movable thing (blot clot of calculi) within not a mass
○ Sometimes blood clot is not moveable
20
Q
excretory urography what need to do for preparation and technique
A
- ENEMA
- GA
- Catheter
- Survey rads
- Iodine 880mg/kg - need large bolus of contrast
- Rapid injection
- Take rads
21
Q
what is the main excretory urography technique used to look at the bladder and other for urethra
A
Vaginourethrocystogram -> Use foley catheter - able to see bladder, vagina and urethra
urethra - urethrogram
22
Q
what are some common findings seen when ultrasounding the prostate
A
1) benign prostate hypertrophy
2) protstatic cysts
3) prostatic mineralisation
23
Q
define dysuria, stranguira, haematuria, cystitis, pollakiruia, urinary incontinence and urolith
A
- Dysuria – difficulty and pain passing urine
- Stranguria – straining to pass urine
- Haematuria – blood in the urine
- Cystitis – inflammation of the urinary bladder
- Pollakiuria – increased frequency of urination
- Urinary incontinence – inability to control urination
- Urolith = stone
24
Q
What is FLUTD, what also known as, how common and what is NOT a cause
A
- Feline lower urinary tract disease
- Group of disease of feline urinary bladder and urethra
- Also known as: Feline urologic syndrome (FUS), Feline idiopathic cystitis (FIC)
- Accounts for 5-10% of feline consultations
FLUTD is not a diagnosis, but a syndrome
What is not a cause - Urinary crystals
○ Common incidental finding
25
What is hte main cause of FLUTH and other causes (how common and more common in males or females)
- Idiopathic FLUTD (unknown) - most common
Other 33-50% of cases
- Bladder stones (uroliths) -> 15-23% of cases, females > males
- Urethral blockage (obstruction) -> 20% of cases, males > females
- Bacterial Urinary tract infection -> 1-5% of cases, rare, unless cats >10 years
- Congenital or acquired urinary abnormalities -> Urethral scar (stricutre) at previous urethral stone
- Urinary tract trauma -> 1-2% of cases
- Urinary cancer (neoplasia) -> 1-2% of cases
- Nerve / spinal disorders (neurological)
26
Idiopathic FLUTD (iFLUTD) how many cases, when age rare in and likely causes
```
- Most common cause
○ 55-64% of cases
- = Feline idiopathic cystitis
- Rare in cats > 10 years of age
- Multiple factors likely responsible
Causes of iFLUTD
- Viral / bacterial infections
- Autoimmune
- Leaky internal bladder lining
○ Increased permeability -> exposure of bladder wall to urinary toxins -> pain & inflammation
- Urinary toxins
- Stress
- Mast cell mediated inflammation
```
27
What are the main risk factors for FLUTD
- Obesity - not using litter tray as much
- Indoor confinement - no going outside to void
- Sedentary lifestyle
- High number of rainy days
- Diet changes - increase stress
- Major public holidays - change to cat routine - stress
- Changes to home population / routine / moving
- Litter tray changes - change in number, not enough
- Inadequate litter trays
- Stress, nervous, fearful, aggressive behaviour
- Multi-cat households
- Historical gastrointestinal disease
- Dry food diets
- Frequent / ad lib feeding
28
what are some common presentations for FLUDT
- Haematuria
- Stranguria
- Pollakiuria
- Inappropriate urination (periuria)
- Dysuria
- Unable to urinate
- Licking at penis / vulva
- Crying
- Painful
- Hiding
- Anorexia
- Depression
- Reduced interaction
Regardless of causes, cats with FLUTD will manifest with similar signs!
29
What is the typical signalment and history of a non obstructed FLUTD
○ Young to middle aged
○ Any breed, Persians may be at increased risk
○ Male or female
○ Typically 2 - 6 years of age
§ Rare in cats < 1 year and > 10 years
○ Acute onset, short duration (3-7 days) of LUT signs - self resolve
○ Usually otherwise well
○ Repeat episodes at unpredictable intervals
§ Generally less frequent and severe with age
30
what is the typical signalment and history for obstructed FLUTD
○ Usually male - longer and more narrow
○ Life threatening emergency
○ Distended painful bladder - unless ruptured
○ Unable to urinate
○ Progress to weakness, vomiting, low heart rates (bradycardia) - hyperkalaemic
○ Coma and death within 2-4 days
31
What are the 7 main things to do in the work-up for a FLUTD case and why
- Why do we do this? -> CAUSES ARE DIFFERENT AND TREATMENT AND MANAGEMENT IS DIFFERENT
1. History
○ Previous episodes, treatment, response, risk factors
2. Physical examination
3. Urinalysis
○ Urine specific gravity, dipstick, and urine sediment
§ Typically in FLUTD well concentrated, red cells (haematuria), acidic - idiopathic
4. Survey Abdominal imaging
○ Radiographs
○ abdominal ultrasound
5. +/- Urine culture
○ Cats over 10 years or those with white cells (pyuria) or bacteria (bacteriuria)
○ Via cystocentesis for aerobic culture
6. Laboratory testing - if systemically unwell
○ Haematology and biochemistry
○ Coagulation testing - if believe there is bleeding
7. Contrast radiology - rarely done now
32
with diagnostic imaging to diagnose FLUTD what are the 2 main modalities used and why
```
1) Radiographs
§ Need to take the entire peritoneal space - INCLUDE THE MALE URETHRA
§ To check for uroliths/plugs
□
§ Be sure to include entire perineum
§ Only radiopaque uroliths visible
2) Abdominal ultrasound
§ Useful, non-invasive
§ Evaluate kidney and bladder
□ Kidney
§ Check for
□ Uroliths – radiolucent and radiopaque
□ Mass lesions
□ Bright (echogenic) urine sediment
□ Bladder wall changes - thickness and irregular
§ Best when bladder distended
§ Can’t evaluate entire urethra
§ Don’t usually see ureters
```
33
in terms of diagnosing FLUTD how use contrast radiography, what find
```
○ Contrast cystourethrography
§ Radiolucent uroliths
§ Uroliths < 3 mm - cannot see on radiographs normally
§ Anatomical abnormalities
§ Neoplasia
§ Bladder wall thickenings
§ Mucosal irregularities
§ Anatomical irregularities
□ Vesicoureteral reflux - urine flow retrograde into kidneys
□ Vesicourachal diverticulum
1) Positive contrast urethrocystogram
2) double contrast cystogram - filling defects
```
34
In a generally well cat with FLUTD how diagnose and 2 main definitive treatments
Therefore if generally well cat
- History, Urinalysis and imaging to ensure no rupture or blockage -> IDIOPATHIC -> go to non-specific treatment
Treatment
1. Biopsy - Cystoscopy - only in females!
○ Visualisation of inflammation and damage
○ Remove of the uroliths or break them down
○ Histopathology
§ Ulceration, oedema, dilated blood vessels, haemorrhage, mast cell infiltration
○ Bacterial culture
2. Surgery
○ Usually not required
§ Not specific
§ Degree of changes not related to clinical severity
35
what doesn't work for treating non obstructed FLUTD
○ Prednisolone
○ Chloramphenicol
○ Propantheline
○ SC fluids
○ Intravesicular (into bladder lumen) lidocaine
○ Short term amitriptyline
○ Pentosan polysulfate sodium (Cartrophen)*
36
What are the 8 things can do in the treatment of non obstructed FLUTD and what not give
1) pain releif
2) relaxants - in MORE SEVERE CASES
3) sedation if anxious
4) anti-anxiety medication - thinking behavioural
5) good hydration - IMPORTANT - keep bladder distended to reduce pain, dilute urine to reduce risk of obstruction
6) diet - C/D
Antibiotics - contraindication UNLESS proven infection
37
In terms of pain relief for FLUTD what use for how long and what need to ensure
○ 3-5 days
○ Prevent increased intensity of pain perception
○ No EMB trials!
○ Opioids
§ Urethral relaxation
§ Buprenorphine, tramdol, fentanyl patches
○ NSAIDs
§ E.g. Metacam (Meloxicam)
§ Must be hydrated / eating / normal kidney function
§ Reduce inflammation
38
what relaxants to use in FLUDT and when use
```
IN MORE SEVERE CASES or recurrence
○ Urethral smooth muscle relaxants
§ Phenoxybenzamine
○ Urethral skeletal muscle relaxants
§ Dantrium / prazosin
§ Care with IV diazapam (hepatoxic)
```
39
Anti-anxiety medication what is the main one to use with FLUDT and which other can use, when use and results in
○ Amitriptyline
§ For chronic forms of FLUTD (not acute setting)
□ Consider if > 1 episode
□ Several weeks for effect
§ Anti-depressant
□ Also pain relief, reduce spasm and inflammation
§ SID PO before bed
§ Adverse effects
§ Required monitoring
§ Reduces signs in ~ 60% of cats
○ Analog of feline facial pheromone - feliway
§ Increased grooming and intake in hospitalised cats
§ Trend* towards fewer days of cystitis, less episodes and reduced negative behaviors
40
Diet therapy in FLUDT treatment what use, what does it do
proven to reduce severity and frequency
○ Increased Omega 3 fatty acid
§ Reduce inflammation
○ High plant based proteins -> Increased urine pH
○ Further increased if high Mg and P diet
§ -> Struvite crystals, plugs, uroliths
○ Diets reformulated in 80’s -> Less plant proteins, Mg, P -> acidic urine -> Less obstructed FLUTD
§ No therapeutic advantage of such diets in cats with non-obstructed FLUTD in the acute setting
§ “Might” reduce the risk of a potential urethral obstruction
□ Vs. Cost, stress, diet change, oxalate stones (not for young, CRD)
○ Salt supplementation - generally not needed to do
§ Increase water intake -> urine output & Ca output in healthy cats
41
What is the prognosis for FLUDT non-obstructed and obstructed and what is important
- Generally good (frustrating) for iFLUTD
○ Self-limiting, short duration < 1 week
○ Recurrence possible (euthanasia)
§ 45% relapse within 6 months
§ 70% will have another episode within 1 year
§ Can’t predict which cats will relapse
§ Male cats at risk of urethral obstruction (death, euthanasia)
- Good to fair/poor with obstructed FLUTD
○ 40-55% cats relapse within 12 months (death, euthanasia)
§ 21% (of 45 cats) euthanized within 1 year due to recurrence
- IMPORTANT TO GO LOOKING FOR UNDERLYING CAUSES
42
preventing FLUDT what is the main aim and the 2 main ways to do this
```
- Aim: Reduce frequency / severity
○ Can’t eliminate the risk
○ Generally limited EBM of benefit in this area
1) Diet : Hill’s c/d (90% reduction)
2) reduce stress
```
43
Using diets to prevent FLUDT what does it do, how and which can work on
○ If uroliths or plugs
§ Control urine pH (6.2-6.4 target for prevention)
§ Minimize the building blocks of stones / plugs in urine
§ Increase water intake
□ If struvite – want reduced Mg, P
® urine pH 5.9-6.1 for dissolution
□ If calcium oxalate – want reduced Ca, oxalates
® Can’t dissolve once formed
44
Reducing stress to prevent FLUDT how can be done
○ Consistent home environment
§ People, pets (no conflict), freedom to move
○ Consistent diet (slow changes with choice)
§ Type, frequency, timing
§ Weight loss
§ Water – tin foods, encouraging water intake
○ Consistent litter tray
§ Number (1 for every cat and 1 spare, 1 on each floor of the house), type (unscented clumping), location, cleanliness
○ Hiding, resting, viewing places, audio / video stimulation
○ Owner interaction, playing , toys (rotate)
45
Benign prostatic hyperplasia how common, due to and signs
- Most common prostate disease in dogs
○ Nearly all entire male dogs over age of 4
- Due to androgen: oestrogen imbalance
Signs:
- Often asymptomatic
- Tenesmus, constipation, HL weakness, thin stools, haemospermia, infertility, ↓ libido, haematuria, haemospermia, urethral bleeding
- Possible concurrent perineal hernia, prostatic neoplasia, UTI, prostatitis
» Consider urine / prostate C+S
46
Benign prostatic hyperplasia diagnosis what are the 3 most useful and definitive
- Typical Signalment
- Rectal: Uniform prostate enlargement
- Response to treatment
MOST USEFUL above
- Radiographs: prostatomegaly
- Ultrasound:
○ Prostatomegaly, homogenous parenchyma, possible hyperechoic, cysts
- Cytology: FNA, prostate wash, semen evaluation - hyperplasia of semen
- Definitive Dx : Biopsy (rarely required)
47
Beign prostatic hyperplasia treatment and prognosis
- Only if signs present
- Castration Rx of choice
- Medical therapy - anti-testosterone to reduce prostatic size and no side effects on fertility - GOOD BECAUSE ONLY USING IN BREEDING ANIMALS
○ Delmadione acetate (SC monthly), Finasteride (SID PO)
○ GnRH analogues
○ Rx constipation
○ Ensure monitor resolution prostate size & clinical signs
- Good to excellent prognosis
48
Urinary tract infection uncomplicated what common in, common pathogen, history, physical exam, diagnoses and treatment
- Common in older female dogs, uncommon in cats
- Bacterial >> fungal
- History: LUT signs, incontinence, inappropriate urination, foul smelling urine
- Physical exam: bladder pain, thickened bladder
- Dx: Cystocentesis C+S (pyuria, bacteruria, haematuria, proteinuria)
- Rx: Based on C+S
○ Empirical first choice: Penicillin / beta lactam,TMS, Rx 7 days, C+S 1 week post antibiotics
- Refractory / relapsing cases: investigate further
49
Complicated urinary tract infections some causes of recurrence
- Resistant organism, mixed infection
- Wrong drug / dose / duration / absorption / compliance
- Immune deficiencies (e.g. DM, HAC, drugs)
- Urinary incontinence, obstruction, incomplete voiding, congenital or acquired abnormalities, catheters
- Uroliths, prostatitis, pyelonephritis, neoplasia, CKD, PU/PD
- Glucosuria, high urine pH
50
Complicated urinary tract infections what to do to investigate further and treatment
- Investigate further
○ Rectal examination - looking for masses, strictures
○ Full urinalysis and culture
○ CBC and biochemistry - specific testing for metabolic disease
○ Imaging - ultrasound, cystoscopy, contrast
○ May need surgery -> biopsy of bladder
○ Anything predisposed????
§ Glucose - diabetes
§ Infection hiding in area cannot reach
- Treat cause, longer antibiotics (4 weeks), follow up C+S, monitor (5-7 days within to ensure negative then a week after treatment, 30 and 50 days after to ensure still negative)
51
Prostatitis how common, main pathogens and clinical signs
- Rare in cats more common in dogs
- Most bacterial – E.coli, Staph, Strep
- Clinical signs
○ Physical: Large, painful, irregular prostate
○ Radiographs: mineralisation
○ Ultrasound: hyperechoic, hypo/anechoic abscess
52
Prostatitis diagnosis and treatment
- Dx: Imaging, positive cultures (prostate, urine)
- Treatment: Supportive, IV then PO antibiotics on C+S, +/- drain, castration (chemical or surgically)
○ Fluroquniolone, trimethylsulfur are good empiric antibiotics until get culture results - need to penetrate prostate
○ Treat like complicated urinary tract infection
53
Pyelonephritis causes, physical examination, blood and urine results
- Acute, chronic, bilateral, unilateral
- +/- concurrent urinary disease
- ascending LUT or Haematogenous
- PE: Pu/Pd, fever, lethargy, depression, abdominal / lumbar pain, ARF / CKD, (normal)
- Bloods: +/- Leukocytosis, +/- renal dysfunction
- Urine: RBC, WBC, Casts, Protein, bacteria
54
Pyelonephritis imaging results, diagnosis and treatment
- Imaging: Dilated renal pelvis / ureters - ultrasound
- Dx: Pyelocentesis C+S from renal pelvis (or from bladder)
- Rx: On C+S as complicated UTI
Fluroquniolone or amoxiclav while waiting for C+S - NEEDS TO PENETRATE
55
Subclinical bacteruria when detect, how common (Causes), is it associated with negative outcomes and treatment
- Positive urine culture with NO clinical urinary disease
○ Eg. Most Enterococcus sp. (Some E.coli).
- Common
○ Dogs: HAC, DM, obesity, immunosuppression, spinal cord disease. 9% healthy dogs
○ Cats: CKD, hyperthyroidism, DM. 13% cats.
- Not associated with long term negative outcomes
○ Like CKD, future UTIs, reduced survival or pyelonephritis
- No treatment required
○ Risk of selecting for antibiotics resistance bacteria population that if become an issue will be harder to treat later, zoonotic
- But monitor and educate client
56
Differentials for lower urinary tract disease signs what are the 6 main ones
1) chronic kidney disease
2) urethral sphincter mechanism incompetence
3) pyelonephritis
4) prostatitis
5) urinary tract infection - complicated/uncomplicated
6) FLUTD - cats
57
Haematuria what is it, how common, where originate and what is important to ask
- Abnormal increased RBC in urine
- Common
- With LUT signs : LUT origin
- Without LUT signs : Upper urinary tract
- Total or terminal (end of the urinary tract)
- Associated with urination?
58
Approach to haematuria what need to do
- History: Urinary & Systemic signs
- Physical : Abdominal palpation, genitalia, rectal
- Dysuria + haematuria : LUT / genital
- Localisation -> DDx -> Diagnostic and Rx Plan
59
What are the 3 most common causes of haematuria
1) bladder neoplasia
2) prostatic neoplasia
3) renal haematuria - rare - renal neoplasia
60
Bladder neoplasia how common, main risks, malignant vs benign, signs
- Most common site (dog), but overall rare
- Risks: Increasing age, female (male cats), breed (terriers and beagles)
- Malignant > Benign
○ Transitional cell carcinoma most common - generally in trigone area of the bladder
§ Local invasive, generally already metastasis to lung liver and spleen
- LUT signs
○ Recurring signs -> think possible neoplasia
61
Bladder neoplasia diagnosis, treatment and prognosis
Diagnosis
- Cystoscopy & biopsy - GOLD STANDARD
- Traumatic catheterisation, biopsy (FNA) - Commonly cause tumour cell seeding
- Staging - has it spread to liver, lung or spleen
Treatment
- (Surgery)
- Urinary stents - help the urinary obstruction NOT CANCER
- Piroxicam - anti-neoplastic
- Chemotherapy (mitoxantrone)
Poor prognosis
62
Prostatic neplasia which is most common, malignant vs benign, signalment and clinical signs
- Adenocarcinoma
- Highly metastatic > benign
○ Spread to back (lumbar lytic lesions) and other areas
- Primary > Secondary
- Old, medium to large breed dogs (rare cats)
- Being entire is NOT a risk factor
- Clinical signs (ensure rectal exam)
○ Constipation, haematuria, sore back
63
Prostatic neoplasia imaging, biochem, diagnosis, treatment and prognosis
- Imaging : Ultrasound, radiographs
○ Generally large prostate -> looks like prostatitis, can occur at the same time
- 50% increased ALKP
- Diagnosis: Cytology (FNA, wash), Biopsy
Treatment
- Palliative: Analgesia, Piroxicam, Chemotherapy, Radiation
- Surgical incision - NOT RECOMMENDED
- Poor prognosis
64
Paraprostatic cyst what is it, presentation, concurrent issues, radiograph, treatment and monitoring
- Cyst attached to prostate - DON'T CAUSE HAEMATURIA
- Single / Multiple
- Developmental / enlarged prostate
- Asymptomatic / Large caudal abdominal mass
- +/- UTI, prostatitis, peritonitis (rare)
- Radiographs: Two bladders??!! (contrast)
- Rx: Excision, drainage, castration
- Monitor for reoccurrence
65
renal haematuria how common, how to know it is from kidney and differentials
RARE
- Haematuria (often anaemia) & no LUT signs
- DDx :
○ Renal neoplasia, trauma, infarction, vascular abnormalities, hypertension, coagulopathy, idiopathic
66
Renal neoplasia primary or secondary, malignant vs benign, behavior, most common in cat and old and young dog and prognosis
- Primary - less common
- Secondary - more common - in this case generally metastasis so bilateral
- Malignant > Benign
- Wide variety in behaviour - generally invasive early and some metastatic
- Cats : Lymphoma
- Dogs : Adenocarcinoma / carcinoma - POOR PROGNOSIS
- Young dogs : Nephroblastoma - GOOD PROGNOSIS if surgical removal, even though can get quite large
67
Renal neoplasia physical exam findings and workup
Physical examination
- Usually vague
- Palpable renal mass
- Haematuria : Intermittent / ongoing
- Hind limb oedema
- +/- CKD - chronic kidney disease - especially if bilateral
- +/- UTI
Workup
- CBC usually normal (+/- anaemia, ↑PCV)
- Biochemistry +/- ↑[Ca], CKD - to determine kidney function
- Proteinuria, haematuria, (rare neoplastic cells)
- Imaging (radiographs, IVU, MRI, CT)
- Ultrasound, extent -> FNA / biopsy for diagnosis
- Scintigraphy for renal function - ESSENTIAL IF REMOVAL
68
renal neoplasia treatment
```
- Ureteronephrectomy
○ Unilateral without metastasis
- Lymphoma – chemotherapy
- Carcinoma 6-12 months - palliative therapy
- Nephroblastoma – often cured
```
69
Approach to urinary incontinence what are the 8 possible steps
1. History - age onset, neutered or entered, history of previous surgy, trauma, ongoing or intermittent, are they aware they are trying to urinate
2. Complete physical exam & neurological exam
○ Attention to urogenital system
○ Rectal
○ Vaginal - strictures and masses
○ Prostate
○ Palpation of bladder before and after expression
3. Urinary catheterisation - help to determine where the obstruction is
4. Urinalysis and culture via cystocentesis
5. Haematology and biochemistry - only if systemically unwell - obstruction and hyperkalaemia?
6. Imaging
7. Urodynamic studies (cystometrogram, urethral pressure profile)
8. Electromyography
70
In terms of urinary incontinence what are the 2 most important questions to ask
1) small or large bladder
2) easy or hard to catheterise
1. large bladder - easy to catheterise
2. large bladder - difficult to catheterise
3. small bladder
71
Large bladder that is easy to catheterise what are the 2 main causes and causes within with the features
1) large bladder - easy to catheterise
1. neurological
- LMN - easy to express
- UMN - hard to express
- detrusor urtethral dyssynergia
- dysautonomia - autonomic nervous disease dysfunction
2. non-neurological
- geriatric
- iatrogenic
- PU.PD
2) large bladder - difficult to catheterise
3) small bladder
- USMI - urethral sphincter mechanism incontinence
- detrusor hyperreflexia/instability
- congenital abnormalities (females > males)
72
LMN neurological issue with large bladder presentation, why, and causes
○ LMN -> easy to express - constantly dribbling urine
§ Often history of pelvic of spinal trauma
§ Gets full but doesn't do much - large overdistended bladder
§ Often reduced tone and sensation around anus on neurological exam
§ Causes - intervertebral disc disease, cauda equina syndrome, sacrococcygeal fractures, tumours
73
UMN neurological issue with large bladder presentation, why and cause
hard to express
§ Loss voluntary control of the bladder - urethral tone is still intact
§ Small periods of urine dripping through as overcome urethral resistance for a short period
§ Loss of conscious proprioception, hyperflexive
§ Causes -> spinal issues about C3, trauma, tumours, secondary infections
74
Detrusor urethral dyssynergia causing large bladder incontinence how common, what occus, bred, presentation and diagnosis
- rare
§ Poor coordination between bladder contracting and urethra relaxing
§ Usually large breed male dogs
§ Generally start to urinate properly and then drips but dog still straining
Hard to prove, history and response to treatment to diagnose
75
Non-neurological causes of a large bladder - 3 main ones
```
○ Geriatric - forebrain tumours
§ Generally other neurological defects
○ Iatrogenic
§ Overdoing IV fluids, putting on frusemide
○ Pu/Pd
```
76
What causes a large bladder that is difficult to catheterise
○ Outflow tract obstruction (paradoxical incontinence)
| ○ DDx: Calculi, plugs, inflammation, urethral spasm, prostatic disease, neoplasia
77
what are the 3 main causes of a small bladder and causes within
1) USMI - urethral sphincter mechanism incontinence
2) Detrusor hyperreflexia / instability (urge) - often with haematuria
§ COMMON: Cystitis: Infectious dog (bacteria and female), sterile cats (FLUTD)
§ Urethral / bladder neoplasia, polyps, idiopathic primary instability
3) Congenital abnormalities (females > males)
§ Ectopic ureters
§ Vaginal strictures
§ Pelvic bladder - more than 5% of urinary bladder within urinary pelvis
□ Pressure within the pelvis is lower than that in the abdomen - tend to over void
□ Can feel trigone area per rectally which shouldn't normally do
§ Pseudohermaphroditism
78
Ectopic ureters what occurs and causes
- No going into bladder - possible into the urethra
- Common congenital abnormality
○ Unilateral > bilateral
○ Intramural or extraluminal
○ Females > males
- Usually seen with other congenital abnormalities +/- infections (recurrent infections)
○ Important that explain to owners - evaluate and treat as many as possible
- Lifelong ongoing/ intermittent urinary incontinence at young age < 5 years
79
Ectopic ureter diagnosis and treatment
```
Diagnosis
- Advanced imaging
- Cystoscopy: gold standard
- CT
- Contrast radiology
- CBC, biochemistry, urinalysis & C+S
Treatment
- Cystoscopic-guided laser ablation
○ Intramural
- Surgery
○ Intramural: Neoureterostomy
○ Extramural: Ureteroneocystostomy
○ (Unilateral nephrectomy)
- Treat secondary infections
- +/- Adjunctive medical management (e.g. USMI)
```
80
What is a normal water intake for dog and cat and when abnormal in dog and cat
- Water intake = water drunk + water in food
- Common guide for normal water intake in dogs and cats: 40-60 ml/kg/d
- Guideline for abnormal water drunk
○ Dogs: >90-100 ml/kg/d
○ Cats: water drunk depends much on water content of food; abnormal:
§ > 10 ml/kg/d if eating moist food
§ >50-60 ml/kg/d if eating dry food
81
Normal water homeostasis
1) water deficit
- intracellular - hypertonicity increase -> osmoreceptors
- extracellular (hypovolaemia) - baroreceptors
2) thirst, ADH release
82
What are the 4 main mechanisms of PU/PD
1. Water diuresis
2. Solute diuresis
3. Abnormal renal concentration gradient
4. Other, unidentified cause
83
Water diuresis leading to PU what occurs and causes
- ADH production, secretion or action abnormal= Diabetes insipidus (DI)
○ Secondary DI more common than primary DI
- Examples of secondary DI
○ Hyperadrenocorticism
§ Glucocorticoids interfere with ADH secretion and also ADH action at the kidneys
○ Hypercalcaemia
§ Interference with ADH action at the kidneys
84
Solute diuresis leading to PU what occurs and common causes
- Solutes act as osmoles, when excreted they ‘draw’ water with them
- Common examples of solute diuresis
○ Diabetes mellitus
§ Glucose excreted draws water
○ Renal failure
§ Proximal tubules are not functioning, hence sodium and glucose are lost, water follows
§ May also have water diuresis -> ADH doesn't work in advanced renal failure
85
Abnormal renal medullary concentration gradient what occurs and common cause
- Renal medulla is hypertonic compared to tubular fluid due to high concentration of urea, sodium and chloride
○ Created osmotic force draws water from tubular fluid (urine)
- Loss of concentration gradient = inability to concentrate urine
- Common example
○ Portosystemic shunt
§ Urea production by liver inadequate –cannot contribute to RMCG
86
renal medullary wash out leading to PU what occurs and examples of when this may occur
- Chronic PUPD (by another cause) results in loss (wash out) of osmoles from the renal medulla
○ Subsequent abnormal RMCG contributes to continuation of PU
- Example when this may occur
○ Chronic primary polydipsia
○ Cannot acutely develop -> just chronic
87
PU secondary to drugs what are some causes and therefore what need to do before diagnosis
- Examples
○ Glucocorticoids inhibit secretion and action of ADH -> prednisolone
○ Barbiturates interfere with the action of ADH
○ Mannitol is an osmotic diuretic
- Need to wean them out before do any diagnostic testing
88
What are the 6 steps in the investigation of PU/PD
1. Confirm PUPD described by owner - water monitoring or USG (morning urine)
- Water monitoring -> examination of urine
2. History and physical examination
3. Urinalysis/USG (if not done before)
4. Haemogram, serum biochemistry, urine culture
5. Abdominal imaging
6. Specific additional tests (eg hormone stimulation/suppression tests, modified water deprivation test)
89
What is the first step in clinical approach to PU/PD
1. Confirm PUPD described by owner - water monitoring or USG (morning urine)
- Water monitoring
○ Use knowledge of water intake to assess if patient is drinking normal amount or not
○ Over 24 hours: Water given to pet –water left in bowl = water drunk
○ Ideally done by owner at home, but can be done in hospital (may not be as accurately)
○ More difficult if and therefore may need to be done in the hospital
§ Pet has access to multiple water sources
§ Multiple pets present
90
Examination of the urine what is step 1 and 2 and what think with certain results
```
○ Check for presence of osmoles
§ Examples: Glucose and Mannitol
○ If present, they may explain PU
§ Glucosuria:
□ DM (diabetes mellitus) (common);
□ renal tubular disease (less common);
□ iatrogenic (glucose infusion)
○ Why as step 1?
§ Osmoles ‘falsely elevate’ USG
□ Affect on refractory index
Step 2 - check USG
```
91
CASE - Snuggles
- 3 yo FN Australian Shepherd.
- The owner describes that she is drinking and peeing more than usual.
- They have noticed her squatting often.
- Physical examination shows a small vulva
- USG is 1.026
- UA shows 2+ WBC and 1+ RBC
Questions - is UP/PD mild or severe, what are most likely cause, which test are most appropriate as next step
1. Is PUPD mild or severe? Mild
2. What are most likely causes? Urinary tract infection, uroliths
3. Which test(s) are most appropriate as next step? Radiograph for uroliths, urinary culture if negative
92
CASE - Snoopy
- 4 YO F German Shepherd
- Is drinking and urinating copious amounts
- Has lost weight and is lethargic
- USG is 1.030
- UA shows 4+ Glucose, 2+ protein
Question - what is likely diagnosis, other disease need to be ruled out
1. What is a likely diagnosis? - renal insufficiency
| 2. What other diseases need to be ruled out? Diabetes mellitus, Cushing, pyometra, acidosis
93
```
CASE - Ignacio
- 8 YO MN Cane Corso
- Drinks copious amounts
- Has lost large amount of weight
- Has no appetite
- Has large peripheral lymph nodes
- USG is 1.006
- UA is unremarkable
Question - what is possible cause of PUPD, what other tests would you perform next
```
1. What is a possible cause of PUPD? Neoplasia, lymphoma
- Lymphoma -> hypercalcaemia
2. What other tests would you perform next? Haematology, biochemistry - for other disease and need for treatment, also FNA lymph nodes
94
```
CASE - Max
- 6 YO MN Yorkshire Terrier
- Drinking a bit more than normal
- Eating well
- Fur a bit thin, although owner hasn’t noticed copious hair loss
- USG is 1.012
- UA shows few epithelial cells
Question - 2 main differentials
```
hyperadrenocorticism and diabetes mellitus
95
What are the most common causes of PUPD in dogs
- Renal disease
- Diabetes mellitus
- Hyperadrenocorticism
- Hypercalcaemia
- Pyelonephritis
- Pyometra
96
What are the 3 main causes of PUPD in cats
- Renal disease
- Diabetes mellitus
- Hyperthyroidism
97
Chronic renal disease besides PUPD what are other clinical signs
```
- Other possible clinical signs:
○ Dehydration
○ Poor appetite and weight loss
○ Pallor
○ Vomiting
○ Halitosis, mouth ulcers
○ Large or small kidneys
○ Painful kidneys
```
98
Urogenital infection what besides PUPD are some other clinical signs
○ Inappropriate urination
○ Haematuria
○ Stranguria
○ Painful, small bladder and/or kidneys
○ In entire females: previous heat, lethargy, inappetence and fever (pyometra)
§ Pyometra -> effect of E.coli on kidney and possible urinary tract infection
99
Diabetes mellitus what age, risk factor and main clinical signs
- Middle-aged to older animals
- Risk factor -> Obesity (especially in cats)
- Other possible clinical signs
○ Increased appetite
○ Weight loss
○ Cataracts (in dogs)
100
Hyperadrenocorticism in dogs signalment and main clinical signs
- Dogs are >6 years
- Other clinical signs
○ Increased appetite
○ Loss of muscle
○ Potbelly
○ Thin hair coat
○ Prominent skin vessels
101
Hyperthyroidism in cats signalment and clinical signs
- Old cats (rare in cats <10 years)
- Other possible clinical signs
○ Increased appetite
○ Weight loss
○ Increased activity, vocalisation or aggressiveness
○ Vomiting and/or diarrhoea
○ Tachycardia and/or gallop rhythm
