Incontinence Flashcards
1
Q
Causes of incontinene in dogs and cats? Which species is more commonly affected?
A
> dogs esp female more common > juvenile - ureteral ectopia - congenital USMI - genitourinary dysplasia - bladder hypoplasia - intersex - pervious urachus - neuro dz > adult - USMI - prostatic dz - neuro dz - urogenital neoplasia - fistulae - bladder aotny - cystitis - detrusor instability - pelvic masses
2
Q
More common cause of incontinence in dogs?
A
> USMI (urinary sphincter mechanism incontince)
- most common neutered bitch but also in entire females and castrated makes
- most commonly acquired after neutering
- can be congenital with anatomical defects eg. Intersex, ectopic ureters
- leakage during recumbency
- severity of leakage variable (hard to monitor Tx efficacy)
3
Q
Which Breeds most commonly affected by USMI? What is the aetiology
A
Large/medium dogs - shorter urethral length pdf - overweight - docked > multifactorial aetiology not fully understood
4
Q
Risk fctors for USMI
A
- bitch
- breed (Irish setter, Doberman, Rottweiler, English sheepdog)
- docked
- overweight
- post neutering (within 3 years if it’s going to happen)
> cause unclear, used to think adhesions form but this has been disproven, oestrogen and progesterone levels and potential gonadotrophins
5
Q
Diagnosis of USMI
A
- PE unremarkable
- Dx based on Hx, CS, investigtion, response to trial tx, r/o other causes
- caudally positioned bladder neck is supportive but NOT diagnostic
6
Q
Is USMI common in make dogs?
A
- no
- but more common in neutered males
7
Q
Is USMI in males similar to female form?
A
- similar to bitch (leak when recumbemt)
- intrapelvic bladder neck and castration risk factors
- responds to medical and surgical tx less well than the bitch
8
Q
What is ureteral ectopia?
A
Ureters bypass bladder into urethra or vagina
- usually congenital (can be acquired)
- more common in females, dogs
- probably inherited or familial (golden retriever PDF )
- openings may be single, double or elongated (troughs)
- in dogs likely intramural ectopic ureter (joins at correct place but only opens more caudally)
- in cats likely extramural ectopic ureter
9
Q
Clinical signs of ureteral ectopia?
A
- constant dribble
- severe scalding
- often UTIs
- may have concomitant USMI
- may have other abnormalities eg. Hydroneohrosis, hydroureter, uterocoeles
10
Q
What is genitourinary dysplasia and which animals is it common in?
A
- rare cause of incontinence in cats (but more common than ectopic ureters cats than dogs)
- on rads no urethra seen, really wide elongated bladder straight out to vagina (very easy to catheterise!)
11
Q
How may Intersexuality cause incontinence? Tx?
A
Rare
- urine refluxing into another structure
- concominant SMI possible
- tx dependent on underlying defect, usually surgical
12
Q
What is Bladder hypoplasia commonly seen with? Px?
A
Rare
- usully w/ other congenital defects ef. bilateral ectopic ureters
- dx radiographically
- poorly compliant bladder -> overflow, guarded px
13
Q
Cause of Bladder atony ? Tx and Px?
A
- 2* to bladder distantion
- tight junctions in bladder wall disrupted -> atonic bladder difficult to manage
14
Q
Previous urachus
A
- more common farm species
- rare smallies
15
Q
Is imaging useful in incontinence investigation?
A
Yes - if normal anatomy seen, suggests functional cause
16
Q
Outline the order of further investigation for incontinence
A
- diagnostic imaging
- plain rads (RLR, VD)
- IVU (IV urography)
- retrograde study
- ultrasound
- others
17
Q
Most useful study?
A
Retrograde vagino urethro cysto gram
18
Q
What is ultrasound useful for?
A
- confirming ureteral emptying into bladder
- additional information on kidneys bladder and prostate
19
Q
Uses of endoscopy
A
> visualising
- ectopic ureters
- lesions of the bladder neck/urethra that can cause incontinence
- subjective evaluatino of urethral tone
facilitates biopsy
laser sx for intramural ectopic ureters
- no info on urethropelvic relatinoships
not widely available UK
20
Q
Tx urinary incontince
A
- without dx Tx is trial and symptomatic
- ensure owners understand what you’re doing , not necessarily bad
21
Q
Medical Tx incontinence?
A
> Tx UTI - base on culture and sensitivity - confirm eradication > Tx underlying systemic dz - PUPD may exaggerate or precipitate condition > diet if obese > specific mess depend on dx
22
Q
Which nerves supply the bladder and LLUT?
A
> hypogastric n (symp) - L1-4 - facilitates bladder filling - b fibres bladder, a fibres neck > pudendal n. (Somatic) - S1-S3 > pelvic n. (Parasympathetic) - S1-3
23
Q
Give 4 drug options for Tx incontinence LOOK UP TABLE
A
> phenylpropanolamine - best but more expensive - less effective in males > ephedrine hydrochloride > oestrol > testosterone - prostatic hyperplasia side effect etc.
24
Q
Which drugs are licenced?
A
- phenylopropanolamine (propalin, Vetoquinol)
- ephidrine hydrochloride (Enurace 50, Janssen)
- Oestriol (Incurin, Intervet)
- Testeosterone (Durateston, Intervet)
25
Side effects of phenylpropanolamine
- irritability
- hypertension
- anorexia
26
How does the risk of adverse effects with oestriol compare to phenylpropanolamine?
- lower
27
how can medical tx be escalated before resorting to surgery?
```
> off lic increase dose of PPA (phenylopropanilamine)
- watch for side effects
- combine with oestriol tx
> Imipramine
- a adrenergic
- improves bladder storage
- anecdotally helps dogs unresponsive to PPA
> GnRH analogues
-> v FSH and LH
- successful
```
28
Further medical options
- see above
29
When is surgical Tx indicated?
Specific diagnosis has to be made
| - not responsive to medical Tx
30
Which abnormalities has surgery been described for?
- ureteral ectopia
- USMI
- genitourinary dysplasia
- congenital Genito-urinary malformation
- masses
- prostatic dz
31
What should be managed prior to surgery?
- weight and UTIs
32
Are surgical procedures effective?
Not very!! No perfect techniques, many described
33
Which techniques have most and least support for them?
```
> most
- colposuspension
- urethropexy
- prosthetic sphincter
- endoscopic injection of collagen
> occasional reports
- vas deferens pexy
- urethrocystoplasty (cats)
- sling urethroplasty
- cyst-urethroplasty
- other transpelvic slings
- other combos
(2 types essentially: Own tissues v implants)
```
34
General Aims of surgery for USMI?
- improve pressure transmission to bladder neck
- increase urethral resistance
- or both
35
What is the oldest described surgery for incontinence?
> colposuspension
- move bladder neck into an intra-abdominal position.
- fix with non absorbable sutures from prepubic tendon to the vagina
36
Which 3 methods are more popular for treating female incontincnece?
> urethropexy
- similar to colposuspension (sutures urethra - prepubic tissue, bladder neck relocated cranially)
> prosthetic sphincters
- currently fashionable
- ^ urethral resistacne (inflatable band around bladder neck)
- filled with saline and allows post-op tweaks
> collagen or synthetic alternatives
- injected into peri-urethral tissues
- open surgery or endoscopic injector
- gets degraded over time, can accidentally cause obstruction
37
Is surgical Tx of males as successful ?
No bitches always do better
38
Surgical treatment for male SMI?
> Vas deferens pexy
- male colposuspension using deferent ducts
- results variable
> Prostapexy
- male colposuspension using prostate to pull bladder forward
- better success rates, no complicatiosn
39
Surgical Tx of ectopic ureters?
> reimplantation of ureter
- neo-ureterocystostomy for intramural (surgery, laser)
- ureteral transaction and reimplantation for extramural
> ureteronephrectomy
- good for charity setting
- providing contralateral is still functioning
40
Complications of ectopic ureter re-implantation?
- continued incontincnece
- UTIs -> pyelonephritis
- bladder oedema and dysuria
- stenosis or new stoma
- recanalisation of lighted distal ureter
- wound breakdown
41
Give egs. Of specific Tx of specific less common causes of urinary incontinence
- correction congenital genito-urinary malformation
- tx prostatic dz (omentalisation etc.)
- excision of bladder, urethral or vaginal masses
- permemenant cystotomy
42
Which tumour is most common in the bladder?
Transitional cell carcinoma
| - not amenable to surgery
43
How can incontinene be categorised? Is this useful?
-
44
Madical tx of neurogenic atonic bladdders?
```
> v urethral tone
- phenoxybenzamine
- diazepam
> ^ bladder tone/contractility
- bethanecol (onl once bladder easily expressed)
> physical bladder emptying
- abdo pressure
- indwelling catheter
- permanent cystotomy
```
