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VMD 461B Westropp
Small animal medicine (Urinary)
| Question | Answer |
|---|---|
| What is the difference between pollakiuria and PU/PD? | PU/PD = increased drinking/urination; conscious of action (just can't make it out of the house); not incontinence Pollakiuria = small frequent urinations (form of incontinence) |
| Where does the Sympathetic Nervous System exit the spinal canal? | L1-L4 |
| Trace the sympathetic NS from the exit of the spinal canal to the bladder and internal sphincter | -Exits at L1-4 -to the caudal mesenteric ganglia -sends 2 branches of the hypogastric n. -one to the bladder and one to the internal urethral sphincter |
| SNS innervation of the bladder | branch of hypogastric n. --> NE--> B receptors--> relax bladder |
| SNS innervation of the internal urethral sphincter | branch of hypogastric n.-->NE-->alpha receptors--> increased sphincter tone |
| Urinary incontinence | lack of voluntary control over the passage of urine |
| Where does the parasympathetic NS exit the spinal canal | S1-S3 |
| Trace the PNS from the exit of the spinal canal to the bladder | -S1-3 -the pelvic n. releases ACh onto muscarinic receptors of the detrusor muscle -causes contraction of the bladder |
| Somatic nervous system innervation of the bladder | -Pudendal n. releases ACh onto nicotinic receptors of the external urethral sphincter -increases sphincter tone |
| The external urethral sphincter is made up of what type of muscle and what type of receptors? | -skeletal muscles -nicotinic receptors |
| The general effect of increased sympathetic tone on the urinary bladder and urethral sphincter is: | urine storage -bladder relaxation -increase internal sphincter tone |
| The general effect of increased parasympathetic tone on the urinary bladder is: | Voiding - bladder contraction |
| The general effect of increased somatic activity on the bladder and sphincter are | Urine Storage - no effect on bladder - increase external urethral sphincter tone |
| What part of the brain determines the onset of urination? | The forebrain |
| 4 classifications of urinary incontinence | -Anatomic abnormalities -Decreased urethral closure pressure -Increased urethral closure pressure/outlet obstruction -Overactive bladder |
| General diagnostics for incontinent animals (not including diagnostics for specific conditions) | -Watch the animal void -Evaluate vulvar conformation -Urinalysis -Urine culture |
| Anatomic abnormalities | -Ectopic ureters -Pelvic bladders -Ureterocoeles -Bladder and urethral hypoplasia |
| Typical signalment for ectopic ureter | -young (<1yr), female -Siberian Husky, Lab, Golden Retriever -most probably bilateral -very rare in cats |
| Diagnosis of ectopic ureter (not including general diagnostics) | -Cystoscopy -IVP, nephropyelogram, retrograde ureterogram, vestibulovaginogram -Contrast CT |
| What are the advantages of cystoscopy for the diagnosis of EU? | -can evaluate vestibule -easy detection of fenestrations -can evaluate mucosa |
| What are the disadvantages of cystoscopy for the diagnosis of EU? | -no evaluation of upper urinary tract -trigone poorly characterized in EU dogs -evaluation depends on vesicourethral jxn, which can be poorly defined in EU dogs |
| What diagnostics can you use to evaluate the upper urinary tract? | -contrast studies -abdominal ultrasound |
| What additional diagnostics should you do if you are doing a cystoscopy? | -anything that looks at the upper urinary tract -urodynamic testing |
| What will urodynamic testing test for? | concurrent decreased sphincter tone and increased bladder contractility |
| Treatment for EU? | -Sx is standard -laser therapy is new and promising |
| What should you tell owners of a dog having EU surgically corrected? | -surgery is only about 50% curative -the dog may have other concurrent disorders that need to be treated as well |
| Pelvic bladder | -bladder located far back in pelvis -urethra is short and wide |
| Diagnosis of Pelvic bladder | -contrast urogram |
| Treatment of pelvic bladder | -Sx (colosuspension), but not very successful -should be performed as a last result (after medical management?) |
| Ureterocoele | -"outpouching" of the ueter -concurrent problem with EU -predispose to recurrent UTI |
| Bladder and urethral hypoplasia | very rare |
| Causes of decreased urethral closure pressure | -USMI -injury to hypogastric nerve |
| USMI | urethral sphincter mechanism incompetence -20% spayed females within 3yrs -middle aged FS dogs -Dobermans and Old English Sheepdogs -can be concurrent with EU |
| Diagnosis of USMI | Diagnosis of exclusion -signalment and history -NE -urethral pressure profile (gold standard, but not routine) -check urine sg |
| Treatment of USMI | -alpha adrenergic agonists -estrogens -GnRH analogues -collagen procedures |
| Urodynamics | - Urethral pressure profile (looks at urethral closure pressure) - Cystometrogram (looks at detrusor muscle) |
| Indications for urodynamic studies | -refractory sphincter mechanism incontinence -reflex dyssynergy -UMN and LMN bladders -EU (screening for other probs prior to Sx) |
| Alpha adrenergic agonists | -phenylpropanolamine (PPA) = mixed alpha agonist -Tx USMI (75-90% good response) -others (pseudoephedrine, ephedrine) -PPA superior to pseudoephedrine |
| Side effects of PPA and Pseudoephedrine | -excitability -tachycardia -aggression -hypertension |
| Estrogens | - estradiol receptors in the transitional epithelium of the proximal urethra -increase alpha receptor sensitivity to NE (can be used with alpha agonists) -65% response -DES, Premarin, Estriol |
| What is an advantage of Estrogens over PPA in the Tx of USMI? | -dosing is much lower (given weekly instead of daily) so cost will be lower |
| Side effects of Estrogens | -bone marrow suppression (rare at these doses) |
| Submucosal urethral collagen injections | -blebs of collagen placed cystoscopically just distal to the trigone - to close urethral lumen (Tx USMI) -variable response -in animals where medical Tx not working or contraindicated |
| Increased Urethral Closure Pressure | -"overflow bladder" -history of stranguria or poor urine stream prior to incontinence -older, male, large breed dogs -mechanical or functional |
| GnRH analogues | -Tx for USMI -downregulate FSH and LH which might be contributing to USMI -variable response (not widely used in US) |
| Mechanical increased urethral closure pressure | -urethrolith -neoplasia -severe/proliferative urethritis |
| Functional increased urethral closure pressure | -UMN disorder (T3-L3 lesion --> hypogastric) -urethral spasms -reflex dyssenergy |
| Diagnosis of increased urethral closure pressure | -Watch the animal urinate -neuro and ortho exams -UA and UCS -Residual urine volume -urethral pressure profile (gold std) -Rads, cystoscopy, contrast imaging (to find mechanical obstruction) |
| Treatment of increased urethral closure pressure | -keep residual urine volume low -alpha antagonists (prazosin)do this first -parasympathomimetics for detrusor atony (behtanecol) |
| Phenoxybenzamine Prazosin | -Tx increased urethral closure pressure (functional urethral obstruction) -alpha antagonists -SE= weakness, lethargy, hypotension |
| Bethanecol | -Tx increased urethral closure pressure (detrusor atony) -parasympathomimetic (contract bladder) -SE= SLUDS |
| Detrusor hyperreflexia | "overactive bladder" -usually not the sole cause of incontinence -distinguish from behavioral probs and submissive urinations |
| Diagnosis of overactive bladder | -cystometrogram |
| Cystometrogram | -assesses threshold volume and pressure, and compliance |
| Indications for cystometrogram | -ectopic ureters -assessment of urinary incontinence -idiopathic cystitis -response to drug therapy |
| Common causes of Overactive Bladder | -UTI -Cystic calculi -Neoplasia -Bladder polyps -rarely idiopathic |
| Treatment of idiopathic detrusor hyperreflexia | -anticholinergics/parasympatholytics (oxybutinin, tolterodine) -tricyclic antidepressants |
| Side effects of oxybutinin and tolterodine | -urine retention -dry mouth -dry eye (usually only reported in humans) |
| 3 categories of urolithiasis formation | 1.increase in urine mineral content (increase in supersaturation) 2.promoter in urine that potentiates stone formation 3.absence of inhibitors of stone formation in the urine |
| Clinical signs of urolith in lower UT, bladder or urethra | -pollakiuria -stranguria -hematuria -(+/-)incontinence |
| Clinical signs of urolith in upper UT, kidneys or ureters | -vague -anorexia -malaise -sublumbar/kidney pain -uremia |
| Intrinsic factors that predispose to urotlithiasis | -Breed -Age -Gender |
| Breeds associated with struvite and CaOx stones | -Mini Schnauzer -Bichon Frise |
| Breeds associated with urate stones | -Dalmation -English Bulldog |
| Breeds associated with cystine stones | -Dachshund -Newfoundland -English Bulldog |
| What age is most common for CaOx stones | -middle age |
| What age is most common for silica stones | -old dogs |
| What gender is predisposed to struvite stones | Female |
| With which stones are male dogs, more than females, likely to present? | -Oxalate -Cystine -Urate -Silicate |
| What are extrinsic factors in stone formation | -commercial diets -Homemade diets |
| Precipitation-crystallization theory | -incriminates supersaturation with crystalloids as primary factor in precipitation and growth of calculi |
| Matrix nucleation theory | -implies that some abnormal substance in the urine is responsible for the initial development of calculi |
| Crystallization-inhibition theory | -suggests that the absence of some critical inhibitor of crystal formation is the primary factor in the development of calculi |
| Inhibitors of crystallization | -decrease urinary supersaturation by forming ion complexes -alter properties of crystal surfaces e.g. citrate and phosphates |
| Epitaxy | precipitation of one crystal on the surface of another |
| Promoters of urolithiasis | -abnormal urine proteins? -Epitaxy (CaOx, CaP, uric acid) |
| T/F Crystalluria is always an indication of stone formation | False. Crystalluria can be found in healthy cats and dogs |
| What 2 crystals would warrant further workup if you found them on a patient's urinalysis? | -Urate (ammonium biurate) -Cystine |
| Homogenous nucleation | -Spontaneous, sustained nucleation that occurs in highly supersaturated(unstable) solution in the absence of preformed organic or crystalline material |
| What are the three different solubility states of a substance? | -stable -metastable -unstable |
| Stable Solution | -crystals will not form -existing stones may dissolve |
| Metastable Solution | -Heterogenous nucleation may occur -inhibitors will impede or prevent crystallization -crystal aggregation will occur -this is where we treat to prevent formation |
| Unstable Solution | -Inhibitors generally not effective -Nucleation will occur |
| Matrix | -substances incorporated into stone lattice as it forms -keeps the crystals together like glue e.g. proteins, cell debris, foreign bodies, drug residues, Tamm Horsfall protein |
| T/F In UA results of a urolithiasis patient, crystal type doesn't always indicate stone type. | True |
| Coffin lid crystals | Struvite |
| Picket fence crystals | CaOx monohydrate |
| Maltese cross crystals | CaOx dihydrate |
| When do you usually see low/moderate levels of amorphous phosphate crystals | -when the urine sample has sat around for a while |
| Stop sign crystals | Cystine |
| Diagnosis of urolithiasis | -plain rads -contrast rads -excretory urography (for kiney and uretoliths) -cystourethrogram -US (doesn't evaluate the urethra) -cystoscopy -Catheterization (to dislodge stone) |
| On a double contrast study, how do you tell the difference between an air bubble and a stone? | - air bubbles are perfectly round |
| Stone radiodensity (decreasing order) | Piss (Struvite = magnesium ammonium Phosphate) On (calcium Oxalate) Cornell (Cystine) University (Urate) |
| What 2 stones are not radiodense? How do you diagnose them? | - Purine and Cystine stones - Need US or contrast study to Dx |
| Treatment options for urolithiasis | -Dissolution -Voiding urohydropropulsion -Basket retrieval -Holmium:YAG laser lithotripsy -Surgery |
| Which stones can be treated with dissolution protocols? Which stone cannot? | -can be dissolved: struvite (and possibly urate and cystine) -can't be dissolved: Ca Oxalate |
| What are the advantages of voiding urohydropropulsion? | -good for patients with recurrent stones -removes stones while they're small -avoids surgery |
| What complications are associated with voiding hydropropulsion? | -Hematuria (resolves ~24hrs) -Can rupture the bladder if small stones are blocking the urethra |
| Laser lithotripsy | -can break up stones that are otherwise too big to void |
| What procedure should always be performed after stone removal? | -radiographs to look for remaining stones |
| is quantitative or qualitative stone analysis more useful? | quantitative |
| what type of stone analysis should you do if you suspect uric acid calculi? | HPLC, because it tells the difference between pure urate and metabolites |
| Primary calculi commonly identified in dogs | -Struvite -CaOx -CaP (apatite) -Urate -Cystine -Silica |
| Primary calculi commonly identified in cats | -Struvite -CaOx -Urate -Dried solidified blood (DSB) -CaP (apatite) |
| CaOx stones in cats and dogs | -mono and dihydrate forms (same Tx) -most often in the bladder |
| Ureteral stones in a cat are usually... | CaOx |
| Ureteral stones in a dog are usually... | Struvite |
| Canines at risk for CaOx | -small yappy dogs -Mini Pinscher, Maltese, Bichon, Lhasa Apso, Chihuahua, Keeshound -males >females -middle aged dogs |
| Felines at risk for CaOx | -Middle aged cats -Males > females -Persians |
| What effect does dietary acidification have on CaOx stone formation? | -decreases urine pH (increases urine acidity) -increases urine Ca excretion -predisposes to CaOx stone formation |
| What are the two common uroliths reported in dogs? | #1 CaOx #2 Struvite |
| Upper urinary tract stones in cats are almost always... | CaOx |
| Prevention of CaOx stones | -Evaluate P for hypercalcemia, hypertriglyceridemia -evaluate diet and environment -increase water intake (moist food, NaCl) -Periodic rads and voiding hydropropulsion -monitor urine -Medications |
| Medications for the prevention of CaOx stones... When should you use them? | -potassium citrate (chelator) -hydrochlorothiazide (increases Ca resorption) Wait to use them until it is a recurrent problem. |
| Dietary principles for CaOx prvention | -increase moisture -NaCl to increase water intake -low fat/calorie (for animals with hypertriglyceridemia) |
| Protocol for CaOx stone Treatment | -remove stones and rad prior to recovery -culture urine -check calcium and triglycerides -put on high moisture, moderate pH diet -increase water intake -rad periodically, possibly VUH |
| Struvite uroliths in dogs | -2nd most common stone in dogs (caused by infections by urease producing bacteria) -females>males |
| what are the 2 most common stones in cats? | CaOx and struvite (1:1) |
| what would make you suspect struvite in a dog? in a cat? | -dog with a urease producing bacterial UTI -cat with urine pH >6.8 and history |
| How do you check on O compliance when treating a cat for struvite stones? | pH should be low urine specific gravity should be low |
| what are contraindications for dissolution? | -urethral obstruction or high risk of obstruction -young animals -lactating animals |
| what diet should you choose for a dog with struvite stones? | haha, trick question. Struvite stones are associated with UTI in the dog |
| Calcium Phosphate stones | -2 forms (apatite and brushite) -precipitates at high pH (alkaline urine) -no dissolution protocol -usually secondary stone |
| Purine metabolism | dietary and endogenous purines --(xanthine oxidase)-->hypoxanthine--(xanthine oxidase)-->uric acid--(uricase)-->allantoin |
| Urate uroliths (cats) | -not usually associated with underlying disorders -check liver function anyway -if liver is normal, manage with high moisture/low protein diet |
| Urate uroliths (Dalmations) | -genetic defect of transporter that brings uric acid into the hepatocyte -excrete more uric acid in the urine |
| Urate uroliths (English Bulldog, Jack Russell Terrier) | -may have similar transport defect as dalmations -may have underlying liver dysfunction |
| urate uroliths (non-dalmation dogs) | -evaluate liver function -in EBD and JRT, if liver is normal, test uric acid transporter |
| Treatment of urate uroliths in dalmations | -increase water intake -allopurinol -low purine diet -alkalinize the urine |
| Allopurinol | -Treatment of urate stones in Dalmations -xanthine oxidase inhibitor (less uric acid produced) -must feed low purine diet -SE (high dose): xanthine stone formation |
| Treatment of urate stones in non-Dalmation dogs | -treat underlying liver disorder(PSS) -Sx to remove uroliths -VUH |
| Cystine stones | -very rare in cat -Newfoundland, EBD, Dachshund -98% males -defect in proximal renal tubule |
| Proximal renal tubular membrane transporter defect affects what amino acids? | Cystine Ornithine Lysine Arginine |
| Treatment for cystine stones | -high moisture, low protein diet -2-MPG -D-penicillamine |
| 2-MPG | -Treatment of cystine stones -forms disulfide bridge with cysteine and decreases cystine excretion SE: mild GI and aggression |
| D-Penicillamine | -Treatment of cystine stones -forms disulfide bridges with cysteine and decreases cystine excretion SE: GI |
| Cystine prevention | -Alkalinize urine (K citrate) >7.8 |
| Silica uroliths | -uncommon in dogs (mostly older males) -GSD, Labs, Goldens -not in cats -jack-like appearance |
| Mixed uroliths | mineral composition mixed throughout the stome |
| Compound urolith | core and shell of different mineral compositions (layered) -treatement is aimed at the nucleus of the calculus (not the shell) |
| Host defenses to UTI | -urine (high osmolality and acidity) -uretrha (longer in male, hydrokinetic washout) -urothelium (local immunoglobulins) -ureters and kidneys (oblique entrance) |
| Does dilute urine predispose to UTI? | No |
| UTI Virulence factors | -urease -beta lactamase -flagella -R plasmid mediated resistance |
| Urease producing bacteria | -Staph -Proteus -Klebsiella |
Created by:
modonnell