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