Urinary Incontinence

Question 1

Define urinary incontinence

Answer 1

Urinary incontinence is defined as involuntary leaking of urine from the bladder during the storage phase of micturition and can result from anatomical or functional abnormalities

Question 2

What are the causes of urinar incontinence? (8)

Answer 2

• Urinary obstrcution with overflow
• Urethral disease
• Neuro disease
• Baldder disease
• Vaginal disease
• Congenital
• Iatrogenic
• Idiopathic

Question 3

How do you work up an urinary incontinence case? (3)

Answer 3

Clinical history:

• What do yo need to ask a client to determine whetehr the animal is incontinet/dysuric
• Could the animal be PU/PD?

Physical exam:

• Differentiate between the possible casues

Note:

• Major bit is asking client and finding out about clinical history, our patients cannot speak to us! Appropriate history from own is paramount. Could animal be PUPD instead?
• Important question to ask is does the dog get up and there is urine where its sleeping or lying? (if its physically healthy and can move, a dog will never urinate where its sleeping) is if the animal is aware its urinating?
• How do we classify a dog as being PUPD? Measure the intake of water, more than 90-100ml/kg/24h of water roughly

Question 4

What would we look for on blood with urinary incontience? (4)

Answer 4

• Look at renal parameters (BUN and creatinine – called azotemia when they are increased together). To differentiate between post, renal and pre:
• Post – most common is obstruction
• Pre-renal vs renal – to differentiate measure USG – ask for urine sample
• Look at potassium and sodium – help determine if renal azotemia or not
• Look at glucose
• Look for alkaline phosphatase – cushings disease?

Question 5

Why is urinary analysis worht doing for urinary incontinence? (3)

Answer 5

• Look for infeciton
• Do a dipstick to look for glucose
• Do an SG to differentiate and have an appropraite SP

Question 6

How can we collect urine samples for analysis? (3)

Answer 6

• Free catch
• Cystocentesis
• Catheteristation

Question 7

Which imaging modality could we use for urinary incontience?

Answer 7

• Ultrasound – look at bladder, any neoplasia, ectopic ureters, congenital abnormalities, uroliths? etc
• Cancers in bladder of dog – transitional call carcinomas

Question 8

What cancer affects the bladder?

Answer 8

Transitional cell carcinoma

Question 9

Early spaying is a catch 22.. why is this?

Answer 9

–Early neutering may cause urinary incontinence

–Studies indicate if not spayed before first season higher risk of mammary cancer –Developement of mammary cancer – discussions about early neutering and early neutering can cause some neoplasia? But this is discussion

Note the difference between vets:

–My friend at a large first opinion practice in Phoenix Arizona recommends spaying dogs at 6 months of age………as she says…….she would rather have a dog that MIGHT become incontinent vs. having the risk of the dog developing cancer !!!!

–At Pride we spay dogs pre-season as well

Question 10

What are the risk factors for developing a urine spinchter mechanism incompetence (USMI)? (4)

Answer 10

–Size & breed

–Neutering

–Discussion about neutering and urethral tone with this - debates

–Urethral tone

–Obesity - If obese, having disucssion about dog may benefit from losing some weight before we look at medications or surgery

Question 11

What breeds are predisposed to USMI? (7)

Answer 11

•Irish Setters, Rottweilers, Dobermanns, bearded collie, rough collie, Old English Sheepdogs & Dalmatians

Question 12

What are the 2 treatment options for urinary incontinence?

Answer 12

–Medical

–Surgical

Question 13

What are the 2 medical options for treating urinary incontience?

Answer 13

–Phenylpropanolamine (Propalin)

–Oestradiol (Incurin)

Question 14

How does phenylpropanolamine (Propalin) work?

Answer 14

–Acts as α2 agonist – sympathomimetic to increase urethral tone

Question 15

How many doses of phenylpropanolamine (Propalin) are recommended daily?

Answer 15

BID - TID

Question 16

How effective is phenylpropanolamine (Propalin)?

Answer 16

75-85% cases

Question 17

What are the side effects of phenylpropanolamine (Propalin)? (3)

Answer 17

• Anxiety
• Tachcardia
• Increased BP

Question 18

How do we dose an animal with phenylpropanolamine (Propalin)?

Answer 18

–Start high and titrate down

–Start of BID or maximum dose, then titrate down to get to where you see an effect

Question 19

How does Oestradiol (Incurin) work?

Answer 19

–Oestrogen therapy – thickens urethral mucosa and induces α2 receptors

Question 20

What are the benefits of Oestradiol (Incurin)? (2)

Answer 20

–Easy dosing: One tablet / dog (any size), then alter dose depending on outcome

–Easy for clients, one tablet – and very small

Question 21

What are the side effects of Oestradiol (Incurin)? (2)

Answer 21

• May see signs of oestrus
• Short acting, so not cumulative,

Question 22

Can we combine the two medical options for treating urinary incontinence?

Answer 22

YES

• As they work in a different way and have 2 different mechanisms of action
• Use incurin first, see if this works, if it doesn’t, then add in propalin and stop incurin sometimes. This is the lecturers preference but this is mainly due to he prefers to give a tablet over drops on food

Question 23

What are the surgical options for urinary incontinence? (4)

Answer 23

–Colposuspension – continence~ 60%

•Moving the vagina <=> therefore moves the bladder & urethra cranially => under same compressive forces in the abdomen

–Urethropexy – effective ~ 60%

•Moves urethra cranially – increased risk too tight

–Medical grade collagen injections; continence ~ 68%

• Put collagen in position of 1.5cm from bladder neck at 2,6,10 o’clock
• May flatten over time, so may need to redo it

–Transobturator Vaginal Tape Inside Out

• TVT-O
• New technique
• Showing good results
• Human procedure that has been used by some specialists in surgery, some good results shown but still new

Question 24

What does surgical options for urinary incontinence aim to do?

Answer 24

aims at repositioning the bladder & stretching the urethra

Question 25

What could we use alongside Transobturator Vaginal Tape Inside Out?

Answer 25

–Can combine with medical therapy, could potentially decrease the amount of medicine we need to give to patient

Question 26

**What questions do you have from this case (2)** **What diagnostics would you do? (3)** –A 10 year old female spayed Great Dane –Chronic history of urinary incontinence managed with Propalin and Incurin – now again showing signs of urinary incontinence – so had her on maximum dose for medical –Quiet at home but eating normally, no vomiting or diarrhoea. No travel history, vaccinated etc. –Not drinking more than always done and no abnormalities noted when urinating. Measured water intake and it was WNL Clinical examination –Quiet, alert and responsive –Weight 60kgs –Hydration good, capillary refill time 1-2 sec and moist mucus membranes –The temperature was normal –Thoracic auscultation and abdominal palpation was unremarkable –No LN enlargement –The rest of the clinical examination was unremarkable

Answer 26

* Urinary incontinence (was it initially diagnosed correct?) * Is she actually more likely PU / PD? –How can we further evaluate this? Diagnostics: •Do urinalysis, haematology and biochemistry

Question 27

How would you interpret these bloods?

Answer 27

* Not anaemic * WBC little bit low according to computer * Platelet count within reference range * No abnormalities on WBC on smear * So in great scheme of things – nothing too exciting * If WBC was REALLY low, might worry. * Repeated bloods in this patient and they were normal at this stage

Question 28

How would you interpret this biochemistry in a possible incontient dog?

Answer 28

* Alkaline phosphatase – only has ref range of 0-90, are we concerned about 281? Not really, as he said only worry about it until its 7x the high end of the normal reference range. * Aspartate aminotransferase – normally elevated when creatinine kinase is elevated also. Why would this be? CK is a muscle parameter that will go a little bit up if doing a blood test as going through the muscle. If CK value is just slightly high, don’t be alarmed – to be concerning they have to be up to something silly such as 10,000-15,000! Is AST and CK slightly up, don’t be alarmed – might just be due to us doing a blood test • * High cholesterol – post-prandial sample. Ask if owner starved the dog. Other things that can cause high cholesterol – hyperthyroid, one of the main players on the field for high cholesterol. No dermatological reasons for hyperthyroid though and had not had weight gain and no behavioural changes. Could ask owner to starve pet for a longer period of time for next test and re-check * Urea and creatinine and liver parameters (ALT) WNL * If ALT up, there is something affecting the liver * Not diabetic

Question 29

How would you interpret this urinalysis? (done by cysto) In a possible incontinent dog

Answer 29

* No abnormalities on dipstick * Okay SG, likely to be more like 1.030 – 1.035

Question 30

**What 3 things can we take/reflect on from this case?** Possible incontient dog: –Did abominal ultrasound was unremarkable, before went to surgeons * Bladder was in normal position * Normal wall tickness * No indication of any abnormalities around trigone area – likely to get neoplasias here * No signs of crystals, uroliths or stones * Internal referral to soft tissue surgeon –Not controlled on medical management –Surgery * Colposuspension and one suture of urethropexy * No complications noticed during surgery * Post operative –No complications post operatively –Was able to reduce medical management but not stop completely

Answer 30

–Always go back to the patient and reevaluate if signs are not fitting your clinical findings –Never be to proud to ask for 2nd opinion or refer to a specialist –Example of patient where both medicine and surgery was needed to control signs