“ no pressure, no diamonds.” -mary case adversity

“No pressure, no diamonds.”

-Mary Case

ADVERSITY

DISEASES OF THE URINARY SYSTEM

CystitisCystic calculi

Urinary obstructionARF & CRF

Incontinence

BLOOD FLOW THROUGH THE KIDNEYS

Renal arteriole > glomerulus > bowman’s capsule > proximal convoluted tubule > loop of Henle > ELIMINATED: distal convoluted tubule > collecting ducts > renal pelvis > urine

COMPONENTS OF THE URINARY SYSTEM and ITS FUNCTIONS

Functions of the kidneysExcretion:

produce urineMaintain homeostasis

Blood filtration, reabsorption, secretion

Fluid balance regulationAcid-base balance regulationHormone production


URINARY SYSTEM IS NORMALLY STERILE AND RESISTANT TO BACTERIAL INFECTIONVoiding of urineUrethral/ureteral peristalsisGlycosaminoglycans in the surface mucosal layer

pH

RECOGNIZING URINARY SYSTEM DISORDERS

About 4 million cats a year are destroyed for “elimination problems”.

DIAGNOSING URINARY SYSTEM DISORDERS

DIAGNOSTIC TESTS THAT MAY BE DONE IN PATIENTS WITH URINARY DISEASE URINALYSIS (dipstick and sediment

exam)RADIOGRAPHS



Urinary obstructionARF & CRFIncontinence

Feline Idiopathic (Interstitial) Cystitis

FACTS:-Occurs in cats 2-6 yrs old-Occurrence in males > females -cause unknown, multi-factorial -not caused by bacterial infection -recurrence is likely

aka FUS/ FLUTD


Clinical SignspollakiuriaHematuriaDysuriaPeriuria (sinks, tubs, carpet, etc.)


DiagnosticsUrinalysis/culture to r/o bacteria as causeOnly 1%-3% of all feline cystitis is

caused by bacteria

Radiographs to r/o calculi; contrast studies may show thickened

bladder wall


TreatmentAvoid unnecessary antibioticsChange diet from dry to moist

Or salt food to ↑ water intakeReduce stress from other cats, kids, etc

Provide hiding placesPheromonotherapy

Behavior modification drugs (may also have pain reducing effectsAmitryptilline (tri-cyclic antidepressant)Clomipramine

Glycosaminoglycan replacementCosequin for catsAdequan


Client infoDisease is self-limiting

As many as 85% of cats will have resolution of clinical signs in 7-10 days

May be recurring problemNo definitive cureReduce stress

Canine Bacterial CystitisCause: Ascending

bacteria up the urethra

Signs↑ frequency of

urinationHematuriaDysuriaCloudy urine,

abnormal colorFrequent licking of

vaginal/urethral area

Canine Bacterial CystitisDiagnostics

Urinalysis: ↑WBC’s, bacteriaCommon bacteria: E.coli, Proteus spp.

Urine culture/sensitivityCollect by cystocentesis or mid-stream collection

Canine Bacterial Cystitis

TreatmentAntibiotics according to sensitivity Treat acute infections x 10-14 dSubsequent infections x 4-6 w

Avoid trauma to urinary tract during surgery

Patients needing indwelling catheters should have a closed system

Closed Urinary Catheter System

Canine Bacterial CystitisClient info

Many uncomplicated urinary tract infections resolve without Rx

Give antibiotics as directed for the time prescribedRelapses are common

due to inadequate treatment

Prostate may be source of recurring infections in male dogs

Urine cultures should be repeated during treatment to assess effect

Feline Uroliths and Urethral Plugs

“Plugged” or “Blocked” male cats are commonly seen in small animal practice and can be fatal if not relieved

Feline Uroliths & Urethral Plugs

The two most common causes of urethral blockage are uroliths and urethral plugs

UROLITHS: composed of minerals and a small amount of matrix

URETHRAL PLUGS: composed of small amount of minerals and large amount of matrix


• Signs– Hematuria– Dysuria– Periuria– Anorexia, vomiting– Collapse, death

• Non-specific signs:– Hiding– Crying while urinating– Frequent trips to the

litterbox


Uroliths (bladder stones) found anywhere in urinary tractFormed from minerals in diet

Some are radiopaque (Ca++ oxalate, urate, struvite) and can be seen on x-ray

Some are radiolucent (cystine) and require double contrast

Pneumocystogram


Uroliths damage bladder, making it more susceptible to bacterial infection, hematuria

Uroliths can cause blockage of the urethra of malesBladder will fill with urineKidneys will stop workingBlood/body will become toxic (azotemic)

Feline Uroliths and Urethral plugs


• DxPalpation of bladder

• Obstructed bladders are full and tight

Radiographs may show uroliths on routine films

Ultrasonography can locate position of urolith

Urolith analysis is necessary to determine its constituents

EKG: atrial standstill, bradycardia, hyperkalemia


Normal double-contrast cystogram

pneumocystogram

Double-contrast cystogramwith stones

Ultrasound of bladder stone


TreatmentMedical treatment (chronic, non-obstructed)Dissolve struvite uroliths (most common-

~60%) by acidifying urine and feeding diet low in Mg (Hill’s S/D, c/d, others) Should resolve in 4-8 wkRe-radiograph, and continue diet 1 mo after

uroliths gone

Cystotomy to remove stones

Antibiotics according to culture/sensitivity


Medical treatment (obstructed)This is a medical emergencyAnesthetize (short acting)

*USE LESS ANESTHESIA IN AZOTEMIC CATS*

Pass Tom cat catheter and back flush

Sew catheter in place for 1-3 d, using a closed system

Closed Urinary Catheter System


Surgical treatment (chronic obstructers)Perineal urethrostomy (PU)

New opening for urethra is created proximal to narrowing

Urethral opening looks similar to female anatomy

*Goal of surgery is to decrease the likelihood of life-threatening obstruction*

Feline Uroliths and Urethral Plugs:Perineal Urethrostomy

Feline Uroliths and Urethral Plugs: Perineal Urethrostomy

Canine Urolithiasis

Os Penis

Canine UrolithiasisUroliths damage mucosa of urinary tract making it susceptible to infection

Uroliths can obstruct urine flow in males

Clinical SignspollakiuriaDysuriaHematuria

Canine Urolithiasis

DxUrinalysis

CrystalluriaHematuria↑ bacteria

Radiographs

Canine Urolithiasis

Canine UrolithsUrolith Breed Sex Contributing factors Rx

Struvite min sch female (80%) alkaline urine acidify urine

(Mg Ammonium Phos) catsbacteria→urease→↑pH antibioticsminerals (diet) Only Hill’s s/d

(dissolve)

↓protein (ammonia)

↑H2O intake (flush stones)

acidy urine

Calcium Oxalate cats males diet high in protein Sx removal (only Rx)

(30-50% of min sch hypercalcemia ↓ dietary Ca

all stones) Lhasa, Yorkie Cushing’s Dis min poodle use of cortisone Hill’s u/d,

w/d, k/dShih Tzu acid urine

Urates Dalmatians males ↑ uric acid from kidneysAllopurinol

E bulldogs acid urine (gout in humans)min schnauzer K+ Citrate

(↑ urine pH)Shih Tzu Hill’s u/d,Yorkshire terrier

Canine Uroliths Struvite Calcium Oxalate UrateType of stone cannot be determined by appearance; chemical analysis is

required

Urolithiasis (Canine)• Treatment

Medical (dissolve stones if Struvite)• diet• Acidify urine

– Urinary acidifiers (methionine, Methogel)• ↑ urine output

– Add salt to diet, increase water intakeAntibiotics for bacterial infection

Surgical removal ( Ca Oxalate)• Some uroliths are not amenable to Medical Rx• However, the cause of uroliths must be dealt with

medically (prevention)• STONE ANALYSIS IS VITAL FOR APPROPRIATE

TREATMENT

Cystotomy

Canine Urolithiasis: Cystotomy for stone removal

Canine UrolithiasisWhat do you see? How many?

Canine Urolithiasis

What do you see? Flush toward bladder (8 times)

Saline flush

One in bladder, 2 in urethra

What do you see?

Canine Urolithiasis

Canine UrolithiasisClient info

Special diet may be required for life-time

Table scraps/treats should be limitedLong-term antibiotics may be requiredUroliths may recur at any timeAlways provide plenty of fresh waterAllow plenty of bathroom time and frequency

“It is possible to store the mind with a million facts and still be entirely uneducated.”

- Alec Bourne

EDUCATION

Renal Failure~20% of Cardiac

outputFiltered by renal

corpuscleReabsorbed by kidney

tubulesWaste excreted as

urine

Renal Failure due to:↓ blood flow

(hypoperfusion)Damage to nephron

and glomerular filtration declines resulting in azotemia

AZOTEMIA

Pre-renaldehydration

RenalPrimary kidney disorders

Post-renalUrinary tract obstruction

Acute Renal FailureThree distinct phases:

Induction: the time from the initial insult until decreased renal function is apparent (hours to days)

Maintenance: the time period during which renal tubular damage occurs (weeks to months)

Recovery: the time during which renal function improves, existing nephrons hypertrophy and compensate for those damaged, and tubular repair occurs (when possible)

Loss of Renal Reserve - Early signs of PU/PD

PU= polyuria (increased urination)

PD= polydipsia (increased drinking)

Renal Insufficiency - Early warning signs, such as

increased thirst, may begin to appear

Renal Failure (Azotemia) - Kidneys cannot eliminate waste

efficiently, causing signs of illness

Advanced Kidney Failure (Uremia) - Severe signs of illness appear; eventually, collapse and death

result

Stages of Kidney disease

Acute Renal Failure

An abrupt decrease in glomerular filtration →azotemia

CausesDamage to nephronNephrotoxic drugs

Aminoglycosides (gentamicin, streptomycin)Chemotherapeutic agentsAntifungal medicationsAnalgesics (acetaminophen)Anesthetics (methoxyflurane [Metafane])Ethylene glycol (antifreeze)

Acute Renal Failure

Causes:Infections (pyelonephritis)Immune-mediated diseases (Glomerulonephritis)

Metabolic: Hypercalcemia↓ Renal perfusion

ShockHypovolemia/dehydrationHypotension

Acute Renal Failure

Signs (non-specific)Kidneys are enlarged and painful on palpation

Signs of azotemiaAnorexia, dehydratedVomiting/diarrheaWeakness

Fever

Acute Renal FailureDx

Urinalysisurine sediment - castslow sp gravity (unable to concentrate urine)

CBCdehydration (↑PCV) acidosis

Chem panel↑ BUN, Creatinine↑K+, Phosphorus

Acute Renal Failure

Tx (aim is to restore renal hemodynamics)

Relieve tubular obstructionDiscontinue any toxic drugs

IV fluids Correct dehydrationCorrect acid/base imbalance

Acute Renal Failure

Client infoRenal function may never be like it was before injury

Prognosis is guarded especially with older pets

Care must be taken to avoid events that may precipitate further damage to kidneyAppropriate dietAdequate water access

Chronic Renal Failure

Common in older pets; cats appear to be more affected than dogs

Irreversible and progressive decline in renal function (nephron damage)

Dogs > 8 yrsCats > 10 yrs

Chronic Renal FailureProgressive

1st function lost: Ability to concentrate urinePU, PD, nocturia

Loss of ADH responseOther functions lost: Ability to cleanse bloodAzotemia (toxemia)

Begins at ~75% of nephron loss↑ BUN, Creatinine

Anemia: erythropoietin secreted by kidneys

Chronic Renal FailureSigns

Dull, lethargic, weakAnorexia, wt lossPU/PD, cervical ventroflexion

hypokalemia

• protein matrix (Tamm-Horsfall mucoprotein)

that makes up the hyaline cast (hyaline with fat)

• particulate material from degenerating cells

• is present within the cast matrix (hyaline to finely granular cast).

Chronic Renal Failure

DxAcidosisAnemia↑ BUN, Creatinineincreased phosphorus HypokalemiaProteinuria

Chronic Renal FailureTx

Fluids for dehydration (IV, SQ)Potassium gluconate, calcium carbonate for electrolyte imbalances

Phosphorous binders: Aluminum hydroxide

Sodium bicarbonate for pH adjustment

HormonesEpoetin

Vit B supplements

Chronic Renal FailureClient info

CRF is progressive and irreversibleRx is aimed at slowing its progressSQ fluids at home are required to maintain hydration

Warm foods to improve palatabilityQuality of life will decrease; euthanasia may have to be considered

ARF (large size)

CRF(small size)

PCV Inc. Dec.

Azotemia: Bun and Creatine

Inc. Inc.

Phosphorous Inc. Inc.

Potassium Inc. Dec.

Other Acidosis, proteinuria

Urinary IncontinenceLoss of voluntary control of micturition

CausesNeurogenic—loss of normal neural function

causing a paralyzed bladderEctopic uretersPatent urachusEndocrine imbalance (after spay)

Urinary IncontinenceSigns

Urine leakage when pet is sleeping or exercising

Perianal area of pet is always wetConcurrent urinary tract infection

DxUrinalysisX-rays/cystographyChem panel to r/o PU from endocrine disease

Urinary Incontinence

Rx (based on specific cause)Surgical correctionEndocrine deficiency in spayed female

Diethylstilbestrol (PO or inj)Phenylpropanolamine (PROIN: for loss of sphincter

tone)Client info

Doses will have to be adjusted for individual animals

Paralytic bladder incontinence may require manual expression or catheterization several times a day

ReferencesAlleice Summers, Common Diseases of

Companion Animalshttp://veterinarymedicine.dvm360.com/vetmed/

article/articleDetail.jsp?id=738082http://ahdc.vet.cornell.edu/clinpath/modules/

index.htmhttp://www.vetmed.wsu.edu/ClientED/anatomy/

dog_ug.aspxhttp://veterinarynews.dvm360.com/dvm/article/

articleDetail.jsp?id=533210http://www.walthamusa.com/articles/c-

kidney.pdf

“ no pressure, no diamonds.” -mary case adversity

Documents

urinary system urinary

stress slide

closed system slide

feline cystitis

cats adequan slide

ducts renal pelvis urine

thickened bladder wall

mid stream collection