Post on 24-Dec-2015
“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
DISEASES OF THE URINARY SYSTEM
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
DISEASES OF THE URINARY SYSTEM
CystitisCystic calculi
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
Feline Idiopathic (Interstitial) Cystitis
Clinical SignspollakiuriaHematuriaDysuriaPeriuria (sinks, tubs, carpet, etc.)
Feline Idiopathic (Interstitial) Cystitis
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
Feline Idiopathic (Interstitial) Cystitis
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
Feline Idiopathic (Interstitial) Cystitis
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
DISEASES OF THE URINARY SYSTEM
CystitisCystic calculi
Urinary obstructionARF & CRFIncontinence
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
Feline Uroliths and Urethral Plugs
• Signs– Hematuria– Dysuria– Periuria– Anorexia, vomiting– Collapse, death
• Non-specific signs:– Hiding– Crying while urinating– Frequent trips to the
litterbox
Feline Uroliths and Urethral Plugs
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
Feline Uroliths and Urethral Plugs
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
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
Feline Uroliths and Urethral Plugs
Normal double-contrast cystogram
pneumocystogram
Double-contrast cystogramwith stones
Ultrasound of bladder stone
Feline Uroliths and Urethral Plugs
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
Feline Uroliths and Urethral Plugs
Feline Uroliths and Urethral Plugs
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
Feline Uroliths and Urethral Plugs
Closed Urinary Catheter System
Feline Uroliths and Urethral Plugs
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
DISEASES OF THE URINARY SYSTEM
CystitisCystic calculi
Urinary obstructionARF & CRFIncontinence
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
DISEASES OF THE URINARY SYSTEM
CystitisCystic calculi
Urinary obstructionARF & CRFIncontinence
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