1. “No pressure, no diamonds.” -Mary Case
ADVERSITY
“No pressure, no diamonds.”
-Mary Case

2. DISEASES OF THE URINARY SYSTEM Cystitis Cystic calculi Urinary obstruction ARF & CRF Incontinence

3. 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

4. COMPONENTS OF THE URINARY SYSTEM and ITS FUNCTIONS
Functions of the kidneys
Excretion:
produce urine
Maintain homeostasis
Blood filtration, reabsorption, secretion
Fluid balance regulation
Acid-base balance regulation
Hormone production

5. DISEASES OF THE URINARY SYSTEM
URINARY SYSTEM IS NORMALLY STERILE AND RESISTANT TO BACTERIAL INFECTION
Voiding of urine
Urethral/ureteral peristalsis
Glycosaminoglycans in the surface mucosal layer pH

6. RECOGNIZING URINARY SYSTEM DISORDERS
About 4 million cats a year are destroyed for
“elimination problems”.

7. DIAGNOSING URINARY SYSTEM DISORDERS
DIAGNOSTIC TESTS THAT MAY BE DONE IN PATIENTS WITH URINARY DISEASE
URINALYSIS (dipstick and sediment exam)
RADIOGRAPHS

8. DISEASES OF THE URINARY SYSTEM
Cystitis Cystic calculi Urinary obstruction ARF & CRF Incontinence

9. Feline Idiopathic (Interstitial) Cystitis
aka FUS/ FLUTD
FACTS:
-Occurs in cats 2-6 yrs old
-Occurrence in males > females
-cause unknown, multi-factorial
-not caused by bacterial infection
-recurrence is likely

10. Feline Idiopathic (Interstitial) Cystitis
Clinical Signs
pollakiuria
Hematuria
Dysuria
Periuria (sinks, tubs, carpet, etc.)

11. Feline Idiopathic (Interstitial) Cystitis
Diagnostics
Urinalysis/culture to r/o bacteria as cause
Only 1%-3% of all feline cystitis is caused by bacteria
Radiographs to r/o calculi;
contrast studies may show thickened bladder wall

12. Feline Idiopathic (Interstitial) Cystitis
Treatment
Avoid unnecessary antibiotics
Change diet from dry to moist
Or salt food to ↑ water intake
Reduce stress from other cats, kids, etc
Provide hiding places
Pheromonotherapy
Behavior modification drugs (may also have pain reducing effects
Amitryptilline (tri-cyclic antidepressant)
Clomipramine
Glycosaminoglycan replacement
Cosequin for cats
Adequan

13. Feline Idiopathic (Interstitial) Cystitis
Client info
Disease is self-limiting
As many as 85% of cats will have resolution of clinical signs in 7-10 days
May be recurring problem
No definitive cure
Reduce stress

14. Canine Bacterial Cystitis
Cause: Ascending bacteria up the urethra
Signs
↑ frequency of urination
Hematuria
Dysuria
Cloudy urine, abnormal color
Frequent licking of vaginal/urethral area

15. Canine Bacterial Cystitis
Diagnostics
Urinalysis:
↑WBC’s, bacteria
Common bacteria: E.coli, Proteus spp.
Urine culture/sensitivity
Collect by cystocentesis or mid- stream collection

16. Canine Bacterial Cystitis
Treatment
Antibiotics according to sensitivity
Treat acute infections x d
Subsequent infections x 4-6 w
Avoid trauma to urinary tract during surgery
Patients needing indwelling catheters should have a closed system

17. Closed Urinary Catheter System

18. Canine Bacterial Cystitis
Client info
Many uncomplicated urinary tract infections resolve without Rx
Give antibiotics as directed for the time prescribed
Relapses 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

19. DISEASES OF THE URINARY SYSTEM
Cystitis Cystic calculi Urinary obstruction ARF & CRF Incontinence

20. Feline Uroliths and Urethral Plugs
“Plugged” or “Blocked” male cats are commonly seen in small animal practice and can be fatal if not relieved

21. 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

22. 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

23. Feline Uroliths and Urethral Plugs
Uroliths (bladder stones) found anywhere in urinary tract
Formed 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

24. Feline Uroliths and Urethral Plugs
Uroliths damage bladder, making it more susceptible to bacterial infection, hematuria
Uroliths can cause blockage of the urethra of males
Bladder will fill with urine
Kidneys will stop working
Blood/body will become toxic (azotemic)

25. Feline Uroliths and Urethral plugs

26. Feline Uroliths and Urethral PlugsDx
Palpation 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

27. Feline Uroliths and Urethral Plugs
Double-contrast cystogram
with stones
Normal double-contrast cystogram
pneumocystogram

28. Ultrasound of bladder stone

29. Feline Uroliths and Urethral Plugs
Treatment
Medical 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 wk
Re-radiograph, and continue diet 1 mo after uroliths gone
Cystotomy to remove stones
Antibiotics according to culture/sensitivity

30. Feline Uroliths and Urethral Plugs

31. Feline Uroliths and Urethral Plugs
Medical treatment (obstructed)
This is a medical emergency
Anesthetize (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

32. Feline Uroliths and Urethral Plugs

33. Closed Urinary Catheter System

34. 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*

35. Feline Uroliths and Urethral Plugs: Perineal Urethrostomy

36. Feline Uroliths and Urethral Plugs: Perineal Urethrostomy

37. Canine Urolithiasis
Os Penis

38. Canine Urolithiasis
Uroliths damage mucosa of urinary tract making it susceptible to infection
Uroliths can obstruct urine flow in males
Clinical Signs
pollakiuria
Dysuria
Hematuria

39. Canine Urolithiasis Dx Urinalysis Radiographs Crystalluria Hematuria
↑ bacteria
Radiographs

40. Canine Urolithiasis

41. Canine Uroliths Urolith Breed Sex Contributing factors Rx
Struvite min sch female (80%) alkaline urine acidify urine
(Mg Ammonium Phos) cats bacteria→urease→↑pH antibiotics
minerals (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/d
Shih Tzu acid urine
Urates Dalmatians males ↑ uric acid from kidneys Allopurinol
E bulldogs acid urine (gout in humans)
min schnauzer K+ Citrate (↑ urine pH)
Shih Tzu Hill’s u/d,
Yorkshire terrier

42. Canine Uroliths Struvite Calcium Oxalate Urate
Type of stone cannot be determined by appearance; chemical analysis is required

43. Urolithiasis (Canine)
Treatment
Medical (dissolve stones if Struvite)
diet
Acidify urine
Urinary acidifiers (methionine, Methogel)
↑ urine output
Add salt to diet, increase water intake
Antibiotics 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

44. Canine Urolithiasis: Cystotomy for stone removal

45. Canine Urolithiasis
What do you see?

46. Canine Urolithiasis Client info
Special diet may be required for life-time
Table scraps/treats should be limited
Long-term antibiotics may be required
Uroliths may recur at any time
Always provide plenty of fresh water
Allow plenty of bathroom time and frequency

47. EDUCATION
“It is possible to store the mind with a million facts and still be entirely uneducated.”
- Alec Bourne

48. DISEASES OF THE URINARY SYSTEM
Cystitis Cystic calculi Urinary obstruction ARF & CRF Incontinence

49. Renal Failure ~20% of Cardiac output Renal Failure due to:
Filtered by renal corpuscle
Reabsorbed by kidney tubules
Waste excreted as urine
Renal Failure due to:
↓ blood flow (hypoperfusion)
Damage to nephron and glomerular filtration declines resulting in azotemia

50. AZOTEMIA Pre-renal Renal Post-renal dehydration
Primary kidney disorders
Post-renal
Urinary tract obstruction

51. Acute Renal Failure Three 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)

52. Stages of Kidney disease
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

53. Acute Renal Failure Causes Damage to nephron Nephrotoxic drugs
An abrupt decrease in glomerular filtration →azotemia
Causes
Damage to nephron
Nephrotoxic drugs
Aminoglycosides (gentamicin, streptomycin)
Chemotherapeutic agents
Antifungal medications
Analgesics (acetaminophen)
Anesthetics (methoxyflurane [Metafane])
Ethylene glycol (antifreeze)

54. Acute Renal Failure Causes: Infections (pyelonephritis)
Immune-mediated diseases (Glomerulonephritis)
Metabolic: Hypercalcemia
↓ Renal perfusion
Shock
Hypovolemia/dehydration
Hypotension

55. Acute Renal Failure Signs (non-specific)
Kidneys are enlarged and painful on palpation
Signs of azotemia
Anorexia, dehydrated
Vomiting/diarrhea
Weakness
Fever

56. Acute Renal Failure Dx Urinalysis
urine sediment - casts
low sp gravity (unable to concentrate urine)
CBC
dehydration (↑PCV)
acidosis
Chem panel
↑ BUN, Creatinine
↑K+, Phosphorus

57. Tx (aim is to restore renal hemodynamics)
Acute Renal Failure
Tx (aim is to restore renal hemodynamics)
Relieve tubular obstruction
Discontinue any toxic drugs
IV fluids
Correct dehydration
Correct acid/base imbalance

58. Acute Renal Failure Client info
Renal 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 kidney
Appropriate diet
Adequate water access

59. 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 yrs Cats > 10 yrs
The normal function of ADH (antidiuretic hormone: released from the brain) on the kidneys is to control the amount of water reabsorbed by kidney nephrons. ADH acts in the distal portion of the renal tubule (Distal Convoluted Tubule) as well as on the collecting duct and causes the retention of water, but not solute. Hence, ADH activity effectively dilutes the blood (decreasing the concentrations of solutes such as sodium).
ADH is secreted to prevent water loss in the kidneys

60. Chronic Renal Failure Progressive
1st function lost: Ability to concentrate urine
PU, PD, nocturia
Loss of ADH response
Other functions lost: Ability to cleanse blood
Azotemia (toxemia)
Begins at ~75% of nephron loss
↑ BUN, Creatinine
Anemia: erythropoietin secreted by kidneys

61. Chronic Renal Failure Signs Dull, lethargic, weak Anorexia, wt loss
PU/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).

62. Chronic Renal Failure Dx Acidosis Anemia Proteinuria ↑ BUN, Creatinine
increased phosphorus
Hypokalemia
Proteinuria

63. Chronic Renal Failure Tx Fluids for dehydration (IV, SQ)
Potassium gluconate, calcium carbonate for electrolyte imbalances
Phosphorous binders: Aluminum hydroxide
Sodium bicarbonate for pH adjustment
Hormones
Epoetin
Vit B supplements

64. Chronic Renal Failure Client info CRF is progressive and irreversible
Rx is aimed at slowing its progress
SQ fluids at home are required to maintain hydration
Warm foods to improve palatability
Quality of life will decrease; euthanasia may have to be considered

65. Azotemia: Bun and Creatine
ARF
(large size)
CRF
(small size)
PCV
Inc.
Dec.
Azotemia: Bun and Creatine
Phosphorous
Potassium
Other
Acidosis, proteinuria

66. DISEASES OF THE URINARY SYSTEM
Cystitis Cystic calculi Urinary obstruction ARF & CRF Incontinence

67. Urinary Incontinence Causes
Loss of voluntary control of micturition
Causes
Neurogenic—loss of normal neural function causing a paralyzed bladder
Ectopic ureters
Patent urachus
Endocrine imbalance (after spay)

68. Urinary Incontinence Signs Dx
Urine leakage when pet is sleeping or exercising
Perianal area of pet is always wet
Concurrent urinary tract infection Dx
Urinalysis
X-rays/cystography
Chem panel to r/o PU from endocrine disease

69. Urinary Incontinence Rx (based on specific cause) Client info
Surgical correction
Endocrine 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
DES: Estrogen

70. References Alleice Summers, Common Diseases of Companion Animals
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