Urinary system is made up of:

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

Urinary system is made up of:
Kidneys (2) Ureters (2) Bladder (1) Urethra (1) Main job of the urinary system: Waste removal Red blood cell production Regulation of water and electrolyte balance Controls blood pressure Kidneys: nephrons within make urine, Ureters: carry urine from kidneys to bladder, Bladder: where urine is stored until ready to be secreted, Urethra: connects bladder to outside world Regulation of water and electrolyte balance by adjusting water and electrolyte content, removes waste materials not needed and returns those necessary substances to the systemic circulation (will get rid of more or less of electrolytes depending on what the body needs) Controls bp: Kidneys secrete hormones in response to how much blood is flowing through the kidneys. There could be a lack of or too much blood flowing through, which would have an effect on the bp.

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 Blood filtration depends on bp, if the bp drops, then filtration in the glomerulus decreases and the production of urine stops. Acid–base balance by excreting hydrogen ions into the urine and reabsorbing bicarbonate from the urine Hormone production helps with BP (aldosterone- bumps up bp and antidiuretic (ADH) increases urine production ). This would be due to an increase in blood flow to the kidneys (could be renal hypertension, narrowing of arteries). Low blood flow could be a result of dehydration.

DISEASES OF THE URINARY SYSTEM
URINARY SYSTEM IS NORMALLY STERILE AND RESISTANT TO BACTERIAL INFECTION B/C OF: Voiding of urine Urethral/ureteral peristalsis Glycosaminoglycans in the surface mucosal layer pH (6.0 – 6.3): water and blood neutral Peristalsis: how urine flows from ureters to bladder and from urethra to outside Glycosaminoglycans are large protein/sugar complexes that have anti-inflammatory properties; can be given as supplements Alkaline urine is high PH, acidic urine is low PH

URINARY SYSTEM DISORDERS
Clients abandon pets or want pet put down because of inappropriate elimination About 4 million cats a year are destroyed or abandoned for “elimination problems”.

Feline Idiopathic (Interstitial) Cystitis
aka FUS/ FLUTD Feline Urologic Syndrome or Feline Lower Urinary Tract Disease Most common cause of UTI in cats; rarely associated with bacteria Cystitis: inflammation of the bladder FACTS: Occurs in cats almost any age Occurrence in males > females cause unknown, multi-factorial, virus(?) not caused by bacterial infection recurrence is likely

Clinical Signs pollakiuria Hematuria Dysuria Periuria (sinks, tubs, carpet, etc.) Pollakiuria – passing small amounts of urine very frequently Periuria: inappropriate urination

Diagnostics Urinalysis/culture to rule out bacteria as cause Only 1%-3% of all feline cystitis is caused by bacteria Radiographs to rule out bladder stones If it is caused bacteria, then it is not idiopathic. Cystocentesis on Dove: on a cat (2mins 10 sec) Cystocentesis on Dove: ultrasound guided (2mins 41 sec)

Treatment Avoid unnecessary antibiotics Change diet from dry to moist or add water to dry food Reduce stress from other cats, kids, etc Provide hiding places Pheromone therapy Behavior modification drugs (may also have pain reducing effects) Amitryptilline (tri-cyclic antidepressant) Clomipramine Glycosaminoglycan replacement Cosequin for cats Adequan Unnecessary antibiotics causes antibiotic resistance. Wet food dilutes urine Pheromone therapy: Feliway products Amitryptilline/Clomipramine: helps with nerve pain Glycosaminoglycan: supplement anti-inflammatory

FELIWAY Can also use pain meds such as Fentanyl patches or butorphanol for pain management. Anti-inflammatories can also be used. (5 mins)

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, but diet change is the most effective (Hill’s c/d Stress) Reduce stress Any treatment instituted will look like it works bc it clears up on its own Cats need to have hiding spots and “safe” places; and access to litter boxes in safe space Increase water intake

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 Bacterial UTI: occurs in 1-3% of feline cystitis, it is the most common cause cystitis in dogs UTI most commonly the result of migration of bacteria up the urethra Once in the bladder, they colonize in the mucosal lining The bacteria can develop when feces or debris enter the area

Diagnostics Urinalysis: ↑WBC’s, bacteria Common bacteria: E.coli, Proteus spp. Urine culture/sensitivity Collect by cystocentesis or mid-stream collection WBC increase due to infection. Remember with free catch there will be more bacteria. Urine culture usually takes up to 24 hours

Treatment Antibiotics according to culture/sensitivity results Treat acute infections x d Chronic infections x 4-6 w Avoid trauma to urinary tract during surgery Patients needing indwelling catheters should have a closed system Indwelling: inside body Most uncomplicated UTI’s resolve without treatment

Closed Urinary Catheter System
Urinary catheter in boy and girl: DOVE 3:20mins, 5mins

Client info Many uncomplicated UTI’s resolve without treatment Give antibiotics as directed for the time prescribed Prostate may be source of recurring infections in male dogs Urine cultures should be repeated during treatment to access effect Urine cultures are expensive Prostate decreases in size when dog is neutered An enlarged prostate gland can cause uncomfortable urinary symptoms, such as blocking the flow of urine out of the bladder. It can also cause bladder, urinary tractor kidney problems

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

Feline Uroliths & Urethral Plugs
The two most common causes of urethral blockage are uroliths and urethral plugs UROLITHS: composed predominantly of minerals URETHRAL PLUGS: composed predominantly of matrix (mucoprotein, rbcs, wbcs, epithelial cells, etc.) Two causes of urethral obstruction Minerals: Struvite, Calcium oxalate, Ammonium urate, cystine Some are radiopaque (can see on rads), others not. Need to do a double contrast cystography to be seen. Urethral plug: a plug formed that can not be passed.

Signs Hematuria Dysuria Periuria Anorexia, vomiting Collapse, death Non-specific signs: Hiding Crying while urinating Frequent trips to the litterbox Periuria: inappropriate urination Anorexia/vomiting due to uremia (waste products in blood/build up of urea (urine in blood) and azotemia (3-6 days blocked). Azotemia: build up of nitrogen in the blood In most cases cause is unknown. Diet high in magnesium produces Struvite uroliths (most common) Could just look like a UTI

Uroliths can be 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 special imaging techniques to visualize Double contrast cystography Ultrasonography: can see location of bladder stones Diet high in magnesium produces Struvite uroliths (most common) Pneumocystogram: radiograph after being injected with air First empty bladder, inject with contrast through urinary catheter (air and contrast)- water-soluble iodine-based contrast and air Pneumocystogram

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 Patient will become azotemic Build up of waste and toxins Azotemia: build up of nitrogen in blood (waste product of the digestive proteins)

Feline Uroliths and Urethral plugs
Hemorrhage: release of blood from a broken blood vessel. This is caused by stones hitting the inside of the bladder wall. Urine will be very bloody

Diagnosis Palpation of bladder Obstructed bladders are full and tight Radiographs may show uroliths Ultrasonography Urolith analysis is necessary to determine its constituents EKG: atrial standstill, bradycardia, due to hyperkalemia Bladder palpation on Dove Bladder will feel like a huge rock Hyperkalemia: high levels of potassium in blood. Happens when kidneys cannot remove potassium from body (kidneys help balance out potassium in the body) Hyperkalemia: Dove video atrial standstill-not contract: absence of atrial electrical activity, this could lead to ventricular arrythmias, fibrillation and asytole.

Treatment Medical treatment (non-obstructed) Dissolve struvite uroliths by acidifying urine and feeding diet low in Mg (Hill’s S/D, c/d) 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 Struvites are made of Magnesium Cystotomy: incision into bladder (2mins 35sec) Alkaline urine is high PH, acidic urine is low PH (high PH leads to stone formation)

Medical treatment (obstructed) This is a medical emergency Anesthetize *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 Can’t process drugs(unable to bind with appropriate proteins)

Closed Urinary Catheter System
Cats are different, you have to suture it in. Unblocking a cat Dove video

Surgical treatment (chronic obstructors) 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* This surgery has risk, more prone to UTI, might need to do a cystotomy to remove stones.

Feline Uroliths and Urethral Plugs: Perineal Urethrostomy
Pull the urethra up to make a hole under the rectum Remove much of the penis and the narrow portion of the urethra and leave a wider opening for the remaining portion under the anus

Feline Uroliths and Urethral Plugs: Perineal Urethrostomy
Hypotension, Dehydration, and Electrolyte imbalance Calcium: You might recognize this as something that is associated with bone health Chloride: This electrolyte helps to keep the tendons and joints health Magnesium: Magnesium helps convert glucose to energy Surgical patients should have IV fluids to prevent?

https://youtu.be/2KcuW- trvPI Feline Perineal Urethrostomy
PU surgery: Dissect surrounding tissues until the urethra is exposed, and then will make an incision in the urethra and the penis. The surgeon will suture the edges of the urethra to the edges of the skin incision to create a wide urethral opening. Some surgeons choose to use absorbable sutures (stitches) that dissolve over time. Other surgeons use non-absorbable sutures that need to be removed in about 10 to 14 days. When the procedure is done to intact tomcats, castration is usually performed as the same time The surgery is done typically between the scrotum and the rectum

CANINE UROLITHIASIS

Canine Urolithiasis Uroliths damage mucosa of urinary tract making it susceptible to infection Uroliths can obstruct urine flow in males Struvite: more common in females 3-8 years Calcium oxalate: more common in males years Urates: common in Dalmatians Most common uroliths in dogs? Urolithiasis: the formation of stony concretions in the bladder or urinary tract UTI’s are common in canines with urolithiasis Small uroliths can become lodged in the penile urethra in boys, slightly larger can be lodged in the female urethra Answer: Calcium Oxalate & Struvite (Magnesium ammonium phosphate)

Canine Urolithiasis The distal portion of the canine urethra is contained in the narrow canal of the os penis. This can be a common location for urethral stones to become lodged. a bone in the penis

Canine Urolithiasis Clinical Signs pollakiuria Dysuria Hematuria Dx
Urinalysis Crystalluria ↑ bacteria Radiographs Pollakiuria: Small amounts but frequent

Canine Urolithiasis

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

Urolithiasis (Canine)
Treatment Medical management - dissolve stones if Struvite Prescription diets Acidify urine Urinary acidifiers ( Methogel (methionine)) ↑ urine output increase water intake Antibiotics for bacterial infection Surgical removal ( Ca Oxalate) Some uroliths are not amenable to Medical Rx Prevention is key STONE ANALYSIS IS VITAL FOR APPROPRIATE TREATMENT Dissolve struvite uroliths by acidifying urine and feeding diet low in Mg (Remember, Struvite is Magnesium ammonium phosphate) Methogel: supplement (helps cause low ph), low PH means the urine is acidic. High PH means urine is alkaline You have to remove Ca Oxalate

Canine Urolithiasis: Cystotomy for stone removal

Canine Urolithiasis What do you see?
Don’t miss the stones lined up in the urethra! Sometimes they can use a RR to push the stones back into the bladder and then they can remove them with a cystotomy.

Canine Urolithiasis Client info Special diet may be required for life
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 Foods that are high in oxalate are potato chips and french fries

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

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 20% cardiac output pass through the kidneys Filtered by glomerular capillary membrane(located in renal corpuscle): removing small molecules, electrolytes, drugs, and other materials Reabsorbed what is needed for the body Hypoperfusion: a reduction in blood flow to an organ (nephron)- examples: dehydration, medications, blood loss Azotemia: build up of toxins within the body

AZOTEMIA Pre-renal Renal Post-renal dehydration
Primary kidney disorders Post-renal Urinary tract obstruction Pre-renal: Most common cause of acute renal failure due to lack of blood flow (Due to dehydration) Renal: Primary kidney disorders (Due to issues with the kidneys) could be due to medications, autoimmune disorders, high blood pressure Post-renal: Urinary tract obstruction (Due to obstruction after the kidneys) a blocked cat

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) Nephrotoxic injury can affect any portion of the nephron. Once any part is damaged, entire unit is lost. Nephrons cannot be replaced, but other nephrons can hypertrophy (grow larger) to help maintain normal renal function.

Stages of Kidney disease
Loss of Renal Reserve - Early signs of PU/PD Renal Insufficiency - Early warning signs, such as PU/PD 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 Azotemia: build of toxins (nitrogen) in blood, elevated BUN, early stage of renal failure. C/S: weakness, v/d, cachexia (weight loss) Uremia: build up of urea (urine in blood), compete renal shut down, can’t filter anything, end stage renal disease. A BUN test is done to see how well your kidneys are working

Acute Renal Failure 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) Antibiotic (Amikacin) Azotemia: build up of toxins (nitrogen) within the body Body is unable to filter correctly Damage to nephron: could be due to trauma/kidney disease

Infections (pyelonephritis)
Acute Renal Failure More causes: Infections (pyelonephritis) Immune-mediated diseases (Glomerulonephritis) ↓ Renal perfusion Shock Hypovolemia/dehydration Hypotension Pyelonephritis: Inflammation of the kidney due to a bacterial infection Glomeruli: what filters blood within the kidney, when damaged it does not filter correctly Hypovolemia: a decreased volume of circulating blood in the body ↓ Renal perfusion: blood flow through kidney

Kidneys are enlarged and painful on palpation Signs of azotemia
Acute Renal Failure Signs (non-specific) Kidneys are enlarged and painful on palpation Signs of azotemia Anorexia, dehydrated Vomiting/diarrhea Weakness Fever Larger kidneys: blockage of the kidney can also result in kidney atrophy

Acute Renal Failure Diagnosis Urinalysis
urine sediment - casts low sp. gravity (unable to concentrate urine) CBC dehydration (↑PCV) Chem panel ↑ BUN, Creatinine A BUN test is done to see how well the kidneys are working. If the kidneys are not able to remove urea from the blood normally, the BUN level rises. Blood creatinine level is a test of kidney function. The kidneys' ability to handle creatinine is called the creatinine clearance rate, which helps to estimate the glomerular filtration rate (GFR)

Tx (aim is to restore renal hemodynamics)
Acute Renal Failure Tx (aim is to restore renal hemodynamics) Relieve any urinary obstruction Discontinue any toxic drugs IV fluids Correct dehydration Correct acid/base imbalance Hemodynamics: Blood flow

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

Chronic Renal Failure Common in older pets; cats appear to be more affected than dogs Irreversible and progressive decline in renal function (nephron damage) 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

Chronic Renal Failure 1st function lost: Ability to concentrate urine
Progressive 1st function lost: Ability to concentrate urine PU, PD, nocturia Loss of ADH response Other functions lost: Ability to filter blood Azotemia Begins at ~75% of nephron loss ↑ BUN, Creatinine Anemia: erythropoietin secreted by kidneys Nocturia is a condition in which you wake up during the night because you have to urinate Creatinine is a waste product from the normal breakdown of muscle tissue. As creatinine is produced, it's filtered through the kidneys and excreted in urine. Doctors measure the blood creatinine level as a test of kidney function

Chronic Renal Failure Signs Dull, lethargic, weak Anorexia, wt loss
PU/PD, cervical ventroflexion hypokalemia Hypokalemia causes generalized muscle weakness; K+ is also lost from excessive vomiting Hypokalemia: Low potassium

Chronic Renal Failure Diagnosis
Look for abnormal blood work associated with kidney function Anemia ↑ BUN, Creatinine Proteinuria Protein build up because kidneys no longer filter correctly

Chronic Renal Failure Treatment Fluids for dehydration(IV, SQ)
Correct electrolyte imbalances Hormones Epoetin Start with normal saline, 5% dextrose, LRS; add electrolytes to bag as needed Epoetin is a man-made form of a protein that helps the body produce redblood cells

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

Urinary Incontinence 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) Patent urachus- tube that carried fetal urine to umbilicus did not close; causes animal to dribble urine from naval area Neurogenic: pt w/spinal cord disease Endocrine imbalance: Estrogen

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 Cystography is an imaging test that can help diagnose problems in the bladder Endocrine disease: Diabetes mellitus Cystography video Dove

Urinary Incontinence Treatment (based on specific cause) Client info
Surgical correction Endocrine deficiency in spayed female Diethylstilbestrol 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 Can see this with UTI’s urethral sphincter mechanism incompetence (USMI) which most often occurs in adult spayed female dogs Cystopexy is a relatively simple procedure that involves permanently securing the urinary bladder in a more proximal direction

Urinary system is made up of:

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