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SA Sx - Urinary 3

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drraythe's version from 2017-09-15 14:51

Incontinence

Question Answer
What is the "urge" incontinence about?Urge to urinate due to inflammation/Infxn
What is usually the problem w/ congenital incontinence?Ectopic ureter, patent urachus
Paradoxical incontinence is bc....Partial obstruction, so sometime a prob sometimes not
What might be the cz of neurogenic incontinence?OVH (bc nn damage to bladder if pull on uterus hard for OHE)
Urethral sphincter mechanism incompetence bc..Estrogen probs most likely
Urethral sphincter mechanism incompetence → how do you treat this medically? (Medically before Sx Tx)Estrogen
Testosterone
Sympathomimetic drugs (Ephedrine, DES, PPA, Gonadotropins & Imipramine)
What are some sympathomimetic drugs you can use to try to medically Tx urethral sphincter mechanism incontinence?Ephedrine
DES
PPA
Gonadotropins & Imipramine
What are the 4 surgical procedures used to Sx Tx Urethral sphincter mechanism incompetence?(1) Colposuspension
(2) Cystourethropexy
(3) Injecting Teflon or collagen around sphincter
(4) Hydraulic occluder
Colposuspension is done in what gender(s)?Females (Colpo means vagina lol)
What are you doing in a Cystourethropexy? What gender(s)?Taking urethra & pinning it against the wall. Reduces lumen & avoids leakage of urine. Can be in males & females. He notes it has low success rates
Why does Injecting Teflon or collagen around sphincter help w/ Urethral sphincter mechanism incompetence?Czs bulging of mucosa at neck of bladder & obstruct leakage of urine. Has to be reinjected 6 mos to 1 yr
How does Colposuspension work? (pic)Place stitches from outside mm grabbing wall of vagina & driving them through abd wall - puts pressure against neck of urethra & occludes it maintains bladder from leaking
Intramural ectopic ureters → which procedure?Neoureterostomy
Extramural ectopic ureters → which procedure?Ureteroneocystostomy
Explain hydraulic occludes & how they work to help w/ Urethral sphincter mechanism incompetencePort-inject saline into cuff. Cuff around neck of bladder & sutured to itself. Then cuff inflated & czs pressure inward around tubing of urethra.
4 czs of FELINE urinary incontinence(1) Neurogenic czs (common)
(2) Iatrogenic (assoc. w/ Sx)
(3) Juvenile
(4) FLUTD
What is going on in feline juvenile urinary incontinence?Vaginal aplasia w/ abnormal bladder neck & very short urethra
What is FLUTD? How is it related to feline urinary incontinence?"Feline lower urinary tract Dz” not always true incontinence, but may urinate inappropriately, e.g. when picked up! With chronicity, can develop thickened bladder wall & decreased compliance & capacity
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Lithiasis

Question Answer
Average age for bladder stones?3-7yr
Most common stone?Struvite
How often are stones renal? How often are they bladder?90% bladder, 10% renal
Even if the stones might be too small to palpate, how might you be able to suspect bladder stones on palpation?can feel thickening of bladder wall due to cystitis/irritation
If you leave an indwelling cath in for a few days, when you take it out, what should you do? & why?Cut off the tip & send in for culture in case there ends up being a problem - bc biofilm on catheter. Lots of bugs - we need to be careful w/ urinary caths. Handle w/ gloves & aseptic technique! make sure collecting bag is not on floor
explain how you'd Dx stones w/ cystoscopySmall incision in abdominal/bladder, 3-4 stay sutures to being bladder forward, insert scope & look around
How does a Percutaneous cystolithotomy work?
If you are going to be performing contrast studies on the bladder for stones, what precautionary measure should you take?Have catheter in place - bc dont want blockage esp male
Most stones you can see on rads - but some you cant (Corrigan says: cystine & urate) in which case, how can you try to see radiolucent stones?Use double contrast
Be mindful not to confuse what w/ stones, when trying to Dx radiographically?Bubbles & clots
4 most common bladder stones?Struvite
Cystine
Ammonium urate
Oxalate
Which bact are more commonly associated w/ bladder stone stuff?Staph more common than proteus
Which stones are sharp & can cz lots of damage?Calcium oxalate (dihydrate)
What do struvite stones look like?Smooth w/ convexity & concavity
Ammonium urate usually lookSmall round & smooth
Cystine usually lookOddly shaped & bumpy
Ca oxalate usually look likeSharp & damaging
Chronic stone problems can cz bladder to be..Irritated & really thickened
Who is prone to struvite??(2)GSD, Schnauzer
Who is prone to ammonium urate? Possible reasons?(5)Dalmatian prone due to genetic defect
Bull dog prone & then all breeds predisposed to PSS - Yorkie, Collie, Schnauzer
Who is prone to oxalate stones? (1)Schnauzer
Who is prone to cystine stones?(4)Dachshund
Basset
Yorkie
Chihuahua
Which 3 breeds are MOST prone to recurrence of stones? (who’s the most? % recurrence?)*Dachshund 47%
Dalmatians 33%
18% schnauzer
Schnauzer get which stones?3/4 types - get struvite & ammonium urate & oxalate...DONT get cystine
What’s up w/ the Dalmatians & the urate stones (why this prob?)Not a lack of uricase!! It's reduced hepatic transport that czs reduction in metabolic rate of conversion. Reduced hepatic transport is like a 3RD compared to other breeds.
Explain procedure for cystotomy - (step 1, clearing the urethra)Easier to do cystotomy w/o a urethrotomy also, (tho might consider both if a chronic recurring problem), so wanna clear urethra. Place urethral catheter, flush urethral calculi into bladder for removal, if possible. If FEMALE: If the stones lodge in the urethra, you can try to push or pull it. *If using forceps, careful not to pinch the urethra. Prolly better to push it back in & see if it comes out normal. If MALE: if male, stone prolly piled up behind os penis. Can place cath. - French is the gauge (Fr) so 8, 10, 12fr is size you want to use. Avoid white stiff caths - will damage bc wont go around ischial arch.
Explain how you are able to flush the urethra (male/ female & male) before a cystotomy w/o squirting water everywhere/not being able to build up enough pressure to push the stones?Insert cath into penis...dont grab tip of prepuce, cz otherwise when you flush you dilate urethra & get backflow that hits your face. So expose penis, grab tip of penis & hold & pinch tight so water doesnt splash into your face. OR, for female & male, put finger in rectum...this is kinda like water test. Push rectal wall down & collapse lumen of urethra. Also hold penis, so then have assistant push plunger of the syringe. (So basically grab penis firmly, push downward w/ finger in rectum, when feel water pressure, then let go & let water push stones into the bladder)
Explain procedure for Cystotomy → (step 2, incision & removal.)You want incise going Ca to Cr (toward apex) in the hypovascular area. Make incision large enough to remove stone so no damage to bladder wall. 4 stay sutures! (2 on each side of incision) & then a stay suture on the apex. Remove stone, consider getting sample for CS. Then flush bladder & remove fluid via suction, then place cath via urethra & flush all the way down & look at tip of penis & see what comes out (make sure to flush bladder & urethra before closure). So have tip of penis isolated & far from incision line - & use gauze to collect flush/sandy material so its not all over Sx field. Flush urethra in antegrade (displace any potential stones by os penis) &/or retrograde to get sandy material out of any crevices so goes back into bladder.
Explain procedure for Cystotomy → (step 3, closure)In a tiny bladder, no place for 2 inverting layers so do simple apposition. Do water test, if leaks, add extra stitch. Flush to make sure NOTHING LEFT BEHIND
What is laser lithotripsy? Are you worried about a high powered laser being in the PTx?Little laser attached to end of cystoscope - laser fires off & breaks up big stones into little pieces which can be the retrieved w/ retrieval basket claw or voided by urohydropropulsion. Photothermal process & the laser energy is absorbed in <0.5mm of fluid, penetrates less than 1mm making it safe for urologic procedures
If you are recc a special stone diet, what should you be sure to emphasize to owners about why they should test their animal 1st?Bc type of diet depends on what stones they have (need to see what stones they have 1st then)
If you are using instruments to pick up stones in the bladder, why must you be super careful?Pinch mucosa → blood everywhere → cant see bc blood everywhere
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Neoplasia/ Trauma

Question Answer
How often are bladder neoplasia malig? Benign?Only 3% are benign! :(
What are the chances that when the animal presents for neoplasia, it has already metastasized?50%
6 possible neoplasias of the bladder?Leiomyoma
Fibroma (the 2 benign ones)
Transitional cell carc.
Adenocarcinoma
Leiomyosarcoma
Rhabdomyosarcoma
Which type of neoplasia is most common at the level of the trigone?TCC ((which means most salvage procedures are moot since the trigone is the 1 place that can't be lost)
What is an immune modulator which MIGHT be able to help w/ TCCs (since you can't remove them bc theyre at the level of the trigone)Piroxicam
How do you try to visualize neoplasia in the bladder via rads?Contrast studies (in example, clearly roughened mass near trigonal area) <img src""height="250">
Are polyps usually malign or benign? How can they appear? How can you Dx them? Which Sx you gotta do for removal?Usually benign, can be on a stalk or kinda like a mushroom. Can see them w/ U/S. might have to do a cystectomy
*Any time you have a HBC, always do what?Cath to make sure no damage to urethra/bladder (always suspect trauma to the bladder)
Rhabdomyoma of the bladder are usually where? How do you Sx Tx them?Tumor usually either in body or apex (most neoplasia are, except TCC = trigone) - facilitates partial cystectomy well (up to 70-75% & can heal well/regain norm Fxn)
CSs of bladder trauma?Dysuria
Anuria
Hematuria
Fluid in the abdomen
Swelling & discoloration of the skin
Abdominal distension & pain
Uremia
*Why is uroperitoneum a medical EMERGENCY? (3 major probs)Hyperkalemia
Uremia
Dehydration
What kind needle/cath do you use to perform an abdominocentesis? How should you prepare the PTx prior to the centesis? HOW do you INSERT needle? (How do avoid risks of sticking needle into abdomen)Can do w/ needle or butterfly. Need to prepare site surgically (aseptic technique). When you insert needle/cath there is a risk you might pinch or perforate bowel. However, if you touch bowel it tends to move/react...so if you enter very delicately & if you happen to touch w/ tip of needle the bowel, the bowel will move out of way! But don't stab in or youll get into the lumen of intestines = baddddd
What tools will you need for a DPL (diagnostic peritoneal lavage)? How much of fluid do you collect after adding for the DPL? What is the benefit of DPL over abdominocentesis?Can either use a special cannula for dialysis (multifenestrated w/ markers) OR, large bore cath & add 2-3 holes you can make w/ scalpel (not more than 30% circumference). 1st add 20-22ml/kg warm LRS, roll PTx, then put on side & collect 30-40-50% of what you inserted. Better sampling than w/ abdominocentesis
Once you have inserted the cath for the abdominocentesis, how do you go about sampling/removing fluid?Connect the cath to extension of a t-port so someone else can work w/ syringe while you are holding catheter in place (so there is no stabbing or falling out)
6 options for Sx Tx of a bladder rupture?(1) Cystotomy (to explore damage)
(2) CystoStomy
(3) Partial cystectomy (w/ or w/o ureteral reimplantation)
(4) Total cystectomy (salvage procedures - giving dog a cloaca)
(5) Urinary diversions
(6) Bladder reconstruction
If there has been a bladder rupture (or severe weakening) how might the body try to compensate for this & how will you have to deal w/ it surgically? Which closure will you use for an uncomplicated bladder rupture/tear?Omentum can adhere to bladder on own if ruptured to try to heal on own. Will have to debride & remove any omentum stuck. Simple interrupted apposition. Lavage abd thoroughly
What are the internal techniques for urinary diversions?It's the salvage procedures (not really recc) Trigonal-colonic anastomosis, Ureteral-colonic anastomosis, Urethral-colonic implantation
What is the external technique for urinary diversions?Cystostomy
4 indications for surgically doing a urinary diversion?Neoplasia
Trauma
Neurogenic incontinence
Temporary following Sx (especially repair of ruptured bladder)
If you are performing an internal urinary diversion, what drugs should you give postop?ABX! Intermittent use for rest of PTx’s life. (Culture of limited value bc of fecal admixture in internal procedures).
If you performed cystostomy as an external urinary diversion procedure, what precaution should you take post-op?protect skin from urine scald
3 complications of using urinary diversion Sx?(1) Ascending Infxn (pyelonephritis)
(2) Liquid mixture of feces & urine excreted
(3) Incontinence (cystostomy)
Explain the basics of how to perform a tube cystostomyProcedure creates new stoma w/ tube. Place purse string, then stab incision inside purse string area. Then make a diff incision near 1° incision (no drains exit through 1° incision!) & insert Foley cath from 2° incision, thread through & insert into bladder through 1° incision. Then inflate balloon, tie purse string, close 1° incision & finger trap the tube to the 2° incision
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