what is going on in feline juvenile urinary incontinence?
vaginal aplasia with abnormal bladder neck and 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 and decreased compliance & capacity
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? and why?
cut off the tip and send in for culture in case there ends up being a problem- bc biofilm on catheter. lots of bugs- we need to be careful with urinary caths. Handle with gloves and aseptic technique! make sure collecting bag is not on floor
explain how you'd dx stones with cystoscopy
small incision in abd/bladder, 3-4 stay sutures to being bladder forward, insert scope and 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 and urate) in which case, how can you try to see radiolucent stones?
use double contrast
be mindful not to confuse what with stones,when trying to dx radiographically?
bubbles and clots
4 most common bladder stones?
struvite, cystine, ammonium urate, oxalate
which bact are more commonly associated with bladder stone stuff?
staph more common than proteus
which stones are sharp and can cause lots of damage?
Calcium oxalate (dihydrite)
what do struvite stones look like?
smooth with convexity and concavity
ammonium urate usually look
small round and smooth
cystine usually look
oddly shaped and bumpy
ca oxalate usually look like
sharp and damaging
chronic stone problems can cause bladder to be..
irritated and really thickened
Who is prone to struvite?? (2)
who is prone to ammonium urate? possible reasons? (5)
Dalmatian prone due to genetic defect, Bull dog prone, and then all breeds predisposed to PSS- yorkie, collie, schnauzer
who is prone to oxalate stones? (1)
who is prone to cystine stones? (4)
Dachshund, basset, yorkshire, Chihuahua
which three breeds are MOST prone to recurrence of stones? (whos the most? % recurrence?)
*Dachshund 47%, dalmations 33%, 18% schnauzer
schnauzer get which stones?
3/4 types-- get struvite, and ammonium urate, and oxalate......DONT get cystine
what's up with the dalamations and the urate stones (why this prob?)
not a lack of uricase!! It's reduced hepatic transport that causes reduction in metabolic rate of conversion. reduced hepatic xport is like a THIRD compared to other breeds.
explain procedure for cystotomy- (step 1, clearing the urethra)
Easier to do cystotomy without 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 and 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 and male) before a cystotomy without squirting water everywhere/not being able to build up enough pressure to push the stones?
insert cath into penis...dont grab tip of prepuce, cause otherwise when you flush you dilate urethra and get backflow that hits your face. so expose penis, grab tip of penis, and hold and pinch tight so water doesnt splash into your face. OR, for female and male, put finger in rectum...this is kinda like water test. Push rectal wall down and collapse lumen of urethra. also hold penis, so then have assistant push plunger of the syringe. (so basically grab penis firmly, push downward with finger in rectum, when feel water pressure, then let go and let water push stones into the bladder)
explain procedure for Cystotomy--> (step 2, incision and 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! (two on each side of incision) and then a stay suture on the apex. remove stone, consider getting sample for C/S. Then flush bladder and remove fluid via suction, then place cath via urethra and flush all the way down and look at tip of penis and see what comes out (make sure to flush bladder AND urethra before closure). So have tip of penis isolated and far from incision line-- and 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) and/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 pt?
little laser attached to end of cystoscope-- laser fires off and breaks up big stones into little pieces which can be the retrieved with retrieval basket claw or voided by urohydropropulsion. photothermal process and 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 first?
bc type of diet depends on what stones they have (need to see what stones they have first 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
What are the chances that when the animal presents for neoplasia, it has already metastasized?
6 possible neoplasias of the bladder?
leiomyoma, fibroma (the two 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 one place that can't be lost)
what is an immune modulator which MIGHT be able to help with TCCs (since you can't remove them bc theyre at the level of the trigone)
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 malig 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 with 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% and can heal well/regain norm fxn)
clinical signs of bladder trauma?
dysuria, anuria, hematuria, fluid in the abdomen, swelling and discoloration of the skin, abdominal distension and pain, uremia
*Why is uroperitoneum a medial EMERGENCY? (3 major probs)
hyperkalemia, uremia, dehydration
what kind needle/cath do you use to perform an abdominocentesis? how should you prepare the pt prior to the centesis? HOW do you INSERT needle? (how do avoid risks of sticking needle into abdomen)
can do with 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, and if you happen to touch with 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 benifit of DPL over abdominocentesis?
can either use a special cannula for dialysis (multifenestrated with markers) OR, large bore cath and add 2-3 holes you can make with scalpel (not more than 30% circumference). First add 20-22ml/kg warm LRS, roll pt, then put on side and collect 30-40-50% of what you inserted. better sampling than with 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 (with or without 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 and how will you have to deal with it sxclly? Which clsure 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 and remove any omentum stuck. simple interrupted apposition. lavage abd thoroughly
what are the Internal techniques for urinary diversions?
what is the external technique for urinary diversions?
4 indications for surgically doing a urinary diversion?
Neoplasia, Trauma, Neurogenic incontinence, Temporary following surgery (especially repair of ruptured bladder)
If you are performing an internal urinary diversion, what drugs should you give postop?
(1) ABX! Intermittent use for rest of patient’s life. (Culture of limited value because 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 infection (pyelonephritis) (2) Liquid mixture of feces and urine excreted (3) Incontinence (cystostomy)
explain the basics of how to perform a tube cystostomy
procedure creates new stoma with tube. Place purse string, then stab incision inside purse string area. Then make a diff incision near primary incision (no drains exit through primary incision!) and insert foley cath from 2* incision, thread through, and insert into bladder through 1* incision. Then inflate balloon, tie purse string, close 1* incision, and fingertrap the tube to the 2* insision