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Urinary Incontinence in the dog
Urinary Incontinence
Urinary Tract Infection

Urinary Incontinence in the Dog

David Tayman, D.V.M
Columbia Animal Hospital

tayman1

If your housetrained dog starts having indoor accidents, it could have a medical condition that’s interfering with its normal elimination habits. With the help of your veterinarian a diagnosis may be determined. Promptly treating your dog will put an end to its discomfort - and your carpet-cleaning bills. And remember, reprimands are unfair and ineffective if your dog’s house soiling problem stems from a medical ailment.

Normally, a circular muscle (sphincter) at the end of the urethra (the urine conduit out of the body) restricts urine flow. As urine fills the bladder, nerves in the bladder wall send signals alerting the brain. The brain then sends a release command to the sphincter, and urine flows.

The most common form of urinary incontinence (loss of the voluntary control described above) is estrogen-responsive incontinence - a condition rarely affecting some spayed females. The common complaint regarding this form of incontinence is leaking of urine while your pet is resting or sleeping. Estrogen depletion, resulting from ovary removal during spaying, apparently causes weakness of the urinary sphincter.

Veterinarians treat this disorder with estrogen supplementation or phenylpropanolamine (PPA).

Phenylpropanolamine stimulates the secretion of norepinephrine, a hormonal substance that increases sphincter muscle tone. Side effects PPA are hyperexcitability. This medication must be administered 2-3 times daily.

Estrogen at low doses is safe and will replace the loss of the hormone due to being spayed. Concerns about adverse effects should be minimized. Side effects include bone marrow suppression (which we have never seen in our practice) and the possibility of causing a false heat if administering to high of a dose. This medication is dosed to effect. That means, it may be given once weekly up to 3-4 times per week, depending on your pets clinical response to this drug.

Another possible cause of incontinence is trauma to the brain or spinal cord. Depending on the degree of nerve damage, a dog with such a condition may dribble urine intermittently or constantly. Most dogs with neurologic incontinence also exhibit other nerve-related maladies, such as loss of coordination.

It’s important to quickly diagnose and treat any form of urinary incontinence. Chronic exposure to urine can cause secondary complications such as skin ulcers, especially in dogs that are immobilized.

Indoor accidents can occur when a dog has a medical condition that generates more than the usual amount of urine. Cushing’s disease, diabetes mellitus (sugar diabetes), bladder stones, liver disease, and chronic kidney failure are several examples. In Cushing’s disease, the adrenal glands produce excess cortisol, which blocks the action of antidiuretic hormone and thus stimulates the kidneys to increase urine output. In diabetes mellitus, the pancreas produces insufficient insulin, the hormone that transports glucose into cells. Glucose then builds up in the blood, and the kidneys excrete excess glucose in large volumes of urine. Dogs with chronic kidney failure also produce large amounts of urine because their kidneys can’t properly channel water back into the bloodstream.

Some dogs feel the urge to urinate frequently when they have urinary-tract infections. Irritation of the bladder wall due to infection can lead to reflexive bladder contractions . Bladder stones can also cause an irritation to the bladder causing an increased urge to urinate. Other bladder conditions causing the dysfunction are tumors and polyps of the bladder.

And sometimes drugs contribute to increased urine volume. For example, diuretic drugs used to treat heart disease stimulate the kidneys to excrete more urine.

In healthy dogs, the anal sphincter prevents release of feces until the rectum fills and stretches. When stretched, rectal muscles signal the dog to relax the sphincter and defecate. Damage to the brain, spinal cord, or spinal nerves can disrupt these signals, causing the dog to defecate involuntarily. However, the most common medical cause of fecal house soiling is diarrhea, often the result of inflammatory conditions of the colon.

To successfully treat medically related house soiling, you must address the instigating cause. Once diagnosed, many cases of illness- induced house soiling clear up with appropriate treatment. While dogs with incontinence due to neurological damage or chronic kidney failure may never regain total control, they often fare quite well if a committed caretaker helps them with their elimination duties and keeps them clean and dry.

Here are some clues your vet will use to identify medical causes of house soiling:

Age: In young dogs, veterinarians consider congenital disorders such as a misplaced ureter (the tube connecting the kidneys to the bladder). Diabetes mellitus is more common in middle-aged dogs. And elderly dogs may suffer from arthritis - which makes natural elimination postures painful - or from chronic kidney failure.

Gender: Female dogs are more prone than males to developing urinary-tract infections. And estrogen-responsive urinary incontinence occurs exclusively in spayed females.

Breed: Boston terriers, poodles, dachshunds, and German shepherds are among the breeds predisposed to Cushing’s disease. And long and low breeds such as dachshunds and basset hounds show higher incidences of intervertebral disk disease, which can result in spinal-nerve damage and subsequent incontinence.

Urination Frequency: Veterinarians often suspect Cushing’s disease, diabetes, or chronic kidney failure in dogs that drink and urinate excessively. But if your dog urinates frequently and strains in the process, it could have an infection, bladder stones, or a bladder tumor.

reprinted with kind permission from David Tayman, D.V.M.
10788 Hickory Ridge Rd.Columbia, MD 21044
Phone: 410-730-2122  Fax: 410-992-9511
E-mail: info@petshealth.com
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THE PET HEALTH LIBRARY

By Wendy C. Brooks, DVM, DipABVP
Educational Director, VeterinaryPartner.com 
 
http://www.VeterinaryPartner.com
    
Urinary Incontinence

When a house pet develops urinary incontinence, many owners fear the worst. Assumptions that incontinence signifies senility or irreparable age related change may lead to delay in medical consultation, relegation of the pet to an outdoor life, or even euthanasia. In reality, urinary incontinence is usually one of easiest problems to solve so it is crucial that veterinary assistance be sought before an owner’s patience is completely worn and before any permanent decisions about the pet’s future become topical.

Causes of Incontinence
It is important to differentiate incontinence (involuntary urine leakage) from behavioral urinary issues (submissive urination), simple lack of housetraining, territorial marking of unneutered males or anxious cats, or the senile loss of house-training from canine cognitive dysfunction. Animals may urinate in the house voluntarily and this is different from incontinence. Watch your pet closely to be sure what you are seeing is really incontinence and if it is, the good news is that most cases are easily resolved with simple inexpensive medications.

There are several important causes of incontinence and most of these are ruled in or out with a urinalysis and urine culture. The urinalysis reveals cell types and biochemical elements in the patient’s urine while the culture isolates and bacteria growing in the urine. The bacterial species grown are identified and tested for their sensitivity towards different antibiotics, the end result being confirmation of the presence of infection and a list of appropriate antibiotics.

Most cases of incontinence are due to:
• Infection in the urinary tract (usually bladder infection)

• Excessive consumption of water

• Weak bladder sphincter (especially common in female dogs)

• Spinal cord disease

Bladder Infection
This is a common cause of urinary incontinence in young adult female dogs and geriatric cats.  This condition is usually easily diagnosed by urine culture, though often signs of infection such as white blood cells or bacteria are actually visible in the urinalysis.  A urine culture will confirm the infection, identify the organism, and list usually several antibiotics which will be effective. An antibiotic is selected based on expense, potential for side effects, and convenience of usage. After a short course (generally somewhere between one and three weeks) of medication, ideally a second urine culture is done to confirm that the infection has truly been cleared up. If a bladder infection is the cause of incontinence, most patients show improvement in their incontinence and comfort after only a few doses of antibiotics (but it is still important to finish the entire course so as to avoid recurrence).

Excessive Water Consumption
Some animals drink so much water that their bladders simply overflow too easily. While some owners have noticed that their pets seem to be drinking more than usual, our experience is that most owners are surprised when the urinalysis shows excessive water consumption. Dilute urine is obvious on the urinalysis through a measurement called “specific gravity” which compares the amount of dissolved biochemicals in the urine to that of pure water (which has no dissolved biochemicals).  A urine specific gravity nearly the same as water, confirms excessive water consumption; blood tests may be indicated to go with the urine tests to determine the cause.

Causes of excessive water consumption include:
• Diabetes mellitus

• Cushing’s Syndrome

• Hyperthyroidism (cats)

• Bladder Infection (see above)

• Diabetes Insipidus

• Kidney failure

There are other causes as well but 90% are ruled in or out by a blood panel and urine culture.

Weak Bladder Sphincter
Aging, obesity, reduced sensitivity of neurologic receptors in the sphincter and possibly other factors all contribute to this condition which is especially common (up to one in five affected) in female dogs. Once other more serious conditions have been ruled out, the weak sphincter may be treated symptomatically with one of several medications.

• Estrogens
It is not entirely clear how estrogens are helpful in this treatment. Originally, estrogens were given to post-menopausal women with urinary incontinence and the treatment was simply extrapolated to dogs. It is possible that estrogens are important in the maintenance of neuroreceptors in the bladder sphincter and without estrogens the receptors become unresponsive to the transmission of the “storage” message from higher neurologic centers.  In dogs, DES(diethylstilbestrol) is the most common estrogen used, though it is now only available through compounding pharmacies.  A higher dose is used to begin therapy and finally a maintenance dose of usually every few days is used to maintain continence. In male dogs, testosterones seem to be more effective than estrogens, possibly through action on the prostate which sits at the neck of the bladder and incorporates the sphincter.

• Alpha-Adrenergic Agonists
These medications act by enhancing release of the neurotransmitter chemicals that act on the receptors of bladder sphincter. Effectively, they turn up the volume dial on the “hold it” message from the high neurologic areas. The usual medication for canine use is phenylpropanolamine, currently available in liquid and chewable tablets and is typically given two or three times daily.  Ephedrine and pseudoephedrine, common decongestants, may also be used. Side effects can include irritability, appetite suppression (phenylpropanolamine was the active ingredient in many human diet pills until recently), and blood pressure changes. Most dogs (male and female alike) tolerate phenylpropanolamine uneventfully.

For especially resistant cases of incontinence, estrogens and alpha-adrenergic agonists can be used together.

• Anticholinergics
Anticholinergic drugs are medications that work, not on the sphincter of the bladder, but on the rest of the bladder where urine is stored, relaxing the muscle fibers thus facilitating storage.  A drug called Imipramine is an anti-anxiety medication commonly used in humans. It has anticholinergic properties and can be used in combination with phenylpropanolamine in the treatment of animal incontinence. Imipramine is not commonly used compared to the other two medication types which are extremely effective but it may provide another choice for the few patients who do not respond to traditional therapy.

Surgical Therapy
Medication works for most patients with weak sphincters, but when medication fails there are some surgical options to consider: colposuspension and cystourethropexy.

Colposuspension, for females only, is the most commonly performed procedure. Here, the vagina (located just above the urethra as the dog stands) is tacked to the bottom of the belly wall entrapping and compressing the urethra.  In one study of 60 female dogs receiving this surgery, 40% were cured of their incontinence and  42% were improved.  In another study, 23 spayed female dogs with incontinence received colposuspension and 55% were cured at their 2 month recheck but only 14% were still cured at the 1 year recheck. This number jumped to 43% fully continent when medication was added back in. Another 43% were judged by their owners as greatly improved when medication was added back in. Over all owner satisfaction with surgery was 86% in this study.

Cystourethropexy is the modification that can be performed in males. Since there is no vagina to use, the ductus deferens are tacked down to compress the urethra. Fibers from the urethral muscles can also be tacked down (in either male or female patients).

Medications listed above are used in conjunction with surgery. Surgery alone improves approximately 50% of patients but often incontinence returns unless medication is also used.

Unusual Causes Of Incontinence
The list of causes of incontinence presented above is by no means exhaustive. While uncommon, other causes should not be entirely counted out. Some possible causes include:

• Ectopic ureter (instead of connecting to the urinary bladder, the ureter transporting urine from the kidney connects to the vagina or rectum so that there is no storage of urine. This condition is typically noted in a puppy that simply cannot be house-broken and leaks urine. The condition can be solved surgically.)

• Spinal damage especially in the lower lumbar area

• Infection higher in the urinary tract (kidney or ureter)

Your veterinarian is in the best position to determine if it is worthwhile to pursue a rare disease or not. Do not hesitate to ask your veterinarian questions regarding your pet’s incontinence, the treatments or procedures described above.
Date Published: 9/6/2004 12:21:00 PM
Copyright 2004 - 2007 by the Veterinary Information Network, Inc. All rights reserved.
This work was originally published by Veterinary Information
Network, Inc. (VIN) and is republished with VIN's permission.

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THE PET HEALTH LIBRARY
By Wendy C. Brooks, DVM, DipABVP
Educational Director, VeterinaryPartner.com 
http://www.VeterinaryPartner.com

Urinary Tract Infection

The urinary tract infection (UTI) is one of the most common ailments in small animal practices, yet many pet owners are confused about the medical approach. Some common questions we hear are:

Are bladder infections contagious?

Why do I have to use the entire course of antibiotics if my pet is obviously better after a couple of doses?

What is the difference between doing a urinalysis and urine culture? Why should both be done?

What is the difference between a UTI and feline lower urinary tract disease?  
  
The urinary tract consists of the kidneys, ureters (tubes that carry urine to the bladder for storage), theurinevetpartner1 urinary bladder, and the urethra that conducts urine outside the body. A urinary tract infection could involve any of these areas, though most commonly when we speak of a urinary tract infection we mean bladder infection.

Bladder Infection
The kidneys make urine every moment of the day. The urine is moved down the ureters and into the bladder. The urinary bladder is a muscular little bag that stores the urine until we are ready to get rid of it. The bladder must be able to expand for filling and contract down for emptying and respond to voluntary control.

The bladder is a sterile area of the body, which means that bacteria do not normally reside there. When bacteria (or any other organisms for that matter) gain entry and establish growth in the bladder, infection has occurred and symptoms can result. People with bladder infections typically report a burning sensation during urination. With pets with UTIs, we see some of the following signs:

Excessive water consumption

Urinating only small amounts at a time

Urinating frequently and in multiple spots

Inability to hold urine the normal amount of time/apparent incontinence

Bloody urine (though an infection must either involve a special organism, a bladder stone, a bladder tumor, or be particularly severe to make urine red to the naked eye)

It is especially important to realize that many animals do not show any externally visible signs of their bladder infections and, since they cannot talk, screening tests are the only route to discovering the infection.

It is also important to realize that it is the inflammation associated with infection that causes these symptoms. There can be infection without much inflammation (particularly if the patient is on a cortisone-type anti-inflammatory medication) and there can be inflammation without infection (the usual situation in feline lower urinary tract disease).

Because bladder infections are localized to the bladder, there are rarely signs of infection in other body systems: no fever, no appetite loss, and no change in the blood tests.

The external genital area where urine is expelled is teeming with bacteria. Bladder infection results when bacteria from the lower tract climb into the bladder, defeating the natural defense mechanisms of the system (forward urine flow, the bladder lining, inhospitable urine chemicals etc.). Bladder infections are not contagious.

Bladder infection is somewhat unusual in cats under age 10 years.

Bladder infection is somewhat unusual in neutered male dogs.

Testing for Bladder Infection
There are many tests that can be performed on a urine sample, and sometimes people get confused about what information different tests provide.

Urine Culture (and Sensitivity)
This is the only test that can confirm the presence of a urinary tract infection. In this test, the urine is spun rapidly in a machine called a centrifuge to separate out the solids from the liquid. The solid part, called the sediment, is transferred to a container and incubated for bacterial growth.
urinevetpartner2

If bacteria grow, then infection is confirmed; further, a positive culture done by a reference laboratory is usually followed and additional important information is found: an estimate of the concentration of bacteria, the identification of the bacteria, and the antibiotic sensitivity profile. Knowing the concentration of bacteria in the sample helps determine if the infection is true or if the bacteria grown could be contaminants. Knowing the species of bacteria also helps determine if the bacteria grown are contaminants. The antibiotic profile tells us what antibiotics will work against the infection. There is, after all, no point in prescribing the wrong antibiotic. Clearly, the culture is a valuable test when infection is suspected.

Urine culture results require at least a couple of days as bacteria require at least this long to grow.

Urinalysis
The urinalysis is an important part of any database of laboratory tests. It is an important screening tool regardless of whether or not an infection is suspected. The urinalysis examines chemical properties of the urine sample, such as the pH, specific gravity (a measure of concentration), and amount of protein or other biochemicals. It also includes a visual inspection of the urine sediment to look for crystals, cells, or bacteria. This test often precedes the culture or lets the doctor know that a culture is in order. Indications that a culture of a urine sample should be done based on urinalysis findings include:

Excessive white blood cells (white blood cells fight infection and should not be in a normal urine sample except as an occasional finding).

Bacteria seen when the sediment is checked under the microscope.

Excessive protein in the urine (protein is generally conserved by the urinary tract. Urine protein indicates either inflammation in the bladder or protein-wasting by the kidneys. Infection must be ruled out before pursuing renal protein loss.)

Dilute urine. When the patient drinks water excessively, urine becomes dilute and it becomes impossible to detect bacteria or white blood cells so a culture must be performed to determine if organisms are present. Further, excessive water consumption is a common symptom of bladder infection and should be pursued.
If the patient has symptoms suggestive of an infection, a urinalysis need not precede the culture (both tests can be started at the same time).

Sample Collection
There are four ways to collect a urine sample: table top, free catch, catheter, and cystocentesis. A table top sample is collected from the exam table or other surface where the patient has deposited urine. This sample is likely contaminated with bacteria from the environment and/or bacteria from the lower urinary tract. This is the least desirable urine collection method but is sometimes the only option. If bacteria are grown, their numbers and species provide a strong clue as to whether or not they represent infection or contamination.

A free catch sample is obtained by catching urine mid-air as it is passed. The sample may be contaminated by the bacteria of the lower urinary tract but will not be contaminated by the floor or other environmental surface.

With the catheter method, a small tube is passed into the bladder and the sample is withdrawn. This is not the most comfortable method for the patient although the procedure is fairly quick. Potentially, bacteria can be introduced into the bladder accidentally with the catheter so this represents a drawback, though fortunately this is a rare occurrence (assuming the catheter is only for urine sample collection and not placed for longer term urine collection). The sample obtained is unlikely to be contaminated and should represent urine as it exists in the bladder.

The ideal collection method is cystocentesis: a needle tap directly into the bladder. In this way, an uncontaminated sample is collected directly from the bladder. Sometimes a little blood is accidentally enters the sample during the needle stick but for culture purposes, the sample should be pristine.

Treatment For Simple Infection
A simple bladder infection is usually easily treated with 10 to 14 days of antibiotics. The patient’s symptoms usually resolve quickly, within the first 2 days of treatment, though the entire course of treatment should be given. Inadequate treatment leads to infection recurrence and possibly future bacterial resistance.

Ideally, approximately 5 days after the last antibiotic dose, a new sample is cultured to be sure the infection is gone. If the infection has not cleared or if a new infection has developed, there is usually a reason why.

Not So Simple Infections
There are several special situations concerning urinary tract infections:

Kidney Infection (Pyelonephritis)
If the patient’s immune system is not ideal, the infection in the bladder may go up into the kidneys, where it can cause kidney failure and a more serious infection. There is currently no good test to determine whether or not a kidney is infected, although there might be hints on the lab work (urinary tract infection in combination with fever, elevated white blood cell count, pain in the area of the kidneys). Ultrasound can help and there are specific radiographic studies that can help as well. If infection in the kidney is suspected, the length of the antibiotic course increases to 4 to 6 weeks.

Bladder Stone
Stones in the bladder can cause infection and infection can cause stones. We have created a section on bladder stones for more information.

Urachal Diverticulum
In embryonic life, urine is removed from the body via the umbilical cord. A structure called the urachus exits at the top of the bladder and enters the umbilical cord so that urine can be dumped into the mother’s bloodstream for removal by her kidneys. After birth, the urachus degenerates, but sometimes a small nipple-like protrusion exists on the top of the bladder. This section can protect a bladder infection, in which case recheck cultures will reveal the same organism over and over until the urachal diverticulum is surgically removed.

Bladder Tumor
Tumors growing in the neck of the bladder (most commonly the transitional cell carcinoma) often become infected. Bladder tumors commonly create urine with a bloody appearance whereas a common bladder infection usually does not. It is important to consider a tumor if a urine sample is clearly bloody, even if infection is documented as both conditions could easily be afoot.

Prostatitis
The unneutered male dog has a special risk: prostate infection. The prostate gland is located at the neck of the bladder and, due to its glandular nature, infection in the bladder readily spreads to the prostate where the special crypts and crannies are particularly protective to the infection. It is nearly impossible to clear the prostate of the infection without neutering.

Most urinary tract infections are straightforward and require only a relatively short antibiotic course for clearance. Hopefully, this article has cleared up some of the confusion that seems to commonly occur in reviewing this topic but if you find you have additional questions, do not hesitate contact your veterinarian.
Date Published: 12/26/2006 10:25:00 AM
Copyright 2006 - 2007 by the Veterinary Information Network, Inc. All rights reserved.
This work was originally published by Veterinary Information
Network, Inc. (VIN) and is republished with VIN's permission.

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The above information is simply informational. It's intent is not to replace the advice of a veterinarian nor to assist you in making a diagnosis of your pet. Please consult with your own veterinarian for confirmation of any diagnosis. Your pets life may depend on it.