Pelvic Bladder

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Pelvic Bladder

Also known as “intrapelvic bladder,” as the urinary bladder neck is caudal to the pubic bone, causing most of the urethra and a variable amount of the bladder to remain inside the bony pelvis. The association of a short urethral length and urethral sphincter mechanism incompetence is common.

 

SIGNALMENT

  • Dog and rarely cat.
  • Primarily young female dogs (< 1 year of age); incontinence often worsens after ovariectomy/ovariohysterectomy.
  • Incontinence is usually detected in male dogs after neutering.

 

SIGNS

  • Maybe asymptomatic
  • Incontinence can be continuous or intermittent
  • Conscious voiding patterns often present
  • The urgency with small volume elimination
  • Perineum stained/soaked with urine; urine scalding; wet vulva/prepuce

 

CAUSES & RISK FACTORS

The position of the bladder in incontinent female dogs has been shown to be more intrapelvic and associated with a shorter urethral length, suggesting that an intrapelvic bladder neck and a short urethra together encourage urinary incontinence.

 

DIAGNOSIS

DIFFERENTIAL DIAGNOSIS

  • Urinary incontinence—ectopic ureter, USMI, inappropriate urination, urge incontinence, urinary tract infection, neurogenic incontinence (lower motor neuron disease).
  • The degree of incontinence often exceeds that seen with USMI but is not as severe as that seen with ectopic ureters.
  • Often associated with ectopic ureters.
  • CBC/BIOCHEMISTRY/URINALYSIS
  • CBC and biochemistries are typically unremarkable.
  • Urinalysis may reveal evidence of UTI (including pyuria, bacteriuria, and hematuria) or polyuria (USG < 1.035).
  • Urine culture and sensitivity via cystocentesis should be performed. Urine culture is often positive.

 

IMAGING

  • Abdominal radiographs may reveal a caudally displaced bladder, but this should be interpreted carefully without bladder distension.
  • Excretory urography may allow visualization of the kidneys, ureteral terminations, urinary bladder, and urethra but does not provide bladder distension. Without appropriate bladder distension, interpretation of bladder neck location should be made with caution.
  • Retrograde vaginourethography or urethrocystography allows visualization of the vaginal vault, urethra, urethral length, prostate, urinary bladder shape, and bladder neck location.
  • If the urinary bladder and urethra are inside the bony pelvis, double-contrast cystourethrography may be required for full visualization. After maximum dilation with an infusion of carbon dioxide or contrast medium, much of the bladder, bladder neck, and entire urethra remain within the pelvic canal, caudal to the bony pelvic brim. There is often a short wide urethra.
  • Ultrasonography of the kidneys, ureters, and urinary bladder can aid in the documentation of concurrent urologic anomalies, hydronephrosis concurrent pyelonephritis, or concurrent ectopic ureters.
  • The diagnostic combination of choice is urethrocystoscopy and cystourethrography. This combination allows careful investigation of urethral, ureteral, cystic, vaginal, and vestibular defects. It also allows more accurate measurement of urethral length and width and aids in formulating therapy.

DIAGNOSTIC PROCEDURES

  • A neurologic exam should be normal.
  • Urodynamic procedures—consider cystometrography and urethral pressure profilometry to evaluate urinary bladder and urethral function, as well as urethral functional length. Detrusor function is usually normal, though higher threshold pressures may be generated at lower fluid volumes. The functional urethral length is shortened, and intraurethral pressure is frequently decreased, resulting in USMI.
  • treatment TREATMENT
  • Identify UTIs and treat them appropriately.
  • The goal is to increase urethral resistance (artificial urethral sphincters, intraurethral injections of bulking agents, etc.), increase urethral length (bladder neck reconstruction), and/or relocate the bladder neck to an intra-abdominal position (colposuspension, urethropexy, prostatopexy, or vas deferensopexy).
  • Detrusor relaxation has been suggested to treat refractory incontinent dogs as an overactive bladder could contribute to incontinence or urgency.
  • Medical management for traditional USMI is typically successful in 75–90% of female dogs.

 

SURGICAL CONSIDERATIONS

  • Colposuspension is the traditional surgical approach. A cure rate of 53% has been reported.
  • Placement of an artificial urethral sphincter, or hydraulic occluder, has been successful and is the currently surgical treatment of choice if other minimally invasive or medical interventions fail. Experience with this procedure has been limited and the risk of urethral strictures can be up to 20%. Cystopexy can also be considered.
  • MINIMALLY INVASIVE TREATMENT
  • Transurethral submucosal bulking agent therapy (e.g., collagen implantation) has been described for the treatment of patients refractory to medical management and is associated with relatively good success. This is accomplished via cystoscopic guidance. This aids in improving incontinence but does not affect the location of the urinary bladder.

 

MEDICATIONS

DRUG(S)

  • Phenylpropanolamine: an α-agonist (1–1.5 mg/kg PO q8h) will improve continence for USMI in a majority of cases.
  • Diethylstilbestrol: initially 0.1–0.3 mg/kg q24h for 7 days, then once weekly; 0.1–1 mg PO for 3–5 days, then 1 mg per week thereafter. Gradually reduce to the lowest effective dose. DES can be toxic to the bone marrow in dogs and cats and can cause blood dyscrasias. This can progress, in rare cases, to fatal aplastic anemia. In some dogs, a combination of estrogen and PPA therapy may be more effective.
  • Estriol: can be used for estrogen-responsive urinary incontinence. The dose is 2 mg once daily per dog (regardless of body weight) for 14 days, followed by the lowest effective daily dose tapered every 7 days.

 

FOLLOW-UP

PATIENT MONITORING

  • Every 3–6 months for UTI.
  • Patients receiving an α-agonist should have serial blood pressure evaluations, as this is contraindicated in hypertensive patients or those with renal or heart disease.
  • Patients receiving estrogen therapy should have serial CBC evaluations to monitor for bone marrow dyscrasia.
  • Use all medications at the lowest effective dose.

 

MISCELLANEOUS

ABBREVIATIONS

DES = diethylstilbestrol

PPA = phenylpropanolamine

USMI = urethral sphincter mechanism incompetence

UTI = urinary tract infection

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