Urohydropropulsion is performed under sedation by filling the bladder with saline through a catheter, holding the dog vertically, and squeezing the bladder to expel the stones through the urethra. In particular, the epidemiology, aetiology, diagnosis, treatment and prevention of non-obstetric fistulae have been described in detail during the recent International Consultations on Incontinence [ , ]. This section does not cite any sources. Urethrovaginal fistulae should preferably be repaired by a vaginal approach. Small stones and sand can be removed using urohydropropulsion.
Description of the urinary system
The leakage is usually painless, may be intermittent if it is position dependent, or may be constant. Unfortunately, intra-operative diagnosis of a GU or GI injury is made in only about half of the cases that result in fistula [ ].
The diagnosis of vesicovaginal fistula VVF usually requires clinical assessment often in combination with appropriate imaging or laboratory studies. Direct visual inspection, cystoscopy, retrograde bladder filling with a coloured fluid or placement of a tampon into the vagina to identify staining may facilitate the diagnosis of a VVF. A double-dye test to differentiate between a ureterovaginal and VVF may be useful in some cases [ ]. Testing the creatinine level in either the extravasated fluid or the accumulated ascites and comparing this to the serum creatinine level will confirm urinary leakage.
Contrast-enhanced CT with late excretory phase reliably diagnoses urinary fistulae and provides information about ureteric integrity and the presence of associated urinoma. Magnetic resonance imaging, in particular with T2 weighting, also provides optimal diagnostic information regarding fistulae and may be preferred for urinary - intestinal fistulae [ ]. Before epithelialisation is complete an abnormal communication between viscera will tend to close spontaneously, provided that the natural outflow is unobstructed or if urine is diverted.
Hence, immediate management should be by urinary catheterisation or diversion. Findings from uncontrolled case series suggest no difference in success rates for early or delayed closure of VVF. There are no data comparing their outcomes. Repair by the abdominal route is indicated when high fistulae are fixed in the vault and are inaccessible through the vagina.
A transvesical repair has the advantage of being entirely extraperitoneal. A simple transperitoneal repair is used less often although it is favoured by some using the laparoscopic approach.
A combined transperitoneal and transvesical procedure is favoured by many urologists and is particularly useful for fistula repair following Caesarean section. There are no RCTs comparing abdominal and vaginal approaches. Results of secondary and subsequent repairs are not as good as primary repair [ ].
A single RCT compared trimming of the fistula edge with no trimming [ ]. There was no difference in success rates but failed repairs in trimmed cases ended up with larger recurrences than untrimmed cases, which were smaller. Very small series single figures have been reported using these techniques, but whilst laparoscopic repair is feasible with and without robotic assistance, it is not possible to compare outcomes with alternative surgical approaches.
Tissue flaps are often added as an additional layer of repair during VVF surgery. Most commonly, such flaps are utilised in the setting of recurrence after a prior attempt at repair, for VVF related to previous radiotherapy described later , ischemic or obstetrical fistulae, large fistulae, and finally those associated with a difficult or tenuous closure due to poor tissue quality.
However, there is no high-level evidence that the use of such flaps improves outcomes for either complicated or uncomplicated VVF. There is no high-level evidence to support any particular practice in post-operative management but most reported series used catheter drainage for at least ten days and longer periods in radiation-associated fistulae up to three weeks. Modified surgical techniques are often required, and indeed, where the same techniques have been applied to both surgical and post-radiation fistulae, the results from the latter have been consistently poorer [ ].
This may in some cases extend life perhaps inappropriately, and where life expectancy is deemed to be very short, ureteric occlusion might be more appropriate. Patients at higher risk of ureteric injury require experienced surgeons who can identify and protect the ureter and its blood supply to prevent injury and also recognise injury promptly when it occurs. Immediate repair of any intra-operative injury should be performed observing the principles of debridement, adequate blood supply and tension-free anastomosis with internal drainage using stents [ ].
Delayed presentation of upper tract injury should be suspected in patients whose recovery after relevant abdominal or pelvic surgery is slower than expected, if there is any fluid leak, and if there is any unexpected dilatation of the pelvicalyceal system. Whilst there is no evidence to support the use of one surgical approach over another, there is consensus that repair should adhere to the standard principles of tissue repair and safe anastomosis, and be undertaken by an experienced team.
Functional and anatomical imaging should be used to follow up patients after repair to guard against development of ureteric stricture and deterioration in renal function. Ureterovaginal fistula occurring in the early post-operative phase predominantly after hysterectomy is the most frequent presentation of UUT fistulae in urological practice. Endoscopic management is sometimes possible [ ] by retrograde stenting, percutaneous nephrostomy and antegrade stenting if there is pelvicalyceal dilatation, or ureteroscopic realignment [ ].
If endoluminal techniques fail or result in secondary stricture, the abdominal approach to repair is standard and may require end-to-end anastomosis, re-implantation into the bladder using psoas hitch or Boari flap, or replacement with bowel segments with or without reconfiguration.
Whilst they are rare, most urethrovaginal fistulae in adults have an iatrogenic aetiology. Causes include surgical treatment of stress incontinence with bulking agents or synthetic slings, surgery for urethral diverticulum and genital reconstruction in adults. Irradiation and even conservative treatment of prolapse with pessaries can lead to the formation of fistulae.
Clinical vaginal examination, including the three swab test, is often sufficient to diagnose the presence of a urethrovaginal fistula. Urethroscopy and cystoscopy can be performed to assess the extent and location of the fistulae.
In cases of difficult diagnosis, voiding cystourethrography VCUG or ultrasound can be useful. Choice of surgery will depend on the size, localisation and aetiology of the fistula and the amount of tissue loss.
Principles of reconstruction include identifying the fistula, creation of a plane between vaginal wall and urethra, watertight closure of urethral wall, eventual interposition of tissue, and closure of the vaginal wall. A vaginal approach required less operating time, had less blood loss and a shorter hospitalisation time.
Most authors describe surgical principles that are identical to those of vesicovaginal fistula repair: Urethral obstruction occurred in 5. If your cat does exhibit these problems and you can afford it, I would recommend a visit to a feline cardiologist to discuss future treatment options for your cat. It may still be possible to give sub-Qs in the future if your cat needs them, but it is a careful balancing act between the needs of the kidneys and the needs of the heart.
If the problem was caused by giving too much fluid, you may find that reducing the amount or frequency of sub-Qs given in the future prevents this problem arising again; so speak to your vet about this. The Subcutaneous Fluids page has information on amounts and frequency of fluids.
I actually recommend that everybody weighs their cat regularly. You might also be able to buy a set of scales secondhand from eBay or similar. I have a Redmon baby scale which I like it can be stored on its side when not in use, saving space , but it no longer seems to be available.
However, if it goes on any longer, or stops and then starts again, I'd recommend a trip to the vet because the cat may quickly become dehydrated which does not only mean water loss, the cat may also be losing electrolytes such as potassium.
Please see Waste Product Treatments for more information on how to treat diarrhoea. Blood in Urine Haematuria. If your vet obtains a urine sample from your cat via cystocentesis a needle into the bladder , this may sometimes cause blood in the urine, which should resolve fairly quickly. Other common causes include a urinary tract infection , bladder or kidney stones or high blood pressure.
If you can find the cause, you may be able to treat this effectively. It may cause foamy urine, weight loss and swollen legs, face and abdomen. Its presence may make the CKD progress faster. Please see the Proteinuria page for more information. Please see the new Pyelonephritis and Urinary Tract Infections page for more information. This section only addresses urinary incontinence. Pet Place has some information about urinary incontinence.
Urinary Tract and Kidney Infections Incontinence may sometimes be caused by either a urinary tract infection or by a kidney infection. A urine culture and sensitivity test should show the presence of a urinary tract infection, but will not detect kidney infections. One of our cats, Harpsie, was prone to kidney infections, partly because he had polycystic kidney disease PKD.
In PKD cats, the bacteria can enter the cysts in the kidneys and cause a deep-rooted infection. We always knew when Harpsie had a kidney infection because he became incontinent, but the incontinence would go away within a couple of days of starting treatment with antibiotics although the treatment would continue for weeks to ensure the infection was completely eradicated.
Please see the Pyelonephritis and Urinary Tract Infections page for more information. If there is no infection present, you might want to try using Vitamin B12 in the form of methylcobalamin in case that helps - some Tanya's CKD Support Group members have found it helpful.
Please also read the Inappropriate Elimination section below in case some of it applies to your cat's situation, and for tips on dealing with the problem from a practical perspective. While you are trying to resolve the problem, using incontinence supplies can help keep your home clean and make this stressful experience a little less stressful for you. Incontinence Supplies Puppy Pads Etc. Having an incontinent cat is a lot less stressful if you take the time to protect your furnishings.
DIY stores sometimes sell plastic sheeting to protect your furnishings when decorating. It is really thin, like those bags used for fresh fruit and vegetables in supermarkets. I used this to cover the bed for Ollie, it was wide enough for my superking size bed and I just cut it to the right length. It's so fine that you can't feel it on the bed, but it helps protect the bed , although urine can pool in it to a degree, plus it is so fine that i t might slip off the bed. Therefore I used mine in conjunction with a washable throw on top.
I got mine from Wilkinsons. Joybies sells piddle pants for cats in several sizes. Handicapped Pets sells pet diapers in a number of sizes. Pet Edge sells puppy pads.
Direct Medical sells human incontinence supplies, which can be cheaper, although you do have to buy in bulk. Amazon sells rubber-backed waterproof sheeting. Amazon sells another type of waterproof sheeting. Amazon also sells waterproof picnic blankets. Bed Wetting Store sells a variety of products which might be helpful. Boots sells incontinence supplies, including protective covers for beds and chairs.
You might wish to place these where your cat spends time, with a blanket on top which can be easily washed. There can be a number of possible reasons for this, but it is definitely not done out of spite. Your cat is trying to tell you something and you need to try to work out what it is. Fortunately inappropriate elimination is usually manageable.
Possible Causes Sometimes this is a behavioural problem, but there may be some other reason for it in a CKD cat. It can be helpful to video your cats around the litter tray, especially if you are not sure who is the culprit. There are links to webcams here. You should also consider the possibility of a kidney infection - our cat was prone to them and used to leak urine uncontrollably when he had one incontinence , which could have been mistaken for inappropriate elimination.
Physical Issues Inappropriate elimination can be associated with the general weakness and weight loss of a CKD cat. If your litter box has a high edge, it might simply be too hard for your cat to clamber in to the tray. Try to provide a lower litter box and see if this makes a difference. The weight loss of CKD can make your cat's paw pads rather tender, which makes standing on litter uncomfortable. This can be remedied by providing softer litter, or by placing a few layers of newspaper on top of the litter which can easily be thrown away with the litter.
In view of their increased need to urinate, many CKD cats simply get "caught short" and cannot make it to the litter box in time. You may also need to clean the litter boxes more often or provide more to offset the increased urination, so the cat always has a clean place in which to go. Other Causes If you have recently had new carpets laid, it is possible that the carpet actually has a urine-type aroma to the cat, which leads the cat to associate the carpets with the litter tray and urinate on them.
Litter Trays If dealing with the above possible causes does not seem to help, you need to consider the possibility of a behavioural problem not necessarily related to the CKD. Reviewing your litter tray arrangements is an important part of this. As a rule of thumb, in a multi-cat household you need one litter tray per cat, plus one. Almost all cats prefer a tray out of the way of household traffic which offers some degree of privacy.
Some cats prefer one litter tray to urinate in and a separate one to defecate in, and some cats like a covered litter tray, while others prefer uncovered.
Litter box preference in domestic cats: The study found "Overall, there was no significant difference between use of the two box styles. Eight individual cats did exhibit a preference four for covered, four for uncovered , but individual preference results are not evenly distributed, with more cats than expected showing no preference between litter box types.
We postulate that, if boxes are kept sufficiently clean ie, once daily minimum cleaning , most cats will not show a preference for either box type. The observation that a minority of cats in the study exhibited a preference supports the recommendation of providing individual cats with a 'cafeteria' of litter box styles, including a covered box, to determine whether such a preference exists.
Therefore some people get large gallon Rubbermaid tubs and cut an entrance for their cats. Try to keep the trays as clean as possible although be careful not to clean them too much; they need to retain toileting associations for the cat. Experiment with the type of litter you use, because this can also be important to cats.
Cat Attract is designed to appeal to cats and some people have had good results with it, and also with the Senior Cat version. It is available from Amazon , among other retailers. Automatic self-cleaning litter trays which clean the litter tray to a degree after use appeal to some cats, though they can be expensive.
Dr Elsey's litterbox solutions has more litter box tips. Many cleaners contain ammonia which is a component of cat urine, so it attracts them back to the spot.
Try to get a cleaner without ammonia in it. Ideally you need an enzymatic cleaner which really removes the smell, though of course you must make sure you do not use a product which is harmful to cats. After the area is completely dry, try putting a litter box in the cat's chosen spot, or if that is not possible try a food bowl cats usually do not urinate where they eat , a pot plant or aluminium foil cats do not like the texture.
It works really well, and without too much effort. Amazon also sells a three pack. Cat Faeries also sell Anti-Icky-Poo. Mystical This is another enzymatic cleaner for which I have heard good reports.
Ashleys Green Products sell Mystical. Medication Occasionally cats benefit from medication to help with inappropriate elimination. Feliway and Zylkène are worth considering. There is more information about these treatments on the Subcutaneous Fluids Tips page.