Semiotic approach to genito-urinary symptons PDF

Semiotic approach to genito-urinary symptons IntegratedClinicalReasoningI Inês Dias F. Cabral, DVM [email protected] 2024/2025...

Semiotic approach to genito-urinary symptons IntegratedClinicalReasoningI Inês Dias F. Cabral, DVM [email protected] 2024/2025 M a s t e r ’s D e g r e e i n Ve t e r i n a r y M e d i c i n e - 3 t h y e a r RCI I Genito-urinary symptons 1  Introduction The urinary system is made up of a set of organs with the function of producing (kidneys), conducting (ureters and urethra), and storing (bladder) urine. Upper urinary tract: Kidneys Ureters Lower urinary tract: Bladder Prostate Urethra RCI I Genito-urinary symptons 2  Introduction Kidneys anatomy Despite the differences between species, the constitution is similar: cortex/ medulla ❖ Dogs and Cats: non lobulated, bean shaped ❖ Small ruminants: non lobulated, bean shaped ❖ Equine: non lobulated, heart-shaped ❖ Bovine: lobulated, fused medulla RCI I Genito-urinary symptons 3  Introduction Kidneys anatomy ▪ The nephron is the structural and functional unit of the kidney. It is composed of the glomerulus and the renal tubule. ▪ The epithelial cells in the glomerulus and the renal tubule play vital roles in determining the permeability of these structures to ion, solute, and water, and hence fulfilling the glomerular filtration function and the tubular reabsorption function, respectively. RCI I Genito-urinary symptons 4  Introduction Kidneys functions: 1. Homeostasis of the internal environment → regulation of the volume and composition of body fluids in order to maintain balance: ▪ Acid base ▪ Volemia ▪ Electrolytic 2. Excretion of metabolic products (++ protein catabolism) and toxic substances 3. Endocrine: calcium and phosphorus metabolism (activation of vitamin D), production of red blood cells (erythropoietin), control of blood pressure (renin) and production of other compounds (prostaglandins, insulin catabolism) Renal dysfunction at the nephron level can lead to changes at this 3 levels of function. RCI I Genito-urinary symptons 5  Introduction Kidneys functions: Urine formation occurs in 3 stages: ▪ Filtration ▪ reabsorption ▪ secretion RCI I Genito-urinary symptons 6  Introduction Urination reflex - regulated by autonomic nervous system: Sympathetic (stores urine): ▪ Hypogastric nerve (L1-L4) ▪ Pudendal nerve (S1, S2, S3 ± L7) Parasympathetic (empty bladder): ▪ Pelvic nerve (S1, S2, S3) Changes in urination due to upper and lower motoneuron lesions: UMN lesion → increased urethral tone. LMN lesion → cause a flaccid bladder with reduced urethral tone. RCI I Genito-urinary symptons 7  Semiotic approach to genito-urinary symptons Clinical Detailed signs Anamnesis Physical Diagnostic examination tests RCI I Genito-urinary symptons 8  Clinical signs Stranguria Oliguria Dysuria Polyuria Polydipsia Anuria Pollakiuria RCI I Genito-urinary symptons 9  Clinical signs Dysuria Stranguria ▪ Discomfort during urination. ▪ Straining or difficulty during urination. ▪ Dysuria most frequently results from an infection/ inflammation in the lower urinary tract (++ ▪ Often due to obstruction or inflammation of the bladder or urethra). It can be caused by urinary lower urinary tract. Common causes include tract infections (UTIs), bladder stones, neoplasia bladder stones, urethral obstruction, UTIs, and (tumours), or urethral obstructions. tumors. ▪ Clinical Observations: ▪ Clinical Observations: ▪ The animal may strain to urinate (stranguria). ▪ The animal may adopt unusual postures ▪ Urine may be passed in small quantities. while urinating. ▪ Vocalizing during urination is often seen in ▪ Stranguria is often associated with pain and cats and dogs with painful conditions. can cause significant distress. RCI I Genito-urinary symptons 10  Clinical signs Polyuria Oliguria ▪ Excessive production and excretion of urine. ▪ Production of abnormally small amounts of urine. ▪ Polyuria is often associated with chronic kidney ▪ Oliguria can be associated with severe kidney disease but also with non kidney diseases disease (acute kidney injury or later stages of (diabetes mellitus, Cushing’s disease CKD), severe dehydration, or shock (hyperadrenocorticism), diabetes insipidus, (hypovolemia). secondary to hypercalcemia and certain drugs (e.g., corticosteroids, diuretics), liver disease, ▪ Clinical Observations: pyometra. ▪ The animal produces very small amounts of urine. ▪ Clinical Observations: ▪ It may be accompanied by signs of systemic ▪ The animal may drink more water illness such as lethargy or vomiting, (polydipsia) to compensate for increased particularly if kidney failure is involved urine output. ▪ Large volumes of dilute urine are produced. RCI I Genito-urinary symptons 11  Clinical signs Anuria Pollakiuria ▪ Complete lack of urine production. ▪ Increased frequency of urination. ▪ Anuria is a critical and life-threatening condition, often indicating complete urinary tract ▪ This sign is typically associated with inflammation obstruction, severe acute kidney injury, or end- or infection in the lower urinary tract. Common stage renal disease causes include cystitis, UTIs, and bladder stones. ▪ Clinical Observations: ▪ Clinical Observations: ▪ The animal will not produce urine despite ▪ The animal urinates more often than normal attempts to urinate. but in small amounts. ▪ Accompanied by signs of toxemia such as ▪ May be accompanied by accidents in the vomiting, lethargy and abdominal pain. house or inappropriate urination in cats ▪ Requires immediate veterinary intervention. (outside the litter box). RCI I Genito-urinary symptons 12  Clinical signs Polydipsia Incontinence ▪ Involuntary loss of urine. ▪ Excessive drinking of water, often occurring alongside polyuria. ▪ Abnormal structure (local lesions) vs abnormal function (neurogenic lesions). ▪ Polydipsia is often associated with chronic kidney disease but also with non kidney diseases like ▪ Urinary incontinence can result from sphincter diabetes mellitus, Cushing’s disease, and mechanism incompetence, neurological disorders hyperthyroidism (cats). (e.g., spinal cord injuries, intervertebral disc disease), or ectopic ureters. Most common in ▪ Clinical Observations: spayed females ▪ The animal may drink unusually large volumes of water. ▪ Clinical Observations: ▪ Polydipsia and polyuria typically occur ▪ Urine leakage while resting or sleeping. together and warrant investigation of ▪ Chronic skin irritation around the perineal systemic diseases. area due to constant wetness. RCI I Genito-urinary symptons 13  Clinical signs Polydipsia and Polyuria Polydipsia and polyuria can only occur for two reasons: 1. The animal increased water intake and thus has polyuria; 2. Decreased renal concentrating capacity, leading in ↑ urine volume → ↑ water intake to maintain neutral water balance. When the cause is increased water intake with adequate urinary concentrating ability, the problem can be categorised as primary polydipsia (e.g., often behavioral problem or a psychological disorder). If the polydipsia occurs to compensate for impaired renal concentrating ability, the problem is categorised as primary polyuria (e.g., absent, deficient or impaired anti-diuretic hormone function → Diabetes insipidus) MAXIMUM NORMAL WATER NTAKE: 60-90 ml/kg/day in the dog and 45 ml/kg/day in the cat RCI I Genito-urinary symptons 14  Clinical signs Nocturia Hematuria ▪ Presence of blood in the urine, which may range ▪ Interruption of periods of sleep by the need or from microscopic (not visible to the eye) to gross urge to urinate. hematuria (visible). ▪ UTIs, medications, behavioral issues (anxiety or ▪ Urinalysis may be required to differentiate changes in the household rotine), etc. hematuria (red cells present in the urine sediment) from myoglobinuria or hemoglobinuria (red cells not present in urine sediment). ▪ Hematuria can occur with bladder stones, trauma, neoplasia, UTIs, kidney disease, coagulopathies, intense exercise, estrus in bitches. ▪ Clinical Observations: ▪ Hematuria is often accompanied by other signs such as dysuria or pollakiuria. RCI I Genito-urinary symptons 15  Clinical signs Hemoglubinuria Hemoglobin – oxygen- carrying protein from RBC Myoglobinuria Myoglobin – muscle oxygen-binding protein ▪ Presence of hemoglobin in the urine. ▪ Presence of myoglobin in the urine. ▪ This can occur when red blood cells are destroyed ▪ Typically results from muscle injury or damage. (hemolysis), and the released hemoglobin is Unlike hemoglobin, myoglobin is released from filtered into the kidneys and excreted in the urine. muscle cells when they are damaged, and it can also be filtered by the kidneys and appear in the ▪ Immune-mediated hemolytic anemia, toxins, urine. trauma, bacterial infection (leptospirosis), protozoal infection (babesiosis) can cause ▪ Severe trauma, excessive exercise, toxins, hemolysis. degenerative myopathy,… ▪ Urianalysis! and blood tests (anemia, hemolysis) ▪ Urianalysis! Blood tests, muscle biopsy or imaging. RCI I Genito-urinary symptons 16  Systemic signs associated with Urinary Diseases Lethargy Vomiting Weight loss ▪ A common sign in animals with ▪ Vomiting and nausea - commonly ▪ Gradual weight loss is often kidney disease or acute kidney seen in kidney failure (both acute observed in animals with injury. and chronic). chronic kidney disease (CKD) due to poor appetite, muscle ▪ Results from toxins accumulating ▪ Caused by the accumulation of wasting, and chronic illness. in the body due to poor kidney toxins (uremia) that irritate the function or dehydration. gastrointestinal tract. ▪ Animals may also experience loss of appetite (anorexia). RCI I Genito-urinary symptons 17  Systemic signs associated with Urinary Diseases Hyperthension Edema/ Ascites ▪ Elevated blood pressure is often ▪ Fluid retention, particularly in the limbs associated with chronic kidney (edema) or abdomen (ascites), can be seen disease, and it can lead to further in severe kidney disease when protein is damage to the kidneys, as well as lost in the urine (proteinuria). secondary effects on the heart, brain, and eyes. RCI I Genito-urinary symptons 18  Detailed Anamnesis 1. Species 2. Age 3. Breed 4. Sex 5. Medical history NOTE: Lower urinary tract abnormalities are characterized by localized signs such as dysuria, hematuria and pollakiuria. Upper urinary tract disorders present with systemic signs such as anorexia and vomiting. RCI I Genito-urinary symptons 19  Detailed Anamnesis The anamnesis should be complete to the different organic systems, as diseases of the urinary system may cause systemic symptoms. First questions Anamnesis should include: ▪ Reason for consultation ? ▪ Frequency of urination ▪ The volume of urine produced ▪ When it started ? ▪ Changes in water intake ▪ How it progressed ? ▪ The appearance and odor of the urine ▪ Associated signs ? ▪ Contact with drugs, nephrotoxins ▪ Food ▪ (…) RCI I Genito-urinary symptons 20  Physical Examination Start with a general physical examination and then specific for the urinary tract. 1. Kidneys In small animals, the kidneys are explored by deep abdominal palpation. Both kidneys can be palpated in most cats and the left kidney in some dogs. Kidneys should be evaluated for: size, shape, consistency, pain and location RCI I Genito-urinary symptons 21  Physical Examination 2. Ureters In small animals, exploration by direct methods is not possible, we can evaluated by complementary exams (e.g., ultrasound) In large animals it is possible to evaluate by rectal examination. RCI I Genito-urinary symptons 22  Physical Examination 3. Bladder Easier to palpate if the bladder is full, and more easier in cats as they have a more elastic abdominal wall. The bladder should be evaluated for degree of distension, pain, wall thickness, and presence of intramural (e.g., tumors) or intraluminal (e.g., calculi, clots) masses. In horses and cattle, we palpate the bladder by rectal examination (or vaginal in females) RCI I Genito-urinary symptons 23  Physical Examination 4. Urethra Difficult to palpate in female dogs and cats. In male cats is usually limited to inspection of the distal portion of the penile urethra. In male dogs the urethra may be examined by inspection and palpation The urethral meatus may be examined after exteriorizing the penis from the procedure In large animals the urethra is examined by rectal palpation (in females vaginal palpation) RCI I Genito-urinary symptons 24  Physical Examination 5. Prostate Digital palpation combined with caudal abdominal palpation in small animals. Evaluation by rectal examination in large animals. RCI I Genito-urinary symptons 25  Physical Examination 6. External genitalia Males: exteriorize and examine the penis, and palpate the testicles. Females: perform a vaginal examination to evaluate for abnormal discharge, masses and appearance of the urethral orifice. Also look for evidence of irritation, excessive licking and self-trauma. RCI I Genito-urinary symptons 26  Physical Examination Clinical examination of the urinary tract of large animals consists of: ▪ Obtaining a history ▪ Performing a distant examination of external genitalia ▪ Visual observation of the act of urination ▪ Examination of the urine physical examination of the urinary tract by inspection and palpation RCI I Genito-urinary symptons 27  Physical Examination Other important aspects of the physical examination for urinary tract problems: ▪ The oral cavity is examined to evaluate the color of the mucous membranes, ulcers, or tongue-tip necrosis, as may occur in renal failure ▪ Ocular examination ▪ Hydratation ▪ Rectal examination ▪ Evidence of edema or ascites RCI I Genito-urinary symptons 28  Diagnostic tests 1. Urine collection and Urianalysis Always start with a minimum database: 2. BUN (Blood Urea Nitrogen) Complete blood count 3. Serum Creatinine Biochemistry Electrolytes 4. Urine Protein/ Creatinin Ratio 5. SDMA 6. Utrasonography 7. Radiography 8. CT (…) RCI I Genito-urinary symptons 29  Diagnostic tests 1. Urine collection and Urianalysis ▪ Mid-stream free flow ▪ Bladder expression (RISKS!) ▪ Catheterization ▪ Cystocentesis RCI I Genito-urinary symptons 30  Diagnostic tests 1. Urine collection and Urianalysis ▪ If possible, evaluate the first morning urine ▪ Carry out the analysis shortly after collection (ideally 30 to 60 minutes after collection) ▪ Refrigerate urine if analysis is not performed immediately ▪ Note the urine collection method RCI I Genito-urinary symptons 31  Diagnostic tests 1. Urine collection and Urianalysis Physical examination - Volume, color, clarity, odor and specific gravity. - pH, Protein, Glucose, Ketones, Nitrites Bilirubin, Chemical analysis Urobilinogen, Red blood cells / Hemoglobin / Myoglobin, White blood cells Microscopic analysis - Urine microscopic analysis/ Urine sediment - RBC, WBC, Crystals, Casts, Epithelial cells, Organisms Culture and Antibiogram RCI I Genito-urinary symptons 32  Diagnostic tests Normal USG values in normal It should be interpreted depending on the patient's dehydration status hydrated animals: Dog (1.015 – 1.045) Reflects the ability of the kidneys Cat (1.035 – 1.060) 1. Urine collection and Urianalysis to concentrate urine Urine test strip Refractometer – measure urine specific gravity RCI I Genito-urinary symptons 33  Diagnostic tests 1. Urine collection and Urianalysis RCI I Genito-urinary symptons 34  Diagnostic tests 2. BUN: Blood Urea Nitrogen Urea is synthesized in the liver via the ornithine cycle from ammonia derived from amino acid catabolism. Amino acids used in the production of urea arise from the catabolism of exogenous (i.e., dietary) and endogenous proteins. ↑ BUN (blood): ↓ BUN (blood): ▪ Renal causes ▪ Low protein diets ▪ High protein diets ▪ Anabolic steroids ▪ Gastrointestinal bleeding ▪ Severe hepatic insufficiency ▪ Increased catabolism (e.g., ▪ portosystemic shunting starvation, infection, fever) (↓ liver ammonia) ▪ Drugs (e.g. glucocorticoids) NORMAL VALUES: 8 to 25 mg/dL in the dog and 15 to 35 mg/dL in the cat RCI I Genito-urinary symptons 35  Diagnostic tests 3. Serum Creatinine Creatinine is a nonenzymatic breakdown product of phosphocreatine in muscle; the daily production of creatinine in the body is determined largely by the muscle mass of the individual. Young animals have lower serum concentrations, whereas males and well-muscled individuals have higher concentrations. Serum creatinine concentration is not affected appreciably by diet. Creatinine is not metabolized and is excreted by the kidneys almost entirely by glomerular filtration. NORMAL VALUES: 0.3 to 1.3 mg/dL in the dog and 0.8 to 1.8 mg/dL in the cat ↑ values! RCI I Genito-urinary symptons 36  Diagnostic tests 3. Serum Creatinine When nonrenal causes have been eliminated from consideration, an increase in BUN or serum creatinine concentration above normal implies that at least 75% of the nephrons are not functioning. RCI I Genito-urinary symptons 37  Diagnostic tests The Urea/Creatinine ratio can suggest the origin of azotemia, but the variability is considerable and needs to be interpreted with the AZOTEMIA = (Azot “Nitrogen” + “hemia” – blood) remaining clinical signs! ↑ Urea + Creatinine + other non-protein compounds in the blood, plasma or serum ▪ Pre-renal (related to decreased renal perfusion): dehydration, hypovolemia, cardiac failure, shock. ▪ Renal (due to kidney disease causing a significant decrease in the glomerular filtration rate) ▪ Post-renal (the cause is distal to the nephron, which can be obstructive or due to leakage of urine into the pelvic cavity). Diseases that cause pre-renal or post-renal azotemia can secondarily affect the kidneys and cause renal azotemia RCI I Genito-urinary symptons 38  Diagnostic tests 𝑃𝑟𝑜𝑡𝑒𝑖𝑛 (𝑚𝑔/𝑑𝑙) 4. Urine Protein/ Creatinin Ratio UP/C = 𝐶𝑟𝑒𝑎𝑡𝑖𝑛𝑖𝑛 (𝑚𝑔/𝑑𝑙 Proteinuria: ▪ Pre-renal: incresed circulating plasma proteins (e.g., ↑ hemoglobin, myoglobin, immunoglobulin light chains) ▪ Renal: It can be part of a primary renal disease process (e.g., primary glomerular or tubular disease) or may represent a manifestation of renal disease in association with another underlying condition. ▪ Post-renal: Inflammation or neoplasia RCI I Genito-urinary symptons 39  Diagnostic tests 5. SDMA Symmetric dimethylarginine (SDMA) is a sensitive circulating kidney biomarker SDMA can detect mild to moderate function loss that creatinine misses. This earlier detection can have a positive impact in diagnosis, treatment, and patient outcomes. RCI I Genito-urinary symptons 40  Diagnostic tests 5. Radiography ++ Small animals and juveline horses and cattle. ▪ Intravenous urography: (visualization of the kidneys, ureters and bladder using IV contrast medium) → Replaced ++ CT/ MRI ▪ Cystography (contrast media introduced into the bladder) Feline radiography RCI I Genito-urinary symptons 41  Diagnostic tests 6. Ultrasonography ▪ Visualization of kidneys, bladder, ureters (-). ▪ Visualization of reproductive system. Canine kidney and bladder ▪ Evaluate size, contours, thickness,… ultrasonography ▪ Transabdominal ultrasonography for small animals and juveline horses and cattle. ▪ Transrectal ultrasonography for adult horses and cattle. RCI I Genito-urinary symptons 42  Diagnostic tests 7. Computed tomography ▪ CT offers some advantages in renal and ureteral imaging. ▪ The entire urinary tract can be evaluated accurately (multiplanar and 3D reconstructions) ▪ Contrast is enhanced and can visualize congenital defects. ▪ Can detect ectopic ureters, but cannot always be identified if disease is intramural RCI I Genito-urinary symptons 43  Other Concepts Uremia ▪ Presence of urine constituents in the blood in abnormal amounts (e.g., BUN, creatinine…) in cases of generalized kidney disease and the existence of clinical signs associated with renal insufficiency (vomiting, depression, anorexia, oral/gastric ulceration). ▪ Uremia can also be observed in cases of: pre-renal and post-renal azotemia. If the animal presents azotemia but no clinical signs are present, it is not uremic. ▪ If filtration is inadequate, there is an accumulation of nitrogenous compounds in the body, leading to the development of azotemia and eventually uremia. ▪ Typically occurs in cases of renal failure (acute or chronic). RCI I Genito-urinary symptons 44  Other Concepts Uremia - consequences ▪ Anemia (uremia → decreased erythropoietin production, along with uremic toxins that interfere with RBC survival) ▪ Digestive alterations (↑urea levels in the blood can cause nausea, vomiting, loss of apetite; uremic toxins: oral ulcers and gastrointestinal ulcers) ↑K ↓Na ↓Ca ↑PO ▪ Electrolyte imbalances: hyperkalemia, hyponatremia, hypocalcemia, hyperphosphatemia ▪ Acid-base disturbances: metabolic acidosis (normal kidney excrete H+ and reabsorb bicarbonate) ▪ Cardiovascular effects: hypertension, arrhythmias (hyperkalemia), edema (kidneys inability to regulate fluid balance can lead to fluid retention) ▪ Neuromuscular signs (uremic toxins →lethargty, altered mental status, depression, tremors due to electrolyte imbalances – hypocalcemia, or, in severe cases – uremic encephalopathy: ataxia) RCI I Genito-urinary symptons 45  Other Concepts Renal insufficiency: is a broad term for all stages of kidney impairment. Acute renal failure: Clinical syndrome characterized by an abrupt increase in serum creatinine and BUN concentrations (azotemia). Early recognition of acute intrinsic renal failure is crucial because it may be reversed. Chronic renal failure: Corresponds to a persistent primary renal insufficiency (months to years), characterized by irreversible renal damage. There is hemodynamic insufficiency, filtration, and renal excretion failure. RCI I Genito-urinary symptons 46  Bibliography RCI I Genito-urinary symptons 47