Urinary and Urolithiasis 2022 - Tagged.pdf

Disease of the ruminant urinary system including urolithiasis Rob Smith Some original slides from Dai Grove-White Learning outcomes • Recognise renal, bladder, vaginal and uterine infections from clinical examination. • Produce a differential diagnosis list and treatment plan for common urinary tr...

Disease of the ruminant urinary system including urolithiasis Rob Smith Some original slides from Dai Grove-White Learning outcomes • Recognise renal, bladder, vaginal and uterine infections from clinical examination. • Produce a differential diagnosis list and treatment plan for common urinary tract conditions in cattle. • Discuss prevention of these conditions through management. • Describe a systematic approach to diagnosis, treatment and prevention of urolithiasis Examination of urinary system. • • • • History – how long / other signs. Frequency/ease of urination. Urine – smell/appearance – sample bottle! Rectal examination – Left kidney, bladder, diseased ureters – pain? • Catheterisation (sub urethral diverticulum). • Prepuce. Urinalysis. • • • • • • • Colour Pus / blood (haematuria) ? Haemoglobinuria SG – 1.02 – 1.045 pH – normally alkaline Protein – usually trace only Glucose –usually trace Clinical signs of urinary disease. • Abdominal pain – pyelonephritis, calculi. • Dysuria – pyelonephritis, calculi, cystitis, (vaginitis). • Haematuria ± pus ±calculi. • Polyuria – diabetes mellitus (post FMD), diabetes insipidus, idiopathic (calves). • Anuria – obstruction by calculi. • Oliguria – prerenal, renal or post renal. • Proteinuria – renal amyloidosis - breed. Gross abnormalities of urine. 1 • Haematuria – frank blood in urine. – Pyelonephritis (+ pus) – Cystitis – Urolithiasis – Enzootic haematuria – Acute bracken poisoning – Toxic nephrosis (Acorn) – Glomerulonephritis, renal infarction etc Gross abnormalities in urine. 2 • Haemoglobinuria – Babesiosis – redwater • “port–coloured urine” – Post-parturient haemoglobinuria – Bacilliary haemoglobinuria – • Clostridium haemoliticum Congenital abnormalities. • Hypospadia. – failure of closure of male urethra – Usually fatten fine • Patent urachus. – Urine from umbilicus – Abcessation – see lecturs on umbilical masses – Surgery – In Practice July 1992 P163 (Barry Edwards) Hypospadia. Pyelonephritis. • Corynebacterium renale classically • Half of cases E.Coli in published series of cases. • Usually sporadic. • More common in suckler cows – venereal spread by natural service? • Secondary to trauma e.g. dystocia Signs of pyelonephritis • • • • • • Chronic weight loss. ± mild pyrexia. Appetite usually OK. Dysuria. Blood & pus in urine (pus on vulval hairs). Examine per-rectum – Swollen painful kidney – Bladder, ureter involvement & thickening. Pyelonephritis Pyelonephritis. Treatment. • Long course of antibiotic – Penicillins, Oxytetracycline • C. Renale sensitive to most antibiotics • E.Coli may not be as broadly sensitive – amoxicillin/clavulanic acid • “Rule of thirds” – 1/3 get better. – 1/3 get better but recur. – 1/3 never get better. Cystitis. • Often associated with pyelonephritis • Secondary to dystocia – ascending infection • Similar signs to pyelonephritis • Straining more pronounced • Treat with antibiotics as pyelonephritis • Organism, and thus sensitivity less, predictable Amyloidosis. • Not common. • Deposition of amyloid & ab/ag complexes • Secondary to other chronic infections. • Primary form has been reported. Signs of amyloidosis • Off food & ill. • Profuse diarrhoea (DDX Johne’s disease). • Generalised subcutaneous Oedema. • Polydipsia/polyuria. • Proteinuria. • Low plasma albumin. • Pale swollen kidneys. Amyloidosis. Haematuria & haemoglobinuria. • Haematuria • Haemoglobinuria • • • • Enzootic haematuria• Bacilliary Bracken poisoning. haemoglobinuria • Post-parturient Toxic nephrosis Pyelonephritis (& pus)haemoglobinuria • Babesiosis redwater Enzootic haematuria. • Haemangiomata in bladder • Associated with long term ingestion of bracken. • Older cows. • Other causes – “teart pastures” high molybdenum • Blood clots in urine. • Tumours in guts – squamous cell carcinoma Enzootic haematuria. Bracken fern. All parts of plant are toxic – dried or fresh Nothing better to eat? Mixed in hay? Bracken poisoning. • Contains a thiaminase – toxic in horses but no effect in ruminants. • Bright Blindness – sheep retinal atrophy. • Enzootic haematuria – long term ingestion. • Gut tumours – sheep & cattle – long term. Bracken poisoning. • • • • • • • • • Bone marrow toxicity. Pancytopaenia & thrombocytopaenia. Petechiae in mouth, conjunctiva, vulva etc. Subcutaneous bruising. Blood clots – nose, faeces. Pyrexia & depression. Diarrhoea (bloody). Haematuria. Death. Acute bracken poisoning. Petechiae Toxic Nephrosis • Oak (acorn) poisoning on pastures 3-5 days after autumn storms. Poss. fresh leaves in spring? • Tannins in acorns => kidney damage. • Sudden deaths. • Anorexia, depression, bloat due to ruminal stasis. • Constipation and straining…… • Progressing to fetid tarry diarrhoea. • Death in 4-7 days despite supportive treatment. • Charcoal, rumenotomy, move other animals off. Bacilliary haemoglobinuria. • Uncommon – wet, high pH pastures in Southwest UK • Clostridium haemolyticum -  toxin. • In soil & dormant in liver. • Migrating fluke – trigger spores (c.f. Black disease). • Pyrexia, jaundice, anaemia, oedema, Hburia. • Fatal. • Vaccinate (black disease), fluke control etc. Pale infarct Infarct Babesiosis – Redwater Fever. • Babesia divergens in UK. • Tick-borne. • Clinical signs in older non-immune animals. – usually moved into the area • “Premunity” results from infection when young (very low level parasitaemia results). Epidemiology. • 3 host ticks – – Ixodes ricinus – Haemaphyllis punctuata – Trans-ovarian transmission • Spring or autumn rise – when do ticks feed? • Bought in animals (so they have no premunity). • Rented grazing = novel exposure. • Inverse age immunity? Infectious load? Clinical signs • Pyrexia • Anaemia & Hb-uria – “port wine urine” • Diarrhoea – “pipe stem faeces” • Later – Constipated – Temperature falls – Anaemic / jaundice Diagnosis of babesiosis. • Blood smear – capillary blood from ear • Thin smear – look at edges • Parasites in RBC • Evidence of anaemia. • ELISA – to assess herd exposure. Treatment of babesiosis. • “Imizol” – Imidocarb – licensed in UK. • 213 days meat, 21 day milk withhold! • And inform DVM – tissue, milk residues. • Curative – 1ml/100Kg once, subcutaneous only. • Preventive – 2.5ml/100Kg once, 4 weeks cover. • immunity depends on adequate challenge by infected ticks during treatment period. • Imizol toxic at 1.75x dose, deaths at 5x dose! • Supportive therapy – blood transfusion, fluids. Post parturient haemoglobinuria. • Uncommon – older high yielding dairy cows. • Sporadic cases: 1 – 4 weeks after calving. • Aetiology – Low phosphorous diet • e.g. Lush spring grass and sugar beet pulp – Kale, rape, turnips (plant breeding reduce risk?) Clinical signs & treatment. • Sudden onset. • Haemoglobinuria, pallor, jaundice etc • Collapse, dyspnoea & death. – Guarded prognosis. • Treatment. – Phosphorous • • • • • Foston injection no longer available. Other products being imported. Vigophos (with B12) Livisto. Catasol (with B12) Bayer Animal Health. Butaphosphan 100mg and cyanocobalamin 50µg (vitamin B12) / ml – Blood transfusion. Blood transfusion. • Cross-matching ? One transfusion is safe. • Sodium citrate (anti-coagulant) – 10 ml of a 3.85% solution added per 100 ml blood • Choke-rope around neck to raise jugular • Jugular trochar or 10 or 12G catheter to collect. • How much blood ? 5 litres. • Collect into Winchester bottle or empty wormer bottle (washed then rinsed with citrate soln pre-collection) • See In Practice 21 (10) Nov/Dec 1999 Jugular Catheters BREAK UROLITHIASIS = Blocked Rams • 2-4 month old ram lambs • Mature goats castrated in first few days of life • Bull beef calves • Usually sporadic but can have “outbreaks” • In U.K. calculi are usually Ca/MgNH4PO4 Calcium/magnesium ammonium phosphate UROLITHIASIS • Associated with: • Ca:P imbalance in diet • High concentrate diet • Water deprivation • Interactions e.g. forage quality and concentrate intake • History of diet change in mature animals • Inappropriate material used in feeds • e.g. pig nuts as source of mineral in goat mix. SIGNS ASSOCIATED WITH CALCULI • Restlessness – mild to severe • Abdominal pain (kicking) & straining (hiccups) • Dysuria or anuria – dry floor - management • Preputial crystals/sand • Progressive till urethra and/or bladder ruptures. • Is swelling in abdomen or under skin ? • Bladder rupture – initially brighter! • high urea & creatinine in plasma/abdomenal fluid Where do you think the system will block? Dyce, Sack, Wensing. Textbook of VeterinaryAnatomy 1987) WATER BELLY Water belly Burdizzo incompetence ! • Bloodless castrators • Placed too high • Rupture urethra • Signs as for water belly Dyce, Sack, Wensing. Textbook of VeterinaryAnatomy 1987) Diagnosis (1) • Abdominal Palpation – Distended bladder – Free fluid wave – s/c fluid – piting, colour of skin • Location indicates site of rupture • Hair of ventral abdomen – “sand” around prepucial orifice • Examination of penis – exteriorise – Sit on rump, grab pelvic flexure and push up towards prepuce, grab base of penis as it leaves prepuce – If cannot then cut down into middle of prepuce Diagnosis (2) • Radiography +/- contrast – replaced by u/s • Ultrasonography – – – – s/c tissue Free fluid in abdomen – timing re bladder rupture Bladder Kidney – cortex/medulla ratio • Abdominocentisis – u/s guided, sample s/c fluid also • Smell, urea test strips. Diagnosis (3) • Palpate urethra per-rectum – if calculi palpable, no point doing anything more distal and probably will not re-canalise due to extent of calculi • Blood sample – – – – Urea / creatinine Potassium PCV Total protein Treatment of urolithiasis. • Relaxants – Buscopan or Xylazine • Aways used but of little use! Other sedatives – Diazepam? • Casualty slaughter – unlikely to pass inspection as uraemic. • Treatment approach based on systematic application of anatomical knowledge! • DO NOT send home and ignore! • Do it yourself or send to someone else before kidneys are damaged. PYELONEPHRITIS Approach • Minimalist to reduce – Loss of value • Is vermiform appendage needed? • Would you certify a ram without it? – Cost – Recovery time – Future problems • Stabilise – i/v fluids Go site by site (1) • Most accessible first • Exteriorise end of penis – Accessible in ram and bull – Not possible in castrate goat • Sedate, local anaesthesia, forceps into prepuce cut down midway to exteriorise end of penis – Partial amputate appendage regardless? – Then palpate to feel if calculi Pea sized calculi as vermiform appendage curves back on persistent frenulum in a castrate goat Go site by site (2) • Catheterise Urethra? – Sigmoid flexure – Urethral recess – Flush with Local Anaesthetic and Walpole’s solution – Thin in early castrated animals – Curved catheter and guide wire best – Damage to epithelium may result if stricture Dyce, Sack, Wensing. Textbook of Veterinary Anatomy 1987 Urethral Catheter Catheter in Curved guide wire passed through and round obstruction Catheter passed up guide wire Go site by site • Percutaneous bladder catheterization if bladder visible by u/s and can be fixed by palpation – – – – Rutgers super-pubic catheter under local anaesthetic NEW catheter types – see next slides Caution regarding entrapping viscera Insert early before bladder leaking and size and resistance to pressure reduced • If bladder ruptured and cannot be catheterized – GA, laparotomy, repair bladder (tear dorsal) – Tube cystotomy with conventional Foley catheter • Flush with 10% Walpole’s Solution in Saline – Gradually increase time catheter closed – Urethra re-canalates in 2 weeks – if pyelonephritis does not occur Rutgers percutaneous or & Foley Catheters Malecot Catheter No balloon to burst but may not stay in as well. Cystofix Catheter Shorter and silicone rubber resistant to damage. Big needle Urethrostomy (Noordsy. Food Animal Surgery, 1994) Urethrostomy • Standing & epidural anaesthesia. • Mid-line incision from 4” below anus in cattle. • Identify penis & blunt dissect. • Transect penis distally to leave a 4” proximal stump. • Suture stump to skin – not through urethra. • Leave indwelling catheter for a few days. • Do NOT allow to scab over! (Noordsy. Food Animal Surgery, 1994) (Winter et al Veterinary Medicine 82 (12) 1261 Dec 198 Water Belly • incise skin in multiple sites to produce drainage. • Necrosis, slough off and re-epithelialize. • Worse if a lot of s/c fat. • Bath/spray with salt water regularly. • Antibiotic cover? • House? Fly treatment? • Welfare. PREVENTION OF (RE) OCCURRENCE • Urinary acidification • Ammonium Chloride (5g oral ram/goat). • Acid Sodium Phosphate. • Check Diet • • • • • • Do not assume someone did not get it wrong when mixing diet. Investigate sources of minerals in “course mixes”. Diets for growing rams should have no added magnesium. (lambs eating ewe nuts – give them own creep feed instead) Calcium Chloride or ammonium chloride in Lamb creep. Calcium/phosphorous ration 1.2-2:1 • (1.5% ground limestone). • 1% NaCl in diet, salt blocks? to increase drinking. • Check/Improve access to water. Urolithiasis – Golden rules? • Take seriously • Be cautious about sedating with alpha-2 agonist • If they do not start dripping and then free flow you have not fixed the problem • Reduction in pain is not always a good sign • Seek advice or refer early if no progress • Others may be at risk, so identify underlying causes