Overflow incontinence on prednisolone

Re: Overflow incontinence on prednisolone

Hanna Bennett — Tue, 20 Nov 2012 20:40:58 GMT

not sure human medicine is more advanced, but i have an immune mediated disease and am on azathioprine. They told me it would take two months to be effective, introduced the dose gradually to ensure i tolerated it well (something i never do in dogs) and monitored my bloods on a reducing basis til i'd been on it for 6 months to ensure any immunosuppression was manageable - was on steroids initally with the idea that i wean off these and stay on the aza long term if no major side effects - which so far are far less than those produced by the steroids - my own personal version of EBM?

Re: Overflow incontinence on prednisolone

Malcolm Ness — Tue, 20 Nov 2012 09:02:13 GMT

[quote user="Michael Woodhouse"]So long as you don't suck it up from the floor should be fine[/quote]

?? even if you wash your mouth out first.

Re: Overflow incontinence on prednisolone

Michael Woodhouse — Mon, 19 Nov 2012 22:50:10 GMT

[quote user="Elisabeth Knappett"]As for urine C&S, how does everyone go about this? I've been 'told' not to submit anything other than cysto samples as will throw up erroneous results - true or false? Thanks![/quote]

Ideally a mid stream sample into a sterile container. Exactly the same as they do in people. So long as you don't suck it up from the floor should be fine.

Re: Overflow incontinence on prednisolone

Elisabeth Knappett — Mon, 19 Nov 2012 16:51:28 GMT

Was he able to urinate normally? And fully empty his bladder? No signs of neuro deficits caudally? Not that I'm thinking of anything in particular, just an unusual presentation. As for urine C&S, how does everyone go about this? I've been 'told' not to submit anything other than cysto samples as will throw up erroneous results - true or false? Thanks!

Re: Overflow incontinence on prednisolone

Kate Richardson — Mon, 19 Nov 2012 10:20:45 GMT

[quote user="Anthony Todd"]

Would I be right in suggesting that urinary overflow or "incontinence" ie involuntary urination, is never caused by an infection and that any bugs cultured are just commensals or incidentals and not the cause?

Is dysuria ie small and often, rather than polyuria a signal of possible [added after before I got corrected] infection?

[/quote]

I think infection is unlikely a primary cause of urine overflow or incontinence but infection is a cause of PUPD which could cause a secondary overflow incontinence in a susceptible animal eg one with a weak bladder sphincter.

Re: Overflow incontinence on prednisolone

Rob Davis — Sun, 18 Nov 2012 17:15:29 GMT

Update: thankfully the dog is continuing to do well on a slightly reduced prednisolone dose, and the incontinence is also improving (although not yet resolved).

[quote user="Michael Woodhouse"]In these 'leaky' cases I have had good success with Propalin in male dogs. Used it a handful of times and always with good success.[/quote]

I too have use propalin in some male dogs (and testosterone injections too in one), but this appeared to be overflow incontinence rather that poor urethral tone.

[quote user="Anthony Todd"]

Is dysuria ie small and often, rather than polyuria a signal of possible [added after before I got corrected] infection?

[/quote]

In theory I would guess you are right, though it is not always easy from the history to distinguish these. In this case the main reason I was suspecting an infection was that the owner had mentioned that the urine saw particularly smelly, which I wouldn't normally expect with steroid-induced pupd.

Re: Overflow incontinence on prednisolone

Anthony Todd — Sun, 18 Nov 2012 09:43:37 GMT

[quote user="Rajat"]starts off with a trickle of case reports,[/quote]

Many is the time that I've suggested, only to be shot down, that a collection of anecdotes is the beginning of a clinical trial........

Keep those unsubstantiated, unmoderated, uncontrolled, unpublished loads of rubbish coming folks!

Re: Overflow incontinence on prednisolone

Anthony Todd — Sun, 18 Nov 2012 09:38:56 GMT

[quote user="Rob Davis"]I should have mentioned in the original post that I have looked at a urine sample which was unremarkable[/quote]

Is dysuria ie small and often, rather than polyuria a signal of possible [added after before I got corrected] infection?

Re: Overflow incontinence on prednisolone

Michael Woodhouse — Sun, 18 Nov 2012 01:07:35 GMT

[quote user="Rob Davis"]That's what I'm hoping.... Will post progress report in due course once (hopefully) reducing the steroid dose.[/quote]

In these 'leaky' cases I have had good success with Propalin in male dogs. Used it a handful of times and always with good success.

Re: Overflow incontinence on prednisolone

Rob Davis — Wed, 14 Nov 2012 19:55:04 GMT

[quote user="Rajat"]Steroid myopathy? Leading to detrusor muscle weakness and sphincter muscle weakness along with pre-existing USMI (mild but now overt due to concurrent issues) would be my best guess.[/quote]

That's what I'm hoping.... Will post progress report in due course once (hopefully) reducing the steroid dose.

Re: Overflow incontinence on prednisolone

Rajat — Tue, 13 Nov 2012 20:13:04 GMT

[quote user="Rob Davis"]Why is the bladder remaining full and overflowing then?[/quote]

Steroid myopathy? Leading to detrusor muscle weakness and sphincter muscle weakness along with pre-existing USMI (mild but now overt due to concurrent issues) would be my best guess.

Re: Overflow incontinence on prednisolone

Rob Davis — Tue, 13 Nov 2012 16:34:01 GMT

[quote user="Kate Richardson"]Either urinary tract infection which may have been pre-existing and sub clinical prior to the pred[/quote]

I should have mentioned in the original post that I have looked at a urine sample which was unremarkable, no significant sediment, no protein, usg = 1.020. I have not run urine culture, though I think infection is unlikely given the normal appearance (I agree clindamycin would not be a good choice for UTI).

[quote user="Kate Richardson"]or subclinical incontinence/sphincter incompetence again exacerbated and made into clinical problem by pupd and increased bladder filling and pressure secondary to pred [/quote]

In which case I would expect the bladder to be relatively empty rather than full and overflowing.

[quote user="Kate Richardson"]or prostatic disease/infection again brought into foreground by use of pred. [/quote]

I was unable to feel the prostate per rectum (big dog so possibly fingers not long enough!) or abdominally. If this was the case I would expect the bladder to be difficult to express, but this was not the case.

[quote user="Kate Richardson"]Given good clinical response to pred for original problem, have you tried reducing the pred? [/quote]

Yes I am reducing the pred, but slowly. I was not intending to reduce the dose for the first couple of weeks, but am cautiously accelerrating this, though it does need to be done gradually.

[quote user="Rajat"]I would definitely look into the urine- full analysis warranted- however I agree the most likely cause is a combo of weaker sphincter in an older dog and massive urine production[/quote]

Why is the bladder remaining full and overflowing then?

Re: Overflow incontinence on prednisolone

Rajat — Tue, 13 Nov 2012 01:44:21 GMT

[quote user="Kate Richardson"]Well I disagree re Clindamycin, have seen many skin cases on it with poor responses. I agree C&S best way forward but is not always an option from a finance point of view. Cephalexin would always be my first choice for skin, and wouldn't be a bad blind choice for a urinary tract infection, but amoxyclav would be broader spectrum. If the dog needs to be on antibiotics anyway for its skin, it might as well be on one that covers a possible UTI as well. [/quote]

I do not mean to argue, but just because you have seen poor responses with it does not mean it is generally a bad choice, right Kate? Maybe you were seeing a skewed population. Or other causes for your poor responses. Mine respond beautifully - but that is a weak arguement.

Clinda mycinis decent choice for skin based on its penetration and the kind of bugs that it is usually active against and the staphs that are primarily involved with pyoderma.

My 2 c is that Amoxy clav is better for a UTI ( if convincing evidence of one) but not for skin . It's broader spectrum is not actually useful for the skin bugs but is for the UTI (if present). Cephalexin on the other hand, is less broad spectrum for urine but better for skin re penetration, active against the vast majority of common skin pathogens, and is excreted into urine too like amoxi clav.

So my interpretation is cephalexin is better if the primary issue is skin, with a secondary consideration of potential UTI.

The clincher is , as I am very sure you know, that one should not use the broadest spectrum ab first off - this is where we run into problems with them. We should try to see which bugs may be involved, which abs are going to penetrate the tissues involved and which abs can we use that fulfill these criteria which are least broad spectrum so we can save the big guns for when needed.

I am fully aware, being in GP that finances are limited sometimes, and I unless it was do and die pyelonephritis/awful infection where I felt I would be doing harm I would not reach straight for amoxi clav...

At least we can agree on the urine sample being a neccessity eh?

Re: Overflow incontinence on prednisolone

Rajat — Sun, 11 Nov 2012 14:45:08 GMT

Sad as it is, I am on holiday so it will take time to look into what you asked Malcolm, but as you seem to be taking the opposite view (that there is no evidence) can you provide any evidence they do not work or negative evidence to their usage?

I don't need to tell you, as someone who has studied far more than us mere mortals, that this kind of information starts off with a trickle of case reports, reviews, and so on, before bigger case studies and then placebo controlled, double blinded, randomised trials etc are published.

I don't think, that coming from a specialist of your eminence, questioning a perfectly reasonable suggestion of AZA/Ciclo as an addition to a dog suffering from an immune mediated disease and significant s/e of steroids is helpful without providing further info- if so you may choose to educate us why you feel that way rather than point blank question the evidence and to some of us reading between the lines the efficacy- for some it may even be seen as gospel as you're a specialist and given the potential benefits to the dog and that so many have used these drugs successfully in these cases, I think the onus of proof rests with you

[quote user="Malcolm Ness"]I love being patronised![/quote]

I didn't mean to patronise you just point out there is evidence - from a very brief search (which I thought you may heave performed before posting). That it may not be as rigorous as we like or not double blinded placebo controlled etc is different- but there is plenty of evidence to be examined, for its strengths and weaknesses.

Re: Overflow incontinence on prednisolone

Malcolm Ness — Sun, 11 Nov 2012 12:26:50 GMT

[quote user="Anthony Todd"]

My colleague [MJV] was interviewing a new vet, and asked him if he was aware of "a mould that had been discovered that grew on bread and stopped the growth of bacteria?" all with a totally straight face.

The potential assistant looked completely non-plussed.....

Perhaps Malcolm could have told him...

[/quote]

I doubt it - that sounds like medicine and I do surgery.

Re: Overflow incontinence on prednisolone

Anthony Todd — Sun, 11 Nov 2012 12:18:29 GMT

[quote user="Malcolm Ness"]I do try - I am learning all about that new-fangle Ether [/quote]

[quote user="Malcolm Ness"]so up to date[/quote]

As an aside.

The potential assistant looked completely non-plussed.....

Perhaps Malcolm could have told him...

Re: Overflow incontinence on prednisolone

Malcolm Ness — Sun, 11 Nov 2012 11:49:02 GMT

[quote user="james herriot lied"]And may I say, Mr Ness, what a refreshing change it is to find a man of your age so up to date with modern veterinary practice.[/quote]

Thank you!

I do try - I am learning all about that new-fangle Ether that lets you do surgery without having to tie your patients down and I can now say with some pride that I carefully sharpen my hypodermic needle between patients and I boil it clean every night (whether it needs it or not).

Re: Overflow incontinence on prednisolone

Anthony Todd — Sun, 11 Nov 2012 11:37:14 GMT

[quote user="Kate Richardson"]One thing I was always taught was that if an animal needs to drink, let it.[/quote]

Quite so, they do drink adequate boiled water but not to excess.

That's how I diagnosed psychogenic polydipsia anyway.

The hardest part was getting the owner to measure the daily water consumption accurately in units of volume and not containers!

Re: Overflow incontinence on prednisolone

james herriot lied — Sun, 11 Nov 2012 11:31:04 GMT

[quote user="Malcolm Ness"]

I love being patronised!

[/quote]

And may I say, Mr Ness, what a refreshing change it is to find a man of your age so up to date with modern veterinary practice.

Re: Overflow incontinence on prednisolone

Kate Richardson — Sun, 11 Nov 2012 10:04:56 GMT

[quote user="Anthony Todd"]One trick which often worked for me, providing the urine is dilute, is to boil the water [let it cool to R temp!] which seemed to stop excessive drinking as they hated the taste, or seemed to.[/quote]

One thing I was always taught was that if an animal needs to drink, let it. The only reason to deliberately stop an animal drinking for whatever reason would be if you has diagnosed pyschogenic polydipsia.

Re: Overflow incontinence on prednisolone

Anthony Todd — Sun, 11 Nov 2012 09:56:23 GMT

[quote user="Joyce Whitehead"]only on 10mg preds for chronic otitis[/quote]

God knows what 10mg of pred would do, if anything, to a Rottie but IMHO some dogs, particularly Westies, seem very sensitive to pred and do become PD/PU, seemingly independent of dose.

One trick which often worked for me, providing the urine is dilute, is to boil the water [let it cool to R temp!] which seemed to stop excessive drinking as they hated the taste, or seemed to.

Re: Overflow incontinence on prednisolone

Kate Richardson — Sun, 11 Nov 2012 09:54:48 GMT

[quote user="Rajat"]Clindamycin is actually a decent choice for skin , and I'd choose it over amoxy clav for this, but personally I;d do a culture before giving any antibiotics unless you re convinced its a UTI (I aint based on your description but I ain't seeing the dog either!) nd/or O has no money. Current prescribing guidelines indicate we should choose the smallest 'gun' available so I'd choose Cephalexin if I was treating blind. [/quote]

Well I disagree re Clindamycin, have seen many skin cases on it with poor responses. I agree C&S best way forward but is not always an option from a finance point of view. Cephalexin would always be my first choice for skin, and wouldn't be a bad blind choice for a urinary tract infection, but amoxyclav would be broader spectrum. If the dog needs to be on antibiotics anyway for its skin, it might as well be on one that covers a possible UTI as well.

One other consideration would also be diabetes induced by the corticosteroids, depending on the patients risk level ie if already overweight. Urine sample definitely needed.

Re: Overflow incontinence on prednisolone

Malcolm Ness — Sun, 11 Nov 2012 09:13:58 GMT

[quote user="Rajat"]And AFAIK it is considered standard practice from a lot of internal medicine specialists (and textbooks) to add in these drugs, (for several immune mediated diseases with preds) as these drugs take time to kick in , ensuring that a) steroids can be weaned with lower chances of relapses b) tougher cases are better controlled and more quickly brought under control.[/quote]

And that is exactly why I asked the question. "Standard practice" and eminence based medicine can become dangerous things when left unquestioned. It used to be standard practice to burn witches - lots of eminent lawyers, churchmen and politicians supported the practice. More recently, my father in law died of lung cancer most likely as a result of his smoking habit. The habit started when he joined the army and it was standard practice to provide all enlisted men with a ration of cigarretes. Smoking was standard practice promulgated by many eminent people. You can read reports of either/both of these practices in the historical literature.

I might have overlooked something but is there anything out there that provides decent evidence to support the (admittedly widely accepted) claims that you re-iterate, specifically "these drugs take time to kick in", "Tougher cases are better controlled" (how is a tougher case defined?) and "more quickly brought under control"

There is more, so much more, to medicine in general and EBM in particular than fishing the literature and quoting passages from case reviews and the tendency that is becoming ever more popular to engage in a kind of mindless "literature top trumps" game is rarely helpful.

[quote user="Rajat"]Did a ten second search, found several reports in the literature, reviews as well as reports [/quote]

I love being patronised!

Re: Overflow incontinence on prednisolone

Rajat — Sun, 11 Nov 2012 07:37:54 GMT

[quote user="Malcolm Ness"]Is there any evidence for efficacy of these drugs in immune mediated polyarthropathies?[/quote]

Did a ten second search, found several reports in the literature, reviews as well as reports of their successful use.

And AFAIK it is considered standard practice from a lot of internal medicine specialists (and textbooks) to add in these drugs, (for several immune mediated diseases with preds) as these drugs take time to kick in , ensuring that a) steroids can be weaned with lower chances of relapses b) tougher cases are better controlled and more quickly brought under control.

Steroid s/e are often a reason for PTS and while one should not do a straight swap from preds to Ciclo/AZA without making sure their effects are well in place, and weaning slowly (as one would anyways with preds at this doseage) I think they will actually be very helpful in such a case- not many owners will put up with urine all over the house especially if its a larger sized dog !!!

I would definitely look into the urine- full analysis warranted- however I agree the most likely cause is a combo of weaker sphincter in an older dog and massive urine production. Clindamycin is actually a decent choice for skin , and I'd choose it over amoxy clav for this, but personally I;d do a culture before giving any antibiotics unless you re convinced its a UTI (I aint based on your description but I ain't seeing the dog either!) nd/or O has no money. Current prescribing guidelines indicate we should choose the smallest 'gun' available so I'd choose Cephalexin if I was treating blind.

Re: Overflow incontinence on prednisolone

Joyce Whitehead — Sat, 10 Nov 2012 21:25:24 GMT

I once had an entire male rottie that had very similar signs, although he was only on 10mg preds for chronic otitis. He was so bad we had to hospitalise and catheterise him, but as soon as the preds were stopped he was fine, and no sign of UTI or prostatic disease found. Not much help in a dog that needs high dose preds for such a nasty condition though...