Incontinent 18 month bitch

RE: Incontinent 18 month bitch

Anthony Todd — Thu, 26 Jul 2018 20:04:11 GMT

[quote user="robloxley"]The presence of multidrug-resistant bacterium does not represent, by itself, an indication for treatment.[/quote]

This is the bit that bothers me!

And then it is sort of yes and no'ed with a sort of ifs and maybes.

viz:

[quote user="robloxley"]The presence of multidrug-resistant bacterium does not represent, by itself, an indication for treatment. Anecdotal information suggests that multidrug-resistant organisms will sometimes be replaced with susceptible organisms if treatment is withheld, and then treatment with routine antimicrobials may be more practical if decolonization is desired or if clinical disease develops."[/quote]

I'd still like to see a survey of totally normal dogs' urine to see how many contain potential pathogens yet the dog is totally normal!

Remember samples are only taken from animals with some sort of urinary related symptom!

RE: Incontinent 18 month bitch

Rob Loxley — Thu, 26 Jul 2018 18:07:35 GMT

[quote user="Anthony Todd"]

What bothers me, and nobody seems to address it, is whether it is possible and/or indeed common, to find bacteria in a urine sample which are not pathogenic [as are many gut and oral bacteria].

It seems possible to me that the presence of these innocent bacteria will trigger the diagnosis and treatment of a bacterial "cystitis" whereas they are just in the urine minding their own, innocent, business.

[/quote]

From "Antimicrobial Use Guidelines for Treatment of Urinary Tract Disease in Dogs and Cats: Antimicrobial Guidelines Working Group of the International Society for Companion Animal Infectious Diseases"

"4. Subclinical Bacteriuria

Subclinical bacteriuria is the presence of bacteria in the urine as determined by positive bacterial culture, in the absence of clinical and cytological evidence of UTI.

4.1. Summary of Recommendations

Treatment may not be necessary in animals that have no clinical signs of UTI and no evidence of UTI based on examination of urine sediment.

In some circumstances, treatment may be considered if there is concern that there is a particularly high risk of ascending or systemic infection (e.g., immunocompromised patients, patients with underlying renal disease) or that the bladder may be a focus of extraurinary infection. Diagnosis and management of the underlying cause is critical and treatment should not be used as a replacement for proper diagnosis and management.

The presence of multidrug-resistant bacterium does not represent, by itself, an indication for treatment. Anecdotal information suggests that multidrug-resistant organisms will sometimes be replaced with susceptible organisms if treatment is withheld, and then treatment with routine antimicrobials may be more practical if decolonization is desired or if clinical disease develops."

RE: Incontinent 18 month bitch

Anthony Todd — Thu, 26 Jul 2018 15:55:36 GMT

What bothers me, and nobody seems to address it, is whether it is possible and/or indeed common, to find bacteria in a urine sample which are not pathogenic [as are many gut and oral bacteria].

RE: Incontinent 18 month bitch

Rob Loxley — Thu, 26 Jul 2018 15:37:59 GMT

[quote user="Kara Gibson"]However given E.Coli is so frequently found in these cases amoxicillin alone is not often going to do the job. We're seeing a lot of multi-resistant urinary E. Coli so I feel culture and sensitivity is hugely important for all but the simplest of cases[/quote]

I think David's point is that typical lab sensitivity tests are based on serum levels of the antibiotic (and relation to MIC), as opposed to levels in the urine which for a renally excreted drug such as amoxicillin is much higher such that the reported resistance may not be real in-vivo for simple UTIs. Prepared to be corrected if labs are actually reporting urine breakpoints. Also appreciate that if bacteria have invaded the bladder wall then just using urine breakpoints may not give effective treatment. I'd happily use amoxicillin as an empiric antibiotic in 1st line uncomplicated UTIs, but if it's not responding as expected then more investigation is needed.

RE: Incontinent 18 month bitch

Kara Gibson — Thu, 26 Jul 2018 08:38:32 GMT

I think 3-5 days of antibiotics for a first uncomplicated UTI is reasonable. However given E.Coli is so frequently found in these cases amoxicillin alone is not often going to do the job. We're seeing a lot of multi-resistant urinary E. Coli so I feel culture and sensitivity is hugely important for all but the simplest of cases.

Also might be worth checking this dogs vulva conformation (if not done already) - some have a very recessed vulva which along with other predisposing factors can make ascending infections more likely.

RE: Incontinent 18 month bitch

David Mills — Wed, 25 Jul 2018 21:02:24 GMT

Xray looks normal to me.

Humans usually get 3-5 day course abx for bacterial cystitis, any longer selects for resistance. I think 2 weeks for a 18mo bitch is overkill personally.

I rarely use urine c and S, similar to ear really, most abx secreted in urine so reach very high concentrations so can overcome the apparently "resistant" ones. Pure Amox or oxytet normally 3 to 5 days dependent on severity I don't like throwing amoxclav at these.

Older dogs different story, they get 10 days normally.

RE: Incontinent 18 month bitch

Anthony Todd — Wed, 25 Jul 2018 17:31:41 GMT

[quote user="Lucy Fleming"]Like you I find that owners have more often than not noticed something )[/quote]

My main point was not to make the link between USMI with infection and one has to wonder how many dogs pass bacteria in their urine which don't cause any clinical signs; judging by this loads.

I would have been happier if there were some controls.

I begin to wonder whether bacteria in urine , without signs, can be innocent rather like the presence of bacteria in faeces?

Maybe their apparent presence is aided and abetted by collection and urethral or perineal contamination??

RE: Incontinent 18 month bitch

Lucy Fleming — Wed, 25 Jul 2018 16:44:02 GMT

[quote user="Anthony Todd"]

Nor me either, but according to Table 5 of your paper only 2 out of 102 cases were incontinent??

The paper seemed much more about "silent" UTIs than incontinence??

[/quote]

Yes, I mainly chose it as you had mentioned that UTIs were always connected with clinical signs. This suggests that they almost as often were not (I must admit I was surprised the percentage was so high! Like you I find that owners have more often than not noticed something )

A mild UTI "unmasking" an early USMI is entirely my own anecdote.

RE: Incontinent 18 month bitch

Anthony Todd — Wed, 25 Jul 2018 15:38:41 GMT

[quote user="Lucy Fleming"]It doesn't seem a vast logical leap (to me) that a dog with a urinary sphincter that does not form as strong a seal - even if the weakness isn't yet sufficient for detectable leakage -[/quote]

Nor me either, but according to Table 5 of your paper only 2 out of 102 cases were incontinent??

The paper seemed much more about "silent" UTIs than incontinence??

Did I get it wrong?

I guess the response to any treatment should be assessed with regard to water intake etc. [they talk about CCS incontinence which I certainly recognised, much to my chagrin!]

RE: Incontinent 18 month bitch

Martin Atkinson — Wed, 25 Jul 2018 14:03:02 GMT

Update on this case. The urine culture came back as a coagulase +ve Staph sensitive to most antibiotics. The owner reports that symptoms have resolved after a course of Co Amoxiclav and she is much brighter in herself - she had also reported loss of appetite in the initial consultation.

Plan is to continue antibiotics for another 7 days then do another urine culture.

RE: Incontinent 18 month bitch

Lucy Fleming — Wed, 25 Jul 2018 09:38:59 GMT

[quote user="Anthony Todd"]if this isn't post-spay incontinence as the history fits and UTIs, in my memory, always have frequency +- some blood??[/quote]

Not always - either not perceived by the owner or genuinely not showing clinical signs increased frequency, straining, visible haematuria etc. Usually haematuric or pyuric on sediment examination though. In a study by North Carolina state (https://onlinelibrary.wiley.com/doi/epdf/10.1111/j.1939-1676.2003.tb02492.x) more than half were asymptomatic at first presentation.

The same study also mentioned that 'dogs with abnormal micturition' tended to have recurrent infections until the underlying disorder was corrected. It doesn't seem a vast logical leap (to me) that a dog with a urinary sphincter that does not form as strong a seal - even if the weakness isn't yet sufficient for detectable leakage - would be more predisposed to an ascending infection (causing struvite crystalluria, strongly associated with the presence of bacterial UTI in dogs).

Similarly, it doesn't seem a vast logical leap that in a dog with a slightly weaker urinary sphincter, that is otherwise normally strong enough to hold urine, might start to show leakage due to the increased irritability of the bladder mucosa associated with a UTI.

That's why I would suggest the two conditions are sometimes interlinked on first presentation.

RE: Incontinent 18 month bitch

Anthony Todd — Tue, 24 Jul 2018 22:47:44 GMT

[quote user="Dinu Catilina"]On the presence of incontinence of course [/quote]

Um,er..... John McEnroe needed here.

RE: Incontinent 18 month bitch

Alasdair Hotston Moore — Tue, 24 Jul 2018 22:13:32 GMT

Uti is certainly a possibility as mentioned

the necessary X-ray for investigation has been missed however: retrograde vaginourethrogram. Check out the chapter in the BSAVA manual of abdominal imaging

RE: Incontinent 18 month bitch

Dinu Catilina — Tue, 24 Jul 2018 21:51:35 GMT

[quote user="Anthony Todd"]Based on what [just interested][/quote]

On the presence of incontinence of course

RE: Incontinent 18 month bitch

Anthony Todd — Tue, 24 Jul 2018 17:45:55 GMT

[quote user="Dinu Catilina"]I did! a couple even[/quote]

Based on what [just interested]

RE: Incontinent 18 month bitch

Liz Barton — Tue, 24 Jul 2018 17:28:16 GMT

[quote user="Sarah Keir"]Is there a particular reason for giving an uncomplicated case of bacterial cystitis 2 weeks of antibiotics? Just asking as my default is 5-7 days (depending where the weekend lies)[/quote]

This is a controversial one as the data isn't out there (to my knowledge). I normally prescribe 14days and ask them to bring in a repeat urine sample at 10 days which I run a basic in house panel including cytology. However, most of the ones I end up treating aren't straightforward (I'm doing mostly ECC and shelter medicine). You're right you can probably get away with less in uncomplicated cases and if any others have relevant data/experience it would be great to see/hear it!

This from 2011

Antimicrobial Use Guidelines for Treatment of Urinary Tract Disease in Dogs and Cats: Antimicrobial Guidelines Working Group of the International Society for Companion Animal Infectious Diseases:

"Adequate evidence regarding duration of treatment is lacking, precluding the ability to make a specific recommendation for treatment duration. Typically, uncomplicated UTIs are treated for 7–14 days. However, the Working Group acknowledges the likelihood that a shorter treatment time (≤7 days) may be effective. Accordingly, in the absence of objective data, 7 days of appropriate antimicrobial treatment is reasonable. Clinical trials supporting shorter durations for treatment of UTIs in dogs and cats are strongly encouraged."

https://www.hindawi.com/journals/vmi/2011/263768/

RE: Incontinent 18 month bitch

Dinu Catilina — Tue, 24 Jul 2018 17:15:08 GMT

[quote user="Anthony Todd"]I don't think I have ever seen an incontinent spayed bitch that ever turned out to have an infection[/quote]

I did! a couple even

RE: Incontinent 18 month bitch

Anthony Todd — Tue, 24 Jul 2018 17:14:12 GMT

I don't think I have ever seen an incontinent spayed bitch that ever turned out to have an infection, or didn't response to sphincter remedies.

Some with dysuria and conscious polyuria which did turn out to have an infection +- stones....

We did, from memory, usually, if not always, let them have one season though??

RE: Incontinent 18 month bitch

Sarah Keir — Tue, 24 Jul 2018 15:42:31 GMT

[quote user="Liz Barton"]

[quote user="Martin Atkinson"]Quite a large number of small struvite crystals and its pH was 8.5. Sample sent for culture.[/quote]

I really can't see anything I'm worried about on the X-rays. But the urinalysis would tend to fit with what others have suggested as suspicious of UTI. As culture can sometimes give a false -ve I'd be treating with co-amox for 2 weeks regardless, and be repeating urinalysis after 10days.

[/quote]

Is there a particular reason for giving an uncomplicated case of bacterial cystitis 2 weeks of antibiotics? Just asking as my default is 5-7 days (depending where the weekend lies).

Sarah

RE: Incontinent 18 month bitch

Anthony Todd — Mon, 23 Jul 2018 17:35:56 GMT

PS I thought struvite crystals were now regarded as normal, particularly in an alkaline urine??

Or is that only in cats?

RE: Incontinent 18 month bitch

Cool — Mon, 23 Jul 2018 17:08:37 GMT

was thinking post spay incontinence too. the radiographs dont seem abnormal to me either. i will go with urinalysis, culture and therapy as suggested above and see how it goes. i wont be surprised if it turns out to be USMI post spay

RE: Incontinent 18 month bitch

Anthony Todd — Mon, 23 Jul 2018 16:30:15 GMT

[quote user="Lucy Fleming"]I do wonder sometimes [/quote] if this isn't post-spay incontinence as the history fits and UTIs, in my memory, always have frequency +- some blood??

RE: Incontinent 18 month bitch

Lucy Fleming — Mon, 23 Jul 2018 16:19:58 GMT

I do wonder sometimes if the increased inflammation of the bladder wall/ sphincter with a UTI can 'unmask' an underlying, otherwise sub-clinical USMI. I would probably agree with the culture/ treatment suggestions, but advise the owners that it might not fully respond, or might recur further down the line. 18 months is pretty young for USMI though, but pretty old for something like an ectopic ureter.

RE: Incontinent 18 month bitch

Liz Barton — Mon, 23 Jul 2018 16:15:40 GMT

[quote user="Martin Atkinson"]Quite a large number of small struvite crystals and its pH was 8.5. Sample sent for culture.[/quote]

RE: Incontinent 18 month bitch

Martin Atkinson — Mon, 23 Jul 2018 08:56:13 GMT

[quote user="James Dunne"]Hard to say for sure, but the bladder neck looks quite intra-pelvic.[/quote]Hmmm....and I as thinking it all looked nicely abdominal!

[quote user="James Dunne"] I guess a urinalysis + sediment analysis would help to see if there is any simple underlying reason that has triggered incontinence.[/quote]Quite a large number of small struvite crystals and its pH was 8.5. Sample sent for culture.