Welcome everyone. Today we are gonna spend about an hour together to discuss about canine urinary incontinence, . Canine urinary incontinence represents the loss of voluntary control of urination, leading to inappropriate voiding of urine, which is often described by the owners as leakage.

These disorders of urination are frequently recognised and many more practised and obviously that has been increasing with the change in the kind of position of the dogs in the family and them spending more and more time indoors and being treated as full members of the family. And therefore it's a very disruptive problem for both the patients but also the owners and their lifestyle. And, it's something that can be eventually treated, that can require long term medications, so it's important to be able to recognise it, and to know that it can be associated with either a structural abnormality or an imbalance between the storage capacity of the bladder and the urethral tone to be able to keep that bladder closed.

So if we look a little bit closer at the bladder, the bladder can be divided into the apex, the body and the neck, the trigone of the bladder. Is a small triangular area on the dorsal aspect of the bladder neck where both ureters are gonna enter and open to allow the flow of urine coming from the kidney to be stored into the bladder. The body and the apex are formed, of a bundle of muscular fibres that have very, various orientation.

Some are spiral, some are longitudinal, some are circular. And that bundle is composed of very intimately fused muscular fibres with very, very tight junctions, allowing for a complete contraction when there is any kind of stimulation of that muscle. So that is the detrusor muscle which is the most important muscle to void and empty the bladder.

Along the urethra, we will find first smooth muscles at the level of the trigon and the neck that will slowly be replaced throughout the lengths of the urethra by striated muscles which form the majority of the musculature in the more distal part of the urethra. Even though there is not like a specific location for a sphincter, we assume that these moose muscles represent what we call the internal urethral sphincter, and the striated muscles will represent what we call the external urethral sphincter, but both have to be fully. Capable, fully able to contract, to allow for continence.

In terms of the physiology, we have to look at the innervation of the bladder and the control of the maturation is attained through a combination of both voluntary or somatic and involuntary or autonomic component of the nervous system. The sympathetic innervation is supplied by the hypogastric nerve and that will regulate the feeling phase. It will stimulate the alpha adrenergic fibres that are present in the trigon and the proximal urethra along these smooth muscles that we just mentioned before, and that will allow to contract the smooth muscle and close this internal urethral sphincter, close the bladder.

In the meantime, the same nerve will have a stimulating effect on beta adrenergic fibres that are present on the detrusor muscle, inducing relaxation of the detrusor and therefore accumulation of urine within the bladder. And this combined effect, obviously, as you can imagine, allow for the urine to be stored properly. Now, if we think of the emptying phase of the bladder, the bladder will fill and distend, and there will be a sensory, stretch receptor that are embedded in the bladder walls, and these stretch receptors are going to be stimulated.

The afferent signals from the stretch receptors are gonna be sent through the pelvic and the hypogastric nerves to the spinal cord, and that will increase the activation of the parasympathetic fibres within the pelvic nerve. That information is relayed into the brain stem because urination and voiding is a conscious action that we perform, and this conscious perception of the bladder distention will lead to the decision of the individual to void when there is, when the individual is in in a in a in an appropriate location or at the right time, and that comes through the parasympathetic nervous system. Which will stimulate the atrial muscle to contract, the inhibition of the somatic effect of the neurons in the preendal nerve and the adrenergic fibres in the hypogastric nerve will result in a relaxation of the external and the internal urethral sphincter respectively, and that will allow for a full voiding of the bladder.

Now, when we want to consider the differential diagnosis for incontinence, I like to always base my differentials on my physical examination findings, and these physical examination findings are, can I palpate a bladder? Is the bladder normal or small in size, or if the, is the bladder distended and very big? When I am looking at a normal or a small bladder, I suspect that there is probably a feeling disorder and the bladder is not able to hold a normal volume of urine.

That can be associated with anatomic abnormalities, decreased bladder compliance, or decreased urethral tone. Among the anatomic abnormalities, ectopicculars are the most common ones. They are a congenital abnormality.

They are often present in very young puppies, although there are a few cases that have been described as adults, either in male dogs or in female dogs that developed incontinence post spay, and were shown to have ectopic curers that were probably being compensated for before the spay. Pelvic bladder with an abnormal position of the bladder within the pelvis, fistula with the GI or the reproductive tract can lead to incontinence. A persistent urachus could lead to some form of incontinence, and vestibular structures will lead to accumulation of urine in the vestibule, at the moment of the voiding and then emission leakage of urine at random times, from that urine being pulled within the vestibule.

In terms of decreased bladder compliance, we can face urge incontinence, associated usually with inflammation and pain, that has been described with urolithiasis, neoplasia, or primary inflammatory disease of the bladder. And then idiopathic detrusor instability, which is an over contraction of the detrusor muscle. Finally, a decreased urethral tone, with urethral sphincter mechanism incompetence, which is quite common in spayed female, adult spayed female, will lead to incontinence as well because there is no way to properly close the bladder and hold the urine as the bladder is filling.

Now if we consider a distended bladder, we can have anatomical urethral obstruction leading to overflow incontinence. We could have a functional urethral obstruction with spasms, or we could have neurological disease leading to an abnormal voiding pattern. In terms of anatomical urethral obstruction, they, they can be secondary to an embedded urethiasis within the urethra, creating obstruction, accumulation of urine in the bladder.

Once the bladder is very, very distended, and the urethra distends as well, there is some urine that will pass probably around and the dog might emit some urine very inconsistently and at very random times. Neoplasia, strictures, inflammation will lead to the kind the same kind of presentation and the same type of urination patterns. Functional urethral obstruction is usually associated with vesicourethral or detrusor urethral dysinergia, which is an abnormal contraction of the urethral sphincter at the same time as the detrusor.

So the dog postures to urinate but cannot urinate at all and is gonna strain trying to urinate. And when the dog moves away and stops trying to urinate, then he's gonna leak unconsciously urine for a couple of minutes. This has been described only in a few case series, and it's been mostly reported in male dogs and large breed dogs such as golden Labrador, or or the large large breed dogs.

When we look at neurological abnormalities, we have to consider a few things. One would be an affection of the lower motor neuron, that would be a sacral disease, an affection of the upper motor neurons, so, the central nervous system, down to L7, and then detris or atomy, which is usually an acquired disease. So lower motor neuron disorder occur secondary to lesions affecting the sacral spinal cord, so sacroilia luxation called the equina syndrome, or the pelvic nerve along the tract, and that will result in an interruption of the local reflex arc in the sacrospinal cord, leading to detrusor and sphincter hyporeflexia.

Therefore, the bladder is gonna be very enlarged, but very easy to express because the external urethral sphincter is not contracted anymore. Now, upper motor neuron disorder will occur when there is a lesion at the level of, that it would be cranial to the sacral spinal cord. So as I said, from the POS to L7, that can be seen with intervertebral disc herniation, fibrocartilaginous embolism, for example.

There is no somatic perception of distension of the bladder, and this will result in the loss of inhibition of the efferent somatic neurons and will continue to increase the extra urethral tone. Therefore, these bladders are usually heavily distended, very, very big, but very turgid and very difficult to express. So as you already suspect, a lot of your investigations will be based on your history and your physical examination because that will help you refine that extensive differential list that we just went through, and will help you classify these anormalities between congenital versus acquired.

In the history, it is very important to acquire obviously the age, the breed, but also the reproductive status of the patient. Is the patient intact, yes or no? It's important to have a very, very good representation of when and how the leakage are occurring.

Is it always, is it intermittent? So you need to question the owners and to ask them to repeat and describe over and over again until you have a very good representation of what the dog is actually doing. It is important as well to confront that history of leakage with other diseases that could mimic incontinence or worsen incontinence, such as any signs of dysuria, abnormal pattern of urination, like stranguria, potauria, hematuria, the presence of PUPD which can worsen a pre-existing incontinence, it can lead to nocturia, for example.

Is the dog on medication? Was the dog on any medication before? What was the response to these medications?

You obviously want to know if the dog has a history of neurological issues, back pain, and you obviously will do a neurological examination of the patient. You want to know the defecation pattern of your patient. Is the patient presenting any form of faecal incontinence, for example, is the patient conscious when he's urinating?

Is the patient stressed? So being as detailed as you can, to try to have the best representation in your mind of what the dog is doing when he's having these incontinence accidents. Phy physical examination starts with a general physical examination as you would do for any of your patients.

Then you would like to palpate the bladder because that's gonna help you to rank your differentials between an empty or normal bladder versus a very large and extended bladder. You want to examine the genitalia of your patient. If you have a male dog, you want to exteriorize the whole penis and eventually needs to sedate the patient to be able to really fully get the entire shaft out.

You want to look at the vulva, you want to look for the presence of inflam. Dermatitis, like on the picture here where you can see that there is urine scaling and inflammatory proliferation around the vulva due to the inflammation of the, the urine being constantly pulled and and the area being always moist. You want to look at the perineum, you want to look at the perineal reflexes, and you want to do a full rectal exam.

You can palpate the urethra on the ventral aspect of the colon. So you want to palpate that urethra, you can sometimes palpate stones or masses. You want to palpate the prostate.

If you have a male dog, you want to palpate the semblo or lymph nodes as well to try to have as much information as you can. And finally, you want to conclude with a, a complete neurological examination, obviously paying a very important attention to the perception of your patient, but also sensation, movement of the tail, perineal reflex, lumbosac lumbosacral pain as well. Through this presentation, we are going to go through the history of three of our patients.

The first patient here is Alfie. Alfie is an 8 month old, cockapoo poodle cross, who was presented to us for incontinence. Incontinence had been present since adoption, when he was 2 months old and seemed to be worsened at night.

Like the bed was always, always, wet in the morning, but also the owner noticed, even though it was a bit more discreet, that is, his abdomen was always, wet as well, and that urine was emitted, at random times during the day. You can see on the picture that the skin is a little bit, Red, around the penis and the the the. The hair is, is very, very wet.

The second patient is Tess, she's also a Cockapoo, and she was presented to us at 6 months of age, for continuous incontinence since she since birth, and she was born where, like the, the, the breeder kept her, so. They had her since birth. She was the picture of the vulva.

I showed you a little bit earlier, so she had, dermatitis and proliferation around her vulva and that was supposed suspected to be secondary to the urine scaling. And the third patient is Alpha, who was presented to us at 2 months old. She was a female Labrador and she was referred for a dermatology consult for these proliferations and the veterinarians were worried that these were like some form of papillomavirus infection or other skin condition.

However, when examining the dog, the dog was constantly dribbling on our table, and you know, the, the hair was completely wet, so we suspected that these were a reaction to urine scaling and inflammatory reaction and dermatitis. Diagnostic investigations for all of these patients is again first very general. You want to make sure that your patient is overall healthy and that the incontinence is the only problem.

These three patients are very young, but if you are confronted to an older patient with incontinence, you also want to make sure that there is no other indication of maybe an underlying disease that could create PUPD such as Cushing's disease, hypercalcemia, something like that. You want to check the renal function of these patients, you want to look at a urinalysis, you want to perform a urine culture and sensitivity in all of these patients to make sure that there is no infection associated with the incontinence. And if your patient is old enough, and if you have.

A suspicion of a transitional cell carcinoma and other tests that could be performed would be a bra mutation research PCR on the urine if you had any suspicion of a neoplastic condition leading to incontinence. This will give you a minimal database and then you want to perform diagnostic imaging. Diagnostic imaging of the urinary tract can take form of an ultrasound.

Can take form of radiographs or CT you could perform some contrast studies to try to highlight some part of the urinary tract, and eventually some urodynamic studies. So we have a lot of choice here for diagnostic imaging. And then finally we also know that we can perform a urethrocystoscopy, so going with an endoscope into the the urinary tract.

To have a direct look inside the urethra and the bladder and see if there is anything we can identify. Based on our patient pool of three very young dogs, our main differential was ectopic utters. These 3 dogs had a small bladder or a normal bladder, and they had been incontinence since birth, so we had to suspect something congenital, and ectopic utters are the most common thing you will diagnose in young puppies with incontinence.

The segment is usually young dogs, female dogs are much more predisposed than male, and we suspect that male dogs are probably able to compensate a little bit better if the ectopia is not too severe because of the lengths of the urethra. Their history is typically the one we had for these 3 puppies, incontinent from birth or from adoption, dribbling any time when they are walking, jumping, running, but also laying down, and the patient have usually a lot of soaking with the urine. They can be smelly, they can have dermatitis, as we've said.

You can see the dribbling in your consult room, on your table. You can see the urine is cold, the dermatitis, and as I said, you will palpate a bladder of normal size or sometimes no bladder at all. So if we look at the anatomy of the uterus, as we said at the very beginning, they are coming from the kidney and they open at the level of the trigone.

When they are ectopic, you can have two configurations. One is an intraluminal path, so the ureter arrives as if it was gonna open in the trigon, but instead of opening, it continues to run through the mucosa and open further down into the urethra somewhere. Or we can have an extraluminal pass where the ureter lives its life outside of the bladder wall and then attaches and opens, but that is much further down than the the trigon and the bladder.

This is less common, the most common ones are intrauminal urethral ectopia. In terms of treatment and investigations, intrauminal ectopiculters can be seen by cystoscopy, fluoroscopy, and can be treated with laser ablation or an open surgery. The extraluminal ones have to be treated by surgery because obviously there is no tract that we can cut and open within the urinary tract.

They can be unilateral, they can be bilateral, they can be one extra, one intra, all of the configurations are possible. As we said, the female to male ratio is 2 to 1, so a very marked overrepresentations of female in that disease. Most of them are intramural, and that means that there is a tunnel that we are going to be able to open to treat this patient.

They have been associated with a lot of comorbidities because you rarely have one anatomical abnormality or one developmental abnormality. So these diseases have been associated with renal dysplasia, hydroureter and hydronephrosis, which usually improve after correction of the ectopic ureter. Sometimes they are associated with a very small bladder that has a hard time to distend, they can be associated with pelvic bladder, they can be associated with congenital USMI.

So these puppies also don't have a normal urethra. The function of the urethra is not perfect. And they can also be associated with the Parmesopheric remnant, which is a little band of flesh, that is closing the, the opening of the vagina and kind of keeps the papilla open and probably worsen the incontinence in some of these puppies.

As I said during your investigation, you want to rule out any kind of other problem, other disease from a urinary point of view, you want to rule out a urinary tract infection. It's also very important to consider behavioural and toilet training issues in these puppies, so a lot of questioning of the owners around that, and in terms of approach, as we said, you gather your baseline data with some blood, some urine, your urine culture. And then you want to perform some imaging.

If you suspect an ectopic curator, the first step is probably to perform an abdominal ultrasound, and abdominal ultrasounds are able to suspect ectopic curers, and when they see them, they are actually quite good at seeing them. Here on the picture you can see that the bladder is the on the left of the of the picture, and between the arrows you have that . Kind of tunnel filled with fluids that continues along the bladder neck without merging with the bladder, and that is suspicious for an ectopic curer.

Based on a recent paper, we know that ultrasonography is quite sensitive and quite specific for detection of ectopic utters in urinary incontinent dog. So it's very easy, very cheap, if you are well trained to look at the bladder and find the opening of the ureters and try to follow them and see if they continue further down. Sometimes they can be multi penetrated, so the visibility of a jet within the bladder is not a definitive rule out for an ectopic curer for me.

Another modality would be to use a CT and if you do so, you will have to do a CT intravenous urogram to try to highlight and timely highlight the urinary tract of the patient. So this is one of our little puppies, she has received contrast. You can see that the two kidneys at the top of the picture are very well highlighted.

And you can see that the contrast is going down where the arrows are, the ureter, and you can also see that the bladder is not taking any contrast, and yet the contrast continues into some form of a tunnel down. Into the urethra. So this is probably one of the best CTs I've seen for the diagnosis of ectopic ureter.

CT sometimes can be difficult to interpret because the contrast in the bladder makes it very blurry sometimes to see where the opening actually is. This is the other CT in in a male dog, where you can see an accumulation of contrast into one of the ureter that is quite distended, so that would be called a hydroureter. You can see the prostate here where that ureter seems to be kind of attached, and you can see that there is contrast going from the bladder into the urethra, I will play it again, but that there is also contrast going from that distended ureter into the urethra as well.

So that was diagnostic for an ectopic ureter in a male dog with an intraprostatic opening. Finally, endoscopy and cystoscopy allows for the direct visualisation of the ectopicculter, and it will allow you to be sure or 100% that this is what you are dealing with. On the picture you have in the screen, sorry, it's a bit blurry because it's been, it's been increased in size, but you can see on the To that you have the normal urethra and that the back, the bladder, which appears very, very black because there is no penetration of the of the light and at the bottom you have another opening just here with this band of flesh here that is your tunnel that is that ectopic culter that is opening further down into the urethra.

You can access the morphology of the ectopicculs here you can see that you have an opening here. But also an opening here. So this is a fenestrated ectopic cutter.

So it's possible that here you could have seen a jet that is close to the bladder, but the ectopic is still opening further down, or you can see a completely abnormal vestibule here with a lot of different things opening at different locations, and then you have to figure out which one is the urethra, which is this is the urethral papillae. You can hear, see already the tunnel of one of the ectopic utters and the normal urethra here, and then this is your vaginal opening with a very big paramezonephric remnant in the middle of it. So as I said in terms of treatment, neoureterostomy was the gold standards open surgery, it's quite invasive and we know that after surgery about half of these cases will be continent, but unfortunately, half of these cases will not be continent and will require either medication for USMI or further treatment, such as a urethral ccluter which will be discussed a little bit later.

We give the same numbers in terms of success when we do an endoscopic correction of the ectopic uterus, except that we don't have to do an open surgery and these patients go home the following day. When we correct the ectopic uterus via endoscopy, so this is a cystoscopy, you can see here a catheter entering the ectopic tunnel, and you can see that tunnel here going towards the bladder. And you want to use a laser to come and cut that tunnel open and recreate a.

Kind of continuum in the urethra and push the opening of the ureter back up into the bladder. So using the laser, we follow the catheter to cauterise and cut the tissue and open slowly but surely that tunnel and create a continuum with the urethra that is already there and allow for the urine to actually be emitted into the bladder and no longer further down into the urethra. So it's a Very neat process, there is coagulation at the same time as the cutting, so there is no, .

When we look at the long term outcome of this dog treated by cystoscopy, they are very little, out in the literature at the moment. There are two retrospective studies, that are designed a little bit differently but kind of come up to the same conclusion. There is very little complications.

The hospital stay is shorter than with surgery, and there are. Sorry, there is a very good success with between 45 and 75% of the dogs, having a markedly improved continent score compatible with complete success of surgery, and the others are needing more medical management. A few dogs had post procedure urinary tract infection, which were treated with antibiotic.

With antibiotics, as well, and there are two dogs that had, kind of continued urinary issues after the procedure and were euthanized, because they could not respond to any form of treatment. So if we go back to our three dogs, Tess, Alpha, and Alfie, Tess had a cystoscopic guided laser ablation. She had a complete resolution, so she's what we call dry.

There is no more emission of urine that is abnormal, no more, dermatitis, complete resolution of the dermatological lesions. She had a UTI after the procedure which required an antibiotic treatment, but that is all resolved and she's now 2 years after her surgery and doing fantastic. Alpha, our little Labrador had cystoscopic guided laser ablation.

She markedly improved all of the skin lesions resolved because the incontinence was much less, but she requires further treatment, so we will discuss that in a minute. And Alfie had a cystoscopy that showed normally located, . Uretery junction, so the ureters were opening well into the bladder, so there was no ectopic ureters for this dog, and we suspected as well, a urethral sphincter mechanism incompetence, and that is the second biggest category for your incontinent patient that you have to know about.

It's A a reminder that the, the urinary continence depends on the bladder capacity and the urethral tone, and in this case, the urethral tone is abnormal, and that can be the tone of the smooth muscle, the tone of the striated muscle, but there is also part of it being secondary to the intraabdominal pressure and the position of the bladder in the body, but also the length and the width of the urethra. So there is no specific sphincter, it's an intricated mechanism of closure between these smooth muscles, these striated muscles, even the mucosa has like folds that we kind of coha together to ensure perfect closure of the urethra and all of that has to work perfectly for it to be 100% functional. So urinary incontinence has been reported for years in 3 to 20% of female spay dog, and it's been shown that it develops after the spay, and I think a lot of textbooks and papers they still say 3 to 4 years post-pay.

However, we know that it can actually occur much quicker, like 6 months to a year sometimes. This is due to the loss of oestrogen, due to the spray, and that will decrease the sympathetic tone in the muscles and therefore the smooth muscle contraction will be impaired. There is also changes within the muscles with more collagen which will also decrease the muscle tone, and the tone overall of the dog is reduced.

So there are more and more evidence that maybe a let's pay after maybe the first heat cycle would be recommended in certain breeds of dog to try to improve or prevent as much as possible, this kind of oestrogen depletion and changes in the muscle fibres. Some breeds seems to be more predisposed than others, so Irish setters, Doberman, bearded collie, rough collie Dalmatians, seems to have a lot of, a lot more female presenting that complication after their spay. It's something that we will find in some male dogs.

So if we think of Alfie, that's what we suspected for him. But it's something that is very rare in male dogs, and it's something that can be congenital, where the function of the muscle is not good to start with, even before the spa, but that is also less common. So the presentation is that adult female dog that will be incontinent as an adult, as a new problem.

However, as we just said, we suspected this for alpha and Alfie, our two puppies, so it can be continental. The incontinence is usually more severe when the dog is laying down or sleeping, so the dog typically like is on the couch to watch a movie with you, and then there is like a wet spot or the bed is wet in the morning when the dog wakes up. Initially, there is no dribbling, although that can progress over time because it's kind of progression, a progressive disease.

The neuro exam will be normal, the defecation is normal, there's no faecal incontinence, there is no PUPD, . And again, you have a small or a normal sized bladder. The age and the progression make usually a congenital disease unlikely in your differential and will bring the USMI as your top differential if you have a spayed female that is 6 years old and it's a brand new problem.

You will do your investigations to rule out any further condition to explain why and then once you've ruled out a urinary urinary tract infection or any systemic diseases, then you have two options. One is to treat. And see if there is a response, or perform imaging to rule out really to 100% almost any other concomitant disease such as stones, a tumour, or anything abnormal within the urinary tract.

If you decide to treat, treat for 1 or 2 months, and if you don't have the response that you want, or if it's progressing, then you can perform your imaging. So this is a disease where there is no perfect plan and both can be easily justifiable. They have to be discussed with the owners and the decision has to be made kind of together with the owners knowing the limitation of treating versus doing the imaging, but if it's just USMI there is not much to lose.

The gold standard would be to do a urodynamic study, so to evaluate the pressure and the flow in the bladder and in the urethra. This is not available everywhere. There are, I think, two places in the UK that offer it.

One is a practise in Bristol and the other one is the University of Cambridge. And they are like in Ireland, for example, we don't have access to this, technology, but this would be the gold standard to prove the lack of efficacy for the urethral tone. In terms of treatment, you've heard of them for sure.

One is phenyl propanolamine. It's an adrenergic agonist, which will lead to a strong closure of your smooth muscle in the proximal aspect of the urethra. It can be associated with hypertension, some behavioural changes like, restlessness, but also tachycardia, so it's important to monitor these things in your patient when they are taking high dose of phenylproppanolamine.

And it has a very good success rate of around 85% in female. In male dogs, the use of phenyl propanolamine is also recommended, however, the response rate is much lower, around 44%. The second drug that we are gonna use is estriol, which is a natural oestrogen, and it will enhance the action of the alpha receptor, to increase the urethral tone at the level of this striated muscle.

So the mechanism is different between the two, and they will have together a synergistic effect. So you can start with one and if it doesn't work, I would recommend to. Add the second one to try to see if with both drugs you get a better control or not of the incontinence.

And that is something that is very well described and very nice because you will have a a complementation between both drugs. If these oral medications are not working, then we can try to do something with the urethra to improve its closure. One of the options is to use a bulking agent, such as collagen or vet foam, to kind of form these like big bulgy white bubbles that you see in the urethra to reduce the diameter, make it narrower, and hopefully help with the ability to hold the urine in the bladder.

The main issue with this is it's great, like it's minimally invasive. You can do that under endoscopy, so there is no open surgery. It's, it's a very, it's a day procedure kind of thing.

However, the effect is a little bit temporary, and we know that there is somewhere between 6 months and a bit over a year of time where the dog is going to be continent. And then they will start to become incontinent again up to the point that they will need to repeat the procedure. So there is a cost that is a little bit prohibitive sometimes when you have very young patients that you would like to use a bulking agent for.

The most recent development in that area has been this artificial urethral occluder, which is basically a cuff that you will place surgically and wrap around the urethra. The cuff is then gonna be distended with sterile saline to create a permanent reduction and narrowing in the urethral sphincter, and that will allow for a better control, . Of, of the, of the continence, by narrowing the diameter, you increase the coaptation of the mucosal fold and hopefully if there is some muscular function and some contraction, maybe having a narrow diameter will allow for that to be enough to hold the bladder into the urine.

The studies to describe the first use of this were very promising and you can see that the continent score pre urethral occluder and after have very much changed and they have increased towards 10, which is a perfect continent score. The main complications that have been reported are . Pain at the time of maturation, so dysuria associated with that discomfort and infections, and some dogs had a very marked inflammatory reaction and had a stricture that developed at the level of the occluder.

USMI in male dog will go with the same approach as you would for a female. It's an exclusion diagnosis, unless you have access to a urodynamic, study, but as I said, this was not widely available. You can initiate treatment with phenyl propanolamine, which is the most common way to start, but we've mentioned before that the efficacy is only around 44% for PPA.

Injections of testosterone, if the male are castrated, are possible. However, they are associated with, like quality of life discussion, having monthly injections, but also, some changes in behaviour have been reported with the use of testosterone, so not all of the owners are committed to do that. Overall, the response rate is below 50% and placement of an occluder becomes then an option for this male, and that is what we did with Alfie, the little male puppy that was incontinent, didn't have ectopic utters and therefore had some form of congenital USMI.

Overactive bladder is another condition that will lead to incontinence, and that's one where your history taking is going to be very, very important. It is called detruder hyperreflexia, as well in humans. It's quite common in women and it's the sudden urgency and loss of urine that is transient and in dogs, it's been associated with normal urination.

The typical pattern would be a dog that postures and urinates, but then continues to emit urine for 1015 minutes after they are done urinating and are moving away and maybe coming back into the house. Again, here, eurodynamic studies would be very important to look at the contractility of the chooser, however, they are not always available, and most of the time the diagnosis is a diagnostic of exclusion based on eliminating everything with culture and imaging, and then a treatment trial with oxybutynin to . Relax the the detrusor muscle, or imipramin as well, which will help kind of relaxing the detrusor muscle and allow for a larger time of bladder feeling.

The truth of urethral dysinegia or dysynergy is a rare disease. Most of the description is in male, large, and gen breed dog. The largest case series is about 22 dogs.

The clinical signs again are quite specific and getting a good history and a good description of the voiding pattern is very essential here. The dogs are gonna go and posture, they're going to strain and have a very hard time to pass more than a few drops of urine. And once they give up and they walk back home or walk back with you to continue, then they will dribble urine and be incontinent at that point in time.

The clinical signs look like a mechanical obstruction with that inability to void properly when posturing. But the neurological examination is going to be normal. These cases are often very chronic because the owners don't really notice.

Sometimes they think that they are starting to defecate. So a lot of these dogs are diagnosed quite late and at that stage, the bladder is then over distended and you have a very big and flaccid bladder already. They are very easy to categorise because there is no obstacle within the urethra.

It's like a spasm and a lack of coordination between the neurological signal. And imaging will be very normal. Sometimes if you do a contrast urethrogram and you do a dynamic study with fluoroscopy instead of radiographs, you can see the spasm on the urethra, but it's not even always visible.

Again, a urodynamic profile would be your gold standard because you want to see the muscular ability and contraction of these muscles, and you want to determine obstruction and overflow incontinence in this patient. Most of the treatments are . Most of the treatments are symptomatic, so we are going to use alpha agonists such as prazocin or Tamillosin to relax the internal sphincter and allow for a better flow when the dogs are posturing to void.

We will use benzodiazepine as well to try to relax the striated muscles and again improve the flow at the time of voiding. Other reports described the use of dantrole, baclofen. Bethanical, if there is a suspicion of bladder atomy, and there are a few discussions around urethral stenting, however, none of these have been perfect in the management and urethral stenting leads to a lot of questions because The spasm can occur in different locations, so it's quite a challenging decision to make to place these stents.

The prognosis is guarded. One of the main complication is bladder atomy, this very large distend bladder that are losing the capacity to actually contract and empty themselves. Chronic UTI due to the repeated catheterization when the diagnosis is not reached.

But the dog has like this big bladder or if there is bladder attorney and you're trying to empty the bladder of these dogs, and then the medication is often lifelong and you keep adding stuff and the owners get kind of discouraged and the quality of life of the patient are also questioned. Finally, Detrizor atne is a neurological condition associated usually with neurological damages at the level of the sacrum or the pelvic nerve. There is a decrease perineal reflex and the bladder can be very easily expressible.

That's your lower motor neuron, bladder. You could have damages to the muscle itself, and that usually is secondary to over distension, so that's iatrogenic, to an obstruction of some kind. It's Easy to diagnose because you will palpate this giant bladder.

You will see if they are expressible or not and see if there is any other concomitant disorder with it. But if the dog doesn't void, doesn't try to, to express the bladder, and if it's just overflowing continence that you see and you witness, then you want to catheterize these patients. You want to maintain the bladder as small as possible to prevent.

The infiltration with fibrous tissue between the muscular fibres because you need these muscular fibres to stay tight and connected one to another. The use of methanol or cisapride is also reported in these dogs to try to improve the contractility of the detrusor muscle. So in conclusion, incontinence is a very important thing to be able to recognise and investigate because it can impair the quality of life of the patients but also their honours.

A thorough history, a description, a very thorough description of the different urinary patterns will help you a lot even though before you start your investigation to classify your differentials. You want to perform a thorough physical examination, obviously, including about bladder palpation and a neurological examination, again, to help you triage within all of the differentials that we have discussed. The prognosis is often good because a lot of them will be treatable either surgically, endoscopically or medically.

And if you don't have a urinary tract infection and you suspect something like USMI very high in your list, then you can often offer a treatment trial, and that is, often very appreciated if the owners have some limited incomes, and you can consider referral for a cystoscopy or more advanced imaging if your treatment trial fails. I hope this helped you understanding a little bit better incontinence and please ask any question. Thank you.