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voiding of urine. It is caused an imbalance between the normal storage capacity of the bladder
and urethral tone, or anatomical disorders which bypass normal urine storage mechanisms.
Although urethral sphincter mechanism incompetence (USMI) is the most common cause of
incontinence relies upon accurate diagnosis of the cause and choosing the most appropriate form
of therapy.
Pathophysiology:
The bladder and urethra are supplied by both somatic (voluntary) and autonomic innervation
(parasympathetic)
(sympathetic)
During micturition, stretch receptors in the bladder wall send impulses via the pelvic nerve and
spinal cord to the brain. Information is co-ordinated to allow for voluntary relaxation of the
external urethral sphincter (pudendal nerve), activation of the bladder detrusor muscle (pelvic
During the storage phase, sympathetic innervation predominates, resulting in detrusor muscle
relaxation and internal urethral sphincter stimulation. Voiding is also inhibited by somatic
Any condition associated with either increased intravesical pressure or decreased urethral tone
may be associated with incontinence. In addition, external factors may be important: the position
of the bladder neck may affect urethral pressure, and increased intra-abdominal pressure (e.g.
with coughing or barking) may increase intravesical pressure and result in urine leakage.
Increased intravesical pressure may be due to increased detrusor activity or increased bladder
Increased bladder volume is most often associated with neurologic disorders, leading to overflow
incontinence. Lesions above the fifth lumbar vertebra lead to upper motor neuron disease of the
bladder, characterized by a distended bladder that is difficult to express. This is due to a lack of
voluntary control of urination and hyperexcitability of the external urethral sphincter. When the
intravesical pressure exceeds the urethral pressure overflow incontinence occurs. Lesions
affecting the sacral segments of the spinal cord are characterised by a distended bladder that is
easily expressed, due to both detrusor and sphincter hyporeflexia. Detrusor paralysis is the term
used to describe bladder atony which develops following prolonged accumulation of large
volumes of urine.
Decreased urethral tone may be caused by neurological or structural abnormalities of the urethra.
The most common condition is urethral sphincter mechanism incompetence, for which the
Finally, incontinence may be due to anatomical conditions which bypass the normal urinary
structures (e.g. ectopic ureters). Conditions associated with pooling of urine beyond the urethral
sphincter (e.g. vaginal stricture) may also lead to pooling and leakage of urine following urination.
The first questions should ascertain whether urinary incontinence is the likely cause of the signs
described by the owner. Differentials other than incontinence include polyuria, reproductive tract
Urethral sphincter mechanism incompetence typically results in no signs other than incontinence,
often with bed wetting at night. It is unusual for dogs with voluntary control of urination to urinate
abnormalities or hind limb neurological deficits. Urge incontinence may be associated with
incompetence is more common in young to middle aged, female, spayed, large breed dogs.
Differential diagnosis:
The differential diagnoses may be divided into those conditions resulting in bladder distension,
Differential diagnosis
Distended bladder:
Neurologic disorders
Upper motor neuron lesions
Lower motor neuron lesions
Detrusor paralysis
Functional or anatomical urethral obstruction
Normal or small sized bladder:
Decreased bladder compliance
Urge incontinence (inflammation, urolithiasis, neoplasia)
Idiopathic detrusor instability
Decreased urethral pressure
Urethral sphincter mechanism incompetence
Primary
Secondary
Anatomical disorders (congenital / acquired)
Ectopic ureters
Ureterocoele
Intrapelvic bladder
Vaginal strictures/ masses
Ureterovaginal or vesicovaginal fistulation
Urachal diverticula
Pseudohermaphroditism
Diagnosis:
Physical examination:
A complete physical examination should be performed. Urine scalding of the skin may be
apparent. The urinary bladder should be palpated to assess size and the effort necessary for
performed to assess the prostate and the proximal urethra. Vaginal palpation should be
performed in female dogs to assess strictures and urethral masses. Neurological examination
should be performed to assess anal tone, perineal sensation and the bulbospongiosus reflex. If
reduced, this suggests lower motor neuron disease. Hind limb neurological deficits may also be
observed.
Clinicopathological testing:
causes of polyuria and polydipsia. Additional testing may be necessary. Urinalysis and urine
bacteriological culture should be performed to exclude urinary tract infection, or to determine the
most ideal antimicrobial therapy. Whilst urinary tract infections are common in incontinent
Diagnostic imaging:
incontinence is suspected. Plain radiography is of limited value, other than in the detection of
radio-opaque uroliths (calcium oxalate, struvite and silicate) and determination of the size and
position of the urinary bladder. Spinal radiography (+/- myelography or more advance imaging)
may confirm spinal cord disease. Contrast studies are often more informative. Positive contrast
contrast media. Double contrast cystography may provide additional information with bladder
disorders. Intravenous urography may be used to identify renal and ureteral abnormalities.
Computed tomography has recently been shown to be more useful than other established
Ultrasonography can be used to assess the kidneys, bladder, proximal urethra, reproductive tract
and ureters (if distended). This is particularly important to document structural abnormalities such
concurrent urinary tract abnormalities in animals with ectopic ureters, such imaging is
Endoscopy:
Anatomical and structural causes of incontinence may also be assessed by endoscopy. It is one
of the most sensitive methods of detecting ectopic ureters in dogs, and can also be used to obtain
Urodynamic testing:
These techniques may be used to assess urethral pressure profiles (UPP) and bladder detrusor
muscle function (cystometrography (CMG)). UPP is the test of choice for the confirmation of
urethral sphincter mechanism incompetence, and may allow prediction of the response to
therapy. CMG may allow confirmation of detrusor instability or to provide an assessment of the
degree of bladder atony in animals with neurologic bladder dysfunction. Unfortunately, it is not
widely available.
Treatment:
Underlying disorders should initially be treated. In general, surgical treatment is necessary for
depending on the severity and type of calculi present. If urinary tract infection is present, this
should be managed with appropriate antibiotic therapy. Neoplasia may be treated surgically or
urethral tone, or alter detrusor activity. The choice of drug is dependent on the specific disorder
(Table 2).
The treatment of urethral sphincter mechanism incompetence is complex and detailed below.
with USMI are spayed. Approximately 75% of affected dogs develop signs of urinary
3
incontinence within one year of ovariohysterectomy, but it may occur at a later stage . It is more
common in large than small breed dogs (30.9% incontinence post ovariohysterectomy in dogs >
2
20kg, 9.3% incontinence in dogs < 20kg) . Early age (<3 months) neutering has been associated
4
with an increased incidence of incontinence in one study .
USMI rarely affects entire female and male dogs. It can be congenital (juvenile USMI).
5
Approximately 50% of bitches with juvenile USMI may recover continence after their first oestrus .
The pathogenesis of this disorder is not fully understood. Reduced urethral length, possible
oestrogen deficiency, intrapelvic bladder, reduced vesicourethral support, urethral smooth muscle
USMI is diagnosed by exclusion of other causes. If available, UPP may be performed to confirm
Treatment:
Medical and surgical therapies may be attempted. Surgery may be successful in animals in
which medical therapy has been unrewarding. If successful, it also negates the need for long term
medical management.
Medical management:
Estriol (Table 2) Estriol increases urethral tone by increasing the density and responsiveness of
-adrenergic receptors in urethral smooth muscle. Studies have reported complete urinary
continence in approximately 65% of treated dogs. Mild and transient oestrogenic effects (vulval
swelling and attractiveness to male dogs) have been observed at higher dose rates (incidence 5-
9%). Side effects are reversed by dose reduction. Bone marrow suppression has not been
Phenylpropanolamine (Table 2) -adrenergic drugs exert their effect by direct stimulation of the
smooth muscle of the internal urethral sphincter. Approximately 85% of treated dogs have
complete urinary continence. Side effects include are rare, and are typically mild and transient.
Combination therapy with both estriol and phenylpropanolamine is often suggested. In theory,
effective when either therapy alone has been unsuccessful. However, one recent study showed
that the administration of both estriol and phenylpropanolamine did not increase urethral
6
resistance more than estriol alone .
Surgical management:
7
The two most commonly performed surgical techniques are colposuspension and urethropexy .
bitches, with a further 40-42% showing significant improvement. 10-18% fail to respond to this
treatment. However, incontinence may redevelop in some animals despite initial improvement.
Complications are uncommon, and include postoperative straining to urinate, inability to urinate,
tearing of sutures from the vagina and recurrence of incontinence. Dyssynergia is often
Urethropexy has comparable success rates, with 56% of dogs showing complete continence and
improvement in a further 27%. Incontinence also recurs in a proportion of these dogs when
followed long term. Similar complications to those seen following colposuspension may occur.
Medical therapy may be re-attempted following surgery if surgery alone has been unsuccessful.
to narrow the urethral lumen and increase urethral resistance. It has been shown to resolve
USMI in male dogs may be managed medically with phenylpropanolamine, or surgically with vas
deferentopexy or prostatopexy.
References:
1. Stocklin-Gautschi, N.M., Hassig, M., Reichler, I.M., Hubler M. & Arnold S. (2001) The relationship
of urinary incontinence to early spaying in bitches. J Reprod Fertil Suppl 57, 233-236
2. Arnold, S., Arnold, P., Hubler, M., Casal, M. & Rusch P. (1989) Urinary incontinence in spayed
female dogs: frequency and breed disposition. Schweiz Arch Tierheilkd 131, 259-263
3. Marchevsky, A. Edwards, G.A., Lavelle, R.B. & Robertson, I.D. (1999) Colposuspension in 60
bitches with incompetence of the urethral sphincter mechanism. Aust Vet Pract 29, 2-8
4. Spain, C.V., Scarlett, J.M. & Houpt, K.A. (2004) Long-term risks and benefits of early-age
gonadectomy in dogs. J Am Vet Med Assoc 224, 380-387
5. Holt, P.E. & Thrusfield, M.P. (1993) Association in bitches between breed, size, neutering and
docking and acquired urinary incontinence due to incompetence of the urethral sphincter
mechanism. Vet Rec 133, 177-180
6. Hamaide, A.J., Grand, J.G., Farnir, F., Le Couls, G., Snaps, F.R., Balligand, M.H. & Verstegen, J.P.
(2006) Urodynamic and morphologic changes in the lower portion of the urogenital tract after
administration of estriol alone and in combination with phenylpropanolamine in sexually intact and
spayed female dogs. Am J Vet Res 67, 901-908
7. Hoelzler, M.G. & Lidbetter, D.A. (2004) Surgical management of urinary incontinence. Vet Clin
North Am Small Anim Pract 34, 1057-1073