Saturday, September 20, 2014

And That's Why They Make Diapers For Old Ladies. Urinary Incontinence in Dogs.

"There is no better place to start than a physical exam." I am sure that I say that a hundred times a day. If there was a quicker, cheaper, easier way around this I would have built an app for it and single-handedly been responsible for closing the doors of the thousands of veterinary clinics around the world.

For as many times as I repeat those words, and believe them to ring true, I say with almost equal frequency and even more resolve "the best value to your pets health is an examination with you beside them." The whole idea of drive-by vaccines or dropping a pet off for an exam is ludicrous to me. Your pet can't speak, they can't give me important historical information, they cannot explain to me the environment they live in, the food(s) you feed, nor can they answer the rest of the questions I might have to help understand your pet, resolve their issues, and discuss the treatment options.

You see medicine is about solving a puzzle. Think of it as the Leap Year Sunday genius edition of the NY Times crossword puzzle with the clues being given to you from an interpreter, who doesn't speak English as their native tongue.

Fewer complaints ring true than the client who calls to report that their dog is "leaving wet spots." For those of us who share the bed with our dogs, the resolution of incontinence is paramount. The only way to diagnose this is with a pet, a history, a whole bunch of talking, a good examination, and a few diagnostic tests.

Here's my experience with urinary incontinence. Or what vets call "urethral sphincter mechanism incontinence" also known as "spay incontinence," or what I refer to as "the reason old ladies need diapers." For post-menopausal ladies, whether because of age or spaying, the decrease in estrogen can cause the bladder and urethra to become less diligent in their duties of maintaining focus while on the job. The essentially become worn out and less tolerant of the high demands placed on them.

I commonly see this condition affecting dogs who are 1-6 years old (middle aged), female, spayed, medium sized dogs.

It most often presents as occasional leakage of urine after a period of sleep. Clients report finding varying sized "wet spots" left behind after the pet wakes up. Why does urinary sphincter incontinence happen? Well, when you sleep muscles relax but the  bladder continues to fill. There is a point at which the pressure on the bladder overwhelms the poorly responsive sphincter and leakage occurs. I tell my clients to think of it as trying to hold a water balloon all day and night. When you fall asleep you will lose your grip and the water will leak out.

For the huge majority of dogs the diagnosis will be "spay incontinence." I know this, I state this, and we plan for this. BUT, there absolutely needs to be a thorough a precise exam and a whole bunch of questions and answers exchanged before we should prescribe a drug to treat the sphincter incompetence.

Here's where I start on gathering a history;
  • Spayed female? 
  • Age and history of when leakage began?
  • Describe the leakage events? When, Where, How much?
  • What does she look like when she postures to urinate?
  • What does the urine stream look like? Is it full and continuous or stops and starts? or small amounts with difficulty, or small amounts produced but taking a long period of time, etc.?
  • How much urine does she produce at the first attempt?
  • How many times does she posture to urinate after the first?
  • How long is it before she postures again?
  • What is the frequency and amount at the beginning of the day versus the end of the day?
  • Have you noticed any changes in amount of water intake?
  • Have you changed anything in the diet or feeding regimen?
Why are all of these questions so important? Well, because one clinical sign (urinary leakage) can be caused by a whole slew of reasons. It is imperative to be treating the correct cause so that you don't either a) cause another problem, or b) exacerbate a pre-existing problem.

After I have collected a full detailed description I perform a thorough examination of the urine, the urinary tract and pet.

The rest is hands on. A thorough physical exam starts at the tip of the nose and ends at the tail.
The kidneys are intimately entwined with the bladder. Don't over look a problem here. Urine specific gravity is important to be accurate and reliable. If urine specific gravity is low, take 4 first urine samples to confirm.

Vets are very good at being able to assess bladder tone. We get tons of practice with those blocked cats. (Oddly, cats have trouble emptying, dogs have trouble keeping). The bladder has a particular 'feel' soft, hard, firm, flaccid, easy to empty, fighting the pressure from your hands, etc. 'feel,' and you can tell a lot about the health of the bladder by its 'feel.' The rest of the urinary tract can be assessed with a rectal and vaginal digital exam. Any odd lumps, bumps, and twists and turns.

An ultrasound can help detect bladder thickness, stones, masses, etc. It is an excellent tool for internal soft tissue abdominal structures, filling and emptying issues. Radiographs can also assist, but they are rarely the last or only diagnostic needed. Choose your diagnostics carefully an understand cost and benefit scenarios.

Because there is a close relationship between the mind and the bladder, nerve function should be assessed. I have only seen bladder dysfunction/interruptions after pelvic injuries. These cases need to be correctly diagnosed and the complications of treatment plans evaluated realistically. Examination at rest, walk, nerves of the head, heart, anal tone are all important places to check.

HX & observed information;

  • Can the patient void normally?
  • Is there constant dribbling or is the patient only incontinent when recumbent or asleep?
  • Is the problem worse when the bladder is full or empty or it doesn't matter?
  • Is the problem worse after the patient has just voided?
  • Does the patient have a higher urine volume than they did previously?

Physical examination;

  • Is the bladder big or small?
  • Does the bladder palpate flabby or firm?
  • Does the bladder empty fully? We may take an x-ray to confirm.
  • Does the urethra (and prostate if male, vagina if female) palpate normally on the rectal exam (and vaginal exam if female)?
  • Does the patient have a normal neurologic exam including the autonomic nervous system?
  • How hard is the bladder to hard as you expect for an awake patient or harder or easier?

The photos in this blog are of my dear patient Eden. Her mom sent them to me and added this about Eden's incontinence issues.

I adopted Eden at the beginning of March 2011 and didn't notice any symptoms of incontinence until the fall/ winter of 2012. I first noticed that there would be little dribbles on the carpet or on her bed after laying down. She seemed to need to urinate more frequently than usual and I would come home to occasional accidents in the house. The symptoms seemed to present themselves rather suddenly, and I think they progressed fairly rapidly, but I took her to see you very soon after the symptoms started for a diagnosis.

She was prescribed with Proin 50mg (half tab 2x a day) around Dec 2012/ Jan 2013. The medication seemed to take care of the issue, with only occasional accidents happening on days that I had to work overtime. However, within the last month, I began noticing more frequent accidents, usually on a daily basis during the work week. Eden also seemed to be spending more time than usual licking her rear end. I contacted you August 26, 2014 and we decided to increase her dosage of Proin to 100mg (1-50mg tab in the morning, 1-50mg tab at night). So far, the dosage increase has been effective.

On a personal note, the incontinence has been "inconvenient" for my hardwood floors, and I no longer have any area rugs down in the house. But I feel this is manageable and would rather refinish my floors years down the road if need be than confine Eden to one room or a crate while I am gone at work during the day. I have friends who don't understand and say that they would "just get rid of her", but of course, you know that would never be an option for me.

I have attached a few photos of the ham, feel free to use any you'd like.

I hope this helps. Let me know if there's anything else you need or any questions I haven't answered!


Eden's mom.. 

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You can find me at my veterinary clinic, Jarrettsville Vet in Harford County Maryland, or on Twitter @FreePetAdvice.


  1. Such a lovely mum Eden has! The dog my family got when I was 14, a male cocker spaniel, was incontinent. We had him from a pup and he was the most darling creature. He would leak when he slept, or sometimes just because. He had a very weak sphincter and vets never seemed to really look into it that much. My mum mopped the floor every day for the entire 11.5 years of his life. Pets are just like kids for me, you can't give your (human) child back if he/she doesn't turn out perfect.

    1. Hello!
      Pets are kids to me too! Diapers for the lifetime and all! Give your mum a hug from me, and tell her that she is a wonderful person, even if her dog never said it to her in those words. (But I'm sure she already knew her kids loved and appreciated her).
      I think that its not about the committed care we give, its about how it fills us with a sense of purpose and fulfillment. We are wired to be helpful and isn't that why we love our pets soo much? They give back the love and kindness..
      Thanks for reading and sharing.
      And a big HI to mum from me too!