ABSTRACT: The ectopic ureter is predominantly a congenital abnormality. The nursing care of these patients is based on observation of the degree of urinary continence following surgery. Owner compliance is key to successful surgical aftercare and should involve ongoing monitoring for incontinence and discomfort.

Physiology

In the normal animal, the ureter forms a connection between the kidney and the bladder where it inserts in an area of tissue called the trigone. The condition of ectopic ureter occurs when the ureter bypasses the bladder and inserts elsewhere than at the trigone – commonly into the proximal urethra.

This bypassing of the bladder means the patient has no control of urination as its control is facilitated by two sphincter muscles within the bladder; these are known, respectively, as the internal sphincter which is under involuntary control, and the external urethral sphincter which is under voluntary control.1 

This condition is usually a congenital abnormality and, as such, becomes noticeable early in the affected animal’s life because of the constant dribbling of urine and incontinence.2 The owner, however, may not become fully aware of the clinical signs until the puppy is being house trained and may initially mistake them for poor compliance with the training.

The five-month-old beagle puppy in Figure 1 suffered from this condition.

Figure 1: A lively five-month-old beagle puppy following successful correction of an ectopic ureter

Admission

When these patients are admitted to the hospital for investigation, the nurse should gather as much information as possible from the owner. The patient will have already been seen by the veterinary surgeon but, history taking at this point is still important as it allows the owner to provide an insight into the patient’s behaviour and its normal routine. Important questions include:

•   How often does the dog urinate in a given period of time?

•   Does the urine have any blood in it?

•   What colour is the urine generally?

•   Is the dog straining when urinating or just dripping constantly?

•   How much – and how frequently – does the patient drink water?

These questions will form a benchmark against which to measure progress when the patient is recovering from surgery, as any difference in routine and frequency will indicate an improvement or decline. 

 

CASE REPORT 

Diagnosis

A urine sample was obtained initially from the puppy to rule out a urinary tract infection. Appropriate questions were asked during the consultation, such that urinary incontinence was diagnosed, as opposed to a simple increase in frequency of urination.

Before diagnostic imaging is performed in these cases, the patient needs to be fasted for 12 hours and an enema should be administered two hours before radiographs are taken to ensure the gastrointestinal tract is empty and the large intestine does not obscure the renal anatomy.3

Imaging

A routine cystogram and a retrograde urethrogram, consisting of positive contrast radiographs of the bladder, were taken. The purpose of this series of radiographs was to ascertain the position of the bladder – which was normal – and to gain information regarding the mucosal lining of the bladder wall, including the presence of any growths.

As the positive contrast radiograph showed nothing significant, the patient underwent an intravenous urogram (IVU) (Figure 2). This was performed by injecting Urografin (Bayer) – an intravenous contrast medium – as a bolus into the cephalic vein. It travels via the blood stream to the renal system where it highlights the collecting ducts within the kidneys and then progresses through the ureters to the bladder (Figure 3).

Figure 2: A radiograph demonstrating a positive contrast image of the bladder and associated physiology

Figure 3: A radiograph demonstrating the use of an intravenous urogram and associated physiology

In this case, the results indicated that the left ureter was bypassing the bladder neck and inserting into the junction of the bladder and urethra. Although it was not possible to make a definitive diagnosis of ectopic ureter from the IVU alone, the fact that the left ureter was malpositioned, taken together with the clinical signs and the positive contrast radiography, confirmed that this condition was likely.

Surgery

Surgery to perform a neoureterocystotomy was then scheduled. Routine surgical preparation of the patient as for an exploratory laparotomy was performed and pre-emptive analgesia was administered.

Having made an incision into the abdominal cavity, the surgeon placed stay sutures to retain the bladder in position and avoid urine spilling into the abdomen once it was incised. The incision was made in a hypovascular region to limit bleeding and to keep the surgical site clear.

The surgeon then located the left ureter which entered the proximal urethra. This was sectioned and a new opening was created into the bladder. A bulge at the sight of the normal insertion of the left ureter at the trigone was apparent but was not patent. A urinary catheter was then inserted into the urethra to ensure that it was not twisted and that it remained patent.

The bladder was closed in a single layer on its ventral surface and the patients abdomen was closed routinely. The patient was maintained on intravenous fluid therapy throughout the procedure, which allowed fluid ‘ins and outs’ to be monitored postoperatively.

Postoperative care

The patient was placed on absorbent pads during recovery to monitor for incontinence and for urine volume production. All of the normal parameters were monitored, including temperature, pulse and respiration rates, alongside the neurological signs indicative of recovery from anaesthesia.

When the patient became ambulatory, he was monitored for signs of urination. This included straining, dribbling and any signs of a conscious effo
rt to urinate. The patient was noted to be dribbling urine following surgery and this continued into the early evening. The following morning he made a conscious effort to urinate and in doing so passed a small amount of urine.

Secondary renal changes may occur as a result of hydronephrosis (swelling of the kidney) as a consequence either of backpressure of urine or pyelonephritis resulting from infection caused by ascending bacteria.4 Indications of pyelonephritis include polyuria, polydipsia, pyrexia and vomiting.5

It is important for the nurse to evaluate routinely the patients vital parameters following surgery and to alert the surgeon should any untoward indication of renal perfusion or instability, such as re occurrence of incontinence, wound dehiscence and pyrexia, be observed.

Home care

On discharge, the owners were advised to monitor how much the patient was drinking, how often he was urinating, and if he had conscious control of urination when he arrived home. Haematuria is expected for 12 to 36 hours postoperatively and the owners were made aware of this, so they would not be alarmed if he was producing urine of this nature.6

The owners were advised on how to monitor for signs of pain, which could include vocalisation and unsettled behavior, and if any signs of non-productive straining, polyuria and polydipsia and incontinence were to occur, they were advised to contact the surgery promptly.

If possible, the nurse should remain in contact with the owner to monitor the patients progress. So in this case, the evening after discharge, a nurse phoned to check on the patient and received feedback that the owners had already noted an improvement – prior to the operation the owners had been coming down every morning to a urine-soaked dog bed, but following surgery he had been continent overnight. The patient had been getting up and urinating frequently but was not incontinent.

Through regular phone checks, the nurse was able to elicit that the patient was improving at a steady rate. The owners had noticed the haematuria which was to be expected and they were continuing to administer the course of antibiotics prescribed by the surgeon.

The veterinary nurse remained in contact with the owners and received feedback to indicate that the wound was healing well and that they had no concerns regarding progress. A fresh urine sample was dropped in to the surgery on alternate days and this was checked (using a dipstick) for leucocytes, protein and the presence of blood, as well as specific gravity.

The patient made a full recovery and is now leading a normal lifestyle.

Conclusion

This condition is amenable to surgical intervention. In some cases, however, full continence may not be regained and postoperative nursing care is critical. Close monitoring for urine production volume is especially important, as is assessment of weather or not the patient is conscious of urinating, as these will aid in determining if surgery has been successful. 

Author

Laura Daniels RVN MBVNA

Laura has been in practice for five-and-a-half years, working in a busy Tier 3 hospital, based in Cheshire. Since qualifying in January 2009, she has developed a keen interest in orthopaedic nursing care and is working to build her knowledge and experience within this field.

To cite this article use either

DOI: 10.1111/j.2045-0648.2012.00209.x or Veterinary Nursing Journal Vol 27 pp 333-335

References

1. TARTAGUA, L. (2002) The ureters, urinary bladder and urethra In; Tartaglia. L & Waugh. A Veterinary physiology and applied anatomy London. Elsevier, pp. 128

2. GREGORY, S (1996) Management of Canine Urinary Incontinence In: Bainbridge. J. & Elliott. J Manual of Canine and Feline Nephrology and Urology BSAVA. Gloucestershire, pp. 161.

3.   SHIEL, R . PUGGIONI. A and KEELEY. B [2008] Canine Urinary Incontinence Part 1 Aetiology and Diagnosis Available trom: http://wwwveterlnaryirelandjournal.com/Links/P DFs/CE-Smal!/CESA_November_2008.pdf (Accessed on 20 December 2011),

4.  SCHAER M [2010] Urinary disorders In Acielno. M & Senior D Clinical medicine of the dog and cat 12nd edn London. Manson pp 532.

5.   MERCK [2011] Pyelonephritis available from: http://www.merckvetmanual.com/mvm/index.jsp?file=htm/bc/130503.htm (Accessed on 16/12/11)

6.   TEAR M. (2011) client postoperative instructions following a cystotomy In: Tear. M. Small animal surgical nursing skills and concepts Missoun. Elsevier pp. 280

• VOL 27 • September 2012 • Veterinary Nursing Journal