Editorial Type: Pearls of Veterinary Practice
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Online Publication Date: 01 Mar 2002

Colposuspension as a Treatment for Urinary Incontinence in Spayed Dogs

DVM, PhD, Diplomate ACVS
Article Category: Research Article
Page Range: 107 – 110
DOI: 10.5326/0380107
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Introduction

Urinary incontinence develops frequently in spayed female dogs. Most respond to medical treatment with either phenylpropanolamine or estrogens. Young dogs and dogs that respond poorly to medical treatment are potential surgical candidates as a treatment alternative. This paper presents one surgical treatment, colposuspension. Although few dogs are cured by this surgery, incontinence severity is generally reduced, particularly in dogs with supplemental drug treatment.

Urinary Incontinence Following Ovariohysterectomy

Urinary incontinence in spayed female dogs has been reported as occurring in >20% of spayed female dogs, with the frequency being 30% in dogs >20 kg.1 Although this frequency seems higher than commonly perceived, many spayed dogs do dribble inappropriately. Most leak urine when asleep or at rest. Many dribble daily or at least several times a week.1 The author postulates that the mechanisms at play are multifactorial. An intrinsic sphincter dysfunction is commonly thought to occur and is the rationale for treatment with alpha-agonist medications. Incontinent dogs typically have decreased urethral outflow resistance as measured with urethral pressure profilometry (UPP)2–4 and leak-point pressures (LPP).5 Both LPP and maximum urethral closure pressure (MUCP) as measured by UPP are lower than that of normal dogs.4 Some dogs respond to cranial positioning of the lower urinary tract, reinforcing the rationale that anatomical factors play a role in urinary incontinence.46–8 It is generally assumed that bladder function is normal in these dogs. In several urinary incontinent dogs with low LPPs, the author has measured lower LPPs at higher bladder volumes (i.e., 150 mL) than at lower bladder volumes (i.e., 75 and 100 mL). It would seem more likely then, that incontinent dogs would have better urinary control when their bladder volume is low. Polyuric diseases can result in clinical urinary incontinence in dogs with a tendency for incontinence, and urinary tract infection can produce instability of the bladder and a tendency for “urge incontinence.”

Evaluation and Management Options for “Spay-Related” Urinary Incontinence

History taking, physical examination, and observation of urination are essential to develop the diagnostic plan in spayed female dogs. Historical questions should include age and time when incontinence was initially observed, progression of clinical signs, timing of incontinence (i.e., frequency, at rest, when stressed, or when about to be let outside), whether the dog consciously attempts to void, adequacy of fecal control, occurrence of urinary tract infections, related health changes, prior or current medication, and diet. Complete blood counts and serum biochemical profiles are also essential to assess for metabolic conditions that can impact the renal system. Dogs with a tendency to be incontinent seem more likely to dribble if they have a urinary tract infection or develop increased urinary output such as with decreased renal function, Cushing’s disease, diabetes mellitus, or corticosteroid treatment. Observation of normal urination and measurement of residual volume can eliminate the bladder as a cause of incontinence. Residual volume is best measured by catheterization, but ability to void completely and retention of urine in the bladder can be determined by ultrasonography. A cystocentesis should be performed to obtain a sample for urinalysis and urine culture. Imaging studies are useful to identify other causes of decreased urinary control such as calculi, masses, and ectopic ureter. A retrograde vaginourethrogram can determine the position of the urethra with respect to the pelvis and entry into the vestibule [Figure 1]. Dogs with a caudally positioned entry of the urethra into the vestibule are more likely to respond favorably to a surgical procedure that moves this entry cranially [Figure 2].4 Urodynamic tests (UPP and LPP) confirm a subnormal urethral resistance of incontinent dogs.45 The LPP increases following colposuspension in those incontinent dogs that improve urinary control following surgery.4

Urinary tract infection must be initially treated. Polyuric diseases should be evaluated and managed before consideration of surgical incontinence treatments. Management of some dogs diagnosed with a typical “spay-related” urinary incontinence can be improved by trying to maintain a small bladder during the times when the dogs are recumbent. If their kidneys can concentrate urine, water can be removed for 3 to 4 hours before bedtime, and the dog should be allowed outside to void just before bedtime. Medical treatment is initially started with phenylpropanolamine at 1.5 mg/kg body weight orally, given three times per day. Approximately two-thirds to three-quarters of incontinent dogs respond favorably.1 Dogs that do not respond to phenylpropanolamine can be administered estrogen orally every 4 days to determine if normal urinary control returns. If the dog becomes continent, the dog is monitored until it becomes incontinent, and then the q 4-day treatment is repeated. The dosage is typically 0.5 mg for a small dog and 1.0 mg for a dog >25 kg. Complete blood counts should be done at regular intervals in dogs frequently receiving estrogen administration to evaluate for the potential occurrence of aplastic anemia.

Since medical treatment is life-long and not consistently successful, clients may prefer a surgical option. At least three options are available. Transurethral injection can be performed, in which a cystoscope is placed into the urethra. A needle is advanced into a submucosal position, and a bulking material is injected in such a fashion that the urethral lumen is at least partially obstructed.910 The other options involve a caudal midline laparotomy to perform surgical procedures designed to move the lower urinary tract cranially or to lengthen the urethra by bladder neck reconstruction. Cranial positioning procedures are colposuspension468 and cystourethropexy.1112 Dogs recommended for these surgical treatments are those not responding well to medical treatment or those for which the owner is either reluctant or unable to regularly administer oral medications.

Experiences With Surgical Treatments for “Spay-Related” Urinary Incontinence

Arnold, et al. has reported favorable clinical responses to injection of Teflon beneath the urethral mucosa of 22 incontinent dogs.9 All were continent 2 months after injection. Two-thirds became incontinent, and most responded favorably when injected a second time. Some specialists are currently injecting glutaraldhyde cross-linked bovine collagen.a,10 Injection therapy remains an attractive alternative, as it only requires anesthesia and cystoscopy.

White reported on a prospective study of 100 dogs operated by urethropexy.12 A high percentage of dogs improved urinary control, with 73 having an excellent outcome (i.e., complete cure with no dribbling) at 1 year and 56 being categorized as having an excellent outcome during a mean follow-up of 35 months.12 Twenty-one dogs had complications, with 14 having increased frequency of urination, six having dysuria, and three having anuria. Urinary tract infections were present in 10 of 30 having a urinalysis performed. In performing the urethropexy technique, it would seem to be critical to avoid iatrogenic urethral obstruction and urinary tract infections associated with inability to void. In a series of 10 spayed dogs with incontinence, cystourethropexy restored normal urinary control for a short period in two dogs and markedly improved two others; phenylpropanolamine restored urinary continence in four other dogs.11

Holt, et al. has reported that approximately 56% of the spayed incontinent dogs are completely cured by colposuspension. The degree and frequency of incontinence are significantly reduced in an additional 40%, and 10% are not improved by surgery.6–8 Colposuspension in the author’s prospective study of clinical patients improved urinary control, increased LPP, and moved the external urethral opening cranially.4 Two months after colposuspension, 55% of the “spay-related” urinary incontinent patients were completely dry, requiring no medical treatment; however, this success rate decreased to <14% at 1 year.4 When drug therapy (usually phenylpropanolamine) was added as an adjunct to the colposuspension technique, 36% had complete control and another 41% were greatly improved 1 year after surgery. Despite <100% surgical success, <5% of the owners of the dogs in this study were unhappy with having had their dog operated.4 Leak-point pressure measurements correlated with improved urinary control. Dogs that were “cured” 2 months after surgery had their LPP increased to a level typical of normal dogs, and LPP was not increased in dogs with persistent urinary incontinence. The MUCP of the UPP did not change in dogs with improved urinary control. The only preoperative predictor of a favorable response to colposuspension was a more caudal preoperative position of the external urethral opening in relation to the pubis.4

Technique for Colposuspension48

Colposuspension is performed through a midline laparotomy extended caudally to the pubis. The subcutaneous fat just cranial to the pubis is dissected from the external sheath of the rectus abdominus muscle to expose the medial margins of the inguinal rings. A urethral catheter is placed to provide identification of the urethra. The pelvic fat is dissected from the urethra and vagina. Identification of the vagina is facilitated by placing a sterile rod within the vagina. An Allis tissue forceps is used to grasp the vagina as far caudally as possible. The vagina is pulled cranially using a traction suture with 2-0 or 0 polypropylene placed caudally into the vagina [Figure 3]. The vagina is stretched cranially, and a second bite is placed to form a cruciate suture pattern in the vagina. Two such sutures are placed on either side. The suture position into the vaginal wall is lateral and dorsal away from the urethra, but avoiding the rectum [Figure 4].

Each suture is then passed through the abdominal wall just medial to the caudal superficial epigastric vessels [Figures 4, 5]. This is in the area of the prepubic tendon. The sutures are tied snugly but not tight enough to obstruct the urethra [Figure 6]. The goal of colposuspension is to move the caudal portion of the urethra cranially, not to produce an encircling loop about the urethra.

Following surgery, the dogs are monitored closely to insure that they can urinate. Most are discharged from the hospital on the day following surgery. Perioperative antibiotics are used by some clinicians. Urinary tract infections should be managed prior to surgery. Dogs developing incontinence signs after surgery should be evaluated for urinary tract infections. The client is cautioned that many dogs will require phenylpropanolamine in order to have the best urinary control.

Acknowledgment

The author would like to thank Mr. Kip Carter for the preparation of Figures 3 through 6.

a

Contigen; Bard Urological Division, Covington, GA

Figure 1—. Retrograde vaginourethrogram of a urinary incontinent, 3-year-old, spayed female collie. The cranial circle outlines the caudal portion of the pubis, and the caudal circle outlines the opening of the urethra into the vestibule. They are 3.8 cm apart. The maximal urethral closure pressure (MUCP) was 35 cm of water, and the leak-point pressure (LPP) was 59 cm of water, both markedly below that of normal dogs. (MUCP±standard deviation [SD], 110±20 cm of water; LPP±SD, 172±25 cm of water)Figure 1—. Retrograde vaginourethrogram of a urinary incontinent, 3-year-old, spayed female collie. The cranial circle outlines the caudal portion of the pubis, and the caudal circle outlines the opening of the urethra into the vestibule. They are 3.8 cm apart. The maximal urethral closure pressure (MUCP) was 35 cm of water, and the leak-point pressure (LPP) was 59 cm of water, both markedly below that of normal dogs. (MUCP±standard deviation [SD], 110±20 cm of water; LPP±SD, 172±25 cm of water)Figure 1—. Retrograde vaginourethrogram of a urinary incontinent, 3-year-old, spayed female collie. The cranial circle outlines the caudal portion of the pubis, and the caudal circle outlines the opening of the urethra into the vestibule. They are 3.8 cm apart. The maximal urethral closure pressure (MUCP) was 35 cm of water, and the leak-point pressure (LPP) was 59 cm of water, both markedly below that of normal dogs. (MUCP±standard deviation [SD], 110±20 cm of water; LPP±SD, 172±25 cm of water)
Figure 1 — Retrograde vaginourethrogram of a urinary incontinent, 3-year-old, spayed female collie. The cranial circle outlines the caudal portion of the pubis, and the caudal circle outlines the opening of the urethra into the vestibule. They are 3.8 cm apart. The maximal urethral closure pressure (MUCP) was 35 cm of water, and the leak-point pressure (LPP) was 59 cm of water, both markedly below that of normal dogs. (MUCP±standard deviation [SD], 110±20 cm of water; LPP±SD, 172±25 cm of water)

Citation: Journal of the American Animal Hospital Association 38, 2; 10.5326/0380107

Figure 2—. Retrograde vaginourethrogram performed 2 months after the collie from Figure 1 had been operated for a colposuspension. The arrow represents the position of the colposuspension suture with cranial tension being applied to the caudal region of the vagina. The circles are as above, but the distance between the pubis and the opening of the urethra into the vestibule has been decreased to 0.6 cm. At 2 months postoperatively, the MUCP was 32 cm of water, the LPP was 189 cm of water, and urinary control was normal. At 1 year, the dog was not being treated medically and had one or two leaking episodes every month.Figure 2—. Retrograde vaginourethrogram performed 2 months after the collie from Figure 1 had been operated for a colposuspension. The arrow represents the position of the colposuspension suture with cranial tension being applied to the caudal region of the vagina. The circles are as above, but the distance between the pubis and the opening of the urethra into the vestibule has been decreased to 0.6 cm. At 2 months postoperatively, the MUCP was 32 cm of water, the LPP was 189 cm of water, and urinary control was normal. At 1 year, the dog was not being treated medically and had one or two leaking episodes every month.Figure 2—. Retrograde vaginourethrogram performed 2 months after the collie from Figure 1 had been operated for a colposuspension. The arrow represents the position of the colposuspension suture with cranial tension being applied to the caudal region of the vagina. The circles are as above, but the distance between the pubis and the opening of the urethra into the vestibule has been decreased to 0.6 cm. At 2 months postoperatively, the MUCP was 32 cm of water, the LPP was 189 cm of water, and urinary control was normal. At 1 year, the dog was not being treated medically and had one or two leaking episodes every month.
Figure 2 — Retrograde vaginourethrogram performed 2 months after the collie from Figure 1 had been operated for a colposuspension. The arrow represents the position of the colposuspension suture with cranial tension being applied to the caudal region of the vagina. The circles are as above, but the distance between the pubis and the opening of the urethra into the vestibule has been decreased to 0.6 cm. At 2 months postoperatively, the MUCP was 32 cm of water, the LPP was 189 cm of water, and urinary control was normal. At 1 year, the dog was not being treated medically and had one or two leaking episodes every month.

Citation: Journal of the American Animal Hospital Association 38, 2; 10.5326/0380107

Figure 3—. The lower urinary tract and vagina are approached through a midline laparotomy extending caudally to the pubis. Using long Debakey tissue forceps or Allis forceps, the vagina is pulled cranially and sutures are placed caudally. These are placed in a cruciate fashion. Two such sutures are placed on either side of the vagina.Figure 3—. The lower urinary tract and vagina are approached through a midline laparotomy extending caudally to the pubis. Using long Debakey tissue forceps or Allis forceps, the vagina is pulled cranially and sutures are placed caudally. These are placed in a cruciate fashion. Two such sutures are placed on either side of the vagina.Figure 3—. The lower urinary tract and vagina are approached through a midline laparotomy extending caudally to the pubis. Using long Debakey tissue forceps or Allis forceps, the vagina is pulled cranially and sutures are placed caudally. These are placed in a cruciate fashion. Two such sutures are placed on either side of the vagina.
Figure 3 — The lower urinary tract and vagina are approached through a midline laparotomy extending caudally to the pubis. Using long Debakey tissue forceps or Allis forceps, the vagina is pulled cranially and sutures are placed caudally. These are placed in a cruciate fashion. Two such sutures are placed on either side of the vagina.

Citation: Journal of the American Animal Hospital Association 38, 2; 10.5326/0380107

Figure 4—. The cranial suture ends are passed through the rectus abdominus muscle just cranial to the pubis and medial to the caudal superficial epigastric vessels. Suture placement should be lateral to the ventral midline but must avoid entry into the rectum.Figure 4—. The cranial suture ends are passed through the rectus abdominus muscle just cranial to the pubis and medial to the caudal superficial epigastric vessels. Suture placement should be lateral to the ventral midline but must avoid entry into the rectum.Figure 4—. The cranial suture ends are passed through the rectus abdominus muscle just cranial to the pubis and medial to the caudal superficial epigastric vessels. Suture placement should be lateral to the ventral midline but must avoid entry into the rectum.
Figure 4 — The cranial suture ends are passed through the rectus abdominus muscle just cranial to the pubis and medial to the caudal superficial epigastric vessels. Suture placement should be lateral to the ventral midline but must avoid entry into the rectum.

Citation: Journal of the American Animal Hospital Association 38, 2; 10.5326/0380107

Figure 5—. Suture placement from the vagina to the area of the prepubic tendon is seen from a ventral perspective. The suture entry through the abdominal wall should encompass enough muscle to provide a firm anchor for providing cranial traction to the vagina.Figure 5—. Suture placement from the vagina to the area of the prepubic tendon is seen from a ventral perspective. The suture entry through the abdominal wall should encompass enough muscle to provide a firm anchor for providing cranial traction to the vagina.Figure 5—. Suture placement from the vagina to the area of the prepubic tendon is seen from a ventral perspective. The suture entry through the abdominal wall should encompass enough muscle to provide a firm anchor for providing cranial traction to the vagina.
Figure 5 — Suture placement from the vagina to the area of the prepubic tendon is seen from a ventral perspective. The suture entry through the abdominal wall should encompass enough muscle to provide a firm anchor for providing cranial traction to the vagina.

Citation: Journal of the American Animal Hospital Association 38, 2; 10.5326/0380107

Figure 6—. Sutures are tightened sufficiently to cranially displace the caudal area of the vagina and the caudal area of the urethra. Over-tightening of the sutures can produce urethral obstruction.Figure 6—. Sutures are tightened sufficiently to cranially displace the caudal area of the vagina and the caudal area of the urethra. Over-tightening of the sutures can produce urethral obstruction.Figure 6—. Sutures are tightened sufficiently to cranially displace the caudal area of the vagina and the caudal area of the urethra. Over-tightening of the sutures can produce urethral obstruction.
Figure 6 — Sutures are tightened sufficiently to cranially displace the caudal area of the vagina and the caudal area of the urethra. Over-tightening of the sutures can produce urethral obstruction.

Citation: Journal of the American Animal Hospital Association 38, 2; 10.5326/0380107

References

  • 1
    Arnold S, Arnold P, Hubler M, Casal M, Rusch P. Urinary incontinence in spayed bitches: prevalence and breed predisposition. Schweiz Arch Tierheilk 1989;131:259–263.
  • 2
    Holt PE, Gregory SP. Can urethral pressure profilometry predict the response to colposuspension in bitches? Vet Rec 1991;128:281–282.
  • 3
    Rosin AE, Barsanti JA. Diagnosis of urinary incontinence in dogs: role of the urethral pressure profile. J Am Vet Med Assoc 1981;178: 814–822.
  • 4
    Rawlings CA, Barsanti JA, Mahaffey MB, et al. Evaluation of colposuspension for treatment of incontinence in spayed female dogs. J Am Vet Med Assoc 2001;219:770–775.
  • 5
    Rawlings CA, Coates JR, Chernosky A, et al. Stress leak point pressure and urethral pressure profile tests to characterize urinary continence in normal female dogs. Am J Vet Res 1999;60:676–678.
  • 6
    Holt PE. Long-term evaluation of colposuspensions in the treatment of urinary incontinence due to incompetence of the urethral sphincter mechanism in the bitch. Vet Rec 1990;127:537–542.
  • 7
    Holt PE. Urinary incontinence in the bitch due to sphincter mechanism incompetence: prevalence in referred dogs and retrospective analysis of 60 cases. J Sm Anim Pract 1985;26:181–190.
  • 8
    Holt PE, Stone EA. Colposuspension for urinary incontinence. In: Bojrab MJ, ed. Current techniques in small animal surgery. 4th ed. Baltimore: Williams & Wilkins, 1997:455–459.
  • 9
    Arnold S, Jager P, DiBartola SP, et al. Treatment of urinary incontinence in dogs by endoscopic infection of Teflon. J Am Vet Med Assoc 1989;195:1369–1374.
  • 10
    Arnold SP. Management of canine urinary incontinence. In: Bainbridge J, Elliot J, eds. Manual of canine and feline nephrology and urology. Gloucester: Brit Sm Anim Vet Assoc, 1996:161–173.
  • 11
    Massat BJ, Gregory CR, Ling GV, Cardinet GH, Lewis EL. Cystourethropexy to correct refractory urinary incontinence due to urethral sphincter mechanism incompetence: preliminary results in ten bitches. Vet Surg 1993;22:260–268.
  • 12
    White RN. Urethropexy for the management of urethral sphincter mechanism incompetence in the bitch. J Sm Anim Pract 2001;42: 481–486.
Copyright: Copyright 2002 by The American Animal Hospital Association 2002
<bold> <italic toggle="yes">Figure 1</italic> </bold> —
Figure 1 —

Retrograde vaginourethrogram of a urinary incontinent, 3-year-old, spayed female collie. The cranial circle outlines the caudal portion of the pubis, and the caudal circle outlines the opening of the urethra into the vestibule. They are 3.8 cm apart. The maximal urethral closure pressure (MUCP) was 35 cm of water, and the leak-point pressure (LPP) was 59 cm of water, both markedly below that of normal dogs. (MUCP±standard deviation [SD], 110±20 cm of water; LPP±SD, 172±25 cm of water)

<bold> <italic toggle="yes">Figure 2</italic> </bold> —
Figure 2 —

Retrograde vaginourethrogram performed 2 months after the collie from Figure 1 had been operated for a colposuspension. The arrow represents the position of the colposuspension suture with cranial tension being applied to the caudal region of the vagina. The circles are as above, but the distance between the pubis and the opening of the urethra into the vestibule has been decreased to 0.6 cm. At 2 months postoperatively, the MUCP was 32 cm of water, the LPP was 189 cm of water, and urinary control was normal. At 1 year, the dog was not being treated medically and had one or two leaking episodes every month.

<bold> <italic toggle="yes">Figure 3</italic> </bold> —
Figure 3 —

The lower urinary tract and vagina are approached through a midline laparotomy extending caudally to the pubis. Using long Debakey tissue forceps or Allis forceps, the vagina is pulled cranially and sutures are placed caudally. These are placed in a cruciate fashion. Two such sutures are placed on either side of the vagina.

<bold> <italic toggle="yes">Figure 4</italic> </bold> —
Figure 4 —

The cranial suture ends are passed through the rectus abdominus muscle just cranial to the pubis and medial to the caudal superficial epigastric vessels. Suture placement should be lateral to the ventral midline but must avoid entry into the rectum.

<bold> <italic toggle="yes">Figure 5</italic> </bold> —
Figure 5 —

Suture placement from the vagina to the area of the prepubic tendon is seen from a ventral perspective. The suture entry through the abdominal wall should encompass enough muscle to provide a firm anchor for providing cranial traction to the vagina.

<bold> <italic toggle="yes">Figure 6</italic> </bold> —
Figure 6 —

Sutures are tightened sufficiently to cranially displace the caudal area of the vagina and the caudal area of the urethra. Over-tightening of the sutures can produce urethral obstruction.

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