Urinary Incontinence in Juvenile Female Soft-Coated Wheaten Terriers: Hospital Prevalence and Anatomic Urogenital Anomalies

Introduction

Urinary incontinence in juvenile female dogs is a common problem, although prevalence within certain breeds is poorly defined. Affected patients have an inability to control micturition with the involuntary passage of urine.¹ Urinary incontinence may result from a variety of functional and/or anatomic anomalies. Anatomic anomalies of the urogenital tract have been shown to be the predominant underlying cause of urinary incontinence in juvenile female dogs.² Ectopic ureters have been reported as the underlying etiology in 55% of juvenile dogs with urinary incontinence.² Anatomic anomalies are often cumulative, and a thorough diagnostic assessment of the urogenital tract is necessary to develop an accurate diagnosis and effective treatment plan.^2–4 While urinary incontinence in juvenile dogs is not typically life-threatening, an indoor pet that repeatedly soils the house can be a contributing factor to owner relinquishment and euthanasia.

Urinary incontinence in juvenile dogs has previously been described in puppies with clinical signs at 6 mo of age or younger.⁵ Clinical signs of urinary incontinence can range from slight dampening of the peri-vulvar hair to leakage of daily urine production. Diagnosis of urinary incontinence in juvenile dogs can be confused with inappropriate voiding of urine or behavioral issues associated with housetraining. A thorough history, physical examination, and diagnostic workup are necessary to identify true urinary incontinence.

Anomalies associated with urinary incontinence in juvenile dogs include ectopic ureters; urethral sphincter mechanism incompetence (USMI), either alone or associated with a pelvic bladder; orthotopic and ectopic ureteroceles; and, less commonly, a patent urachus.^6–9 Anomalies can occur concurrently, complicating successful treatment.

Urinary incontinence has been reported 6.6 times more frequently in juvenile female dogs compared to males of the same age.² It has been hypothesized this discrepancy is likely reflective of both a true sexual predisposition as well as anatomic differences in urethral length and presence of high-pressure zones associated with the prostatic and penile urethra in males.^10–12

Multiple diagnostic modalities are available that may assist in identifying the underlying etiology of urinary incontinence in juvenile dogs. Imaging including plain abdominal radiographs, excretory urography, contrast cystography, retrograde vaginocystography, fluoroscopy, contrast-enhanced computed tomography, and ultrasonography can be used to evaluate both the upper and lower urinary tract for anatomic anomalies.^13,14 Uroendoscopy permits the clinician to obtain a magnified view of the luminal surface of the lower urinary and distal reproductive tract. Uroendoscopy has been reported to be 100% sensitive and specific in identifying ectopically displaced ureteral orifices in female dogs when compared to direct visualization during surgery via ventral cystotomy.⁴ Treatment of urinary incontinence in juvenile dogs varies depending on the underlying anomalies and may involve both medical and surgical therapies. The success of treatment is varied and multiple therapeutic modalities may be required.

Although urinary incontinence can affect any breed of dog, a number of breeds are repeatedly cited throughout the veterinary literature including Labrador retrievers, golden retrievers, Doberman pinschers, boxers, Siberian huskies, poodles, and soft-coated wheaten terriers (SCWTs).⁶ Previous studies have associated a number of congenital and medical conditions with SCWTs including USMI, ectopic ureters, protein-losing enteropathies, and protein-losing nephropathies.^6,15 However, no previous publications have specifically evaluated urinary incontinence in juvenile female SCWTs using uroendoscopy.

The objectives of this study are: (1) determine the prevalence of urinary incontinence in juvenile female SCWTs at a large referral hospital compared to other affected female dogs with juvenile urinary incontinence; (2) characterize anatomic anomalies of the lower urogenital tract in juvenile female SCWTs with urinary incontinence utilizing uroendoscopy; and (3) describe the incidence of ectopic ureters, presence of a paramesonephric remnant, and presence of a short urethra in SCWTs compared to other juvenile female dogs affected with urinary incontinence.

We hypothesize juvenile female SCWTs have an increased hospital prevalence of urinary incontinence compared to other breeds of dogs presenting for clinical signs of urinary incontinence at a young age. In addition, we hypothesize the incidence of ectopic ureters, paramesonephric remnants, and short urethras will be increased in juvenile female SCWTs compared to non-SCWTs with urinary incontinence in our hospital population.

Materials and Methods

Electronic medical records of all female dogs with clinical signs of urinary incontinence 2 yr of age or less, and presenting to The Ohio State University Veterinary Medical Center from January 2000 to December 2011, were identified for review. Medical records were individually evaluated to identify all female dogs with clinical signs of urinary incontinence documented at 6 mo of age and younger. For the purpose of this study, these dogs were defined as juvenile. The goal of this design was to include those cases with urinary incontinence developing at 6 mo of age or younger, but that were not referred to our institution until later in life.

To be included in this study, a video recorded endoscopy of the lower urogenital tract was required. In cases that had multiple endoscopies on record, only the first endoscopy performed at our referral institution was used. In all patients, the uroendoscopic evaluation was performed by an experienced, board-certified veterinary internist or surgeon.

Information summarized from the medical record included: signalment (age, breed, neuter status), age when acquired, age at time of neuter, age when clinical signs of urinary incontinence were first noted, and results of all diagnostic imaging. Uroendoscopic findings included: presence of displaced ureteral orifices; a septal band across the cingulum, known as a paramesonephric remnant; and a subjectively shortened urethra.

Prevalence of urinary incontinence in juvenile female dogs in a large referral hospital population (The Ohio State University Veterinary Medical Center) was calculated. All female dogs 6 mo of age or younger with a diagnosis of urinary incontinence were compared to the total number of female dogs in the same age group treated during the study period. For the purpose of this calculation alone, recorded video uroendoscopic evaluation was not required for inclusion. Comparative evaluation was narrowed to only those breeds representing 5% or greater of the referral hospital's total population of juvenile female dogs with urinary incontinence because the remaining breeds had insufficient numbers to draw relevant conclusions.

To provide a comparison of the structural changes, endoscopic reports of the lower urogenital tract were compared between the 12 SCWTs and 107 non-SCWTs. Records were reviewed for the presence of ectopic ureters, a paramesonephric remnant, and a subjectively shortened urethra. These findings were evaluated solely based upon uroendoscopy with the exception of confirmatory diagnostics for determining intramural versus extramural ectopic ureters. Hospital prevalence of these anatomic anomalies in SCWTs were compared to all non-SCWTs. Additionally, individual breed comparisons were made for all breeds found to represent 5% or greater of the referral hospital's total population of juvenile female dogs with urinary incontinence.

Additional description of all anatomic anomalies of the urogenital tract affecting juvenile SCWTs with urinary incontinence was obtained via review of the initial video-recorded uroendoscopic evaluations by three independent experts (Mary A. McLoughlin, Julie K. Byron, and Dennis J. Chew). Digital video recordings of the uroendoscopic evaluations of juvenile SCWTs and twice as many juvenile non-SCWTs were evaluated blindly using a standard scoring form (see Appendix 1). For the purpose of this manuscript, the 24 randomly selected non-SCWTs were used to prevent bias. Each uroendoscopic examination was evaluated for the following: presence and location of ectopic ureters, presence of a paramesonephric remnant, presence of a bifid vagina, presence of a subjectively shortened urethral length, presence of structural anomalies of the external urethral meatus, and presence of anomalies to the vesicourethral junction (VUJ).

A paramesonephric remnant was characterized as a centrally located septal band dividing the opening to the cranial vaginal vault in a dorsal to ventral direction.¹⁶ A bifid vagina is defined as a septal band extending within the vagina, resulting in one portion of the cranial vaginal vault ending in a blind-ended pouch (Figure 1).^16,17 For the purpose of this study, a short urethra was defined as one where the evaluators could see directly into the bladder lumen with the scope positioned at the external urethral meatus.

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Ectopic ureters are characterized by termination of one or both ureters at a site other than the craniolateral aspect of the bladder trigone.¹⁸ Intramural ureters were identified during cystoscopy when long tunnels were documented. To determine tunneling, careful attention was given to avoid excessive fluid insufflation resulting in collapse of the tunnel. The tunnels were entered with the scope or catheter and followed within the urethra. Extramural ureters cannot be definitively excluded during uroendoscopy, especially when there is little evidence for tunneling. Diagnostic imaging using ultrasonography or contrast radiography was completed for full assessment of the ureters.

Descriptive statistics were calculated using commercially available software.^a The Kolmogorov-Smirnov test for normality was performed. Chi-square analysis of contingency with Holm's correction for multiple comparisons was used to evaluate breed predilection. Fisher's exact test with Holm's correction procedure was used to compare SCWTs to non-SCWTs with regards to incidence of ectopic ureters, paramesonephric remnant, and a shortened urethra. In addition, Fisher's exact test with Holm's correction procedure was used to compare anomalies between commonly presenting juvenile breeds with urinary incontinence in our hospital population. A P value of less than 0.05 was considered statistically significant.

Results

A total of 134 female dogs, including 43 different breeds, met the criteria for juvenile female dogs with clinical signs of urinary incontinence during the study period. Breeds with sufficient numbers to draw relevant conclusions included Labrador retrievers (16/134, 11.9%), golden retrievers (13/134, 9.7%), SCWTs (12/134, 9.0%), mixed-breed dogs (12/134, 9.0%), Siberian huskies (7/134, 5.2%), and German shepherd dogs (7/134, 5.2%). All other breeds constituted less than 5% of the total population of juvenile female dogs with urinary incontinence.

During the study time period, a total of 803 juvenile female Labrador retrievers (2.0% diagnosed with urinary incontinence), 374 golden retrievers (3.5% diagnosed with urinary incontinence), 2,119 mixed-breed dogs (0.57% diagnosed with urinary incontinence), 72 SCWTs (16.7% diagnosed with urinary incontinence), 221 Siberian huskies (3.2% diagnosed with urinary incontinence), and 763 German shepherd dogs (0.92% diagnosed with urinary incontinence) presented to The Ohio State University Veterinary Medical Center for medical care. The hospital prevalence of urinary incontinence in juvenile female SCWTs based on the patient population at The Ohio State University Veterinary Medical Center from 2000 to 2011 was found to be statistically greater than all other breeds with a higher prevalence of urinary incontinence in our hospital population (P <0.05%).

Uroendoscopic evaluations were performed and video-recorded for 119 of 134 (88.8%) juvenile female dogs with urinary incontinence. Within breeds with a higher prevalence for urinary incontinence in juvenile female dogs in our hospital population, 15 Labrador retrievers, 13 golden retrievers, 12 SCWTs, 10 mixed-breed dogs, 7 Siberian huskies, and 3 German shepherd dogs had uroendoscopy performed. German shepherd dogs were not included in statistical analysis as a result of the low number of dogs with uroendoscopy. Eleven of twelve SCWTs were intact at the time of noted urinary incontinence and uroendoscopy. The remaining dog had an ovariohysterectomy performed prior to 6 mo of age; however, the exact age was not available.

Based on uroendoscopic imaging, ectopic ureters were diagnosed in 67/119 (56.3%) of the dogs. Displacement of the ureteral orifices was diagnosed as bilateral in 55/67 (82.1%) and unilateral in 12/67 (17.9%) of affected dogs (Figure 2). Intramural ectopic ureters were diagnosed in 63/67 (94.0%) dogs, and 4/67 (6.0%) were diagnosed as extramural. When extramural ectopic ureters were suspected based upon deviation of the submucosal tunnel from the urethra, further diagnostics were performed to confirm. Additional diagnostic testing in the form of ultrasonography, contrast radiography, or exploratory laparotomy was performed on 53/67 dogs in our study diagnosed with ectopic ureters. Three of the dogs with extramural ectopic ureters were confirmed via contrast radiography, and one was confirmed via exploratory surgery.

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From the breeds presenting most commonly with urinary incontinence in juvenile female dogs in our hospital population, ectopic ureters were present in 12/15 (80%) Labrador retrievers, 8/13 (61.5%) golden retrievers, 8/12 (66.7%) SCWTs, 3/10 (30%) mixed-breed dogs, and 7/7 (100%) Siberian huskies. No statistically significant difference in incidence of ectopic ureters between the 12 SCWTs and 107 non-SCWTs with urinary incontinence was identified (P =0.5477). Additionally, the incidence of ectopic ureters in SCWTs compared to the other commonly presenting breeds was not statistically different.

Re-evaluation of uroendoscopic videos permitted documentation of the specific location of the displaced ureteral orifices in SCWTs compared to those of the 24 non-SCWTs. While statistics were not performed in this pilot evaluation, it was noted that the displaced ureteral orifices of SCWTs were all located within the distal trigone, VUJ, and proximal 1/3 of the urethra. Comparatively, the non-SCWT group had displaced ureteral orifices distributed throughout lower urinary tract including the distal trigone; VUJ; as well as the proximal, middle, and distal 1/3 of the urethra. While no SCWTs were found to have ectopic orifices distal to the proximal 1/3 of the urethra, 41.7% of the non-SCWT group had ectopic orifices distal to this location (Figure 3).

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The presence of a paramesonephric remnant dividing the opening to the cranial vaginal vault was identified in 78/119 (65.5%) juvenile female dogs with urinary incontinence. The breeds most commonly presenting with urinary incontinence in juveniles in our hospital population with an identifiable paramesonephric remnant included: 11/15 (73.3%) Labrador retrievers, 9/13 (69.2%) golden retrievers, 10/12 (83.3%) SCWTs, 4/10 (40%) mixed-breed dogs, and 6/7 (85.7%) Siberian huskies. In 9 of the 10 SCWTs with a paramesonephric remnant, the band encompassed the dorsal aspect of the external urethral orifice, resulting in subjective elongation and enlargement (Figure 4).

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Of the juvenile dogs with ectopic ureters, 56/67 (83.6%) also had a persistent paramesonephric remnant. Incidence of a persistent paramesonephric remnant in the 12 juvenile female SCWTs were compared to the 107 non-SCWTs with urinary incontinence. No statistical difference was identified (P =0.335). An evaluation of the presence of a paramesonephric remnant in SCWTs compared to each of the commonly presenting breeds in our hospital population found no statistical difference in incidence.

Re-evaluation of the 12 SCWTs uroendoscopic videos identified the presence of a tissue anomaly across the cingulum in all dogs. Ten of twelve SCWTs were found to have a paramesonephric remnant dividing the central portion of the cingulum. The other two dogs had a tissue membrane completely covering one side of the opening into the cranial vaginal vault (Figure 5). Additionally, in 8/10 SCWTs with a paramesonephric remnant present, the septal band extended deep within the vagina resulting in a bifid vagina (Figure 1). Six of the eight SCWTs with ectopic ureters had a bifid vagina and two of the four SCWTs without ectopic ureters had a bifid vagina.

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Urethral length was subjectively evaluated during uroendoscopy. Short urethral length was diagnosed via uroendoscopy in 45 of the 119 (37.8%) juvenile female dogs with urinary incontinence. From the most commonly presenting breeds with urinary incontinence in juveniles in our hospital population, a short urethra was identified in 1/15 (6.7%) Labrador retrievers, 3/13 (23.1%) golden retrievers, 10/12 (83.3%) SCWTs, 2/10 (20%) mixed-breed dogs, and 4/7 (57.1%) Siberian huskies. SCWTs were found to have a significantly higher hospital prevalence of a short urethra compared to juvenile non-SCWTs affected with urinary incontinence (35/107, 32.7%) (P =0.001). In addition, SCWTs were found to have a significantly higher hospital prevalence of a short urethra compared to Labrador retrievers, golden retrievers, and mixed-breed dogs (P <0.05), but they did not significantly differ compared to Siberian huskies (P =0.477).

Additional anatomic anomalies of the urogenital tract in urinary incontinent juvenile female SCWTs were identified via review of the video uroendoscopy. The structure of the VUJ was subjectively noted to be abnormal in 7/12 (58.33%) SCWTs. In three of the dogs, the evaluators described the VUJ to be identifiable but abnormally shaped, and in four dogs the evaluators were able to see directly into the bladder from the urethra with no distinguishable VUJ present. The identification of an abnormal VUJ was not directly related to the presence of other identified anomalies.

Discussion

In the present study, urinary incontinence in juvenile female dogs is defined as having documented clinical signs at 6 mo of age or less. The authors would like to propose the use of the term “juvenile urinary incontinence” for persistent urinary incontinence noted in dogs 6 mo of age or less. Use of this terminology will allow for ease and consistency of future comparisons between urinary incontinent juvenile and adult dogs. In addition, this may give a better understanding of the etiology of urinary incontinence when such a diagnosis has been given.

In our hospital population, we identified juvenile SCWTs to have an increased prevalence of urinary incontinence (16.7%). The authors acknowledge this prevalence to be specific to our particular referral institution. While we initially evaluated all affected breeds, we chose to only compare those breeds representing 5% or greater affected dogs because only these breeds had sufficient numbers to draw relevant conclusions. The finding of increased prevalence in SCWTs was significantly greater compared to all other breeds representing 5% or greater of the total population of juvenile female dogs with urinary incontinence in the same hospital setting. Siberian huskies, Labrador retrievers, and golden retrievers have been previously documented to have an increased frequency of anatomic anomalies resulting in urinary incontinence.^11,19 The cause for breed predisposition is not known, but it is likely multifactorial. The high hospital prevalence for SCWTs relative to others may indicate a greater genetic risk and should be further investigated. Previous studies evaluating dogs with ectopic ureters have identified parent–offspring transmission, suggesting a possible genetic basis of this condition.^20,21 In this study, 2/12 (16.7%) SCWTs were littermates, both diagnosed with bilateral ectopic ureters. A current study evaluating pedigree and DNA samples for specific gene mutations is underway for golden retrievers with ectopic ureters, but the present authors are not aware of any similar studies in SCWTs.²²

Endoscopic examination of the lower urogenital tract was used for comparison of ectopic ureters, a paramesonephric remnant, presence of a short urethra, and description of anatomic anomalies in SCWTs. Of the 119 juvenile female dogs with urinary incontinence, ectopic ureters were identified in over half the cases (56.3%). Of the 67 dogs identified with ectopic ureters, 82.1% were bilateral and 17.9% were unilateral. Previous studies have identified ectopic ureters to be bilateral in 48–91.6% of affected dogs.^4,23 Uroendoscopy allows for direct visualization of the ureteral orifice, and whether this technique was utilized in recent studies may account for the variable frequency in diagnosing bilaterally affected dogs.

Although the presence of ectopic ureters did not differ significantly between SCWTs and non-SCWTs, all displaced ureteral orifices in SCWTs were located within the distal trigone, VUJ, and proximal urethra. For a pilot comparison, evaluation of the 24 juvenile female non-SCWTs with urinary incontinence found a more varied distribution throughout the lower urinary tract (Figure 3). A previous study evaluating 48 ectopic ureters found 5 ureteral orifices in the urinary bladder neck/proximal portion of the urethra, 1 at the level of the VUJ, 17 in the proximal urethra, 4 in the mid urethra, and 21 in the distal urethra.³ This is consistent with our pilot evaluation in the 24 non-SCWTs. The clinical significance relating location of the displaced ureteral orifice to the effect on urinary incontinence is currently unknown and warrants further investigation. While the argument can be made that displaced ureteral openings that are more proximally located allow for more normal urethral anatomy, the impact on the trigone and proximal urethra may outweigh any potential benefits. In addition, further investigation is needed to determine whether surgical or laser ablation of these proximal ureters provides any benefit in regaining urinary continence.

The presence of a tissue anomaly across the opening to the vagina was the most commonly visualized anomaly, affecting 100% of SCWTs. Two of the dogs had a tissue membrane completely covering one side of the vaginal opening and the other ten had septal bands present in the center of the vaginal opening. This band is a result of incomplete fusion of the caudal paramesonephric ducts, with retention of a medial partition.¹⁶ Incidence of a paramesonephric remnant in the SCWT population did not significantly differ compared to non-SCWTs presenting with urinary incontinence as juveniles. Currently, the effect of a septal anomaly on urinary incontinence is not known, but there is speculation that dorsal traction on the external urethral meatus, as well as pooling of urine in the vagina, may contribute to clinical signs of urinary incontinence.³

In 80% of SCWTs with a paramesonephric remnant, the band formed a bifid vagina. Similar to a paramesonephric remnant, a bifid vagina results from incomplete fusion of the caudal paramesonephric ducts with retention of a medial partition.¹⁶ However, this rare manifestation results in a long dividing septum with one segment ending in a blind pouch.^16,17 Previous studies have reported that bifid vaginas have a 13% prevalence rate when uroendoscopy was used to evaluate urinary incontinent female dogs.³ It is not currently known why SCWTs frequently manifest this anomaly. This finding is most important when determining treatment options in urinary incontinent juvenile female SCWTs. Recently, some endoscopists have recommended ablation of this band to prevent vaginal pooling and chronic infections, though the salutary effect of this procedure has not been proven.³

In this study, urethral length was subjectively evaluated by the specialist performing the uroendoscopy. A diagnosis of “shortened” was only noted when the evaluators could see into the bladder lumen with the scope positioned at the external urethral meatus. We recognize this definition only selects for inclusion of urethras that are severely shortened and likely missed many of those less severely affected. However, this definition allowed for objective comparison, as a calibrated measurement system was unavailable in these retrospective cases.

The finding of significantly more dogs with shortened urethral length in SCWTs compared to non-SCWTs is likely of clinical importance. In female dogs, the smooth muscles of the urethra functionally serve as an internal urethral sphincter.²⁴ The abdominal portion of the urethra is exposed to increased pressure that acts as an external occluding force, unlike the portion within the pelvic canal.²⁴ Thus, a shortened urethra and resultant pelvic positioning of the bladder neck has been associated with urinary incontinence in some dogs when combined with USMI.^14,25 An approximate urethral length of 5 cm has previously been reported in normal functioning urethras.²⁶ In a recent study, the urethral length of 32 incontinent female dogs diagnosed with ectopic ureters was measured.³ The median urethral length was found to be 4 cm.³ Due to the retrospective nature of the present study, recorded evaluation of urethral length was based upon subjective observation, and corresponding urethral pressure profiles were not available to confirm concurrent USMI. To more accurately assess urethral length via endoscopy, prospective evaluation utilizing a calibrated measuring device and an evaluation of breed, age, and size variations are needed.

Review of the uroendoscopic evaluation of the 12 juvenile SCWTs with urinary incontinence revealed anatomic anomalies in all patients. However, no direct association between abnormalities was identified. Unfortunately, endoscopic evaluation of the urogenital tract of SCWTs without clinical signs of incontinence was not available. A previous study evaluating Entlebuchers found 6 of 11 patients with ectopic ureters to be urinary continent.¹⁸ It is possible urinary continent SCWTs may also have a variety of the anatomic anomalies similar to those identified in the present study. Previous studies have found female genitalia are variable and can be affected by breed, conformation, and hormone status.²⁷

The present study had several limitations including its retrospective nature, resulting in the recorded uroendoscopic evaluation being performed by multiple clinicians. As a result, much of the examination was subjective and based upon the evaluators' experience level. This limited the amount of objective data available. Secondly, endoscopic evaluations were not available in urinary continent female SCWTs in order to establish breed standards. Third, although no breed specific recruitment for urinary incontinence occurred by our institution during the study time period, a referral bias for different breeds is possible. Fourth, because of the study time frame and changes in therapeutic options available, therapeutic outcomes comparing SCWTs and non-SCWTs could not be assessed, nor could the impact of multiple anatomic anomalies on the response to treatment.

Conclusion

This study represents the first attempt to document the relative prevalence of urinary incontinence in juvenile female SCWTs in a large referral hospital population compared to other breeds. In addition, this is the only study in the current literature to characterize the anatomic anomalies associated with urinary incontinence in juvenile SCWTs via uroendoscopy. Based on the results of this retrospective clinical study, juvenile SCWTs have an increased prevalence of urinary incontinence compared to other commonly presenting breeds at our referral institution. While the hospital prevalence of ectopic ureters did not significantly differ, the location of the displaced ureteral orifices in SCWTs were isolated to the bladder trigone, VUJ, and proximal 1/3 of the urethra. SCWTs were found to have anomalies of the vaginal opening in all cases, either in the form of a paramesonephric remnant (n = 10) or a membrane completely covering one side of the vaginal opening (n = 2). In 9 out of 10 cases in which a paramesonephric remnant was present, it extended into the dorsal wall of the external urethral meatus. In 8 of the 10 dogs with a paramesonephric remnant, the band extended to form a bifid vagina. In addition, SCWTs were found to have a subjectively shortened urethral length.

This information will help to guide veterinarians in recognition of a breed-related disorder of the lower urogenital system in SCWTs, and will encourage recommendations for a complete evaluation of the urogenital tract including the use of uroendoscopy. Based on identification of this breed-related urinary incontinence, further research is necessary to determine the optimal treatment protocols for urinary incontinence in juvenile SCWTs. In addition, further studies should explore possible genetic markers in SCWTs that result in anomalies of the urogenital tract and associated urinary incontinence.

APPENDIX 1  Uroendoscopy evaluation form utilized by the examiner to record abnormalities when blindly reviewing digital video recording from juvenile female dogs with urinary incontinence. Definitions of abnormalities were made available to the examiner prior to completing the evaluations.