Interpretation of cystoscope:

Vaginal vestibule:

The appearance of the normal vaginal vestibule when distended with fluid. The vagina is located at the top of the screen, the cingulum is the band of tissue between the vagina and the urethra and the external urethral orifice is the opening in the middle of the image.

Urethra:

The normal female urethra is characterized by smooth, pale pink mucosa and a dorsal urethral membrane. The male urethra appears similar, but the urethral lumen is smaller and less distensible. Normal location of the ureters within the bladder:

The ureters are located just inside the bladder neck in the trigone. They are c-shaped and the open areas of the c’s face each other; both ureters are located in the same plane within the bladder. The right ureter is located on the right side of the screen and the left ureter on the left side of the screen.

Normal vagina:

The caudal female reproductive tract can be examined via cystoscope from the vagina to an area just caudal to the cervix called the pseudocervix. The vagina has numerous mucosal folds and with distension, a dorsal membrane similar to that seen in the urethra, may be appreciated. The appearance of the mucosa changes during the estrus cycle.

When is Cystoscopy Indicated??

Cystoscopy can be used to help identify ectopic ureters in dogs, a common reason many young dogs present with urinary incontinence. We can also use cystoscopy to less invasively obtain biopsies of the lower urinary tract if mass lesions such as polyps or tumors are suspected.

ECTOPIC URETERS

Oftentimes, we use this technique to evaluate dogs and cats that present with recurrent urinary tract infections; if no underlying cause is found, biopsy forceps can be inserted through the scope and small samples of the bladder wall can be obtained and submitted for histopathology and culture analysis.

Finally, the cystoscope can be used as a treatment option for stones ectopic ureters, as well as sub mucosal urethral collagen injections for treatment of urinary incontinence.

Why It Is Done??

Cystoscopy may be done to:

Find the cause of symptoms such as blood in the urine (hematuria), Painful urination (dysuria), urinary incontinence, urinary frequency or hesitancy, an inability to pass urine (retention), Or a sudden and overwhelming need to urinate (urgency). Find the cause of problems of the urinary tract, such as frequent, repeated urinary tract infections or urinary tract infections that do not respond to treatment. Look for problems in the urinary tract, such as blockage in the urethra caused by an enlarged prostate, kidney stones, or tumors. Evaluate problems that cannot be seen on X-ray or to further investigate problems detected by ultrasound or during intravenous pyelography, such as kidney stones or tumors. Remove tissue samples for biopsy. Remove foreign objects. Place ureteral catheters (stents) to help urine flow from the kidneys to the bladder. Treat urinary tract problems. For example, cystoscopy can be done to remove urinary tract stones or growths, treat bleeding in the bladder, relieve blockages in the urethra, or treat or remove tumors.

Place a catheter in the ureters for an X-ray test called retrograde pyelography. A dye that shows up on an X-ray picture is injected through the catheter to fill and outline the ureter and the inside of the kidney.

Limitation of Cystoscope:

ü  Invasive.

ü  Time-consuming.

ü  Expensive.

ü  The mucosa at the bladder neck and within bladder diverticula is not accessible.

ü  Need sedation.

ü  Susceptibility to infection or injury

Complications and Sequelae of Cystoscope

ü  Cystoscopy generally is a very safe test.

ü  If a general anesthetic is used, there are some risks of general anesthesia.

ü  There is no risk of loss of sexual function.

ü  Profuse bleeding.

ü  Damaged urethra(swelling).

ü  Perforated bladder.

ü  Urinary tract infection.

ü  Injured penis.                                               

ü  scar tissue.

CYSTOSCOPY

Normal:	The urethra, bladder, and ureters are normal.
	There are no polyps or other abnormal tissues, swelling, bleeding, narrow areas (strictures), or structural abnormalities.
Abnormal:	There is swelling or narrowing of the urethra because of previous infections or an enlarged prostate gland.
	There are bladder tumors (cancerous or benign), polyps, ulcers, urinary stones, or inflammation of the bladder walls.
	Abnormalities in the structure of the urinary tract present since birth (congenital) are seen.
	Pelvic organ prolapse is present in a woman.

What Affects the Test (contraindication) ??

A cystoscopy is usually not done if you have an infection of the bladder, prostate gland, or urethra.

Uses of cystoscopy in small animals

Introduction:

Cystoscopy is the use of a scope (cystoscope) to examine the bladder. This is done either to look at the bladder for abnormalities or to help with surgery being performed on the inside of the urinary tract (transurethral surgery). 

Areas that can be examined include the following: 

Urethra or urinary channel, Bladder, which collects and stores urine, The 2 ureters, which are small internal tubes that conduct the urine made by each kidney into the bladder. Cystoscopy is a powerful tool for characterization of lower urinary tract disease in dogs and cats.  Current applications of cystoscopy include diagnostic and interventional techniques. 

Cystoscopy equipment:

Rigid cystoscopes are used for females and male cats with perineal urethrostomies. It is important to match the size of cystoscope to the size of the patient.  The best image will be obtained with the largest cystoscope that can be easily passed through the urethra.

Light sources:

Many different light sources are available for use in cystoscopy. Xenon light sources are generally considered optimal and are available from several different companies. Some newer light sources have automatic light adjustment, but most require that an assistant adjust the light level throughout the examination.

 Image capture:

Images of the lower urinary tract may be viewed through the eyepiece of the cystoscope or via camera equipment attached to the cystoscope eyepiece.  Still images or video images may be captured in a variety of formats depending on the equipment used.

Biopsy instruments:

Most cystoscope’s have an instrument channel that will accommodate a biopsy instrument. The cystoscope can be used to select an optimal location for biopsy and to direct the biopsy instrument.

CYSTOSCOPY PROCEDURES

Male dog cystoscopy procedures:

In the male dog, the penis is extruded from the prepuce by an assistant while the examiner passes the cystoscope up the urethra. Fluid is injected through the instrument port to distend the urethra and ease the passage of the cystoscope.  The instrument is manipulated to keep the image of the urethral lumen in the center of the screen.

Male cat cystoscopy procedures:

Just as in the male dog, the male cat penis is extruded from the prepuce and the flexible cystoscope is directed up the urethra while fluid is simultaneously infused to distend the urethra and ease the passage of the cystoscope. A mosquito hemostat or stay sutures secured to the prepuce may be necessary to maintain extrusion of the penis throughout the examination.

Female cystoscopy procedures:

The cystoscope is directed slightly dorsally to enter the vaginal vestibule. The vulvar labia are pressed firmly closed and retracted slightly to form a chamber that is distended with irrigation fluid.

Critical care management in birds

TREATMENT OF CASUALTY AND EMERGENCY IN BIRDS

Handling the Avian Emergency:

The avian practitioner will be presented with three classes of birds:

-       - The well-bird,

-       - The obviously sick bird

-       - The bird harbouring a sub-clinical infection. 

The first two classes of birds are very straight forward to deal with, but it is the sub-clinically ill bird that is most problematic for most avian practitioners

Birds are masters at hiding signs of illness as a protective mechanism. So, the ill bird will act as normal as it possibly can for as long as it can

DO see a sick bird as soon as possible:

It is very important to know about the differences between avian medicine and dog and cat medicine. Any delay in providing diagnosis and treatment may result in the death of the bird.

Sick birds:

Most sick birds require supplemental heat, which is easy to provide with an incubator, aqua brooder or heating pad. If the bird appears critical, provide the bird with heat and supplemental oxygen before you attempt to do anything else to it

DON'T handle a sick bird until a thorough history and visual evaluation have been performed:

A bird can be emaciated and weak, yet when it fluffs out its feathers, it may look normal. Have oxygen ready, warmed lactated ringers in a syringe, perhaps a syringe of warm hand-feeding formula and a stainless steel feeding tube, and any other equipment or medications that you feel might be necessary.

DO assess the avian patient's condition every moment during the time it is being handled:

In cases where the bird is very ill, it may be most important to stabilize the bird first, and procure tests later. With a critically ill bird, tests may need to be performed in stages, or sometimes, they must be forgone, so that all efforts are directed towards support care.

DON'T forget your sound medical background when dealing with the avian emergency:

Remember that birds have air sacs, and if there is serious damage to the beak, oropharynx or glottis, and establishing an airway is difficult, an air sac can be cannulated, and the bird can safely and easily breathe through the tube.

Fracture:

Birds also have some pneumatised bones, and a fracture may result in extensive SC emphysema. This is often puzzling to the beginning avian vet, who may suspect rib fractures. However, SQ emphysema is a common sequelae to a fractured pneumatised bone and will usually spontaneously resolve with 24 hours.

SHOCK:

Birds may be treated for "shock" although their physiological response to injury does not result in shock as occurs in mammals. We must always remember that steroid use in birds has potentially more serious and long-standing consequences than its use in mammals does.

One injection of a steroid in a critical bird is worth the risk, however, its use will increase the chance that the bird may develop aspergillosis, a serious fungal disease. Steroids have limited benefit in avian species, and topical preparations are also dangerous.

Thermoregulation:

Many sick birds also require supplemental heat, as they are not thermoregulating properly. Keeping a sick bird in a cage with a controlled temperature and humidity is very important. Birds will do well in an incubator set at between 87-92 degrees F. Humidity should be over 75%.

Sick baby birds often become ill from being kept at too low of a temperature. When this happens, the GI tract slows down dramatically. Therefore, giving any medications orally is usually not a great idea, as absorption will be erratic and slower than normal. Parenteral antibiotics and therapeutics are a better choice.

Supportive:

Many ill birds are dehydrated. Fluids may be given SC (over the back of the neck, where there is lots of loose skin, just beware of the jugular veins), intraosseously or intravenously. Hydrating a critical bird is very important.

When bandaging or splinting a bird, make sure that the sternum moves freely. Birds breathe like a bellows, in and out, not up and down, as mammals do. If the sternum's movement is restricted, the bird may asphyxiate

Stress:

DO plan to clip the wings of hospitalized birds. DO minimize stress in sick birds.

Keep critical birds in a stress-free environment. Don't put them in stainless steel cages where they can see their reflection. Keep them in a warm, quiet, dark environment. Don't keep a sick bird in a cage on the clinic floor. Birds are most comfortable up high, so take that into consideration when deciding where to put birdcages.

DO maintain total haemostasis when working on a bird:

Although it is not true that a bird will die from losing a few drops of blood, it is very important to minimize any bleeding. If a bird is bleeding badly, it is vital to stop the bleeding as quickly as possible. If a bird won't stop bleeding after venepuncture, a pressure bandage may be applied for 20 minutes or so, until clotting has occurred.

Liquid clotting agent, is safe and effective to use in birds. Use of a radio surgical unit (and NOT an electro cautery unit) is very helpful in stopping bleeding.

Emergency treatment for the ill bird at home:

•      Provide Warmth.

•      Give energy fluids by mouth.

•      Give sterile seed and remove all other foodstuffs.

•      Clean out the cage and disinfect with a Cage cleaner.

•      If possible give the appropriate medicines by mouth.

Know aggression !!!

Aggression has in relation to pain and an understanding of aggression is important for those working with animals in distress. Aggression is not a unitary phenomenon. Clearly the emotion underlying predatory behaviour (sometimes referred to as predatory aggression) is quite different from that underlying defense of a resource from conspecific (affective aggression), or bouts of ‘apparent aggression’ arising during acts of play. These three types of activity belong to functionally different behavioural systems and are directed towards very different goals. While they might all (in the case of carnivores in particular) share the potential to cause harm to another individual, it is potentially confusing to link them with each other through the use of the term aggression in their description. Injury that arises during play might be a result of aggressive play, but that does not make it a form aggression, it is first and foremost a form of play.

The further subdivision of affective aggression is of questionable value. It may be divided according to descriptive context, such as ‘owner directed aggression’, or according to motivation/mechanism, such as ‘defensive aggression’. Both have their advantages and disadvantages. For example, contextual labels have both the advantage and disadvantage of not implying anything about motivation and so might  be quite reliable terms, but do not link with underlying mechanism or treatments aimed at addressing the cause  in a reliable way. This is something that is frequently overlooked in the literature. The main problem with motivational descriptions is knowing with confidence what the precise motivation is.

Aggressive displays should be distinguished from aggressiveness, which can be used to describe both the mood and temperamental trait relating to the propensity to show aggression when environmental circumstances dictate it might be used. Animals may become temperamentally more aggressive if they are in chronic pain. This may resolve once the pain is eliminated, but the animal may also learn to use displays of aggression in a wider range of contexts as a result of this episode. In this situation specialist assistance should be sought to help resolve the problem.

The expression of aggression depends on a range of underlying external contingencies as well as internal predispositions. Historically, psychology has focused on the external factors producing aggression and these are well summarised by Archer (1976).

Namely aggression may occur when:

1. A territorial boundary is crossed.

2. The personal space is entered.

3. The body is touched.

4. The animal is faced by uncertainty/novelty in the environment.

5. An expected reward is absent or withdrawn.

6. An expected reward is reduced.

7. Behaviour is frustrated from being executed – this includes the application of intended punishment to an animal that is already nervous.

These situations may all occur when a physiotherapist is trying to treat a patient and are perceived at a time of potentially aversive change (i.e. an unpleasant near-future). A number of individual factors determine whether overt aggression rather than freezing, flight or some form of appeasement is offered.

These include the following:

1. The emotional state (mood) of the animal– Fearfulness in the absence of an easy route for escape, greatly increases the probability that aggression will be used, but more generally there are a wide range of factors which can increase irritability (an enhanced predisposition towards aggression), including low grade chronic/subclinical pain. This is particularly worth investigating when the pattern is not entirely predictable, and probably underestimated in veterinary practice.

2. The animal’s appraisal of the situation– This depends on the animal’s perceived ability to win the contest, the value of any resource that is being disputed and the expected cost of defense. Learning can be very important in this, as an owner who always gives way to their dog will be perceived both as an inferior competitor, and as an individual who does not put up much of a fight. It is perhaps for this reason that clinicians and therapists are often able to handle an animal in a way that would be impossible for the owner. This can obviously be to the physiotherapist’s advantage, but must also be taken into consideration when making recommendations for treatment. Owners may not only lack the skill to undertake certain procedures in the home, but also the necessary authority. While handouts, such as those by Landsberget al. (2001), can be very useful in the management of such problems, they should not be used without understanding the fundamental nature of the problem faced. Therapists should also consider the potential need for specialist intervention in handling aggression, and ensure the risks to others of injury from an aggressive episode are minimised.

This involves:

•Informing owners of their responsibility to prevent injury to others.

•Advising owners to avoid situations that are likely to exacerbate the problem. This may include identifiable trigger stimuli, such as approach towards a particularly painful area, uncertainty in handling the animal, frustrating or fearful situations.

•The animal should not be approached when it has no opportunity to retreat.

•If it is safe to do so, the owner should be encouraged to muzzle-train an aggressive dog away from arousing or dangerous environments. A basket muzzle is preferable to a nylon one, as it allows the dog to pant and drink but not bite while it is on. The most common problem with muzzles is that they are only used when the dog is already showing aggression and will resent restraint. So training should begin away from distractions and associated with rewards placed in the muzzle. Once trained, the dog should be muzzled before the problem arises, i.e. before arriving at the treatment center.

Reference: Animal Physiotherapy: Assessment, Treatment and Rehabilitation of Animals

Edited by Catherine M. McGowan, Lesley Goff, Narelle Stubbs.

Assessing pain in animals

Pain assessment involves the integration of measurements of behaviour and physiology together with knowledge of the bi-directional mechanisms that control pain. Morton and Griffiths (1985) proposed a framework for the recognition of pain, distress and discomfort based on a combined assessment of appearance, food and water intake, behaviour, cardiovascular functioning, digestive system activity and neurological/musculoskeletal signs. This provides a useful framework, but, the correlation between physiological measures such as heart rate, respiratory rate and pupil dilation versus subjective pain scores may be poor and there is a need for greater validation of pain scales.

Given the enormous range of individual factors that can affect pain perception in a given context discussed above, it should be apparent that it is difficult to accurately assess the pain of an individual without a thorough history, including baseline assessments of behaviour and temperament. In addition, given the differences that inevitably exist between assessors, it is also important that assessment is repeated by the same assessor on all possible occasions, in order to reduce this possible source of error.

Laboratory methods to assess pain in domesticated animals might be thought of as being more objective and are increasingly sophisticated. Clinical assessment generally relies on evaluating a range of behavioural signs of pain, and these may be integrated into subjective scoring systems. Verbal rating scales involve qualitative description of behaviour observed, and simple quantitative scales involve subjectively rating pain as No Pain, Mild, Moderate or Severe. These assessment protocols have been criticised not only for the large variation between different observers, but also for their lack of sensitivity.

Numeric scales rating pain between 0 and 10, and visual analogue scales marking pain on a ruler on which 0 = No Pain Present and 100 = Worst Pain Imaginable, are generally considered to provide better sensitivity and reliability. However, the validity of these systems may be questioned owing to a lack of transparency regarding pain parameters considered by observers, and these are weighted in the final score. Some observers may reliably weight vocalisations heavily because of ease of measurement and anthropomorphism, but these vocalisations may not correlate well with pain experiences since dogs occasionally vocalise while under anesthesia when pain is presumably prevented.

Although the science of valid pain assessment in animals is in its infancy, this does not negate the responsibility of those that work with animals in pain to institute and apply pain assessment criteria within their practice. Given current knowledge, the physiotherapist should at the very least use some form of pain scale that both the owner and the physiotherapist can complete and keep a behavioural diary of therapy sessions to monitor pain responses. Should there be any doubt that a certain condition is painful, it is good practice to assume that what would be painful for a person is painful for that animal (IRAC 1985). Further information on the recognition and assessment of animal pain is hosted by the University of Edinburgh at: www.vet.ed.ac.uk/animalpain/, and readers may wish to refer to this for further detail of some of the principles that have been discussed in this chapter.

Source of pain	Behavioural response
General responses	Lethargy Reduction in grooming Depression Reduced feeding, drinking Protection of painful site Vocalization (dog: whining, growling; equine: groaning) Aggression Hanging tail Ear position (equine: pinned ears) Facial expression (canine: furrowed brow; equine: clenched jaw, wrinkled muzzle) Restlessness/weight shifting between all limbs
Limb	Avoidance or reduction in weight bearing Abnormal gait Head bobbing during locomotion Rubbing, licking wound site Weight shifting away from painful limb
Abdominal/ Spinal/ Visceral pain	Tucked up posture Glancing or nosing abdomen Abnormal stance, stretching of hind limbs Restlessness Sweating Trembling
Head pain	Headshaking and facial rubbing Head shyness Grimacing Signs often exacerbated by exercise Intranasal pain Snorting and sneezing Turning of the upper lip Intra-oral pain Reduced appetite and/or dropping of food being chewed Teeth grinding

Reference: Animal Physiotherapy: Assessment, Treatment and Rehabilitation of Animals

Edited by Catherine M. McGowan, Lesley Goff, Narelle Stubbs.