5 year old FS Husky who had a pyometra at age 4 and was spayed at that time. Has had continuous incontinence, not cyclical, since that time. She is constantly licking. Did not respond to DES or PPA. UA’s in the past were unremarkable and no reported blood work abnormalities.
On ultrasound, I was able to see the right ureter that appeared small and connected in a normal region to the trigone. I’m presuming the other tubular structure also seen to the right on the transverse images is the residual uterine body containing some anechoic fluid, but would love some confirmation. If so, I could not find any ectopic ovarian tissue. The continuous incontinence confuses me. Would we proceed with vaginal cytology and the AMH testing?
Comments
The tubular structure in
The tubular structure in video 1 is not normal for residual uterus or for a ureter. The tubular dilation in video 3 is not normal either. Putting video 1 and 3 together would make sense for an ectopic ureter bypassing the trigone and entering the vacginal vault directly. You may even see wiht wiht a speculum in the vaginal vault. Cystoscopy is the way to go here and/or CT if you arent able to connect the dots. CT with contrast would give the most info. If an ectpic ureter i would expect the clincial signs to be there her whole life. If 1 and 3 are uterus then ovarian remnant likely is present just not seen sonogrpahically. CT would cover all the bases here for ectopic ureter, o remnant and uterine remnant. Or keep trying with linear probes behind the kidneys and along the body wall at times you just push the remnant out of the way when its adhered to the body wall.
Thank you for the input,
Thank you for the input, Eric. On the first video (transverse), the larger tubular structure is what I’m thinking is uterus because I can see the small tubular structure go into the trigone and felt pretty confident that was the ureter. The second video is trying to show the small ureter in longitudinal. May be that the upload isn’t giving good enough resolution.
She definitely wasn’t incontinent prior to the pyometra/OHE. Do you think it is reasonable to do vaginal cytology and hormonal testing? I know we still need to figure out where the ovarian tissue is, but seems like could at least help confirm that I think we are dealing with uterus before recommending CT or exploratory surgery.
That’s a lot of uterus to
That’s a lot of uterus to leave post OVH. I personally would just explore and take the uterus down to the cervix, ensure no adhesions to the bladder or CUJ that may be tethering the lower urinary tract and inspect the O fosse and likely do another ultrasound pass prior to sx of the O fossae. I’m betting there is a remnant there and all of this is owing to incomplete OVH with maybe some adhesion or physical stimulation on the bladder/lower UT… This is what i see most in mobile US and telemed when faced with these scenarios. Ectopy would have been manifesting since birth to some extent. I may run it through the CT first, well because i have one…:) if i really wanted to know what i had to address surgically but surgery is where its headed any time there are any sort of “extra tubes” 🙂
New update – this patient has
New update – this patient has been on DES. Would that be a reason for residual/excessive uterine tissue to be fluid filled?
Retained ovarian tissue
Retained ovarian tissue should not cause persistant urinary incontinence so vaginal cytology and the AMH testing may not be helpful. One possiblity would be that post surgery the bladde has become a “block/pelvic” bladder. Would consider doing a contrast cystogram as not sure if CT can pick up block/pelvic bladder, especialliy if voided. Has the patient become obese post surgery? as this can also contribute to incontinence.
Hi Dr. Lobetti! No the
Hi Dr. Lobetti! No the patient is not obese – she is actually the most beautiful and calm Husky I think I have ever met. I didn’t really appreciate the bladder being more caudal during the ultrasound, but I will pass along the idea of checking for this prior to an exploratory and/or CT
New update – this patient has
New update – this patient has been on DES. Would that be a reason for residual/excessive uterine tissue to be fluid filled?
Very likely as estrogen will
Very likely as estrogen will result in hyperplasma of the uterine stump.
makes sense. Would you say
makes sense. Would you say regardless this is a lot of uterine tissue to leave in place and that it should be removed now or would you recheck an ultrasound in a set number of weeks after stopping the DES to see if resolves?
Long term danger would be
Long term danger would be development of stump granuloma/pyometra so would recommend surgery once the etiology of the incontinence has been addressed.
More follow up in trying to
More follow up in trying to get to the bottom of this. Sounds like you are not thinking the enlarged uterine stump is not the cause of the incontinence, correct?
Owner updated that dog has been off of DES for 3 weeks as of the time of the ultrasound. Would it still be fluid filled this far out?
Primary accidents happen as follows – will squirt about 1/4 tsp and then lick herself. ONly happens when awake and not when she is excited. She has no straining and she does not lick herself after a “normal” urination.
Thank you for your input!
With updated clinical picture
With updated clinical picture sounds more like an urge/irritaion rather than incontinence. Thus would go for surgery to remove the retained uterine tissue.
Thank you – that’s what I was
Thank you – that’s what I was thinking makes a lot of sense in this case.