犬、猫排尿困难之处理

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MANAGEMENT OF DYSURIA IN THE DOG AND CAT
犬、猫排尿困难之处理

Clinical Signs & History 临床症状及病史:

Can include all or some of the following 可包括以下之全部或部份:
•    Pain and difficulty in passing urine 排尿困难及疼痛 .
•    Straining prior to/ during or after urination (stranguria) 排尿前/排尿时或排尿后疼痛(痛性尿淋沥).
•    Increased frequency of urination (pollakiuria) and often small amounts 排尿次数增加及尿量少(尿频).
•    Blood in the urine (haematuria) 尿中带血(血尿).
•    Foul smelling urine e.g. Proteus spp cystitis 尿有恶臭味，例如.变性菌性膀胱炎
•    Licking of the perineal, vulval or penile areas 舔会阴，外阴或阴茎.
•    No urine passed (anuria) e.g. urethral blockage排不出尿（无尿），例如尿道阻塞.
•    Swollen abdomen e.g. bladder rupture or urethral blockage. 腹部肿大，例如膀胱破裂或尿道阻塞
•    Anorexia, vomiting e.g. urethral blockage.厌食，呕吐；例如尿道阻塞
•    The duration of clinical signs is also important to consider. 临床症状出现的时间亦要考虑

Differential Diagnosis 鉴别诊断:

•    Bacterial cystitis/ urethritis e.g. E. coli and Proteus spp. Common in dogs unusual in cats. Recurrent cases think other primary cause such a uroliths, diabetes etc.细菌性膀胱炎／尿道炎，例如：大肠杆菌，变性菌属。常见于犬，不常见于猫。如经常复发的病例应考虑其它原发性之疾病如结石、糖尿病等。
•    Feline Lower Urinary Tract Disease (FLUTD).猫下泌尿道疾病
•    Urolithiasis (dogs and cats).尿石病(犬、猫)
•    Crystalline urethral plugs (cats).结晶性尿路栓塞(猫)
•    Neoplasia e.g. papillomas and transitional cell carcinomas.肿瘤，例如乳头状瘤、移行细胞瘤
•    Trauma.创伤
•    Enlarged prostate due to infection/ inflammation, hormonal hypertrophy, cysts or neoplasia.前列腺肿大，由于感染、发炎、荷尔蒙性肥大、囊肿或肿瘤
•    Atonic bladder e.g. neurological disease. 无张力性膀胱，例如神经系统疾病
•    Urethral prolapse. 尿道脱垂

It is possible to have more than one of the above at any one time e.g. uroliths and bacterial cystitis.同一时间可以有超过一项以上所述的情况发生，例如结石及细菌性膀胱炎


Physical Exam/Work Up身体检查

Depending on the severity of the condition can include all or some of the following:视乎情况之严重性，可包括以下部份或全部之检查

•    Full Clinical Examination 全面临床检查(全身各系统器官，尤其要特别注意以下几项)(of all body systems paying particular attention to the following)
1.    Abdominal palpation to check for bladder size/ presence of pain; occasionally can palpate uroliths if large or plentiful.触诊腹部以检查膀胱大小及有否疼痛
2.    Rectal examination e.g. prostate in male dogs and cervix/vagina in female dogs. Often useful if done concurrently with abdominal palpation.直肠检查，例如公狗之前列腺、母狗之子宫颈及阴道。通常在腹部触诊检查后接着施行
3.    Examination of the penis and vulva for signs of neoplasia and trauma e.g. transmissible venereal tumour.检查阴茎或阴户有否肿瘤及创伤，例如传染性性病性肿瘤
4.    Neurological exam to ensure reflexes are intact e.g. atonic bladder in spinal trauma.神经学检查以确定反射正常，例如脊椎创伤引致之膀胱无力

•    Bloods血液
1.    Haematology (CBC) e.g. anaemia in the case of chronic bleeding tumours; leucocytosis in the case of infection.全血计数；肿瘤慢性出血引致的病例、感染引致的血细胞增多症
2.    Biochemistry e.g. high ALKP/Cholesterol and Glucose in Cushing’s Disease (recurrent bacterial cystitis); high renal parameters (BUN, Creatinine etc) in the case of urethral obstruction (post renal renal failure).血液生化；库兴氏综合症(复发性细菌性膀胱炎)时之高碱性磷酸酶/高胆固醇及高血糖，尿路阻塞(肾后性肾衰竭)时之肾脏指数升高(血尿素氮，肌酸酐)
3.    Electrolytes (Na+/ K+ and Cl-) e.g. high potassium in the case of urethral obstruction in cats.电解质(钠+、钾+及氯-离子) 例如在猫尿路阻塞时的高钾水平

•    Urine Analysis尿液检查
1.    Preferably taken by cystocentesis (to reduce bacterial contamination) but urethral catheterisation or mid stream flow collection is also acceptable if cystocentesis is not possible e.g. very nervous excitable or aggressive dog.最好是以膀胱穿刺采尿(减低细菌性污染)，可是如果患犬是非常的神经质或带攻击性、无法以膀胱穿刺采尿时，以导尿管导尿或采排尿时中段之尿液也可接受
2.    Dipstick, microscopy (of centrifuged/settled sediment sample) and culture and sensitivity (C&S).测验片，显微镜检查(离心/沉淀之尿渣样本)及细菌培养和抗生素敏感试验(C&S)
3.    Samples should be fresh not overnight samples ideally within 2 hours.样本要新鲜，最好为2小时内，不可以用隔夜的样本
4.    Samples for C&S should be refridgerated after collection to prevent bacterial multiplication. 细菌培养和抗生素敏感试验(C&S)的样本在采样后需要冷藏以免细菌数增加
5.    Examples of abnormalities found include crytalluria (possible uroliths) and glucose positive (diabetes; often responsible for recurrent infections).异常的例子包括结晶尿(可能为尿结石)及葡萄糖阳性(糖尿病；经常是重复感染的结果)

•    Urethral Catheterisation导尿管导尿
1.    Recommended if concerned there is urethral obstruction or want to take a urine sample by this method.建议采用在有尿道阻塞的情况
2.    Can be performed conscious in male dogs but usually under sedation or general anaesthesia for females.可在清醒的公犬施行，在母犬通常都需要镇静或全身麻醉
3.    Often a good idea to cystocentise the bladder first to remove the back pressure if urethral obstruction suspected (see later).当怀疑有尿道阻塞时，先施行膀胱穿刺采尿可以减低膀胱之压力


•    Radiology放射线学
1.    When x-raying the bladder the recommended position is in lateral recumbancy with the hind legs pulled back or forward to avoid superimposition especially if the animal is conscious.当要照膀胱X光时，建议采侧卧保定，两只后腿要往后或往前拉以免位置重迭，尤其是动物是在清醒的状态下
2.    If the rectum is full of faeces an enema may help improve visualisation.如果直肠内充满粪便时，灌肠可让视野增加
3.    When looking for bladder stones always include the kidney as there could be renal uroliths too.在查看膀胱结石时，要把肾脏也包括在内，因为也有肾脏结石的可能
4.    Plain technique: useful to check settings; reveal radiopaque uroliths either in the bladder or urethra; an enlarged prostate or emphysematous cystitis.单纯技术：方便检查拍摄条件；显示在膀胱或尿道中辐射透不过的尿结石；增大的前列腺或气肿性膀胱炎
5.    Contrast techniques (sedation or general anaesthetic is recommended).对比技术（建议要镇静或全麻）
a)    Pneumocystogram: catheterise and completely drain the bladder of urine. Inject air slowly using a syringe and 3-way tap. Palpate the abdomen whilst doing this to avoid over stretching/ inflation (it is possible to rupture the bladder using this technique). Amount of air injected depends on size varying from 20-40cc for a cat up to 250ml for a large dog. Very useful to show uroliths and helps to outline the bladder lining.膀胱充气造影照片：以导尿方式把膀胱内的尿完全抽掉。使用一个针筒与三通管缓慢地注入空气。同时要触诊腹腔以免过度伸展／充气（此方法有令膀胱破裂的可能）。注入空气的量视乎体形大小，猫大约在20至40毫升之间，犬最多至250毫升。可令结石及膀胱的轮廓显现。
b)    Double Contrast Pneumocystogram: proceed as above but instead of air inject a small amount (2-20ml) of dilute, water soluble contrast medium 150-200mg/ml iodine e.g. Iopamidol “Iopamiro” 300mg/ml diluted 1:1 with sterile water or saline. Massage the bladder and then inject air slowly as per pneumocystogram. This technique is very good for outlining mucosal detail e.g. polyps and transitional cell carcinomas and can also outline radiolucent stones e.g. cystine uroliths.双重对比膀胱充气造影照片：步骤如前，只是注入少量(2-20毫升)已稀释及水溶性碘(150-200mg/ml)之显影剂，例如：碘帕醇Iopamido l“Iopamiro” 300mg/ml以无菌水或生理盐水稀释１比１。按摩膀胱然后像膀胱充气造影般缓慢注入空气。此方法可使粘膜的细节轮廓显现，例如移行细胞癌；而且可使射线可透的结石呈现，例如胱胺酸结石。

•    Ultrasonography超声波检查法
1.    Advantages over radiology is this technique is non-invasive and does not require a general anaesthetic or sedation.此法相对于放射学检查的优点是非侵入性而且不需要镇静或全身麻醉
2.    It can often be used in combination with radiography (the two can complement each other).经常与放射学检查同用(两者可互补)
3.    Ideally use a 5MHz transducer (as bladder/ kidneys are superficial in the body) with a sector rather than a linear scanner. 最好使用5MHz探头(因为膀胱/肾脏位于身体的浅层)，而扇形比线性探头为佳
4.    Clip hair, remove debris from the site and apply ultrasound gel. 剃毛，清洁皮肤表面，涂上传导凝胶
5.    As with radiographs when looking for bladder stones check the kidneys too. 与X-光检查同理，在扫描膀胱结石时，顺便检查肾脏

Biopsy活组织检验
1.    Of suspected lesions; usually performed at exploratory laparotomy but can be done by ultrasound guided fine needle aspirate. 对于怀疑之病灶，多采取开腹探查取样，但亦可在超音波诱导下进行细针穿刺
2.    The latter technique requires an experienced operator and care needs to be taken otherwise it is possible to seed neoplastic cells into the abdomen e.g. with transitional cell carcinoma of the bladder trigone. 后者需要有经验之操作者和非常小心，不然可致肿瘤细胞散落腹腔中，如膀胱三角区移行细胞瘤之取样便有机会发生此情况


Selected Cases病例

We will now look at some of the common presentations in more detail.我们现在来详细的看看几个典型的病例

I. Bacterial Cystitis细菌性膀胱炎

•    Work up to include urine analysis; microscopy plus culture and sensitivity (C&S) 检查包含尿液之分析 ; 显微镜检尿渣及细菌培养和抗生素敏感试验(C&S).
•    Do not start on antibiotics until a urine sample for C&S has been taken as it will affect the results. 在尿液样本做C&S检测前不宜先投予抗生素之治疗 , 以免影响检测结果
•    Once taken whilst waiting for results a sensible antibiotic effective against “known common pathogens” should be started e.g. clavulanate/amoxycillin “Clavulox”/”Synulox” at 12.5-25mg/kg per os twice daily. 在等待C&S检测结果之时 , 可以开始投予广效性的(对一般病原菌)抗生素 , 如:clavulonate/Amoxicillin (Clavulox / Synulox) , 以12.5mg/kg一天两次投予.
•    Antibiotics should be given for at least 14-21 days and it is very important to make sure the owner completes the course. 抗生素的投予最少要给予14~21天的疗程 , 并要确保畜主能依时依量的投予
•    Ideally a C&S should be repeated 4 days after completion of antibiotics to confirm the infection has been eliminated. 最理想的做法 , 当是在动物完成疗程后的4天 , 再做C&S检测 , 以确保病原已完全清除
•    In some cases anti-inflammatories e.g. non-steroidals can be given for the first few days to improve patient comfort: 在一些病畜中 , 尚须投予一些抗炎症性药物 , 如:非固醇类的抗炎症药物 , 在治疗头几天就可投予 , 以减少病畜之痛苦
a)    Carprofen “Rimadyl” dogs at 4mg/kg as a loading dose followed by 2mg/kg per os twice daily thereafter. 卡洛芬 / 卡布洛芬 第一次剂量犬可投予4mg/kg , 之后为2mg/kg , 一天两次的投予
b)    Meloxicam “Metacam” dogs at 0.2mg/kg once only for one day then 0.1mg/kg per os thereafter and cats at 0.3mg/kg once only for one day then 0.1mg/kg for 4 days then one drop/day/cat thereafter. 美洛昔康“metacam”犬为第一天0.2mg/kg一天一次 , 之后为0.1mg/kg ; 猫0.1mg/kg一天一次共4天 , 之后则为一天一滴
c)    Both the above should be given with food to avoid gastro-intestinal side effects. Also special care should be given in cats with Meloxicam especially if kidney disease is a concern. 以上的两种药物投予时必须与食粮混合给予 , 以免引起胃肠道之副作用 , 另(美洛昔康)之药物在投予给猫只时 , 如已有肾脏之问题时 , 则应份外留意
•    In the case of recurrent bacterial cystitis look for underlying disorders such as diabetes, uroliths, tumours and Cushing’s Disease. 在一些反复性发生细菌性膀胱炎化病畜 , 则应考虑该病患尚存在一些潜在性的疾病 , 如:糖尿病 , 尿结可 , 肿瘤或库兴氏病

II. Bladder Uroliths膀胱结石

•    Diagnosis is by palpation, radiology or ultrasound (as previously mentioned always check the kidneys for uroliths). 诊断之方法有: 触诊 , 放射线或超声波(跟前章提及的一样 , 在检查时一定也要同时查看肾脏是否也有结石的生成)
•    Urine analysis might be helpful to determine the type of urolith and treatment considered e.g. struvite (magnesium ammonium phosphate or triple phosphate) crystalluria would suggest struvite uroliths. In this case it might be possible to dissolve the stones with a prescription diet such a Royal Canin Urinary Support (dry or canned). It is preferable to repeat the radiographs in 6-8 weeks to check the diet is working. Warn the owner during this time blockage could occur as the stones decrease in size and may lodge in the urethra especially true in male dogs尿液的分析可能有助于检测出尿石的种类及治疗的方向考量 . 如:鸟粪石(镁, 铵, 磷或三重磷酸盐)尿结晶，可能是为此类结石 ，因此便可建议食用署方性饲料，像法国皇家泌尿系统专用食品的干粮或罐头来解决这类结石问题，并在喂食后之6~8星期后，再做放射线之诊断，来评估此食粮之工效，同时并须提醒畜主要注意，因此食粮会使结石慢慢溶解，而使膀胱中之结石体积变小，而流入尿道中，引起结石性尿道阻塞，尤其对于雄犬而言.
•    In cases where it is not possible to dissolve the bladder stones it is necessary to perform a cystotomy e.g. calcium oxalate uroliths. 对于一些无法用食粮性方法溶解之膀胱结石，则须要以膀胱切开术，将之待移除，如:草酸钙类结石.


Cystotomy膀胱切开术

•    The animal should be placed in dorsal recumbancy; the surgical site prepared aseptically (including the prepuce/penis in male dogs). 病畜须采取仰躺姿势 , 术部须完全清洗消毒(雄犬更包含包皮阴茎)
•    A sterile urethral catheter should be placed and urine removed from the bladder. 插入无菌导尿管 , 排除膀胱中之尿液
•    A ventral midline coeliotomy from umbilicus to pubis is performed. 切开部位由腹部之脐部至耻骨位 , 延腹中线切开
•    The bladder is isolated using laparotomy pads and stay sutures. 取出膀胱 , 以腹部手术复垫隔离腹部其它脏器 , 并以缝线回固定膀胱
•    The bladder is opened by a ventral cystotomy incision; care being taken to place the incision away from the urethra and large blood vessels in the wall. 以膀胱之腹侧作为切开点 , 切开时应避免伤及尿道及避开膀胱壁之粗大血管
•    The bladder is flushed with sterile, warm saline to remove the uroliths (if possible count the numbers of stones and compare to the x-ray). 膀胱应以无菌温热之生理盐水冲洗 , 并移除其中之结石(尽可能的把取出之结石数与放射线片中所照之结石数作一比对 , 以确保所有结石之移除
•    Send the uroliths for analysis and C&S (+/- a sample of bladder wall mucosa for C&S too). 取出之结石应送往分析及作C&S之检测(+/-膀胱壁黏膜样本亦应同时作C&S检测)
•    Remove the catheter 0.5cm at a time whilst flushing to ensure all stones have been removed. 把导尿管从膀胱中移除0.5公分 , 退入尿道中 , 再做膀胱冲洗 , 以确保所有结石之移除
•    The bladder wall should be sutured with either a double-layer appositional technique (first layer simple interrupted followed by a continuous layer or visa versa) or single layer appositional technique (simple interrupted or continuous) using absorbable suture material e.g. polyglyconate “Maxon”, polyglactin “Vicryl”, lactomer “Polysorb” or polydioxanone “PDS” with a swaged on round bodied needle. Please be careful in alkaline infected urine as this can increase the degradation of the suture material. 膀胱壁之缝合一般采用双层反向技术(第一层采用简单间断缝合 , 之后采用简单连续缝合 , 反之亦可)或是单层反向技术(采用简单间断或简单连续缝合) , 以可吸收缝线作为缝合材质 . 如聚葡糖酸酯类 Maxon ; Polyglactin “Vicryl” ; Lactomer “Polysorb” 或polydioxanone “PDS” 配以圆形弯针作为缝合 , 特别注意比类缝线不可碰触碱性尿液 . 因此类材质会被降解
•    Try to avoid intraluminal penetration (this is especially common in thin walled bladders although the use of absorbable suture material (unlike non-absorbable) is not associated with increased urolith formation. 缝合膀胱壁时应避免针线穿透膀胱壁 , 尤其在一些比较薄的部位更应小心 . 虽然可吸收材质之缝线(不像非吸收缝线)    不会增加形成结石的风险 , 但亦不被允许穿透膀胱壁
•    After suturing the bladder wall should be tested for patency by placing 30-40 cc of sterile saline into the bladder and check for leaks. 膀胱缝合后 , 尚须注入30~40亳升无菌生理盐水 , 以作膀胱渗漏测试
•    Post operative radiographs should be performed to ensure there are no uroliths remaining in the bladder or urethra. 术后 , 须再照一张放射线照片 , 以判定再无任何结石存在于膀胱或尿道中
•    The patient should be kept in hospital overnight for pain control, intravenous fluids and observation for urination. 病畜完成手术后 , 尚须留医过夜 , 以做静脉输液 , 尿量监测及术后之疼痛处理
•    Post operative pain control is essential for a quick return to normal function examples include: 术后之疼痛处理是必须的 , 使病畜之生理状况尽快回复到正常状态 , 疼痛控制的药物有
a)    Morphine: Dogs 0.25-2mg/kg intravenously, intramuscularly or subcutaneously repeated every 4-6 hours as required. Cats 0.1-0.5mg/kg intramuscularly or subcutaneously repeated every 6-8 hours as required. 吗啡类 – 犬0.25亳克/公斤 静脉,肌肉或皮下注射 , 氏必要时可每4~6小时投予一次 , 猫0.1~0.5毫克/公斤以肌肉或皮下注射 , 必要时可每6~8小时投予一次
b)    Buprenorphine “Temgesic”: Dogs and Cats 0.006-0.03mg/kg intravenously, intramuscularly or subcutaneously every 8 hours. Cats can also be given this medication orally. 丁丙诺啡“Temgesic”:犬和猫为0.006~0.03毫克/公斤以静脉,肌肉或皮下每8小时投予一次 , 次药对猫则可以口服之方法投予
c)    Tramadol: Dogs only 2-4mg/kg by intravenous injection twice daily or 1-4mg/kg twice daily orally. Tramadol: 只可用于犬类2~4毫克/公斤每天两次静脉投予 ; 或是以1~4毫克/公斤一天两次口服投予
d)    To go home on oral medications such as Carprofen or Meloxicam as per bacterial cystitis. 病畜回家后尚可以口服性药物作为疼痛之控制 , 如: 卡洛芬或美洛昔康投予剂量与方式和细菌性膀胱炎之投予方法一样
e)    Antibiotics are recommended and should be started at the time of surgery e.g. clavulanate/ amoxycillin 8.5mg/kg by injection subcutaneously followed by 12.5-25mg/kg twice daily orally. The selection may need to be changed based on the results of C&S on the urolith (+/- bladder wall). 抗生素之投予一般建议在手术时就可开始投予 , 如: Clavulox8.5毫克/公斤皮下注射之后则改为12.5~25毫克/公斤一天两次口服式投予 , 抗生素之选择 , 最终将依据结石之C&S检测结果而有所改变 , (+/-膀胱壁黏膜C&S检测)
•    Once the urolith analysis results are known a suitable diet should be selected to help prevent recurrence e.g. Royal Canin Urinary Support canned OR dry food for struvite uroliths plus plenty of water. 当得知分析后之结石可以饲粮来作为预防此类结石之再生成时 , 则应改以此饲料 , 如: 鸟粪石类结石可用法国皇家泌尿系统专用食品的干粮或罐头 , 另加充足水份便可达到目的
•    Underlying causes should also be looked into e.g. hypercalcaemia leading to calcium oxalate stones; hepatic problems with urate stones. 潜在性的原因 , 亦要被注视 , 如: 高血钙症 , 易引发草酸钙结石 ; 肝脏问题则易有胺类结石的发生


III. Urethral Uroliths尿道结石

•    These can cause urinary obstruction usually in male dogs (very rare in females due to the shorter urethral tract). 这些结石会引起尿道的阻塞 , 尤其对雄性的犬只更甚(雌性犬只的发生率则很少 , 这是由于其尿道较短的原因 )
•    The site of obstruction should be identified by attempted catheterization and radiology. 结石阻塞的部位通常可在插入导尿管时和放射线照片中发现
•    An attempt should be made to urohydropulse the stones back into the bladder so a cystotomy can be performed (best to wait 1-2 days if possible after urohydropulsion to allow the bladder wall to recover; a good idea to place a foley catheter in place during this time). 发现结石后 , 可用尿道水压脉冲法 , 把尿道中的结石冲回膀胱中 , 之后便可用膀胱切开术 , 取出所有结石 . (如果可以的话 , 在做完尿道水压脉冲法后的1~2天再做手术 , 如此可让膀胱壁得到休养的机会 ; 一个很好的建议则是在术前保留导尿管于尿道中 ,  以防尿道被再阻塞.)
•    Prior to urohydropulsion it is preferable to perform cystocentesis to reduce the back pressure from the bladder. 在做尿道水压脉冲法时 , 最好之前能以膀胱穿刺法 , 排除膀胱中的尿液 , 以减少对膀胱的压力
•    Urohydropulsion: place a urinary catheter into the urethra distal to the stone and inject saline (or a 1:1 mix of saline and aqueous lubricant) slowly while the urethra is occluded by a finger placed within the rectum (see diagram). Once the urethra is dilated remove the finger (releasing the pressure) thus allowing the stone to be flushed back into the bladder. 尿道水压脉冲法: 置一导尿管于尿道中 , 直通向结石阻塞部 , 此时注入生理盐水(或以生理盐水混合水溶性润滑乳1:1混合) , 慢慢注往阻塞部 , 与此同时以手指伸入直肠压迫尿道(看图) , 当尿道被扩充开时 , 松开手指(释放压力) , 因此阻塞的结石就会顺利的被冲回膀胱中
•    If the stone is unable to be dislodged by the above technique either a urethrotomy or permanent urethrostomy is necessary. The type of procedure depends on the position of the blockage and if the problem is of a recurrent nature. 如果以上的方法依旧无法冲回阻塞的结石时 , 则必须采用尿道切开术或是永久性尿道造口术或在一些反复发生此类阻塞的病畜时亦应采取此类手术.
•    Please note it is always preferable to attempt to flush the stones back into the bladder and perform a cystotomy rather than perform the following procedures due to the risk of urethral stricture formation. 请注意最优先选择的方法为是把阻塞的结石推回入膀胱中 , 再施行膀胱切开术 , 在迫不得已的情况下才会施行尿道切开术 , 因此术会造成尿道狭窄等问题

Urethrotomy (Prescrotal/Male Dogs) 尿道切开术

•    This technique is usually used to remove calculi from the distal penile urethra. 此手术常用于移除阴茎尿道末端之结石
•    The animal should be placed in dorsal recumbancy; the surgical site is prepared aseptically (including the prepuce/penis in male dogs). 病畜须采取仰躺姿势 , 术部须完全清洗消毒(雄犬更包含包皮阴茎)
•    A sterile urethral catheter should be placed in the penile urethra to the point of the blockage. 置入无菌导尿管于阴茎尿道阻塞处
•    A ventral midline incision through skin and subcutaneous tissue is made between the caudal aspect of the os penis and the scrotum. 切开部位于阴茎骨至阴囊间之腹中线 , 切开皮肤,皮下组识就可见中线位置
•    Identify, mobilise and retract the rectractor penis muscle laterally to expose the urethra. 确认可收缩移动性阴茎收缩肌 , 并将之向侧面拨开 , 就可暴露出尿道的位置
•    Using a No. 15 scalpel blade an incision is made into the urethral lumen; fine iris scissors can be used to extend the incision if necessary. 可用15号手术刀片切开尿道至尿道腔内 , 如有须要可用尖细的虹膜剪将切创口扩大
•    Uroliths are removed gently with forceps and the urethra should be flushed with warm saline via the catheter.
•    The opening is usually left to heal by secondary intention over 7-10 days or it can be closed with 4-0 or 5-0 synthetic absorbable suture material with a swaged on round bodied needle e.g. “Vicryl” or “Maxon” followed by routine skin closure. 切创口可在7~10天经第二期愈合 , 或是用4-0~5-0的可吸收材质之缝线(如vicryl 或maxon)配以圆形弯针 ; 作常规性的皮肤缝合
•    Haemorrhage should be expected from the surgical site for 3-5 days post operation particularly during urination or when sexually excited. The owner should be warned regarding the above; it is best to keep the patient in hospital overnight to observe for excessive bleeding and normal urination. 切创口会在预期的术后3~5天内都会有出血的情形 , 尤其是在小便时或正在性兴奋时 , 更易见到出血情形 , 以上情形必须要告知畜主 ; 术后病畜最好是能留医过夜 , 以利观察是否有过度出血或小便正常与否的情况
•    This technique also helps facilitate the flushing of stones back into the bladder especially useful in “traffic jam” presentations. Cystotomy can be performed at the same time or later if the condition of the dog is not stable; the general anaesthetic has already been long or the bladder wall is friable and inflamed. 这种手术有助于促进尿道中结石被回冲于膀胱中 , 特别是在遇到多量结石阻塞于尿道中时 , 此后便可实时进行膀胱切开术或是因应病畜的情况而延后进行手术 , 如因全身性麻醉时间过久或是因膀胱壁过于碎弱和发炎等时
•    Post operative care is as per cystotomy with pain relief, antibiotics and prescription diet etc. 术后所注意事项如膀胱切开术般 , 有疼痛的控制和处理 , 抗生素的投予和署方饲料喂食等等


Urethrostomy (Scrotal/Male Dogs) 尿道造口术(阴囊/公狗)

•    This creates a permanent urethral opening; employed when stones lodged in the os penis can not be dislodged, recurrent obstructive uroliths which can not be managed medically, urethral strictures and severe/ acute penile or urethral trauma (both distal to the site) and penile/ preputial neoplasms which necessitate penile amputation.此法可形成永久尿道造口。适用于处置阻塞于阴茎骨位置，无法取出的尿石、无法以内科处理的再发性尿石阻塞、尿道狭窄、严重/急性阴茎或尿道创伤(创伤远程)及因海绵体/包皮肿瘤需要海绵体切除等状况
•    In intact males castration and scrotal ablation must accompany this procedure.未去势之公畜需同时进行去势及阴囊切除。
•    The animal should be placed in dorsal recumbancy; the surgical site is prepared aseptically (including the prepuce/penis in male dogs).病畜仰卧，消毒术区(包括包皮/阴茎)。
•    A sterile urethral catheter should be placed in the penile urethra to the point of the blockage.放置无菌导尿管，从海绵体部之尿道至阻塞位置。
•    The surgical approach is similar to urethrotomy except the position is more caudal at the castration/scrotal ablation site. The incision in the urethra is from 1-4cm in length (length of incision should be 6-8x the diameter of the urethra).手术程序与尿道切开术相似，但位置较后，于去势/阴囊切除处。尿道切开约1-4公分长(切口之长度为尿道直径之6-8倍)。
•    Uroliths are removed gently with forceps and the urethra should be flushed with warm saline via the catheter.用镊子轻柔地取出尿石，然后用温生理盐水经导尿管冲洗尿道。
•    A permanent opening is created by suturing the urethral mucosa to the skin using 3-0 to 5-0 synthetic absorbable suture material with a swaged on tapercut needle e.g. “Maxon” or “Vicryl” in a simple interrupted pattern beginning at the caudal aspect of the incision. Alternatively a non-absorbable suture material e.g. polypropylene “Prolene” can be used and the sutures removed after 10-14 days.把尿道黏膜和皮肤缝合形成永久造口，利用3-0至5-0、针联机、圆体角针合成可吸收线材如“Maxon” 或 “Vicryl”，以简单间断缝法从切口尾端缝合。另一方法可使用不可吸收线如聚丙烯“Prolene”，10-14天后拆线。
•     Post operative care is as per cystotomy with pain relief, antibiotics and prescription diet etc.术后照顾对照膀胱切开术：止痛药、抗生素、处方饲料等。
•    Complications include并发症包括:
1.    Haemorrhage should be expected from the surgical site for 3-5 up to 10 days post operation particularly during urination or when sexually excited.术后3-5至10天术区会有出血，特别在排尿或受性刺激时。
2.    Leakage of urine subcutaneously causing cellulitis.尿液皮下渗漏导致蜂窝性组织炎。
3.    It was believed that creating a permanent opening at this site increased the risk of ascending bacterial infections although this has not been confirmed by current studies.有传说形成永久造口会增加上行性细菌感染机会，但此说到目前未有研究数据支持。

Others Urethrostomy Sites (Male Dogs)其它尿道造口位置(公狗)

•    Perineal and antepubic urethrostomies are indicated if stricture or irrepairable laceration/ crushing exist proximal to the scrotal urethra.会阴及耻骨前尿道切开适用于阴囊尿道近端之狭窄或无法修补之裂伤/压伤。
•    The principles for the surgery are the same as per scrotal urethrostomy, however, complications are greater.手术原理与阴囊前尿道造口术一样，但并发症较多。
•    Perineal会阴: complications include perfuse haemorrhage, persistent urine scald of the perineum, and an increase risk of urine leaking into the peri-urethral tissue as the urethra is deeper at this point.并发症包括灌流性出血、持续流出之尿液灼伤会阴、由于尿道会较深而增加尿渗漏到尿道周组织的风险。
•    Antepubic耻骨前: this is salvage procedure and is technically difficult because the vascular and nerve supply to the bladder neck must be preserved.此为补救用的手术方法，因为膀胱颈之血液与神经供应必须保存，所以有技术上的困难。

IV. Bladder Neoplasia膀胱肿瘤

•    Is more common in dogs than cats.在狗比猫常见
•    Clinical signs include intermittent haematuria, dysuria, pollakuria, stranguria, painful abdomen and cystitis which resolves on antibiotics and recurs once the course is completed. With advanced malignant neoplasia signs of metastasis could be the presenting signs e.g. respiratory distress with lungs secondaries. 临床症状包括间歇性血尿、排尿困难、频尿、痛性尿淋沥、腹痛及受抗生素控制但停药后立刻再发的膀胱炎。就诊时呈现的症状可能为早期恶性肿瘤之转移症状，例如肿瘤肺部转移造成之呼吸困难。
•    Diagnosis requires a thorough work up including urine analysis (microscopy of sediment after centrifugation or settling can reveal neoplastic cells), double contrast radiography, ultrasonography and biopsy either at exploratory laparotomy or through ultrasound guided fine needle biopsy (care with seeding of tumour into the abdominal cavity).确症需要彻底之检查包括尿检(离心或静置后的尿渣可揭示肿瘤细胞)、双对比造影照相、超音波检查及活组织检查。组织的取得可循开腹探查或超音波导引之细针活组织检查(注意肿瘤组织可能散落腹腔的问题)。
•    Benign growths include polyps, papillomas and leiomyomas and usually have a good prognosis after surgical removal.良性肿瘤包括息肉、乳头状瘤及平滑肌瘤，以上在手术后皆预后良好。
•    Malignant growths frequently metastasize to the sub-lumbar lymph nodes and lungs and can extend locally into the urethra and ureters e.g. transitional cell carcinomas, rhabdomyosarcomas and squamous cell carcinomas. Important to check this on x-ray +/- ultrasound so correct prognosis and treatment options can be given to the client.恶性肿瘤多转移至腰下淋巴结和肺部而且能够从局部蔓延到尿道和输尿管，例如：移行细胞瘤、横纹肌肉瘤、扁平细胞瘤。放射线及超音波检查在确诊及决定治疗方案上非常重要。
•    Transitional cell carcinomas (TCC) are one of the most common (up to 70%) malignant bladder neoplasms in dogs (and cats). Usually occurring in middle aged to old dogs (mean age 10 years), more common in females then males, increased predilection in certain breeds e.g. Terriers, Collies, Shetland Sheepdogs and Beagles. Prolonged cyclophospamide treatment can be a causal agent along with other carcinogens in the urine. Usually found at the bladder neck resulting in dysuria, haematuria and stranguria. Lameness may be associated with hypertrophic osteopathy paraneoplastic syndrome in dogs. Common to get urethral and prostatic involvement through local spread. Due to their position they are not normally resectable and metastasis to other organs e.g. lungs is quite common. Treatment normally involves chemotherapy and treating any clinical signs e.g. bacterial cystitis.移行细胞瘤是于犬(及猫)间最常见(到70%)之恶性膀胱肿瘤。多发于中老年犬(平均年龄10岁)，雌性多于雄性，若干品种好发，例如：梗犬、边境牧羊犬、喜乐蒂牧羊犬和比格犬。长期cyclophospamide之治疗加上其它尿中致癌物质可为成因。肿瘤多长于膀胱颈部引起排尿困难、血尿及痛性尿淋沥。肥大性骨病瘤外综合症(hypertrophic osteopathy paraneoplastic syndrome)于犬可造成跛行。局部蔓延至尿道及前列腺常见。由于位置关系切除不易，会转移到其它器官常见如肺部。治疗多包括化疗及临床症状，例如细菌性膀胱炎之治疗。

Treatment of Transitional Cell Carcinoma (dogs)

•    Any electrolyte or biochemical (e.g. renal) abnormalities should be corrected with fluids.利用点滴修正电解质或生化(例如：肾指数)之异常。
•    Concurrent urinary tract infections are treated with appropriate antibiotics following C&S results.并发之尿道感染先进行抗生素敏性试验，再投予合适之抗生素
•    Treatment can involve chemotherapy +/- surgical excision although the majority of these tumours are found in the bladder trigone area and are technically very difficult if not impossible to resect.治疗包括化疗加减外科切除，不过大部份的膀胱肿瘤皆位于膀胱三角区，手术难度很高。
•    For the purpose of these notes we will concentrate on treating medically.这章讲义会集中于内科疗法。
•    Piroxicam “Feldone” 0.3mg/kg (non-steroidal anti-inflammatory) once daily to once every other day. Often it is better to start with an every other day dosing and increase to once daily if no response. There is a risk of gastrointestinal ulceration particularly at the once daily dosing it is thus recommended to give Misoprostol “Cytotec” at a dose of 1-5 microg/kg per os three times daily to help prevent this common side effect. Response to treatment is usually seen in the first 10 days but can take up to 3 weeks. Piroxicam therapy is usually well tolerated and can give median survival rates of around 190 days in one study (dogs have been reported to survive over 2 years on this therapy and die of non tumour related problems). Piroxicam “Feldone” 0.3毫克/公斤(非类固醇性消炎止痛药) 每天一次至隔天一次。 开始时最好先隔天一次，如反应不佳再增至每天一次。胃肠道溃疡乃常见之副作用，特别在每天一次的投予，建议使用米索前列醇(Misoprostol “Cytotec”) 1-5 微克/公斤每天三次口服作预防。Piroxicam治疗反应多见于首十天内但亦有晚至三星期的情况。Piroxicam治疗通常都有好的耐受性，在一个研究中，中数生存率约为190天(在此研究中接受治疗的有狗只生存时间达二年，而且最后死于与肿瘤无关之疾病。)
•    Radiation therapy has also been used to treat TCC; in this case the bladder can either be exposed surgically and the tumour irradiated directly or through the body wall. It is unclear which procedure works best. Incontinence is a common side effect due to scarring.放射线治疗亦可用于治疗移行细胞瘤。在此情况下可开刀让膀胱肿瘤暴露再直接用放射线照射或者不开刀让放射线穿透体壁照射肿瘤。两种操作何者较优未有定论。治疗后行形成之瘢痕常导致失禁。
•    Other treatments include the following which are all chemotherapeutic agents:上述之外的治疗，包括以下，皆为化疗：
a)    Cisplatin 50mg/m2 intravenously every 4 weeks. Nephrotoxic; so pretreatment diuresis and regular monitoring for azotaemia is necessary. 顺铂(Cisplatin) 50毫克/平方公尺 每四周一次静脉注射。含肾毒性，用药前需作利尿之前置处理及定期监测血尿素氮。
b)    Carboplatin (a Cisplatin analogue with less renal toxicity) at a dose of 300mg/m2 intravenously at 3 week intervals. Response to trials have proved disappointing. 碳铂(Carboplatin，顺铂另一异构物，肾毒性较低) 300毫克/平方公尺每三周一次静脉注射。在一些试验中其反应令人失望
c)    Mitoxantrone 6mg/m2 intravenously every 2-3 weeks for four treatments. This drug can be given in combination with Piroxicam “Feldone” at 0.3mg/kg either once daily or every other day. For many oncologists this is the treatment of choice. 米托葱醌(Mitoxantrone)6毫克/平方公尺每二至三星一次静脉注射共实施四次。此药可与Piroxicam “Feldone”共同使用，剂量为0.3毫克/公斤每天一次至隔天一次，此疗程获众多肿瘤科专家所采用。

Tube Cystotomy管状膀胱切开术

•    If the TCC is diagnosed late in the disease process and the patient is unable to pass urine and it is not possible to place an urethral catheter; a temporary tube cystotomy can be performed to divert urine whilst chemotherapy attempts to reduce tumour size (this technique can also be used for temporary urinary diversion following urethral rupture repair).如移行细胞瘤在末期才诊断出来，而病畜排尿有障碍又不能置放导尿管，可进行临时性之管状膀胱切开术让尿液排出，与此同时使用化疗企图减小肿瘤体积(此技术亦适用于尿道破裂修复后作临时尿液分流。)
•    Requires a DePezzer mushroom tipped or Foley balloon tipped urinary catheter of appropriate size (6-14 French). Remember to check patency of bulb before  placement.使用适当大小(6-14 French)的DePezzer氏蘑菇状头导尿管或Foley 氏带气球之导尿管。在放置前记得要检查管端汽球有否漏气。
•    The animal should be placed in dorsal recumbancy; the surgical site prepared aseptically (including the prepuce/penis in male dogs).病畜仰卧，术区消毒(于公狗需包括包皮及阴茎。)
•    A caudal ventral midline coeliotomy from umbilicus to pubis should be performed. The bladder is examined to ensure adequate blood supply remains.由脐到耻骨之腹中线作腹部切开。检查膀胱确定有足够之血液供应。
•    Stay sutures are placed in the bladder and a suitable area located midway between the trigone and apex on the ventro-lateral bladder wall. A purse string suture of 2-0 or 3-0 synthetic absorbable suture material e.g. “PDS” or “Maxon” is placed at this point.于膀胱三角与顶端中间、腹外侧之膀胱壁上作支座缝合(stay suture)，上述位置使用2-0或3-0合成可吸收线(例如：“PDS” or “Maxon”)作荷包缝法。
•    If a foley catheter is used it is placed through a small stab incision in the body wall approximately 2cm lateral to the ventral midline at a level which will minimally disort bladder position .如置放foley catheter，则于体壁腹中线外侧2公分作一小切口，而切口之的位置应以尽量不使膀胱变形为准。
•    The catheter is then inserted into the bladder lumen through a stab incision in the centre of the purse string suture. The balloon of the catheter is then inflated but kept away from the bladder wall to avoid inadvertent catheter balloon puncture.于刚才作荷包缝法中心之膀胱壁上作一小切口，再经此切口置放导尿管于膀胱内腔。此时将导尿管末端之气球打饱，注意操作要离开膀胱壁，避免打气时不慎气球爆破。
•    Once the catheter is in the bladder the other end of the catheter should be occluded using artery forceps or a bung.当导尿管置放停当后，暴露外面的另一端应以动脉钳或塞子堵好。
•    If a mushroom catheter is used the other end should be fed through the body wall in a similar position as previously described. 如使用蕈头导尿管，出口端则循前述造口位置穿过体壁置放。
•    Four cystopexy sutures using 2-0 to 3-0 “PDS” or “Maxon” are pre-placed in a box configuration around the abdominal and bladder wall incisions. Ideally the pexy sutures should pass through the seromuscular layers of the bladder wall and partial thickness through the body wall. 使用2-0 to 3-0 “PDS” or “Maxon”作四个互相成盒形的膀胱固定缝合于腹壁与膀胱壁切口之四周。固定之缝合最理想为只穿过膀胱浆膜肌膜层及体壁的部份厚度。
•    Sutures are then tied and the catheter tip drawn up to the bladder wall. The tube is secured using either a Chinese Finger trap suture or tape tabs sutured to the skin. Abdominal closure is routine. 缝合系好后导尿管末端会引到膀胱壁。管身利用中式手指网套缝法(Chinese Finger trap suture) 或tape tabs suture固定于皮肤，最后作例行之腹部关闭。
•    Usually the catheter is attached to a closed collection system initially. After a period of a few days, intermittent drainage can be commenced.最初时会把导尿管接到封闭的收集系统，几天后可进行间歇性的排放。

V. Feline Lower Urinary Tract Disease (FLUTD) and Urethral Obstruction in Cats猫下泌尿道症候群(FLUTD)及尿道阻塞

•    Clinical signs include: dysuria (difficult urination), pollakiuria (increased frequency of urination), haematuria, excessive grooming lower abdomen, urethral obstruction and/or periuria (inappropriate urination). 临床症状包括：排尿困难、频尿、血尿、过度整理下腹皮毛、尿道阻塞及/或在不适当地点排尿。
•    Causes of FLUTD or obstruction: 下泌尿道症候群或阻塞之起因
a)    Feline idiopathic cystitis (FIC): most common. Suspected causes are stress; compounds within the urine (acid pH, K+, Mg and Ca+) or defects in the protective glycoSaminoglycans (GAG) layer may result in increased bladder wall permeability allowing noxious substances within the urine to cause inflammation. Infectious agent may be involved.猫不明原因之膀胱炎Feline idiopathic cystitis (FIC): 最普遍。估计起因为压迫；尿液中化合物(偏酸, K+, Mg and Ca+)或葡萄糖胺聚醣[glycoSaminoglycans (GAG)]保护层的损坏，会使膀胱壁透性改变，容许尿中有害物质刺激膀胱发炎。有时会有细菌感染。
b)    Urinary calculi.尿石
c)    Urethral plugs: important because they are associated with urethral obstruction. Composed of a colloid matrix +/- crystalline material (usually struvite). The colloid matrix is believed to leak from the inflammed bladder wall.尿栓子：很重要，因为和阻塞有关，成份为胶体基质+/-结晶(多为鸟粪石)。胶体基质相信是由发炎的膀胱壁溢出。
d)    Others: anatomical defects; behavioural issues; neoplasia.其它：结构缺陷、行为问题、肿瘤。
e)    Infectious causes: bacterial infection is a rare cause of FLUTD. Where it is seen, it is usually iatrogenic, or secondary to urolithiasis, an anatomical defect or neoplasia.感染导致：细菌感染导致的猫下泌尿道症候群非常罕见。一般所见多为不明原因、尿石造成的二次性感染、结构缺陷或肿瘤。
f)    Interacting combinations e.g. bacterial cysititis secondary to neoplasia or uroltihs.互为影响的组合例如肿瘤或尿石造成的二次性细菌性膀胱炎。
•    Work Up & Diagnosis: 检验及诊断：
a)    Age, sex, breed and history: FIC most frequently seen in large male cats, nervous disposition, multi-cat household and dry food. If the cat is <10yrs more likely FIC, if >10yrs more likely infection or neoplasia.年龄、性别、品种及病史：猫不明原因之膀胱炎(FIC)多见于体形大之公猫、神经质、饲养多猫只的家庭和干饲料为主食。病畜<10岁多为FIC，如>10岁多为感染性或肿瘤。
b)    Physical examination: Determine if bladder large or small; if large it is an indication for urethral obstruction. In all cases, the caudal abdomen is likely to be painful and in male cats the prepuce and penis are often swollen. Cardiac irregularity may indicate severe hyperkalaemia. 身体检查：膀胱大小，大的话显示尿道阻塞。几乎所有病畜的后腹部都会疼痛，公猫则包皮及阴茎肿胀。不规则心跳可能表示有严重之高血钾症。
c)    Serum biochemistry and haematology: unremarkable unless urethral obstruction (high BUN, creatinine, phosphorous, and potassium). Some cases of severe and chronic haematuria may develop blood loss anaemia.血液生化及血液学：无特异性除非有尿道阻塞(血尿素氮、血肌酸酐、血鏻及血钾升高)。在长期严重血尿的病例会发展失血性贫血。
d)    Urinalysis: best method is via cystocentesis but care with fractious cats. Should be examined within 2 hours as crystals precipitate at room temperature. Specific gravity, pH (stress can cause an alkaline urine), urine sediment assessment, C&S if taken by cystocentesis. Urine from cat with FIC is typically concentrated and is of acid pH, haematuria and proteinuria but without bacteriuria.尿检：膀胱穿刺为最佳方法但遇到恶猫时操作要小心。为避免在室温下形成结晶，尿液应于收集后2小时内进行检验。尿比重、酸碱度(压迫会使尿变碱)、尿渣评估、培养及抗生素敏感性试验(如使用膀胱穿刺)。FIC之病畜典型之尿液为浓缩, 偏酸、血尿及蛋白尿却无菌。
e)    Survey abdominal radiographs: to rule out radiopaque calculi. Struvite uroliths should be treated by dietary means, oxalate uroliths need to be surgically removed as previously mentioned.探查性腹部X光：排除X光阳性结石的存在。鸟粪石尿石应以食疗治疗，草酸盐尿石如前述需要开刀取出。
f)    Further diagnostic imaging: including radiographic contrast studies and abdominal ultrasonography as previously described.进一步之影像检查：如前所述，包括contrast studies及腹部超音波。
•    Treatment: where a specific cause can be identified then its treatment can be undertaken. Where no underlying cause can be identified then the cat should be managed as for FIC.治疗： 查明病因再治疗。如无法查明病因时应当成FIC处理。
•    Urethral plugs: initially, the urethra must be unblocked. In the long term treatment may be aimed at reducing the protein matrix and the crystals. The first line of treatment is therefore to change their diet to wet food. Where significant crystalluria persists, the nature of the crystals should be assessed and an appropriate prescription diet can be fed (preferably the wet form) e.g. RC Urinary Support canned. 尿栓子：急性期时, 要把尿道先疏通。长期的治疗目标为减少蛋白基质及结晶。第一线的治疗先把饲料由干转湿。如果尿中长期有明显的结晶，要评定结晶的性质再喂饲适当的处方饲料，例如：法国皇家的Urinary Support罐头。
•    Bladder stones: struvite stones may dissolve with dietary manipulation but oxalate stones need to be surgically removed unless they are small enough to be expelled. 膀胱结石：饍食控制可能会把鸟粪石溶解，但草酸盐结石则需要开刀取出，除非是细小到可以随尿排出。
•    Neoplasia (as previously described). 肿瘤(如前述)
•    Urethral spasm: since both smooth and skeletal muscle fibres are responsible for generating urethral tone, it may be beneficial to give drugs to counter both of these effects. Injectable drugs e.g. Acepromazine “ACP” 0.05 – 0.2mg/kg intravenously, intramuscularly, subcutaneously or 1-3mg/kg per os may be given at the time of relieving the obstruction. Followed by a 7-14 day course of Prazosin 0.25-1.0 mg/cat per os every 8-12 hours and Dantrolene “Dantrium” 0.5 – 2.0 mg/kg per os every 12 hours. These two drugs can be given together, and longer or intermittent courses may be required in some cats. It is best to wean them off the drugs over a few days rather than stopping them suddenly.尿道痉挛：平滑肌和骨骼肌皆负责产生尿道收缩力量, 以药物来抗衡两者的效应可能会有所得益。针剂，例如乙酰丙嗪(Acepromazine) “ACP”0.05-0.2毫克/公斤 静脉/肌肉/皮下注射或1-3毫克/公斤 口服，以上可在疏通阻塞时使用。期后7-14日可使用Prazosin0.25-1.0毫克/猫 每8-12小时口服及Dantrolene “Dantrum”0.5-2.0毫克/公斤 每12小时口服。以上两种药物可同时使用，有些病畜需要使用更长的时间或间断使用。需要停药时请以数天时间慢慢而减量避免突然停用。
•    Smooth muscle anti-spasmodics include: Acepromazine “ACP”, Prazosin and Phenoxybenzamine “Dibenylin”.平滑肌镇痉剂包括：Acepeomazin Prazosin and Phenoxybenzamine
•    Skeletal muscle anti-spasmodics include: Dantrolene “Dantrium”.骨骼肌镇痉剂包括：Dantrolene “Dantrium”
•    Feline Idiopathic Cystitis: although most cases are self-limiting, treatment is recommended as it is painful, distressing to cat and owner, there is a risk of urethral obstruction, and cats may become anorexic and/or develop behavioural changes. All treatments should be considered with appropriate caution as most are based on clinical observations and personal opinion.  Therapy includes: reducing stress, creating more dilute urine (wet diet and free access to water) and medications.猫不明原因之膀胱炎：虽然大部份病例会自愈，如果有疼痛、不安(病畜及畜主)、有阻塞的危机、病畜厌食或/及有行为改变，则建议治疗。治疗基于临床观察及个人见解。治疗如下：减低紧迫、使尿稀释(湿饲料和供应足够清水)及药物。
•    Medical management:内科处理
a)    GAG supplements: there is a lack of controlled studies in cats, but they have proved to be beneficial in humans. Examples includes N-Acetyl Glucosamine “Cystaid” 125mg/cat per os once daily and Pentosan Polysulphate “Cartrophen” 3mg/kg subcutaneously on day 1, 2, 5 and 10 and then every 5-10 days.葡萄糖胺聚糖补充剂：缺乏用于猫的对照研究，可是在人类的使证实有效。例子包括乙基葡萄糖胺(N-Acetyl Glucosamine “Cystaid”) 125毫克/猫 每天一次口服及Pentosan Polysulphate “Cartrophen”3毫克/公斤 于第1、2、5和10日然后每5到10日。
b)    Tricyclic antidepressants: both behavioural and organic effects. They have anticholinergic, anti-inflammatory, anti-alpha-adrenergic, analgesic and antidepressant effects. They are usually reserved for cats with very severe or chronic disease and should be used with caution. Amitriptyline hydrogen chloride 2.5-5mg/cat once daily in the evening; adjust dosage to achieve a mild “calming effect” usually 2.5-12.5 mg/day. Side effects include somnolence, urinary retention and elevation in liver enzymes. As such liver function should be assessed prior to starting therapy, reassess one month later and then every 6-12mnths while the cat is on treatment. Short-term treatment doesn’t appear to be effective. Long-term therapy with environmental adjustment recommended.三环抗抑郁剂：行为上及有机作用。此类药物有抗胆碱、消炎、抗α肾上腺素、止痛及抗抑郁等效果。多用于严重或慢性之病例，使用上要非常小心。阿米替林(氯化氢)(Amitriptyline hydrogen chloride)2.5-5毫克/猫每晚一次；调整至 “镇静效果”的剂量通常为每日2.5-12.5毫克。副作用包括嗜睡、尿滞留和肝指数上升 。所以在开始用药前应先评估肝功能，治疗期间于一个月及每6-12个月再评估。短期使用效个不显著。长期时用时建议配合环境改造。
c)    Analgesics and anti-inflammatories may reduce the severity of the clinical signs but is rarely sufficient. Butorphanol injection or tablets or Fentanyl patches may have some beneficial effect. For acute irritant signs Piroxicam “Feldene” 0.3ml/kg per os every 2 days or Butorphanol “Torbutrol” 1-1.25mg every 6-12 hours.止痛及消炎或可改善临床症状但通常作用不大。针剂或口服布托啡诺(Butorphanol)或芬太尼(Fentanyl)贴布或有改善的效果。急性炎症症状时可使用??罗昔康(Piroxicam “Feldene”) 0.3毫升/公斤口服每2天 一次or 布托啡诺(Butorphanol “Torbutrol”) 1-1.25毫克每 6-12 小时一次。

Urethral Obstruction in Cats (“Blocked Cat”)猫的尿道阻塞

•    The clinical signs can often be missed by the owner until the cat becomes critical especially in a multi-cat household; it can also be confused with constipation.饲主常常忽略临床症状直到非常危及时才发现，特别是饲养多只猫的家庭；而且会常常和便秘混淆。
•    This is an emergency situation and the following is a protocol commonly adopted.这是急症，以下为一般沿用之处理程序。
•    The patient should have a full physical exam to include all major body systems.先为病畜作一包括各重要系统、详细之身体检查。
•    An emergency blood database should be taken to include PCV/ total protein/ BUN/ creatinine/ blood glucose/ electrolytes and ideally a full biochemistry.急症血液数据应包括：血细胞压积/总蛋白质/血尿素氮/肌酸酐/血糖/电解质，如可能的话全血液生化更为理想。
•    If the bladder is large, decompressive cystocentesis should be performed to prevent rupture.如果膀胱非常涨满，应先用膀胱穿刺术把尿先抽出避免膀胱涨破。
•    Always stabilise the patient’s cardiovascular signs before anaesthesia and unblocking. 应先稳定病畜之心血管症状，才进行麻醉和导尿
a)    Fluid therapy (up to 40-60ml/kg/hr). 输液(最多40-60毫升/公斤/小时)
b)    Treat any hyperkalaemia with calcium gluconate 10% solution 0.5- 1.5 ml/kg @ 1 ml/minute intravenously. 使用10%葡萄糖酸钙溶液治疗高钾血症( 0.5-1.5毫升/公斤，速度为1毫升/分钟 静脉输液)
•    Under general anaesthetic (preferred) or sedation relieve the obstruction. A safe anaesthetic/ sedation would be diazepam “Valium” 5mg/ml at 0.5mg/kg and ketamine 100mg/ml at 2.2-4.4mg/kg intravenously. DO NOT USE DOMESEDAN “DOMITOR” due its severe hypotensive properties.在全身麻醉(最理想)或镇静的状态下解除阻塞。安全的麻醉/镇静应使用 “安定” (diazepam “Valium”) 5毫克/毫升 于0.5毫克/公斤和氯胺酮(ketamine) 100毫克/毫升于2.2-4.4毫克/公斤作静脉注射。 「不能使用DOMESEDAN “DOMITOR”」，因此药会造成严重之低血压。
•    Palpate the penile urethra to the pelvic brim and attempt to manually break up any obstruction. If the penis is cyanotic, palpate for intrapenile obstruction.从阴茎海绵体到骨盆边沿，一边触诊，一边尝试弄散尿道中的阻塞物。如果阴茎发绀，则触诊是否海绵体内阻塞。
•    Use a non-traumatic, ideally open-ended, urethral catheter e.g. “Slippery Sam” and lubricate well. Pass the urinary catheter into tip of penis for 2-4 mm; gently twist and advance catheter; inject 0.5 ml Lignocaine 2% while advancing and withdrawing. Attach a syringe with isotonic flush (warm saline) NEVER use Walpole’s solution. Administer short, sharp flushes whilst twisting and advancing catheter.使用非创伤性，最好末端开口的导尿管(例如：“Slippery Sam”)加上润滑剂。先把导尿管尖端探入阴茎2-4毫米；轻轻地旋转导尿管及前进；在前进及抽出时均注入0.5毫升2%利多卡因。管尾接上一针筒的等张冲洗液(温生理食盐水)，千万不要使用Walpole’s solution。在导尿管旋转前进时要同时用短促有劲的节奏去冲洗。
•    Once the urethral obstruction has been relieved fully empty the bladder and flush with warm saline repeatedly until the urine is as clear as possible. Massage the bladder while flushing to evacuate as much sediment as possible. Suture the catheter in place and attach to intravenous tubing and an empty fluid bag (sterile closed-collection system). Ideally tape/secure intravenous tubing to tail. A buster collar should be applied to prevent catheter removal. Leave the urinary catheter in place for 1-2 days until the urine is clear.在疏通阻碍及排空膀胱后，要使用温生理食盐水重复冲洗膀胱直至尿液越澄清越佳。冲洗时按摩膀胱使当中沉积物尽量排出。缝合固定导尿管，再在末端接上用完的空点滴管和点滴包(无菌密闭型收集系统)。可用胶带把点滴管固定在尾部。戴上伊利莎白项圈防止病畜弄出导尿管。导管放置1到2天直至尿液清澈。
•    A lateral abdominal radiograph should be taken to check for uroliths. 拍一片侧躺腹部X光片确定有否尿石。
•    Further treatment and monitoring should include: 后续治疗及监测包括
a)    Fluid therapy initially 5-10 ml/kg/hr if euvolaemic and no contraindications then modify on the basis of urine output, PCV, total protein, electrolytes and hydration status. 点滴起始速度5-10毫升/公斤/小时???再根据排尿量、血细胞压积、总蛋白、电解质及脱水度再作调整。
b)    Monitor electrolytes/ renal output and enzymes (BUN/  creatinine and phosphorous). 监测电解质/肾排出量及酵素(血尿素氮/肌酸酐及血鏻)。
c)    Consider the need for analgesia and anti-inflamatories. 考虑是否需要止痛及消炎
d)    Spasmolytics should be used while the catheter is in place and for a further 1-2 weeks there after (see earlier). 置放导尿管时及后1-2周应使用解痉剂 (如前述)。
e)    Only give antibiotics if suspect secondary infection from urine analysis or C&S. 只有在尿检或培养及敏感性试验指出有二次性感染的可能时才需要使用抗生素。

Perineal Urethrostomy in Cats猫之会阴尿道造口术

•    This salvage procedure is indicated in cases of urethral obstruction which can not be relieved with catheterisation, distal urethral stricture secondary to obstruction and where repeat obstructions (in the distal urethra) frequently occur which can not be managed sufficiently medically此操作应用于处理无法利用导尿解决的尿道阻塞、阻塞造成的二次性远程尿道窄狭及内科无法处理的重复性阻塞(尿道远程)。
•    The patient is placed in ventral recumbancy with the perineal region elevated slightly. 病畜俯卧，会阴部略提高。
•    Place a purse string suture in the anus and catheterise the penis if possible.肛门用荷包缝法缝起，阴茎最好放置导尿管。
•    An elliptical incision just dorsum to the scrotum and ventral to the prepuce is made; castration is included in this procedure if not already performed.于阴囊背方及包皮腹侧作一椭圆形切口；如病畜未结扎，将会同时进行去势手术。
•    Allis tissue forceps are placed on the end of the prepuce or around the catheter to help manipulate the penis. 用Allis tissue forceps夹在包皮末端或包住导尿管方便操作阴茎
•    The penis is reflected dorso-laterally and the surrounding loose tissue is sharply dissected on either side. The dissection is extended ventrally and laterally toward the penile attachments of the ischial arch.阴茎翻往背外侧方，先切开两边的疏松组织，再向腹侧及两边外侧延伸到坐骨弓和阴茎间的连接。
•    The penis is elevated dorsally and the ventral penile ligament is severed.阴茎往背侧方提高，把阴茎腹侧韧带切断。
•    The ischiocavernosus and ischiourethralis muscles are transected close to their insertion on the ischium to avoid damaging branches of the pudendal nerve and minimise haemorrhage.在坐骨海绵体肌和坐骨尿道肌靠近坐骨的附着处上作一横切，以避开阴部神经分支和减低出血。
•    The penis is reflected ventrally to expose its dorsal surface. 阴茎翻往腹侧方暴露出背面。
•    The bulbourethral glands are exposed proximal and dorsal to the bulbospongiosus muscle and cranial to the severed ischiocavernosus and ischiourethralis muscles. Excessive dorsal dissection should be avoided to prevent damaging the nerves and vessels supplying the urethral muscle. 此时暴露出的尿道球腺位置在球海绵体肌的近端背面 及已切断的坐骨海绵体肌与坐骨尿道肌的前方。操作时要避免把背面作过多的剥离，不然会伤及尿道肌肉的神经及血管供应。
•    The retractor penis muscle over the urethra is removed and longitudinally incise the urethra using a No. 11 blade or sharp tenotomy scissors. Continue the urethral incision proximally to approximately 1cm beyond the level of the bulbourethral glands. Pass a closed mosquito forcep up the urethra to ensure the urethral width is adequate.移除尿道上的阴茎缩肌，再于尿道上以11号刀片或切肌剪(tenotomy scissors)作一纵向之切口。继续沿此尿道切口住近端切开大概1公分至超过尿道球腺。用一支闭合的止血钳伸入尿道确定足够的宽度。
•    The urethral mucosa is sutured to the skin with simple interrupted sutures using either 4-0 or 5-0 absorbable e.g. Maxon or non-absorbable e.g. “Prolene” sutures on a swaged on tapercut needle.利用4-0或5-0连针、圆体角针(tapercut)的可吸收缝线如Maxon或不可吸收缝线如Prolene，以简单间断缝法把尿道黏膜缝和皮肤作缝合。
•    Suture the proximal 2/3rds of the penile urethra to the skin; amputate the distal end by placing a mattress suture through the skin and penile tissues and severing the penis distal to this ligature. Suture the remaining skin with simple interrupted sutures.把近端2/3的尿道海绵体部缝合到皮肤上，远程的部份切断。切断前用褥式缝合法穿过皮肤和海绵体组织，然后再把缝合远程的部份割断，剩余的皮肤则以简单间断缝法缝合起来。
•    Post operative care: petroleum jelly should be applied to the site twice daily and it is advisable to place a buster collar to prevent self trauma. Paper rather than gravel litter should be used until the wound is healed. The sutures if necessary can be removed after 10-14 days.术后照顾：术区涂抹凡士林每天两次，戴上伊利莎白颈圈防止病畜自残。在伤口康复前要使用纸张代替石灰猫砂。使用不可吸收线者可于10至14后拆线。
•    Complications include: 并发症如下：
o    Urethral sphincter dysfunction (pudendal nerve damage). 尿道括约肌功能障碍 (阴部神经受损)
o    Recurrent bacterial cystitis. 再发性细菌性膀胱炎
o    Leakage of urine subcutaneously. 尿液皮下渗漏
o    Strictures/obstruction in the remaining proximal urethra due to calculi, previous trauma/fibrosis or because the stoma created is too small. 尿石、旧创伤/纤维化或造口太细所导致的剩余近端尿道窄狭/阻塞
o    Rectal prolapse. 脱肛
   

养殖之旅

老兄别为了多发几个贴子，搞些无聊的东西来，没劲。