Methods of urine collection

Objectives of Urine collection:
        To obtain laboratory results that provides prevalence estimate of disease, risk factor for exam components and bone line information on health and nutritional status of the population.
Collection technique of urine:
1.Natural micturation.
2.Manual compression of bladder.
3.Catheterization.
4.cystocentesis.

Micturation

Definition of micturation:
It is a process by which urine is evacuated from urinary bladder.

Mechanism of micturation:
Sympathetic nerve
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Stretching of transitional epithelium
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Urine
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Increase pressure 30mmhg
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Activation of stress recsptors
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Sensory nerve
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Brain
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Parasympathetic motor nerve
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Acetylcholine
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Contraction of bladder muscle
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Relaxation of spincters
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Micturation



Contradiction of normal micturation :
When we have to urinate frequently the condition is called polyuria.When we are up frequently during the night the condition is called nocturnal polyuria or nocturia.
Frequent urination can cause problems at work and socializing.The constant fear of use the bathroom can effect one everyday life and happiness and nocturia can cause many sleepless night.
Nocturia increases risk of death.

Abnormal micturation:
Interruption of afferent nerves:
Tabes dorsali's interruption of dorsal roots - reflex construction of the bladder lost - distended, them and hypotonic  - there are some contraction due to intrinsic response in the muscle.
Interruption of both afferent and efferent:
Tumors - Bladder is flacid and distended - shrunken and pertrophied.

Frequent urination indicates:
     1.Infection in bladder.
      2.Infection in urethra.
      3.Infection in kidney.
      4.Bladder stones.
      5.Diabetes.
      6.Tumor in pelvis.
      7.Bladder cancer.
      8.Sign of stroke.


Manual compression of the urinary bladder:
Introduction:
 Manual compression of the bladder can be used to indicate urination in dogs and cats. Application of steady gentle pressure should result in relaxation of urethral sphincter and flow of urine, provided there is adequate urine in the bladder and patent outflow tract.
Procedure:
1) Identify the bladder in the caudal abdomen by palpation.
2) Apply moderate digital pressure to either side of the bladder as possible with fingers and thumb of one hand on with the fingers of both hands and gradually increase pressure until the urine is voided.
3) Collected the urine in a sterile universal container.
Advantages:
This method is often used in patients unable to urinate such as neurological and spinal patients.
It is a quick and easy method in animals.
Provides method for obtaining urine sample when voluntary micturation has occurred.
The risk of iatrogenic urinary tract infection and iatrogenic trauma is minimal.
Disadvantages:
The urinary bladder may traumatized if excessive digital pressure is used. This is not only detrimental to the patient, the associated hematuria may interfere with interpretation is result.
The urinary bladder may not contain a sufficient volume of urine to facilitate this technique.
Samples are frequently contaminated with cells, bacteria and other debris located in the genital tract or on the skin and hair.
Precautions:
Care must not be taken to avoid the rupturing the thin walled bladder particularly as urethral obstruction may be present in animal that present in stranguria or hematuria.
Try to direct the force towards the of the urinary bladder.
Steady continous pressure should be applied rather than forceful intermittent squeezing motions.
Obtain appropriate information to be sure that complete obstraction of the urethra does not exist.
Note:
 If the animal does not urinate during manual expression be ready to collect a voided sample because many animal in this situation will urinate soon after being returned to their house.





Catheterization

Indication:
Diagnostic catheterization may be indicated to :
Collect bladder urine for analysis or bacterial culture.
Determine the volume of residual urine in patients with suspected neurogenic inconfinence.
For renal functions studies.
Evaluate the lumen for calculi, strictures.
Instill constant media for constant radiography.

Therapeutic catheterization may be indicated to:
Instill the medications into the urinary bladder.
Relieve obstruction to urine flow.
Facilitate the surgical repair of the urethra or surrounding structures.

Types of catheter:
Rigid metal canine female urethral catheter.
Folsy self-retaining catheter with valve.
Canine flexible urethral catheter.
Olive tip human urethral catheter.
Blasucci human urethral catheter with flexible filiform tip.
Blasucci tip human urethral catheter.
Right metal lacrimal cannula.
Silver abscess cannula.
Tomcat catheter.
Open end tomcat catheter.
Intradermic polyethylene tubing with one end flared.

Care of urinary catheter:
Only sterilized catheters that are in excellent condition should be used. Weakened rough external surface should be avoided.
Catheters should be individually packaged prior to use.
Non-sterilized catheter should never be used because they may cause introgenic infection & contaminate the urine.
Catheter must be sterilized by autoclaving and by using
Ethylene oxide (best)
Quaternary ammonium compounds.



Potential complications:
Trauma :
Trauma to the urinary tract avoided by selection of smooth flexible catheters and a good technique.
Haematuria indicates poor equipment or technique’
Trauma leads to bacterial infection that damage the body defensive mechanism.

Infections:
A resident population of bacteria (mainly streptococci & staphylococci) and mycoplasma are normally present in the urethra.
By systemic natural defense mechanisms of kidneys, ureters & urinary bladder prevent the urinary tract infections in normal animal.
Preventable causes of bacterial infections of the urinary bladder associated with catheterization include:
Inadequate cleansing of the peri-urethral tissues.
Use of non-sterilized equipment.
Catheter induced trauma to the mucosa of ureter &   bladder.
When necessary for diagnostic or therapeutic purposes, carefully executed catheterization of the urinary bladder should be performed without hesitation.
Reduce the incidence of introgenic infection by :
Avoiding indiscriminate use of the technique.
Allowing only properly trained personnel to perform the procedure.
Irritation of the bladder with antibacterial solutions (neomycin, furacin, polymyxin etc.

Use of catheters impregnated with antibacterial agents designated for man.



Equipments of catheterization:
Sterile gloves - consider universal precautions
Sterile drapes
Cleansing solution e.g. Savlon
Cotton swabs
Forceps
Sterile water
Foley catheter
Syringe
Lubricant
Collection bag and tubing.



Procedure:
Steps are to…….
Gather equipment.
Open catheterization kit and catheter
Prepare sterile field, apply sterile gloves
Check balloon for patency.
Generously coat the distal portion (2-5 cm) of the catheter with lubricant
Apply sterile drape
If female, separate labia using non-dominant hand. If male, hold the penis with the non-dominant hand. Maintain hand position until preparing to inflate balloon.
Using dominant hand to handle forceps, cleanse peri-urethral mucosa with cleansing solution. Cleanse anterior to posterior, inner to outer, one swipe per swab, discard swab away from sterile field.
Pick up catheter with gloved (and still sterile) dominant hand. Hold end of catheter loosely coiled in palm of dominant hand.
In the male, lift the penis to a position perpendicular to patient's body and apply light upward traction (with non-dominant hand)
Identify the urinary meatus and gently insert until 1 to 2 inches beyond where urine is noted
Inflate balloon, using correct amount of sterile liquid (usually 10 cc but check actual balloon size)
Gently pull catheter until inflation balloon is snug against bladder neck
Connect catheter to drainage system
Secure catheter to abdomen or thigh, without tension on tubing
Place drainage bag below level of bladder
Evaluate catheter function and amount, color, odor, and quality of urine
Remove gloves, dispose of equipment appropriately, wash hands
Document size of catheter inserted, amount of water in balloon, patient's response to procedure, and assessment of urine


Cystosentesis
Cystocentesis:
Cystocentesis is a urinary procedure where a needle is placed into the urinary bladder through the abdomen of a animal and a sample of urine is removed. Diagnostic cystocentesis is used to present sample taken  for urinalysis from being contaminated with bacteria, cells and debris from lower urogenital tract.
Symptoms of cystocentesis:
       ~Duffuculty urinating.
       ~Urinating out of the litter box.
       ~Painfull urination.
      ~Blood in the urine.
      ~Reduced playfulness.
Indication:
~Routine collection of urine samples for urinalysis or urine culture.
~Immediate relief of bladder over distention in animals with urethral obstruction.
Contradiction:
~Coagulopathy.
~Pregnancy.
~Confirmed transitional cell carcinoma.
~Severe and diffuse cutaneous disease of abdomen.
Potential complication
~Seeding of transitional cell carcinoma and tumor cells into the abdomen or along the needle track.
~Transient hematuria.
~Bladder rupture.



EQUIPMENTS:
1) We routinely  use 22-gauge needles. Depending on  the size  of the patient  and the distance  of the ventral bladder  wall  from the  ventral  abdominal wall .1.5 inches hypodermic  or 3 inches  spinal needles  may be needed.
2) Small capacity  (2.5 to 12ml) syringes are usually employed for diagnostic  cystocentesis, while large  capacity(20-60 ml)syringes are used  for therapeutic  cystocentesis . Alternatively, therapeutic  cystocentesis  may be performed  with  6-12 ml syringes  and a  2-way or 3-way valve.
SITE:
1) Careful planning  of the  site and  direction  of  needle  puncture  of  the  bladder   wall is recommended. The needle  is inserted  in the  ventral  or  ventro-lateral  wall of the urinary bladder,in order to minimize the  chance  of  trauma  to  the  ureters  and  major  abdominal  vessels.
2) If therapeutic cystocentesis  is  to be  performed, recommended  insertion  of  the  needle a short  distance  cranial  to  the  of  the bladder with the  urethra rather than at  the  vertex  of  the bladder. This  will  permit  removal  of  urine  and  decompression  of  the  bladder  without  need  for  re-insertion  of  the  needle  into  the  bladder  needle.
3) The  needle  will be  directed  through  the  bladder  wall at  approximately  at  45 degree  angle so that oblique  needle  tract  will  be  created.
TECHNIQUE:
1) In order  to  perform  cystocentesis  without  risk  to  the  patient  deliberate planning  of  the  site  and  direction  of  the  needle  puncture  is  essential.The  bladder  must  contain  a  sufficient  volume  of  urine  to permite  immobilization  and  localization  by  palpation. Excessive   hair should be removed with scissors or clippers. The  ventral  abdominal skin  penetrated  by  the  needle  should  be  cleansed  with  an  antiseptic  solution   each time  cystocentesis  is performed.
2)In case   of cat, it is  usually  easier  to  perform  the  procedure  with  the  patient   in  lateral  or dorsal  recumbency.
3)In dogs, the procedure  may be  performed when  the  patient is  standing.
4)Following  localization  and   immobilization  of  the  urinary  bladder  the  needle  should  ne  inserted  through  the  ventral  abdominal  wall  and  advanced to  the  caudo-ventral aspect  of the  bladder. The needle should  be  inserted  through  the  bladder  wall at an  oblique  angle.
5.excessive digital pressure should not be applied to the bladder wall while the needle is in its lumen in order to prevent urine from being forced around the needle into the peritoneal cavity.
6. An appropriate quantity of urine for analysis of analysis and/or bacterial culture should be aspirated into the syringe. If disease of the bladder wall or virulence of urine pathogens is a likely cause of complications associated with loss of urine into the peritoneal cavity, the bladder should be emptied as completely as is consistent with atraumatic technique. These potenytial complications have not been a problem in patients.
7. Use of a prophylactic antibacterial therapy following cystocentesis must be determined on the basis of the status of the patient and retrospective evaluation of technique.
8. In order to minimize contamination of the peritoneal cavity with urine , unnecessary digital pressure should not be applied to the urinary bladder following cystocentesis.
9. In case of rabbit,
        a) Restrain and position  the rabbit since excellent restraint is critical if the rabbit is conscious. So, have the rabbit restrained in dorsal recumbency.
       b) Locate the bladder by pulpating just cranial to the pelvic brim on the ventral midline.
       c) Assess the bladder volume.
d) Clip the fur.
e) Disinfect the skin.
f) Isolate the bladder.
g) Direct a small needle attached to a syringe into the bladder.
h) Retract the syringe plunger slowly.
i) Transfer the urine sample to an appropriate container.

Precaution:
-In most domestic rabbit there is no need for sedation. However sedation for anaesthesia will prevent the rabbit for struggling and reduce the rise of damage to the internal structures.
- Repeated puncture of the bladder can result in inflammation and subsequent stone formation.
- Precaution should be taken to avoid introgenic trauma/infection of urinary bladder and surrounding.

-potential complications include damage to the bladder wall or adjacent structures with the needle, local or generalized peritonitis, vesicoperitoneal fistulas and adhesion of adjacent structures to the bladder wall.
- penetration of loop of intestine by the needle may result in false positive significant bacteriurea and varying degrees of microscopic hematuria might be expected for a short period of time following cystocentesis.