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Detrusor urethral dyssynergy in dogs:

35 cases (2007 2019)
C. Stilwell1,*, J. Bazelle†, D. Walker‡, G. Stanzani* and J. Florey *

*Dick White Referrals, Cambridge, CB8 0UH, UK

†
Davies Vet Specialists, Hitchin, SG5 3HR, UK
‡
Anderson Moores, Winchester, SO21 2LL, UK
1
Corresponding author email: cecilia.stilwell@dwr.co.uk

Objectives: To evaluate clinical presentation, diagnosis, treatment and outcome of dogs diagnosed with
detrusor urethral dyssynergy.
Materials and Methods: Multicentre (n = 3 UK referral clinics), retrospective, observational study.
Database searches were performed (2007 to 2019) to identify dogs with detrusor urethral dyssynergy.
Dogs with structural abnormalities or detectable neurological disorders affecting micturition were
excluded. Clinical presentation, diagnostic procedures, treatment and outcome were evaluated.
Results: Thirty-five dogs were included. Middle-aged, large-breed, male neutered dogs were most
frequently documented. Four female dogs were included. Fifteen breeds, including Labrador retrievers
(8/35; 22.9%), golden retrievers (5/35;14.3%) and cross-breeds (5/35; 14.3%) were identified.
Median duration of clinical signs was 152 days (range 0 to 1095). All dogs were dysuric at presenta-
tion with 17/35 (48.6%) reported to have an altered stream of urine and 17/35 (48.6%) to be stran-
guric. Follow-up data were available for 34 dogs (median 136 days, range 4 to 2188). Response was
classified as good (20/34; 58.8%), partial (7/34; 20.5%) or poor (7/34; 20.5%). Overall time to
response was known for 21 of 34 dogs (partial n = 6, good n = 15) with a median of 11 days (range 1
to 155). Four dogs had surgical intervention (castration n = 4, cystostomy tube n = 2). Three dogs
were euthanased due to partial (n = 1) or poor (n = 2) response. Medications were discontinued in 11
of 20 (55.0%) dogs with a good response to therapy, two of these relapsed.
Clinical Significance: Detrusor urethral dyssynergy is an uncommon micturition disorder in dogs, in
particular females. Medical therapy with or without surgery resulted in a favourable prognosis in the
majority of dogs, although many require long-term medication.

Journal of Small Animal Practice (2020), 1–10

DOI: 10.1111/jsap.13286
Accepted: 26 November 2020

INTRODUCTION respectively, with subsequent voiding of urine (Wein 1994a, Bar-

Micturition refers to the normal process of passive storage and
active voiding of urine. In the healthy animal, micturition is
controlled primarily by the parasympathetic nervous system.
Impulses are transmitted from the pontine micturition centre
(PMC), along the pelvic nerve, to stimulate contraction of the
detrusor muscle. Before, and during detrusor muscle contrac-
tion, there is inhibition of the hypogastric and pudendal nerves
resulting in relaxation of the urethral smooth and skeletal muscle
santi et al. 1996, Grauer 2009). Disorders of urine voiding can be
due to a mechanical or functional obstruction and typically result
in dysuria and urine retention (Lane 2000).
Detrusor urethral dyssynergy (DUD), also known as reflex
dyssynergia, is a disorder characterised by insufficient relaxation
of the urethral sphincter at the time of detrusor contraction
leading to functional urethral obstruction and urine retention
­(Barsanti et al. 1996, de Groat et al. 2001). Dogs with DUD typ-
ically present with normal initiation of urination which abruptly

Journal of Small Animal Practice • © 2020 British Small Animal Veterinary Association 1
 C. Stilwell et al.
ceases or becomes attenuated (e.g. spurts or dribbles of urine).
These dogs are typically unable to completely void their bladder,
despite continued attempts to urinate (Bartges 2017).
A definitive diagnosis of DUD in humans requires urody-
namic studies, via electromyography, voiding cystourethrography
or urethral pressure profiles (Wein 1994b, Blaivas & Chancellor
1996). Urodynamic procedures such as cystometry and urethral
pressure profilometry are available at some veterinary teaching
hospitals; however, in the majority of cases in veterinary medi-
cine DUD is a diagnosis of exclusion (Barsanti et  al.  1996,
Lane 2000). In clinical practice, a presumptive diagnosis is typi-
cally made by observing the dog urinate with an interrupted pat-
tern, documenting a residual urine volume greater than 0.5 mL/
kg and following the exclusion of detectable causes of urinary
obstruction (Díaz Espiñeira et al. 1998, Lane et al. 2000, Byron
2015). Ultrasonography of the urinary tract is recommended
to assess for evidence of structural bladder abnormalities and
chronic obstructive disease, characterised by ureteral and renal
pelvic dilatation. Additional diagnostic imaging includes contrast
urethrography, and urethrocystoscopy to allow detailed assess-
ment of the urethra (Byron 2015).
In humans, the classically described cause of DUD is neuro-
logic in origin, with the degree of dyssynergia associated with
severity of neuronal damage (Krane & Siroky 1979, Wein 1994a).
Neurologic localisation usually consists of an upper motor neu-
ron lesion occurring between the spinal cord sacral segments and
the PMC (Wein  1994a). A non-neurogenic functional urinary
obstruction has also been reported primarily in male adults and is
frequently associated with prostatic disease (Jorgensen et al. 1982,
Lane 2000). In the veterinary literature, the cause of DUD is often
unknown. Proposed neurological abnormalities include lesions in
the reticulospinal tract, Onuf ’s nucleus (origin of pudendal nerve),
caudal mesenteric ganglion and resultant disruption of inhibi-
tion signals to the pudendal and hypogastric nerves (Lane 2000,
de Groat et al. 2001, Bartges 2017). In previous studies of dogs
with presumed idiopathic DUD, concurrent abnormalities have
included urinary tract infection (UTI), prostatic enlargement, pri-
apism, urolithiasis or recent prostatitis (Díaz Espiñeira et al. 1998,
Lane et al. 2000). Clinical signs have also been reported to worsen
with exercise, increased water intake and sexual excitement (Rosin
& Barsanti 1981, Collins et al. 1986, Díaz Espiñeira et al. 1998).
The largest descriptive study evaluating dogs with DUD was
published over 20 years ago (Díaz Espiñeira et al. 1998). In that
study, DUD primarily affected middle-aged, male entire, large
and giant breed dogs. No female dogs were reported. All dogs
received the α-adrenoreceptor antagonist prazosin and some
also received antimicrobials and/or carbachol. Other veteri-
nary studies have reported the use of alternative α-adrenoceptor
antagonists, such as phenoxybenzamine and terazosin (Barsanti
et  al.  1996, Lane  2000, Haagsman et  al.  2013). Tamsulosin
hydrochloride has been used in humans with prostatic hyperpla-
sia and its use has been suggested for refractory cases of DUD in
dogs; however, clinical efficacy has not yet been evaluated (Lucas
et al. 2005, Hamaide 2014).
The aim of this study was to conduct a retrospective analysis
of dogs diagnosed with DUD within UK referral centres in order
2 Journal of Small Animal Practice
to evaluate signalment, presentation, diagnosis, treatment proto-
cols and outcome.
MATERIALS AND METHODS
The electronic medical records of dogs presenting to three UK
referral centres between October 2007 and January 2019 were
retrospectively reviewed. Due to differences in recording prac-
tices, two strategies were employed to identify dogs diagnosed
with DUD. For referral centre A, eligible dogs were identified by
searching for presenting signs of “dysuria” and “stranguria.” In
contrast, for referral centres B and C, a database search for dogs
with a diagnosis of “DUD” was performed.
A presumptive diagnosis of DUD was made following exclu-
sion of a detectable cause of urinary tract obstruction or disease
on the basis of physical examination, urinalysis, bacterial urine
culture and diagnostic imaging. Diagnostic imaging techniques
deemed appropriate were abdominal ultrasound, contrast ure-
throcystography, computed tomography (CT) of the urogenital
tract or cystoscopy. Dogs were eligible for inclusion provided
imaging techniques allowed for the complete assessment of the
entire lower urinary tract.
UTI was defined as the presence of compatible lower urinary
tract signs (pollakiuria, haematuria, dysuria) with concurrent evi-
dence of bacterial cystitis (pyuria ≥3 white blood cells/hpf and/
or bacteriuria) and a positive bacterial urine culture (Byron 2019,
Weese et al. 2019). Dogs were included in the study if urinary
signs persisted despite resolution of any documented UTI; char-
acterised by absence of bacteriuria and a negative bacterial urine
culture.
Dogs with structural abnormalities, detectable neurological
disorders reported to affect micturition or recent history of uro-
genital surgery were excluded from the study.
In eligible dogs, patient data collected for analysis included
signalment (age, breed, sex and neuter status), presenting
complaint(s), duration of clinical signs, physical examination,
neurological examination, rectal palpation, clinicopathological
abnormalities, imaging findings and comorbidities. In addition,
therapeutic protocol (urinary catheterisation frequency, medica-
tion type, dose, frequency, modifications and duration), response
to treatment, and follow-up were also analysed. Modification to
the treatment protocol was defined as the subsequent introduc-
tion of new therapy (medication(s) or surgical intervention), sub-
stitution of a medication and/or a dosage change.
Presenting complaints were listed according to how they were
recorded in the clinical notes. Dysuria is defined as difficult or
painful urination and frequently incorporates the terms stran-
guria and pollakiuria (Labato  2017). For the purpose of this
study, dysuria was sub-categorised to include stranguria, altered
urine stream (dribble, interrupted, squirts, thin, weak, slow, pro-
longed), pollakiuria, incomplete voiding of urine, urine obstruc-
tion and urine retention.
Cross-breed dogs with an unknown phenotype were catego-
rised according to their weight. Weight was stratified into six
categories, in line with published growth standard charts (Salt
• © 2020 British Small Animal Veterinary Association
 Detrusor urethral dyssynergy in dogs

et al. 2017): I (toy breed <6.5 kg), II (small breed 6.5 to 9 kg), III
(medium breed 9.1 to 15 kg), IV (medium breed 15.1 to <30 kg),
V (large breed 30 to <40 kg) and VI (giant breed >40 kg).
The duration of clinical signs was defined as the interval (days)
between the onset of clinical signs and the first appointment at
the referral centre. To identify abnormalities in clinicopathologi-
cal data, results were compared to the reference intervals pro-
vided by the respective laboratories.
Long-term follow-up information regarding response to ther-
apy, discontinuation of medication, relapse of clinical signs (dur-
ing medical therapy or after discontinuation of therapy) adverse
effects (to medication, surgical intervention), and survival (if
deceased, whether related to DUD or unrelated) were gained
from medical records or telephone/email correspondence with
the referring veterinarian or owner. All cases had signed consent
forms from admission that allowed the use of patient data. Data
were collected and anonymised in accordance with the General
Data Protection Regulation (EU). The follow-up period was
defined as the time from discharge to the animal’s death or the
last point of contact with the client or referring veterinarian.
Response to therapy was evaluated by two authors and was
classified as a good, partial or poor response to medical therapy
based on the last available clinical record. The authors were unan-
imous in their classification of response. A good response was
defined as dogs that demonstrated complete resolution of clinical
signs at the time of last follow-up. Poor response was defined as
dogs with no improvement in their urinary signs with therapy. A
partial response was defined as dogs with improved but incom-
plete resolution of urinary signs at the time of last follow-up.
Relapses and any treatment adverse effects noted by the primary
clinician were also evaluated.
Statistical analysis
Descriptive statistics were used to describe the dog’s characteris-
tics and treatment protocols. Continuous variables were assessed
for normality using histograms and Shapiro–Wilk tests. Para-
metric data are reported as mean (sd) and nonparametric data as
median (range). Categorical variables were expressed as percent-
ages. Data were analysed using commercial statistical software
(IBM SPSS Statistics for Macintosh, Version 26.0).
Demographics
There were 31 male dogs (18 neutered and 13 entire) and four
female dogs (two neutered and two entire). Mean age was 6 years
4  months (±2 years 7  months). Median weight was 37.7  kg
(range 4.4 to 91.0 kg). Fifteen breeds were represented (Table 1)
including Labrador retrievers (8/35; 22.8%), golden retrievers
(5/35;14.3%) and cross-breeds (5/35; 14.3%). One cross-breed
dog was reported to be a Labrador-cross while the phenotype
of the remaining four cross-breed dogs were unknown. Of the
remaining four cross-breed dogs one dog each was categorised as
category I (toy breed), category IV (medium breed), category V
(large breed), category VI (giant breed).
Co-morbidities
One dog had a previous diagnosis of inflammatory bowel dis-
ease; however, it was not reported to be on any medication at the
time urinary signs developed. Two dogs had a previous diagnosis
of prostatitis. The first was diagnosed 1 year before presentation.
Dysuria had persisted despite resolution of the prostatitis (inac-
tive urinary sediment and absence of inflammation or bacteria
on cytology of the prostate) and castration. The second dog
was diagnosed 1 month before referral; however, at the time of
presentation, repeated prostatic wash for cytology and culture
revealed resolution of bacterial prostatitis.
Presenting complaint
The median duration of clinical signs was 152 days (range 0 to
1095 days). Presenting complaints for the 35 dogs are summarised
in Table 2. A median of two presenting complaints (range 1 to
4) were reported for each dog. All 35 dogs were classified as dys-
uric. An altered stream of urine (17/35; 48.6%) and stranguria
(17/35; 48.6%) were the most common presenting complaints.
Physical examination
General physical examination findings were normal for 23 of 35
dogs. Fourteen abnormalities were reported in 12 dogs included:
Excessive body condition (n = 6), large bladder (n = 5), grades I to
II/VI left apical systolic heart murmur (n = 1), urine staining on
the fur of the hind legs (n = 1) and distended abdomen (n = 1).
Neurological examination was specifically recorded for 21 of 35

RESULTS Table 1. Summary of dog breeds documented in study

Breed Number of dogs (%)

Initial database search identified 210 dogs across the three refer- Labrador retriever 8 (22.8)
Cross breed 5 (14.3)
ral centres. Referral centre A identified 180 dogs with a presenting Golden retriever 5 (14.3)
complaint of dysuria (n = 116) or stranguria (n = 64) while referral Boxer 2 (5.7)
centres B (n = 11) and C (n = 19) identified 30 dogs with a diag- Bull mastiff 2 (5.7)
Cocker spaniel 2 (5.7)
nosis of DUD. A total of 173 dogs were excluded from the study. Clumber spaniel 2 (5.7)
Of these, 132 dogs had a detectable neurological or mechanical Newfoundland 2 (5.7)
abnormality that could affect micturition. One dog had a recent English bull terrier 1 (2.7)
Great dane 1 (2.9)
history of trauma to the lower urinary tract; another dog devel- Hungarian wirehaired vizsla 1 (2.9)
oped signs after hemipelvectomy and 39 dogs had incomplete Irish wolfhound 1(2.9)
medical records. A total of 35 dogs with a presumptive diagnosis of Jack Russell terrier 1 (2.9)
Tibetan mastiff 1 (2.9)
DUD were included; 16, 6 and 13 dogs from centres A, B and C,
Weimaraner 1 (2.9)
respectively.

Journal of Small Animal Practice • © 2020 British Small Animal Veterinary Association 3
 C. Stilwell et al.

Table 2. Summary of presenting complaints as recorded in Table 3. Summary of urine biochemical, cytological and
the clinical records bacteriological abnormalities in 25 dogs
Presenting complaint Number of dogs (% total Urinary findings Number of dogs (% total
population) population)
Dysuria 35 (100) Urine dipstick
Sub-categories of dysuria Alkalinuria (pH >7) 7 (20.0)
Altered stream of urine 17 (48.6) Proteinuria 15 (42.9)
Stranguria 17 (48.6) Trace 1 (2.3)
Inability to void urine 3 (8.6) + 8 (22.9)
Pollakiuria 3 (8.6) ++ 3 (8.5)
Urinary obstruction 2 (5.7) +++ 2 (5.7)
Incomplete voiding of urine 1 (2.9) Haematuria/Haemoglobinuria 13 (37.1)
Urine retention 1 (2.9) Trace 1 (2.3)
Complaints in addition to dysuria + 3 (8.5)
Incontinence 6 (17.1) ++ 3 (8.5)
Haematuria 1 (2.9) +++ 3 (8.5)
Intermittent priapism 1 (2.9) ++++ 2 (5.7)
Bilirubinuria 8 (22.9)
Urine sediment examination
Crystals
Bilirubin 2 (5.7)
dogs and was normal in 20 dogs. The dog with an abnormal neu- Struvite 4 (11.4)
Pyuria (≥3 WBC/hpf) 3 (8.6)
rological examination had evidence of mild lumbosacral pain on
Haematuria (>0–2 RBC/hpf) 9 (25.7)
examination with no neurological deficits. No complaint of spi- Bacteriuria 2 (5.7)
nal pain was reported by the owner. Magnetic resonance imaging Positive urine culture 1 (2.3)
revealed a non-compressive L4 to L5 disc extrusion. This find- USG: urine specific gravity, RBC: red blood cell, hpf: high power field, WBC: white blood cell

ing was considered unlikely to be of clinical significance by the

primary clinician. The results of rectal palpation were recorded
in 20 of 35 dogs and palpation was normal in 16 dogs. Prostato-
megaly was documented in four dogs; three male entire and one
male neutered dog.
Clinicopathological data
Haematology and serum biochemistry were reported in 29 of 35
and 31 of 35 dogs, respectively. When compared to the reference
range of each laboratory, the results were within normal limits
in 24 of 29 and 21 of 31 dogs, respectively. Abnormal results are
summarised in Table S1, none of which were considered to be of
clinical significance.
Urinalysis was performed in all dogs. Mean urine specific
gravity was 1.029 (±0.01). Urine biochemical, cytological and
bacteriological results were unremarkable in 12 of 35 dogs.
Proteinuria (15/35; 42.9%) and haematuria/haemoglobinuria
(13/35; 37.1%) were the most common findings identified on
urine dipstick. Haematuria (9/35; 25.7%) was most frequently
identified on urine sediment examination (Table  3). Two dogs
had evidence of bacteriuria. Method of urine collection was not
recorded in either case. One of the two dogs with bacteriuria
also had pyuria and urine culture was positive. The clinical signs
of dysuria persisted in this dog despite resolution of the docu-
mented urinary tract infection on urinalysis and urine culture.
The second dog with bacteriuria (occasional rods) had no evi-
dence of pyuria, urine culture was negative and there was no
improvement in urinary signs following antimicrobial therapy
with amoxicillin clavulanate.
Imaging findings
Imaging modalities performed in the 35 dogs included abdomi-
nal ultrasound (30/35; 85.6%), retrograde contrast urethrocys-
togram (28/35; 80.0%), cystoscopy (12/35; 34.2%) and CT
(3/35; 8.6%, two with intravenous contrast, one without con-
trast) (Table 4). The majority of dogs had two imaging modali-
ties performed (26/35; 74.2%), with ultrasound and retrograde
urethrocystogram (21/35; 60.0%) being the most common com-
bination.
Abnormalities were identified in 30 of 35 dogs. Ultrasound
abnormalities were reported in 21 dogs and included benign
prostatic hyperplasia (n = 7, all male entire), pyelectasia (n = 2),
mild medial iliac lymphadenomegaly (n  =  2), urinary bladder
sediment (n = 1), heterogeneous prostate (n = 1, male neutered
dog with palpable prostatomegaly), adrenal mass (n = 1), renal
cyst (n = 1), renal mineralisation (n = 1), splenic nodule (n = 1),
hyperechoic liver (n = 1), intrapelvic bladder also confirmed on
abdominal radiographs (n = 1), suspected hepatic nodular hyper-
plasia (n = 1) and a fluid distended bladder and urethra (n = 1)
which not identified on subsequent retrograde urethrocysto-
gram. Cystoscopy abnormalities were identified in three dogs and
included mild erythema of the urethra (n = 2) and an incidental,
non-obstructive, vaginal polyp (n = 1). Abnormalities identified
by CT were reported in three dogs and included mild thickening
of the urinary bladder (n = 2) and mild colic lymphadenomegaly
(n  =  1). A caudal position of the bladder neck and narrowing
of the urethra at the pelvic flexure was identified in one dog on
retrograde urethrocystogram. The narrowing was considered a
normal variant and there no abnormalities were identified on
cystoscopy. No other structural abnormalities or filling defects
were identified with this modality.
The male neutered dog with palpable prostatomegaly and a
heterogeneous prostate, identified on ultrasound, had been diag-
nosed with prostatitis and castrated a year prior. On this occa-
sion, the prostate was reportedly reduced in size compared to the
initial ultrasound scan.

4 Journal of Small Animal Practice • © 2020 British Small Animal Veterinary Association
 Detrusor urethral dyssynergy in dogs

Table 4. Summary of diagnostic imaging modalities Table 5. Summary of medications administered to the 35
performed dogs with DUD
Imaging modality n (%) Drug n (% total Dose
population)
One modality 3 (8.7)
AUS 0 (0) Smooth muscle relaxant 33 (94.3)
RET 0 (0) Prazosin 17 (48.6) 0.5–3 mg/dog, PO, q8-12h
CYS 1 (2.7) Phenoxybenzamine 19 (54.2) 0.24–1.8 mg/kg/day, PO,
CT 2 (5.4) divided q8-24h
Two modalities 26 (74.2) Tamsulosin 3 (8.6) 400 mcg/dog, PO, q24h
AUS + RET 21 (60.0) hydrochloride
AUS + CYS 3 (8.6) Skeletal muscle relaxant 17 (48.9)
RET + CYS 1 (2.9) Dantrolene 10 (28.6) 1–2.7 mg/kg/day, PO, divided
CT + CYS 1 (2.9) q8-12h
Three modalities 6 (17.1) Diazepam 8 (22.9) 0.04–0.8 mg/kg/day, PO,
AUS + RET + CYS 6 (17.1) divided q8-12h
AUS Abdominal ultrasound, RET Retrograde urethrocystogram, CYS Cystoscopy.
Parasympathomimetic
Bethanechol 13 (37.1) 2.5–25 mg/dog, PO, q8-24h
NSAID 12 (34.2)
Meloxicam 7 (20.0) 0.1 mg/kg, PO, q24h
Carprofen 2 (5.7) 1–3.2 mg/kg, PO, divided
Treatment q12-24 h
One dog had received an injection of osaterone acetate (Ypo- Robenacoxib 1 (2.9) 1 mg/kg, PO, q24h
zane, Virbac) and marbofloxacin before referral. Medications Prednisolone 1 (2.9) 1 mg/kg, PO, q24h
Chemical castration 5 (14.2)
before referral were unknown in the remaining dogs. All 35
Osaterone acetate 2 (5.7) 0.3 mg/kg, PO, q24h for 7 days
dogs received medical therapy for DUD (Table 5) with a median Delmadinone acetate 3 (8.6) 1 mg/kg, SC, once
of two (range 1 to 7) drugs prescribed for each dog. A smooth PO per os, q Frequency, NSAID Non-steroidal anti-inflammatory, SC Subcutaneous injection.
muscle relaxant, consisting of the α-adrenoreceptor antagonists
prazosin, phenoxybenzamine or tamsulosin hydrochloride, was
and bethanechol. The death was unexpected and the cause
most frequently prescribed (33/35; 94.3%), with only two dogs
unknown. A post-mortem examination was not performed. Four
not receiving this class of drug. A skeletal muscle relaxant (dan-
dogs were managed as day patients and 31 dogs were hospital-
trolene or diazepam), prescribed to nearly half of the dogs (17/35;
ised for a median of 2 days (range 1 to 19 days). Median follow-
48.9%), was the second most common medication.
up was 136 days (range 4 to 2188 days). According to the last
Urinary bladder catheterisation was recorded in a third of
medical record, response to therapy was good, partial and poor
dogs (11/35; 31.4%). Difficulties with catheterisation and resid-
in 20 of 34 (58.8%), 7 of 34 (20.6%) and 7 of 34 (20.6%) dogs,
ual urine volume were not documented in the medical records.
respectively. These three populations are compared in Table  6.
Two dogs that were intermittently catheterised for 1 month and
Overall time to improvement in urinary signs was known for 21
8 months, respectively, had one verified urinary tract infection
of 34 dogs (partial n = 6, good n = 15) with a median of 11 days
(active urinary sediment and positive urine culture), but reports
(range 1–155 days).
of additional UTIs were suggested in the medical records.
Four dogs had surgical intervention. Two dogs were castrated
Good responders
before the introduction of medical therapy; of these, one had
a cystopexy concurrently performed. The remaining two dogs Of the 20 dogs that demonstrated a good response to therapy, 16
were castrated and had a cystostomy tube placed following a poor of 20 (80.0%) dogs responded to medical therapy alone and four
response to initial medical therapy. of four (100.0%) dogs responded to medical and surgical ther-
Eight dogs received antimicrobials consisting of amoxicil- apy. Five dogs (5/20; 25.0%) required urinary catheterisation;
lin clavulanate (n  =  5), cephalexin (n  =  2) and marbofloxacin once before referral (n = 1), intermittently till cystostomy tube
(n = 1). Reported rationale for antibiotic prescription included: placement (n = 2) or placement of an indwelling catheter for 4
prophylaxis following cystoscopy (n  =  2), treatment of UTI and 5 days following the introduction of therapy (n = 2). Medical
(n = 1) and bacteriuria (n = 1). One dog received marbofloxa- therapy included: smooth muscle relaxant (18/20; 90.0%), skel-
cin for previously reported bacterial prostatitis, but antimicrobial etal muscle relaxant (9/20; 45.0%), parasympathomimetic (6/20;
therapy was discontinued once prostatic wash analysis confirmed 30.0%), NSAID (7/20; 35.0%). Six of the eight (75.0%) male
resolution. Indication for antimicrobials in the remaining three entire dogs were castrated as part of the therapeutic protocol.
dogs was unknown. Six dogs had one modification and one dog had two modifica-
tions to the therapeutic protocol before a response to therapy was
Outcome seen. Time to resolution of urinary signs was known for 15 of 20
Overall population dogs with a median of 8.5 days (range 1 to 137). Therapy was
successfully discontinued in 11 of 20 (55.0%) dogs. Time to dis-
Thirty-four dogs were discharged from the hospital. A 4-year-old continuing treatment was known for 9 of 11 dogs with a median
male neutered Jack Russell terrier acutely died in hospital 3 days of 27 days (range 5 to 343). Four dogs demonstrated a relapse,
after the introduction of therapy consisting of p
­ henoxybenzamine two whilst receiving medications and two dogs once medications

Journal of Small Animal Practice • © 2020 British Small Animal Veterinary Association 5
 C. Stilwell et al.

Table 6. Comparison of signalment, treatment and adverse effects amongst dogs that responded to therapy and those
with no response
Variable Good Partial Poor
n 20 7 7
Follow-up (days), median (range) 151 (4–2188) 90 (30–422) 90 (30–1460)
Age (years), mean (sd) 6 .3 (2.7) 6.3 (2.0) 5 .2 (2.7)
Weight (kg), median (range) 40 (18.1–91.0) 34.9 (23–81) 35.2 (4.4–67.8)
Duration of clinical signs (days), median (range) 121 (0–1095) 365 (14–1095) 121 (60–760)
Sex, n (%)
ME 8 (40.0) 2 (28.6) 3 (42.9)
MN 10 (50.0) 4 (57.1) 3 (42.9)
FE 1 (5.0) 1 (14.3) 0
FN 1 (5.0) 0 1 (14.3)
Death due to DUD, n (%) 0 1 (14.2) 2 (28.6)
Treatment
Modifications, median (range) 0 (0–2) 2 (0–3) 1 (0–1)
Urinary catheterisation 5 (25.0) 3 (42.9) 3 (42.9)
Once 1 1 0
Twice 0 2 0
Intermittent 2 0 1
Indwelling 2 0 1
Daily 0 0 1
Monotherapy
Smooth muscle relaxant, n (%) 7 (35.0) 2 (28.6) 3(42.9)
Skeletal muscle relaxant, n (%) 1 (5.0) 0 0
NSAID, n (%) 1 (5.0) 0 0
Combination medical therapy
SM + SK, n (%) 2 (10.0) 0 1(14.3)
SM + PARA, n (%) 2 (10.0) 0 1 (14.3)
SM + PARA + NSAID, n (%) 1(5.0) 1 (14.3) 0
SM + SK + PARA, n (%) 1 (5.0) 1(14.3) 2 (28.6)
SM + SK + NSAID, n (%) 3(15.0) 3 (42.9) 0
SM + SK + PARA + NSAID, n (%) 2(10.0) 0 0
Castration, n (% male entire dogs) 6 (75.0) 1 (50.0) 0 (0.0)
n Number of dogs, ME Male entire, MN Male neutered, FE Female entire, FN female neutered, SM Smooth muscle relaxant, SK Skeletal muscle relaxant, PARA Parasympathomimetic, NSAID
Non-steroidal anti-inflammatory, PBZ Phenoxybenzamine, Praz Prazosin, Tam Tamsulosin hydrochloride.

were discontinued (30 days and 365 days after discontinuation,
respectively).
Partial responders
Of the seven dogs with a partial response to therapy, all dogs
received medical therapy alone. Three dogs (3/7; 42.9%)
required urinary catheterisation; twice following introduction of
medical therapy (n = 2) and once following retrograde urethro-
cystogram (n = 1). In comparison to the good responders, a simi-
lar proportion of partial responders received a smooth muscle
relaxant (7/7; 100%) and skeletal muscle relaxant (4/7; 57.1%).
A parasympathomimetic was prescribed less frequently (2/7;
28.6%) and a greater proportion of dogs received a NSAID (4/7;
57.1%). One of the two male entire dogs (50.0%) was castrated.
Two dogs had no medication modifications, four dogs had two
and one dog had three modifications to the therapeutic proto-
col due to initial lack of improvement in urinary signs. Time to
improvement of urinary signs was known for six of the seven
dogs with a median of 38 days (range 2 to 155). Therapy was dis-
continued in two dogs due to the presence of only mild urinary
signs: however, both dogs experienced significant deterioration
of urinary signs after discontinuation. Two dogs demonstrated
worsening of urinary signs whilst on medication; one dog after
prazosin was discontinued and another when the medications
were unchanged. The latter dog’s signs improved again follow-
ing 48 hours of regular bladder decompression via an indwelling
urinary catheter.
Poor responders
Seven dogs demonstrated no response to medical therapy. Three
dogs (3/7; 42.9%) required urinary catheterisation: indwelling
urinary catheter for 2 weeks (n = 1), intermittently until eutha-
nasia 8  months after diagnosis (n  =  1), daily for 2 years as the
sole means of management (n  =  1). Medical therapy included:
smooth muscle relaxant (7/7; 100.0%), skeletal muscle relax-
ant (3/7; 42.9%), parasympathomimetic (3/7; 42.9%). None of
these dogs received a NSAID and none of the three male entire
dogs were castrated. Five dogs had one modification due to lack
of response to therapy and two dogs had no modifications. Medi-
cations were discontinued in two dogs; one dog was considered
to have mild, but not improving urinary signs, whereby adequate
voiding was possible. Medications in the other dog were discon-
tinued due to the owner’s complaint of lethargy associated with
the medications. This dog’s urinary signs were managed with
daily urinary catheterisation. Recurrent urinary tract infections
were documented with daily catheterisation. At the time of data
collection, the owners were considering euthanasia versus place-
ment of a cystostomy tube.

6 Journal of Small Animal Practice • © 2020 British Small Animal Veterinary Association
 Detrusor urethral dyssynergy in dogs

Entire male subset in five dogs and dose reduction in three dogs. Complications fol-
lowing cystostomy tube placement were reported in both dogs.
Seven of the 10 male entire dogs that responded to therapy (good One dog had a 24 hour, self-limiting, episode of haematuria. The
n = 6, partial n = 1) were castrated as part of their therapeutic other dog had a minimum of two urinary tract infections and
protocol (chemical n = 3, surgical n = 2, chemical and surgical the cystostomy tube tip broke on removal, necessitating a general
n = 2). Four dogs had additional amendments to the therapeutic anaesthetic and cystostomy for retrieval. Five further dogs were
protocol at the time of castration: these included the introduc- euthanased during the follow-up period. Death was related to
tion of phenoxybenzamine (n = 2), meloxicam (n = 1), dantrolene DUD in three dogs due to lack of response to therapy.
(n = 1) and bethanechol (n = 2) and a cystsotomy tube was placed
(n = 2). In one of the two dogs that had a cystostomy tube was
placed, prazosin was discontinued and tamsulosin hydrochloride DISCUSSION
was introduced. Following castration, two dogs required one fur-
ther treatment modification and one dog required two further This descriptive study investigates the signalment, presentation,
modifications due to lack of response to therapy. Rationale for diagnosis, treatment and outcome of 35 dogs diagnosed with
cystostomy tube placement included: persistent urinary signs, DUD at three referral centres in the UK. In line with previous
recurrent urinary tract infections and frequent requirement for studies, the majority of dogs were male neutered, middle-aged,
urinary catheterisation in one dog. In the second dog, placement large-breed dogs (Oliver  1987, Blackwell  1993, Díaz Espiñeira
provided a means of discharge from hospital for on-going man- et al. 1998, Haagsman et al. 2013).
agement at home. Four female dogs were diagnosed with DUD in this study. A
similar proportion of females and males demonstrated a response
Dogs presenting with an inability to void urine to therapy (75.0% and 80% respectively). Canine female func-
tional urethral obstruction is rarely reported in the veterinary
Of the five dogs reported to be unable to void urine or with signs literature although it has been documented in a spayed female
consistent with urinary obstruction four (4/5; 80%) required Shetland sheep dog (Moreau, Lees & Hobson 1983) and anec-
urinary catheterisation; once prior to referral (n = 1), twice after dotally reported in bitches following vaginal stimulation, e.g. after
introduction of therapy (n = 1), once after retrograde urethrocys- colposuspension (Holt 1990). The initiating factor for DUD in
togram (n = 1) and once on recovery from investigations (n = 1). this population remained unknown.
Two of the five dogs demonstrated a good response to therapy, In our study, two dogs initially developed lower urinary tract
two had a partial response and one dog died while in hospital, the signs secondary to prostatitis and one dog as a result of a uri-
cause of death was unknown. nary tract infection. Urinary signs persisted despite resolution
of these initial disease processes. Both UTIs and prostatitis have
Adverse effects and mortality been suggested to result in urethral spasm and subsequent func-
tion obstruction, and this could have accounted for the persistent
Adverse medication effects were reported in 12 of 34 (35.3%)
urinary signs consistent with DUD in these dogs (Rosin & Bar-
dogs (Table 7). Adverse effects led to medication discontinuation
santi 1981, Lane et al. 2000).
The characteristic pattern of urination for dogs with DUD
Table 7. Summary of adverse effects associated with
involves posturing to urinate and passing a normal urine stream
medical therapy and surgical intervention that abruptly becomes interrupted or stops completely. Dogs
Drug Adverse effect n Action may continue to posture to urinate or make several subsequent
Phenoxybenzamine Lethargy 1 Discontinued
attempts but generally are unable to fully void the bladder (Bart-
Incontinence 1 Discontinued ges  2017). In this study population, and in line with a previ-
Disorientation 1 Discontinued ous descriptive study (Díaz Espiñeira et al. 1998), all dogs were
Phenoxybenzamine Lethargy 1 No change
dysuric on presentation. There was, however, minimal informa-
and Dantrolene
Phenoxybenzamine Sedation and miosis 1 Both reduced tion with regards to the initial stream of urine and inconsistent
and Diazepam information about the residual urine volume. This was likely
Diazepam Sedation 1 Reduced due to inherent variability between clinicians’ nomenclature and
1 Discontinued
Diazepam, Prazosin Sedation 1 No change record keeping. Development of a consensus for more consis-
and NSAID tent description of veterinary urological clinical signs and severity
Bethanechol Vomit 1 Discontinued could be beneficial for future prospective studies.
Diarrhoea 1 Reduced
Prazosin Diarrhoea 1 No change Functional urinary obstruction can be broadly categorised
Tamsulosin Mild transient lethargy 1 No change as DUD or neurogenic functional urethral obstruction (upper
hydrochloride motor neuron bladder). The majority of dogs with DUD do not
Cystotomy tube Self-limiting haematuria 1 No change
Recurrent UTI 1 Tube removal have discernible neurological deficits. In contrast, dogs with the
Broken tube tip on 1 Cystotomy neurogenic form commonly present with spinal pain and other
removal neurological signs such as paresis and, on occasion, nociceptive
NSAID Non-steroidal anti-inflammatory, UTI Urinary tract infection. loss (Byron 2015). Thorough physical and neurological examina-

Journal of Small Animal Practice • © 2020 British Small Animal Veterinary Association 7
 C. Stilwell et al.
tion is required to help differentiate between the conditions and
therefore allow targeted diagnostic investigations and therapy.
In this study, specific results of neurological examination were
reported in just over half of the patients (20/35; 57.1%). It is
standard practice in the referral centres involved in this study to
have a neurological examination performed as part of a general
physical examination in patients with clinical signs consistent
with DUD. It is therefore surprising that these results were not
included in the medical records but it does not necessarily imply
that such evaluation was not performed. This is an inherent flaw
of a retrospective study without a standardised means of diagnos-
tic protocol and record keeping.
Treatment for DUD is primarily directed at achieving ure-
thral sphincter relaxation (Byron 2015). This was reflected in our
study, whereby all but two dogs received a smooth muscle relaxant
(33/35; 94.3%) and approximately half (17/35; 48.9%) of dogs
received a skeletal muscle relaxant. Alpha-adrenoreceptor antago-
nists such as phenoxybenzamine and tamsulosin hydrochrloide
have been reported to decrease the tone of the internal urethral
sphincter, which is comprised of smooth muscle. Prazosin, an α1-
adrenoreceptor antagonist has also been reported to exert effects
on the skeletal muscle of the external urethral sphincter (Fischer
et al. 2003). In some cases, if the external urethral sphincter is
more significantly affected, which is often inferred from an initial
lack of response to therapy, additional skeletal muscle relaxation,
e.g. with benzodiazepines (centrally acting) of dantrolene (direct
acting), may be required (Byron 2015).
Bethanechol, a parasympathomimmetic, was prescribed
to approximately a third of patients (13/35, 37.1%). This
drug stimulates detrusor muscle contraction and is indicated
in dogs with evidence of detrusor hypocontractility or atony
(Byron 2015). With uncomplicated DUD, detrusor function is
typically normal (Oliver  1983, Barsanti et  al.  1996). The rou-
tine use of bethanechol is therefore controversial. Furthermore,
bethanechol has been reported to increase urethral smooth mus-
cle tone, and should not be used as a sole agent in animals with
DUD (Wein 1994a, Barsanti et al. 1996). It also imperative that
any urethral obstruction, whether functional or mechanical, is
relieved before the introduction of bethanechol (Byron  2015).
With increasing chronicity of bladder outflow obstruction,
detrusor overactivity, reduced compliance and, eventually, detru-
sor hypocontractility can develop (Barsanti et  al.  1996, Dmo-
chowski 2005, Bosch et al. 2019). In our study, it was unclear
from the medical records whether dogs suffered from detrusor
dysfunction and the rationale for introducing this medication.
A NSAID was administered to 12 of 35 dogs (34.2%). Inter-
estingly, one dog encountered complete resolution of clinical
signs following this drug alone. None of the dogs with a poor
response to therapy received an NSAID. The dog that received a
NSAID alone had abdominal ultrasound and urethrocystoscopy
performed and no abnormalities were reported. Urine dipstick
and sediment examination were also normal. The favourable
response to an NSAID could suggest an underlying inflamma-
tory or pain component to DUD in some dogs, not identified
during diagnostic investigation; however, case numbers were lim-
ited in this study and larger, prospective, case-controlled studies
8 Journal of Small Animal Practice
are required to evaluate the utility of this drug in the manage-
ment of dogs with DUD.
Adverse effects of medical therapy were infrequently reported
and in the majority of cases medication was not discontinued.
Hypotension is a recognised side-effect of α-adrenoreceptor
antagonists and associated clinical signs include lethargy, col-
lapse and syncope (Fischer et al. 1998, Lane 2000). Tamsulosin
hydrochloride, however, is reported to have a wide spectrum of
safety due to its specificity for α-1A-adrenoreceptors, which are
primarily located in the lower urinary tract, and therefore hypo-
tension is less common (Sato et al. 2007, Kobayashi et al. 2009).
Blood pressure assessment was not recorded in this study and it is
therefore plausible that lethargy and disorientation described in
association with administration of an α-adrenoreceptor antago-
nist, in particular phenoxybenzamine, could have reflected hypo-
tension.
Sexual excitement and prostatic disease have previously been
described as a possible cause of DUD in intact male dogs and
castration has been reported to result in temporary relief of dys-
uria in some of these patients (Collins et al. 1986, Holt 1990,
Lane et  al.  2000, Coit et  al.  2008, Haagsman et  al.  2013). In
our study, seven male entire dogs that encountered resolution of
their urinary signs were chemically and/or surgically castrated as
part of their treatment protocol. Interestingly, of the three male
entire dogs with no response to therapy, none were castrated. It is
plausible that the documented improvement in urinary signs of
the castrated male entire dogs could be due to reduction in sexual
behaviour and/or prostate size. However, due to small patient
population and marked variation in treatment protocols it was
not possible to determine the exact role of castration in this study.
In refractory cases, placement of a cystostomy tube or urethral
stent, inserted across a narrowed portion of urethra or area of ure-
thral spasm, may be considered (Hill et  al.  2014, Bartges  2017).
Proposed benefits include allowing time for the medical therapy to
take effect (Holmes 2015) and, through maintenance of a small uri-
nary bladder, for tight junctions in the detrusor muscle to re-estab-
lish, thereby restoring normal function (Byron 2015). Cystostomy
tubes have the potential to remain in place for several years; how-
ever, both major and minor complications are reported to occur in
49% of dogs (Beck et al. 2007). In this study, cystostomy tubes were
placed in two dogs. and both were discharged from hospital with
resolution of dysuria within 1 to 3 months of tube placement. Both
dogs experienced complications (one minor and one major, the lat-
ter requiring surgery), which were resolved. This further highlights
the importance of discussing potential complications with owners.
Future prospective studies are needed to assess the use of cystos-
tomy tubes further to see if regular decompression of the bladder
improves the remission rate in dogs with refractory DUD. Five
dogs presented with inability to void urine and four (4/5; 80%)
of these required urinary catheterisation on one or two occasions.
This presenting sign did not appear to be associated with a poor
outcome, given that all four dogs with follow-up data demonstrated
a response to medical therapy (good n = 2, partial n = 2); however,
larger studies would be required to evaluate this finding further.
The majority of dogs in this study demonstrated a good or par-
tial response to therapy (27/34; 79.4%). This corresponded with
• © 2020 British Small Animal Veterinary Association
 Detrusor urethral dyssynergy in dogs
previous studies with reported response rates of 63 to 100% (Díaz
Espiñeira et al. 1998, Lane et al. 2000, Haagsman et al. 2013).
Medications could be discontinued in 11 of 20 (55.0%) of dogs
with a good response; however, relapse of urinary signs was not
uncommon (2/11; 18%). Therefore, in line with the 1998 study
(Díaz Espiñeira et al. 1998), whilst the prognosis for most dogs
with DUD can be considered good, many will require long-term
medical management.
The follow-up data gained from this study suggests that most
(88.6%) dogs with DUD require a short period of hospitalisa-
tion to allow for the necessary investigations and introduction
of therapy. There was considerable variation in response and
remission times amongst dogs. Of the dogs that demonstrated
a good response to therapy, resolution of urinary signs typically
occurred within 2 weeks (median 8.5 days, range 4 to 137) of
treatment being introduced; however, some dogs required con-
siderably more time. In contrast, for those that experienced a par-
tial response to therapy, the documented improvement occurred
approximately 5 weeks (median 38 days, range 2 to 155) after
therapy was initiated. This information may provide a useful
guide to educate owners and help manage expectations.
There were a number of limitations to this study. DUD is
an uncommon condition in dogs and rare in females and there-
fore the study population size is limited despite collecting data
over a 12-year period. Furthermore, due to the inclusion of
multiple referral centres and retrospective nature of this study,
dogs were not randomised to treatment and the treatments
used varied considerably in the medications, doses and out-
patient protocols. It was, therefore, not possible to compare
management strategies amongst dogs and establish the efficacy
of individual therapies. Data regarding residual bladder urine
volumes at time of diagnosis when assessing response to treat-
ment were not recorded in the clinical notes. Thus, another
limitation of the study is that response to treatment is based
on the owner’s and clinician’s impression, and not objective
criteria, allowing for possible bias. Differences in the manner
of recording keeping (i.e. presenting complaint, pattern of uri-
nation, severity of clinical signs and adverse effects) were also
present between referral centres and clinicians. Despite efforts
to obtain detailed long-term follow up, this was not always pos-
sible. These limitations in data collection may have resulted in
dogs with DUD being excluded from the current study and
may mean that relapses, minor complications or adverse effects
were not ­documented.
In conclusion, DUD is an uncommon micturition disorder
of male dogs, and rare in females. Medical management with or
without surgical intervention can result in a favourable prognosis
in the majority of dogs, although many will require long-term
medication. Future prospective studies are required to evaluate
for possible prognostic factors and optimal management strate-
gies for dogs with DUD.
Conflict of interest
None of the authors of this article has a financial or personal
relationship with other people or organisations that could inap-
propriately influence or bias the content of the paper.
Journal of Small Animal Practice • © 2020 British Small Animal Veterinary Association 9
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Supporting Information
The following supporting information is available for this article:
Table S1. Raw data spreadsheet.

10 Journal of Small Animal Practice • © 2020 British Small Animal Veterinary Association