This is a great topic for understanding clinical decision-making. Not a headliner like brain tumours, but perfect as a simple example of balancing consideration of costs, convenience, and risk, when choosing the treatment for a common problem which, if not controlled, may demand rehoming or even euthanasia. About 1 in 10 of female dogs develop incontinence, anywhere from months to years after their desexing surgery.
Many diseases can be treated a number of ways: with surgery, or with several drugs that vary in price, effectiveness, and risk of side effect. Deciding which drug is sometimes difficult for both prescriber and pet owner. If there’s only one drug available, side effects are mild, and the disease is life-threatening, the choice can be easy.
The more options there are, and the more serious the potential side effects, the harder it becomes to decide what’s best. Cost and ease of administration can also be big issues for pet owners, especially for diseases like incontinence where treatment may be daily, for life. Possible hidden side-effects, when drugs are given in the long-term, also raise justifiable concerns for many.
Incontinence is a topic that sees continual conversation in vet forums, as colleagues try to reconcile these issues. Weighing the pros and cons of each option can be swayed by the information we receive, and how well we cope with risk.
Cause and symptoms
Loss of oestrogen, once ovaries are removed during desexing, results in decreased pelvic nerve and muscle function and hence loss of urinary control. About 10% of neutered bitches will suffer incontinence; slightly higher for larger breeds, and lower for smaller breeds.
Symptoms range from bed wetting to more constant dribbling; sometimes persistent, others intermittent. The impact on enjoyment of pet ownership can can vary from none, for outdoor dogs, to profound, for those with severely incontinent dogs, living entirely indoors on carpet.
Early onset incontinence (age 2-8) can often be identified as ‘hormonal’ with confidence. In older dogs, incontinence can be secondary to diseases of thirst, and arriving at the vet clinic with jar of urine, ready for analysis, will get your answer quicker. See Liquid Gold: save time & money with urine.
Treatments
These are commonly used alone, but sometimes in combination for stubborn cases.
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Oestrogenic compounds (Incurin®, Stibestrol/DES)
Could be considered a type of replacement therapy, giving a hormone lost when ovaries were removed, and therefore looked-upon as addressing the root cause of the problem. These agents are old-school hormones or analogues that are off-patent, and cheap to manufacture.
They usually require an initial higher dose, with tabletting daily, tapering to several times weekly, and sometimes as infrequently as fortnightly. This can make treatment very cheap and easy. Annual cost for a 20kg dog could be as low as $50.
Any oestrogen has the potential to stimulate growth of certain tumours, most commonly breast, or suppress blood cell production in the bone marrow. These side effects sound catastrophic, especially when treating a non-life threatening problem, and can easily be used by vets and drug manufacturers to guide pet owners towards more expensive alternatives.
In reality, the doses prescribed for incontinence have not been reported to cause bone marrow problems. While there are several other sex hormones used in dogs, which do have well-recognised effects on the development of breast cancer and even diabetes, oestrogens, at anti-incontinence doses, don’t appear to be one of them.
Admittedly, hormones have many and diverse effects in the body, especially in the long term; far more so than drugs which act on neuromuscular function, described below. Without large-scale population studies of bitches on treatment it is impossible to say with mathematical certainly, but there isn’t even anecdotal reports or discussion amongst colleagues, implicating oestrogens in any sinister causal role. Progestigens, like megestrol acetate, are a very diferent matter, and those looking for hazardous use of hormones in pets should fix their gaze in this direction.
Comparison with the recently identified increase in breast tumours in post-menopausal women receiving HRT oestrogens seems superficially valid, although the hormonal life-story of a woman, with pregnancy, breast-feeding and contraceptive pills, is so much more complex than the ovarectomised bitch. Interestingly, in women, late puberty coupled with early childbirth significantly reduces breast cancer risk, while in the bitch, a similar reduction in risk can be achieved by desexing before their first heat.
If you’re concerned about breast cancer, focus more on the timing of the spey than theoretic side effects this medication.
Cost: …….. Cheap as
Ease: ………A pill weekly to fortnightly
Efficacy: ….83% response rate
Risk: ……….Very Low
.
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Alpha-adrenergic agents (Propalin®/PPA, Sudafed®/pseudoephidrine)
These are drugs that act on nerve receptors in the ‘valve’ of the bladder neck, stimulating it to contract and maintain continence. Compared to the hormones described above, they are very short-acting and need to be given 1 to 3 times daily. As soon as treatment stops, incontinence returns. Syrup formulations can be added to food to make administration easier, but they are most effective when given on a empty stomach. Side effects are uncommon and, like the drug, short-lived. They may include nervousness, insomnia, tremour: not ideal for the anxious or highly strung.
These drugs were freely available at chemists as nasal decongestants (Sudafed®), and slimming tablets (Slim-rite®), until their use in elicit drug manufacture saw a clamp-down on over-the-counter availability. Now marketed as a prescription vet product, Propalin Syrup®, treating a 20kg dog may cost around $250-500 per year, depending on dose. Hence the financial incentive for vets and drug manufacturers to overstate the risks of inexpensive hormonal drugs and move patients on to these alpha-adrenergic agents.
Cost: …….. Relatively expensive
Ease: ………Dosing several times daily
Efficacy: ….90% response rate
Risk: ……….Very Low
.
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Acupuncture and chiropractic
Treatments are available. Sourcing information regarding frequency of treatments and efficacy.
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Traditional Chinese and herbal remedies
Interestingly, some of these remedies may contain natural chemicals that act on adrenergic receptors or as phyto-oestrogens, and hence behave like the man-made drugs above.
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Lifestyle
The cheapest, drug-free option for incontinence is lifestyle change, as owners of outdoor dogs may not even notice their pet’s incontinence. Eviction from the house, or restricting access to tiled areas alone, may make the medical problem a non-issue. Many owners can’t cope with the welfare impact of this option; the forlorn looks, from behind glass door, too much to bear.
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Surgery
There are surgical treatments rarely recommended for incontinence, poorly responsive to pharmaceuticals. This should be considered as a separate issue, and involve your primary veterinarian and possibly a surgical specialist, as they are costly, invasive, and outcomes are variable.
- Unless your mother’s death from breast cancer has left a permanent emotional scar, or you can’t cope with risk’s of 1 in the 10′s of thousands, I’d try the hormonal option first. If your bitch responds well, and only low doses are required, it’s safe, easy and cheap.
- If you don’t like tampering with hormonal systems unnecessarily, you have a chilled-out or relaxed dog, and not phased by the cost, try the alpha-adrenergic agents.
- If you like natural remedies, get a referral to practitioners who specialise in acupuncture or traditional Chinese medicine.
It’s important to emphasise this conversation is not relevant to other types of incontinence associated with
- Congenital malformations of the urinary tract, usually in dogs under 6 months of age;
- Inflammatory lower urinary tract disease (infections, bladder stones) which usually have associated painful or frequent urination, and malodorous or bloody urine;
- Spinal diseases, such as slipped discs, tumours and fractured vertebrae, which can damage the nerves supplying the bladder.
- Polydipsia (increased thirst). These often need to be investigated and treated differently to ‘hormonal incontinence’, although some of these treatments may be used as adjunct to other specific therapies. See Liquid Gold: save time & money with urine.
Tags: acupuncture, bloody urine, breast cancer, canine, chinese herbal remedies, clinical decision-making, clinical risk, desexing, dog, efficacy, hormones, HRT, incontinence, Incurin, megestrol acetate, ovarid, progestigens, Propalin, side effects, smelly urine, spay, spey, Sudafed, thirst, vet, veterinary
I copied and pasted this of your website -
•Unless your mother’s death from breast cancer has left a permanent emotional scar, or you can’t cope with risk’s of 1 in the 10′s of thousands, I’d try the hormonal option first. If your bitch responds well, and only low doses are required, it’s safe, easy and cheap.
What on earth has this to do with Dog incontinence?
If you read the full article, it describes the theoretic association between breast cancer and oestrogen therapy. Those personally touched by a particular disease, even if in a human relative, may be understandably reluctant to use medication similar to HRT in another loved companion, albeit canine.
My kelpie had low dose hormone treatment for incontinence soon after I got her (she was about 18 months old) and about 12 months later she no longer needed the tablets. She is now 6-7 years old and has never had the problem again.
Thats unusual but a great outcome, Jayne. I havent been aware of such permanent responses, but they could go unnoticed by vets – we are only alerted by dog owners if a drug fails rather than succeeds.
Cool. Thanks for writing this. It is always great to see someone educate the community.
My 2yr old Boxer started bed wetting a few months after her desexing (at 6months). We tried Propalin first…. worked well so long as you never missed a dose morning or night or dropped below .55mls per dose. Then we tried Stibesterol higher dose at first then dropping to the recommended 1 tablet per week. As soon as we dropped the dose to 1 tab per week the bed wetting started again.
I guess the answer is leave her on a higher dose? but what is considered a high dose? at what point do the risks outweigh the benefits? do these drugs put pressure on the organs?
hi melissa, your boxer has a greater incontinent tendency than most. With 20/20 hindsight it may have been better to delay desxing until after a few heats, to allow the natural oestrogen cycles to strengthen pelvic floor/bladder neck tone. Although thers no guarantee this would have prevented the problem. The downside of delaying desexing surgery is the associated increase in breast cancer incidence in later life.
If twice daily propalin is too much of a drag, and you cant change lifestyle to accomodate some incontinence, oestrogens are your only alternative. Its possible, over time, you may be able to decrease the oestrogen dose to 1mg/ week or even lower. While no exact level of DES dose is described as safe, ending up on 25-50% more than the recommended dose wouldn’t conern me if she was my dog.
The doses that cause oestrogen dependent cancers in experimental studies were about ranging from 60 to 495 mg given over 1 month. Bone marrow suppression has been described at doses about 2.2 mg/kg per day – that would be about 40 x 1mg DES pills a day for your boxer. In this context 1-2 pills per week is a very small dose indeed.
hope this helps
matt
Hi Matt,
Thanks for the information. I give my 2 yr old mix 25 mg of Proin per day. She’s been on it about a year or so and it works. I’m worried, however, about the anecdotal data about strokes possibly being caused by Proin. I realize this cannot be proved, but I wondered your opinion. Also, do you know anything about the natural remedies such as parsley or soymilk?
Thanks!
-Emily
hey emily,
youre right, pharmacovigilence in the vet context is poor, and its unlikley we’ll see any statistical proof of rarer adverse events any time soon.
While PPA doesnt have any direct effect on clot/stroke formation, theres definately a potential for PPA to exasserbate underlaying cardiovascular disease. Stroke could occur secondarily.
The nastier side of any drug is usually revealed by overdose and to quote from Plumb, the vet drug bible…… Symptoms of overdosage may consist of severe cardiovascular (hypertension to rebound hypotension, bradycardias to tachycardias, and cardiovascular collapse) or CNS effects (stimulation to coma) can be seen.
It wouldnt be difficult to imagine a thromboembolic event arising from overdose, but not at therapeutic doses
Unless your 2 year old was born with a heart condition, its unlikely she’ll have any heart froblems for a few years yet, so will probably be ok for now.
Dunno about parsley, but soy milk is probably a source of phyto-oestrogen, and hence may act like the oestrogens described in the article.
If your concerned about potential sie effects, I’d recommend you explore other options, including acupuncture or herbs, as you dont have anything to lose…..except your paitence having to clean up urine. I’d be interested to hear if parsley worked!
cheerio
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