Involuntary Urination

By Mary Straus

When my dog Popcorn woke up one morning many years ago in a puddle of urine, I panicked, certain that only a deadly illness could cause this perfectly housetrained dog to wet her bed. I rushed her to the vet, where he did a thorough physical exam and urinalysis. I can still remember the relief I felt when my vet told me it appeared to be a simple case of incontinence.

As it turns out, incontinence, which is defined as involuntary urination, is quite common in dogs, especially spayed females, where about one in five dogs (20 percent) is affected.

Estrogen responsive incontinence or hormonally responsive incontinence, commonly called spay incontinence, is the most frequent cause of involuntary urination in dogs. It can occur anywhere from immediately after spaying to 10 years later, with the average being around three years.

Low estrogen levels and other factors can lead to a weak bladder sphincter, resulting in anything from small urine drips to complete emptying of the bladder, usually while sleeping or resting. Leaking can happen daily or just periodically. Large breed dogs are more commonly affected than small breeds, and German Shepherds, Boxers, Spaniels, and Doberman Pinschers appear to be more at risk than other breeds.

A recent study showed that early spaying (before the first heat) reduced the chance of incontinence, from 18 percent to 9.7 percent in large breed dogs, but increased the severity when it occurred. It is possible that spaying midway between heat cycles may help prevent spay incontinence, but this is just speculation, as no studies have been done. Hormone-related incontinence can also affect neutered males, though much less commonly than females.

Incontinence can occur for many other reasons, including urinary tract infections, bladder stones, congenital structural defects (e.g., ectopic ureters), spinal cord disease, and excess water intake. Older dogs, overweight dogs, and dogs with neurological problems may develop a weak bladder sphincter. These causes of incontinence can affect dogs of both genders, whether intact or neutered.

When additional symptoms such as frequent urination, painful urination, trying to urinate without success, or blood in the urine are seen, then urinary tract infection (UTI) or stones (uroliths) are likely. Keep in mind that about 20 percent of UTIs will not show up on urinalysis alone, so it’s important to do a urine culture to rule out infection.

Neurological problems should be suspected when signs such as weakness in the rear, stumbling, or incoordination are present. Ectopic ureters are the most common cause of incontinence in young female dogs (under a year); they are uncommon in males.

Most causes of incontinence other than weak bladder sphincter can be identified from a urinalysis and urine culture, but sometimes it is necessary to see a specialist. Additional tests that can be done to find the cause of incontinence include X-rays or ultrasound to look for bladder stones or structural defects, dye contrast studies, and exploratory surgery.

In addition to being a problem for the owner who has to clean up after a leaky dog, incontinence can be very distressing to dogs who are housebroken, and can also lead to urinary tract infections, vaginitis, and sometimes skin ulcers caused by urine scald and licking.

Incontinence should be suspected as a contributing factor in dogs with recurrent bladder or vaginal infections. Incontinence aids such as doggie diapers and pads to protect furniture and dogs beds are available, but it’s very important to keep the dog clean and to get the incontinence under control, if at all possible. Baby wipes can be used to keep the skin clean, and will also soothe irritation, as does aloe vera gel. Use only those lotions that will not be a problem if a dog licks and ingests them.

Treatment
Treatment of incontinence is usually simple and effective. There are many different ways of treating incontinence, and the choice may depend on the cause. Phenylpropanolamine (PPA), a decongestant that helps to tighten the sphincter muscle, is the most commonly used treatment for incontinence in both male and female canines.

Spay incontinence can also be treated with estrogen supplements, usually in the form of DES (diethylstilbestrol), but estradiol, a more natural form of estrogen, can be used. Neutered males with hormonally caused incontinence may respond to monthly testosterone injections, though these can also lead to urine marking and an increase in aggressive behavior.

Ectopic ureters, where the tubes leading from the kidney do not properly connect to the bladder, require surgical correction. A new surgery using collagen injections is now available for incontinence that does not respond to any other form of treatment.

Natural treatments are frequently helpful for incontinence, once more serious conditions have been ruled out. Herbs, acupuncture, chiropractic treatment, and homeopathic remedies have each helped many dogs. Feeding a homemade diet can also make a difference.

Conventional treatment options
PPA (phenylpropanolamine) is the most commonly used veterinary treatment for incontinence in both male and female dogs. It is a decongestant that works by tightening the sphincter muscle from the bladder. PPA is effective in controlling incontinence in about 70 percent of dogs who try it, with improvement in most of the rest. A veterinary PPA product called Proin comes in chewable tablets made for dogs, and is also available in liquid form.

PPA must be given daily, usually two or three times a day, as its effect lasts only 8 to 12 hours. It can be used on an as-needed basis for dogs who have only occasional problems with incontinence. Most dogs tolerate PPA without any problems, but side effects can include irritability, nervousness, panting, restlessness, rapid heartbeat, and excitability. PPA should not be given to dogs with high blood pressure or heart disease. PPA has been removed from over-the-counter human products due to an increased risk of stroke, but this side effect is not a concern with dogs.

DES (diethylstilbestrol), a synthetic form of estrogen, can be used to treat spay incontinence. It is given daily for the first week, and then dosage is dropped to once or twice a week. It’s important when using this treatment to experiment and find the lowest possible dose that will work to control the incontinence, once it has been found to be effective. Estrogen supplements are considered relatively safe, but in rare cases they can cause bone marrow suppression leading to anemia that does not go away when the treatment is stopped. Higher doses and non-DES forms of estrogen are more likely to cause this effect. DES is readily available thru compounding pharmacies.

PPA can be combined with DES when needed to control difficult cases. Imipramine (Tofranil), a tricyclic anti-depressant that causes urine retention in some patients, is occasionally combined with PPA for dogs who do not respond to other medications.

A natural estrogen supplement called Genesis Resources Canine Incontinence Support is available for treating spay incontinence, as are ovarian glandular products. I have heard reports of each of these working for some dogs.

Herbal treatment options
There are several natural treatment options for incontinence, including a number of different herbs. Corn silk is the herb most commonly used to treat incontinence. It can be given in capsules, brewed into tea, or made into a tincture.

Beth Teffner of Ohio has a four-year-old Doberman, Inga, who was rescued from a puppy mill. Inga has spay incontinence, which Teffner has treated successfully with corn silk. “We first tried giving her Proin, but it made her cranky,” says Teffner. “Inga now gets three capsules of corn silk (425 mg) a day, two in the morning and one in the evening, opened and sprinkled over her food. She leaks only when extremely tired. She is dry 90 to 95 percent of the time.”

Teas made from corn silk (and other herbs) may be more effective than capsules. To make an herbal tea, add 1 tablespoon of fresh or dried herb per 2 cups of boiling water. Give 1 teaspoon of strong tea per 20 pounds of body weight, twice a day. Other herbs that can help with incontinence include raspberry leaf, horsetail, saw palmetto, nettle root, couch grass, uva ursi, agrimony, marshmallow, and plantain.

Glycerin tinctures (also known as glycerites) containing these herbs in any combination are another alternative. Give 12 to 20 drops of glycerite per 20 pounds of body weight, twice a day.

There are also commercial herbal blends made for dogs with incontinence. Products that have worked for some include Azmira’s Kidni Kare, Animals’ Apawthecary’s Tinkle Tonic, and Vetri-Science Bladder Strength for Dogs.

Traditional Chinese medicine (TCM) also offers herbal combinations for controlling incontinence. Chinese herbs helped Ben, a 13-year-old Border Collie owned by Laura Miller of Lovetteville, Virginia, after the dog started leaking urine about six months ago. The leaking began with a urinary tract infection, but continued after the infection was gone.

“While Proin controlled the problem, it seemed to make him grouchy to the point where the other dogs in the house were avoiding him,” says Miller. “With the help of a veterinarian who practices both conventional and holistic medicine, we were able to switch him to a Chinese herbal combination that has been as effective as the Proin, without the grumpiness.”

The formula her vet prescribed is called Sang Piao Xiao San – Mantis Formula 524, from Sun Ten. (Note: Chinese herbal formulas are typically custom-prescribed for the unique needs of the patient, rather than indicated for specific sumptoms. Your veterinary TCM practitioner may prescribe a different Chinese herbal forumula for the same condition in your dog.)

Diet can make a difference
Some dogs stop being incontinent when all grains are removed from their diet. Maizey, a 12-year-old Bull Terrier owned by Shari Mann of San Francisco, is one of those dogs. “Soon after she was spayed, Maizey started dribbling, especially at night or when taking a long nap,” Mann says.

“Maizey has eaten a raw, grain-free diet since 12 weeks of age. The only grains she ever got were in my home-baked cookies made from liver and organic wheat. I stopped giving her the cookies, in an effort to help with a yeasty ear problem. To my utter surprise and delight, not only did her ears clear up, but her dribbles also stopped. I did not believe it. Just to be sure, I again gave her one cookie a day for two weeks, and she began dribbling again.” Maizey has been off all grains, and free of incontinence, for 10 years.

Judi Rothenberg’s Doberman Lucy is another dog who responded to the elimination of grains from her diet. Although DES was effective in controlling Lucy’s spay incontinence, Judi preferred something natural. “I give Lucy corn silk (¼ teaspoon twice a day), but removing grains from her diet helped the most. As long as I remember not to give her treats with grains in them, Lucy no longer needs the DES.”

Sometimes, just a homemade diet can help, even if it includes grains. Judy Coates of Pennsylvania had two male beagles, Guillaume and Darwin, who were neutered in April 2003, when Guillaume was 10 and Darwin was 9 years old.

“At the time of neutering they were eating a high quality dry food,” Judy says. “After a few months they started leaking while they were relaxed or sleeping. I increased the amount of fresh food I added to their kibble, and eventually began feeding all home-cooked meals at the beginning of 2005. As soon as they started to get fresh food, their water intake dropped and the leaking went away. Even now, with Guillaume testing positive for Cushing’s and drinking more water than he did, he still has no problem with leaking.”

When preparing homemade diets, keep in mind that certain vegetables, such as parsley and celery, have diuretic properties and may increase leaking.

Other natural treatments
Incontinence may respond to alternative treatments such as chiropractic adjustments and acupuncture. Acupuncture may be particularly effective if done on the spay incision.

Maggie is a 10-year-old Vizsla owned by Maisie Griffiths in Canberra, Australia, and fed a raw, grain-free diet. “Maggie began to have some episodes of incontinence about a year ago, just dribbles that only occurred in her sleep,” says Griffiths.

“The leaking increased at the same time that she began to show more obvious signs of the effects of her spondylosis. My vet is also a chiropractor; we began to give Maggie chiropractic treatments. The urine dribbles turned into floods for a few days following each treatment and then returned to dribbles. We continued the treatments as her movement was improving. Gradually, the incontinence following each treatment completely disappeared, along with the original dribbles.” Griffiths reports that Maggie now moves better than she did two years ago and has no incontinence at all.

Homeopathic remedies, both individual and combinations, have helped many dogs. Jo Wells of Euless, Texas, has a 10-year-old Rottweiler mix also named Maggie who was diagnosed with spay incontinence about a year ago.

Wells says, “We tried corn silk capsules with no success. The homeopathic formula Leaks No More from Homeopet worked for us, but I quit using it because of the expense. It comes in such a small bottle and using it three times a day it only lasted about 10 days for a large dog. I switched to Herbasaurs Bedwetting homeopathic formula made for children. It has worked for us and a bottle lasts me for three to four weeks. I just put it in her food and she scarfs it right down.”

Other homeopathic remedies recommended for dogs with incontinence are Sepia, Solidago (goldenrod), and Hyland’s EnurAid.

A combination of treatments
For some dogs, the treatment isn’t so simple. Mindy Fenton of Southern California adopted a two-year-old Chow also named Maggie who leaked urine continuously. Maggie was diagnosed with an ectopic ureter using a dye test. Fenton explains, “The ureter was attached to the kidney but at the distal end it emptied right out instead of going into the bladder. The vets said it was probably genetic. Maggie could hold no urine; her bladder never filled. She would squat and try to pee but she also constantly leaked.”

Maggie required surgery to correct this defect. The surgery was successful and allowed Maggie to urinate normally, but she continued to have problems with dribbling during any kind of stress. “The specialist had told me at the time of surgery that it is common for dogs with an ectopic ureter to not be fully continent post-surgery. Within a couple of months after surgery, Mags was greatly improved but she would still leak from time to time, and the leaking made her susceptible to bladder infections.”

Fenton tried DES, which didn’t help at all, but she had success using Proin. She preferred more natural methods, however. “I used a number of supplements, including vitamin C, cranberry capsules (which help prevent bladder infections), and Animals’ Apawthecary’s Tinkle Tonic. I would make my own tincture using corn silk in an alcohol (brandy) base and I added uva ursi. I tried adding corn silk directly to her food, but that did nothing. Switching to a raw, grain-free diet helped quite a bit. Mags was nine years old when I made the switch.”

This approach worked most of the time, but under stress, the dribbles would return. “When she would drip, I would give her PPA, twice a day, which I usually had to do only for about three days at a time. I also used PPA as a preventative when I knew there was going to be stress and thus a high likelihood that she would drip.”

Incontinence secondary to other diseases
Sometimes incontinence is secondary to other disorders, so treatment is directed at the primary disease. Any illness that causes the dog to drink excess amounts of water, including diabetes mellitus, kidney disease, liver disease, Cushing’s disease (hyperadrenocorticism), and more, can lead to incontinence. Most of these can be ruled out by blood tests. Certain drugs can also cause increased water intake.

Kathy Moffett of Le Roy, Illinois, has a Brittany Spaniel named Abby who began having major incontinence issues associated with drinking lots of water at age 11. “Abby turned out to have a rare condition called diabetes insipidus,” Moffett explains. “The only symptoms of this condition are drinking lots of water and increased urination, including problems with incontinence.”

The treatment for DI involves injections twice a day with desmopressin, which controls the excess drinking and also the incontinence. (Note that there is no relationship between diabetes insipidus and the more common diabetes mellitus. See “Yo Adrenals!” July 2006.)

My own dog Nattie developed some incontinence when she was diagnosed with kidney disease and put on subcutaneous fluids. I did not give her medication for this, but solved the problem by getting up during the night to let her out one extra time, and by using washable waterproof pads under her bedding to protect the beds and furniture.

I found the mattress pads and liners made for children’s beds to be the most cost-effective and reliable way to keep dog beds and other places she liked to sleep dry. You can also find waterproof liners and pads made for dogs and dog beds in pet supply stores and catalogs. Diaper garments made for both female and male dogs can also be purchased.

Incontinence has also been known to develop following corticosteroid treatment. Steroids such as prednisone cause excess drinking, which may lead to temporary incontinence, but sometimes, the incontinence continues even after the steroids are stopped.

Steroids also suppress the immune system, which can lead to increased risk of urinary tract infections. In addition, steroids can push a dog with a tendency toward diabetes into exhibiting symptoms. It makes sense to have a urinalysis done if your dog develops incontinence following the use of prednisone.

Dawn Lange of Duluth, Minnesota, has a retired racing Greyhound named Sly who experienced problems following the use of prednisone.

“Sly’s incontinence started at about eight years old, almost immediately after receiving multiple steroid injections for pannus.” says Lange. “It took about six months before the incontinence gradually stopped. None of the treatments that are used for spay incontinence worked. We chose to diaper her during the problem period, using Female Pet Bloomers from Drs. Foster & Smith, with a maxipad inside.”

Surgical options
Once in a while, you may have a dog who does not respond to any of the traditional or natural treatments for incontinence, or who cannot take them for various reasons. In those cases, surgery may help.

One older procedure for female dogs, colposuspension, surgically tacks the vagina to the belly wall, compressing the urethra.

Colposuspension surgery has been shown to be effective in curing incontinence in 40 to 55 percent of dogs initially, though many relapse within the first year. Most dogs show improvement, which is often increased when medications are added back in. Male dogs can have a similar procedure called a cystourethropexy.

Collagen injections (performed under anesthesia) into the area around the urethra offer a newer and more effective surgical method for controlling incontinence in female dogs. Studies show these injections to be completely successful in up to 75 percent of the dogs who receive them, with most of the rest improved and many of those responding to the use of PPA after surgery when they did not before.

The major drawback to this approach is cost, which can run more than $1,000 – and the treatment may have to be repeated, as the body removes the collagen over time. Retreatment with collagen is usually easier and may be less expensive. The average duration of effectiveness was 17 months in one study, though the effects can last more than five years. It has few side effects, usually only transient problems with urination immediately after surgery in a small percentage of dogs. There is a current study of this procedure being done at Purdue University.

Beth Teffner is involved with Hand Me Down Dobes, a rescue group in Columbus, Ohio, that recently took in a two-year-old Doberman named Reese. Surrendered by her original owner due to incontinence, Reese would leak urine while standing and walking around, even immediately after urinating. Exploratory surgery did not find a cause.

The group contacted Ohio State, where the collagen injection procedure is being studied on Dobermans. “Fortunately, our group had an angel who donated money, and Reese has had the injections. She did not need additional surgery and is leak-free,” Teffner says. “She is now in a foster home waiting to be adopted.” (If you can help, contact Hand Me Down Dobes at 614-470-2851 or www.handmedowndobes.org.)

Experimental treatment
A recent report from Europe involves the use of use of GnRH (gonadotropin releasing hormone) analogs to control spay incontinence that does not respond to traditional treatments.

In one small pilot study, seven of 11 dogs treated this way once or twice were cured for periods ranging from two months to two years, with all but one of the remaining dogs becoming continent when PPA was added. This treatment is still experimental and has not yet been approved, though GnRH is used with dogs for other purposes involving reproduction.

Be persistent
With the many different treatments available for incontinence, it’s important to keep trying various remedies when needed. Many people try a number of different remedies before finding the one that works best for their dogs. Don’t give up when your dog does not respond to the first or second remedy you try.

When natural treatments and traditional medications do not work, look for other possible causes, and if needed, consider surgical options. Almost all dogs with incontinence can be successfully treated with persistence.

-Mary Straus does research on canine health and nutrition topics as an avocation. She is the owner of the DogAware.com website. She lives in the San Francisco Bay Area with her dog Piglet, a 14-year-old Chinese Shar-Pei.