Lower urinary tract signs (LUTS) or lower urinary tract disease (LUTD) are common presenting complaints in small animal practice for our feline patients. The source can be behavioral, inflammatory, infectious, obstructive, lithic, neoplastic, conformational, or idiopathic. This article focuses on nonobstructive LUTS in cats. It is important to note most lower urinary tract obstructions are preceded by a nonobstructive disease process and recognizing early may help avoid an obstructive event altogether. Long-term management is key to prevent chronicity as one study reports a recurrence rate of 58 percent after a cat’s initial episode.1 Feline interstitial cystitis (FIC) was used to describe LUTS in cats, but was lacking in the whole-body consideration for the source of the signs. Pandora syndrome was coined to describe a host of clinical diseases resulting from a previous adverse life-event or chronic stress. One possible manifestation of Pandora syndrome in cats is LUTS.2 History The common owner-reported LUTS in cats include dysuria, stranguria, hematuria, pollakiuria, and periuria. Along with diagnostics, the signs may help to determine treatment needed acutely. A more detailed history about the cat and its environment is also essential to identify the source and formulate the long-term plan. Some important questions to consider when obtaining a history for a cat with LUTS are: who, what, where, when, why, and how? Who? Figure 1: In-clinic Uricult urine culture paddle with bacterial growth. Photo courtesy Nicole Martell-Moran Who is this cat? Is its personality relaxed or anxious? How does it respond to being in the clinic (i.e. unfamiliar surroundings)? How does it respond to strangers? Does it hide or flee at home? Is the cat intact? Who has contact with this cat at home? Do they get along? Does the cat prefer a particular person in the house? Have there been new people lately or visitors? Who likes or does not like the cat in the house (including other animals)? Who feeds and cares for the cat’s basic needs? What? What is the cat eating (be specific with moisture, texture, brand, frequency)? What signs is it exhibiting at home? What has been done about the signs so far? What new events or occurrences have happened in or around the house lately? Where? Where does the cat go? (e.g. roam the neighborhood, access to a patio) Where is the cat kept in the house and/or where is the cat not allowed in the house? Where does the cat prefer to see the environment (floor or elevated)? Where is the cat’s food and water dish? (Same location and in a quiet environment?) Where are the litter boxes? Details on location, size, number, cleanliness, open or closed, type of litter. Ask the owner to bring a photo. Where is the cat when urinary signs are noticed (if periuria present, where, and on what surface)? Where does the cat scratch in the house? Where has the cat traveled in the last month? When? When did the signs start? When do you see the urinary signs? When has this happened before? Why? Why did you choose the current diet, feeding schedule, and litter or box configuration? Why are any of the above answers not ideal for this cat’s health? (for the veterinarian to consider) Why does the cat have urinary tract signs? (i.e. is this medical, behavioral, or both for the veterinarian to consider) How? How does the cat move (screening for orthopedic disease)? Is it able to jump normally? Can it run and climb? Does it ever move slowly or appear “stiff”? Diagnostics Physical exam findings may vary depending on the condition of the cat. There may not be physical exam abnormalities in a cat with nonobstructive urinary tract disease. The bladder may be small and empty due to the frequent straining, or you may witness the patient straining while in the exam room. Figure 2: Cystolith in the urinary bladder of a cat. Photo courtesy Heather Sims If the patient has obstructive disease, the bladder may be distended and painful on palpation. The obstructed patient may also be in acute renal failure with accompanying signs, such as anorexia, arrhythmia, dehydration, and lethargy, which require immediate attention. A mass may be palpable within the bladder, if present. An orthopedic exam may reveal decreased range of motion, pain on palpation of vertebrae or hips, joint pain, effusion, or crepitus. Clinical pathology diagnostics recommended to explore the medical source of urinary tract signs are a complete blood count (CBC), blood chemistries, total T4, retroviral testing, urinalysis, and urine culture with antibiotic sensitivity. Further, regular use of bacterial infection screening with in-house culture paddles (Figure 1) is an inexpensive option to screen all urine samples for bacterial infections. If growth is present on the culture media it can be sent to the laboratory on the paddle for identification and antibiotic sensitivity. Genetic BRAF mutation testing is not available in cats as it is with dogs for transitional cell carcinoma. Neoplasia may be diagnosed on urine cytology and may require traumatic catheterization for a diagnostic sample. Fine needle aspirate of a bladder mass is possible, but discouraged due to the possibility of tumor seeding into the abdomen. Although rare, fungal agents can also affect the immunocompromised patient3 and urine antigen testing may be recommended. Imaging is often required to obtain a clear diagnosis and may include use of ultrasonography, radiography, and/or cystoscopy. Ultrasonography can be a quick and useful tool to evaluate the bladder wall and contents, including cystoliths (Figure 2), blood clots, or masses. The most common cause of an extensively thickened and irregular hypoechoic bladder wall is cystitis. A thickened and irregular bladder wall may also be associated with calculi, necrotic debris, or blood clots. Ultrasonography is also helpful to diagnose pseudomembranous cystitis,4 vesicourachal diverticulum, and masses such as transitional cell carcinoma (Figure 3), lymphoma,5 or fungal granulomas.6 Radiography can be used to rule out lower urinary tract pathology; however, radiolucent stones may be missed. First obtain survey abdominal radiographs without contrast. Positive-contrast cystography using an iodinated contrast medium with a total dose of 6-12ml/kg of a 10 percent solution can be used to evaluate position of the bladder or rupture. Negative-contrast cystography is achieved by introducing 6-12ml/kg of gas (air, CO2, or NO) to improve visualization of the bladder, but is least effective in identifying bladder wall pathology. Double-contrast cystography involves introducing air and a water-soluble iodine contrast solution to diagnose a bladder rupture, mass, vesicourachal diverticulum, or pseudomembrane. A urethrogram should also be included in the study to rule out urethral tear, stenosis, and radiolucent urethroliths. Methods for this are outlined in most radiology textbooks.7 If orthopedic disease is suspected, radiography of the hips, vertebrae, and limbs are indicated. Arthritis and hip dysplasia are important to rule out as a source of pain leading to litter box avoidance or stress-induced disease. Cystoscopy is available at some facilities for treatment and diagnosis of LUTD. A rigid scope is used for female cats to obtain biopsies, examine the urethra, ureteral openings, and bladder wall, and remove small stones.8 A 1.2-mm semi-rigid scope can be used for males for visualization; however, sampling abilities, and availability may be limited. Surgical biopsy of the bladder is a useful diagnostic tool when the aforementioned diagnostics are inconclusive. When neoplasia is suspected and fine needle aspiration is nondiagnostic or not ideal due to concerns of tumor seeding, a surgical biopsy sample can be obtained. Care should also be taken during surgery to prevent tumor seeding within the abdomen. Submission of a surgical biopsy sample for culture and antibiotic sensitivity may be helpful to rule out a mucosal bacterial infection not found on routine urine culture. Treatment Figure 3: Transitional cell carcinoma in the urinary bladder of a cat. Photo courtesy Nicole Martell-Moran All practitioners have go-to practices treating LUTS in cats. The following represents my usual management progression. Acute disease: Address the acute disease first. Relieve the obstruction if present and re-establish hydration. For pain management, also consider a combination of a nonsteroidal anti-inflammatory (NSAID) as well as opioids. My usual protocol includes use of buprenorphine 0.01-0.03 mg/kg oral transmucosal every eight to 12 hours, and robenacoxib if the patient’s renal function is not compromised. If the patient’s pain level is high and otherwise healthy, this may be preceded by an injection of buprenorphine 0.24 mg/kg SC every 24 hours before then transitioning to the oral dosing. Gabapentin 5-20 mg/kg PO every eight to 12 hours may also be useful for neuropathic pain and as an anxiolytic. If the patient is anesthetized, consider a sacrococcygeal epidural. If the cat has a urinary catheter in place, or has evidence of infection, treat with antibiotics as indicated. Although controversial, in a patient with urethral spasms, use of an alpha-1 adrenergic receptor antagonist, such as prazosin, may be helpful to decrease contractility of urethral smooth muscle. For cats with neoplastic conditions, the acute treatment may also become the long-term management plan including an NSAID, opioids, and gabapentin whether or not surgical intervention is an option. Surgical intervention: A recent study demonstrated a partial cystectomy and use of NSAIDs for cats with Transitional Cell Carcinoma (TCC) significantly increased survival time.9 Tumor location and potential for ureteral or urethral involvement needs to be considered in surgical planning. If an acquired macroscopic diverticula is identified that does not spontaneously resolve after treating LUTD,10 it may require surgical excision to remove a source of urine stasis. A congenital vesicourachal diverticulum should also be surgically excised and may go undetected if microscopic until increased intraluminal pressure stretches the diverticulum to become macroscopic.11 In the case of a cat with a urethral obstruction that cannot be relieved, an emergency perineal urethrostomy (PU) may be required. A PU is also indicated in patients with recurrent urethral obstructions that cannot be managed medically. Long-term management: Long-term management for non-surgical cases can take many forms and needs to be tailored to the client and patient’s individual needs. The best management plan is the one a client can stick to long-term. Topics to consider: Litter box: Cats usually prefer a low entrance litter box with no top, scoopable fine granule litter cleaned daily with a minimum of 1.5 in, of litter. The general rule is one box more than the number of cats in the environment, in a quiet location, at different ends of the house. Medically managing stress at home may include nutraceuticals (e.g. Zylkene, NutriCalm, Composure treats), selective serotonin reuptake inhibitors (e.g. fluoxetine) or tricyclic antidepressants (e.g. amitriptyline), calm diets, and pheromones. Environmentally managing stress may include increasing food hunting behavior (i.e. puzzle feeders or hiding food), increasing territory size (e.g. adding a catio, wall shelving, or tall cat tree), introduce more play time, address inter-animal stress, negative relationships with people in the house, and allow for appropriate scratching surfaces. Playing cat-specific music may be helpful especially in times of anticipated stressful events.12 Diet will play a role in management as well, and should consist of mostly or all wet food. Increasing dietary water intake is essential to the prevention of LUTD, especially in neutered males. The addition of water fountains can be helpful, giving low sodium chicken broth, ice cubes in water dishes, or adding warm water to wet food. Prescription urinary diets are helpful in magnesium ammonium phosphate (struvite) urolithiasis dissolution and should be continued long term if the patient cannot be on a mostly or all wet food diet. In the literature A recent study published demonstrated partial cystectomy and NSAID therapy provided the longest survival time for cats with TCC when compared to no treatment or NSAID use only.9 Less common causes for cystitis in cats reported in the literature include: cystitis glandularis,13 Aspergillus sp.14 and Penicillium sp.6 cystitis, encrusting cystitis secondary to Corynebacerium urealyticum infection,15 and pseudomembranous cystitis.4 Recent reports on treatment options showed there was no difference in the number of days with cystitis signs for cats treated with oral glucosamine compared to controls,16 however, intravesical glycosaminoglycans used in patients with obstructive cystitis may help reduce immediate recurrence.17 One study found no clinical benefit to adding two weeks of low-dose meloxicam to prevent re-obstruction.18 To date. there have been no studies on use of robenacoxib for cystitis, but this may also be considered. Use of an anti-inflammatory dose of prednisolone showed no difference in resolution of cystitis signs compared to placebo19 and the same was found for pentosan polysulphate.20 There was a significant reduction in lower urinary tract signs (including territorial marking) in cats using multimodal environmental modifications and should be used in long-term management.21 A study evaluating risk factors for cystitis in Norwegian cats corroborates the theory that stress is a significant factor. Affected cats in this study were also more likely to be overweight and have a nervous disposition compared to controls.22 Treating cystitis with a synthetic feline facial pheromone (FFP) has been explored. A pilot study in 2004 found there was no statistically significant difference when using an FFP to manage cystitis; however, the trend was that length and severity of disease was positively affected.23 A systematic review in 2013 also found no significant evidence an FFP positively affected the treatment of cystitis.24 Lower urinary tract signs in cats can be frustrating if a primary curable disease process is not found and will require commitment on both the owner and veterinarian’s part. Ultrasound is the most useful tool in small animal practice to immediately visualize the bladder and its contents; however, if this is unavailable, radiographic cystograms can be helpful to rule out radiolucent uroliths, bladder rupture, mass, vesicourachal diverticulum, and pseudomembrane. Long-term management must involve attention to dietary moisture and stress management in the home. Clients need to be prepared their commitment and patience is essential to a successful outcome. Nicole Martell-Moran, DVM, MPH, DABVP (feline), is a graduate of Michigan State University’s College of Veterinary Medicine, the School of Public Health at the University of Minnesota Twin Cities, and is currently a boarded feline specialist with the Feline Medical Center in Houston, Texas. Dr. Moran has a special interest in imaging modalities to diagnose and manage chronic disease in cats along with incorporating environmental modifications based on the individual cat’s personality. References Kule E, Hartmann K, Reese S, et al. Recurrence rate and long-term course of cats with feline lower urinary tract disease. J Feline Med Surg. 2020; 22(6): 544-56. Buffington CAT, Westropp JL, Chew DJ. From FUS to Pandora syndrome: where are we, how did we get here, and where to now? J Feline Med Surg. 2014; 16(5): 385-94. Taylor AR, Barr JW, Hokamp JA, et al. Cytologic diagnosis of disseminated histoplasmosis in the wall of the urinary bladder of a cat. J Am Anim Hosp Assoc. 2012; 48: 203-8. Le Boedec K, Pastor ML, Lavoué R, et al. Pseudomembranous cystitis, an unusual condition associated with feline urine outflow obstruction: Four cases. J Feline Med Surg. 2011; 13(8): Penninck D and d’Anjou M (Eds.). Atlas of Small Animal Ultrasonography. 2nd Ed. Ames, IA: John Wiley & Sons Inc, 2015; 369-70. Soonthornsit J, Banlunara W, Niyomthum W. Penicillium species-induced granuloma in a cat resulting in chronic lower urinary tract disease. J Feline Med Surg. 2013; 15(12):1154-9. Real MIG. Atlas of Radiographic Interpretation in Small Animals. Zaragoz, Spain: Grupo Asís Biomedia SL. 2014; 30-7. Tams TR and Rawlings CA. Small Animal Endoscopy. 3rd Ed. St. Louis, MO: Elsevier, 2011; 507. Griffin MA, Culp WTN, Giuffrida MA, et al. Lower urinary tract transitional cell carcinoma in cats: Clinical findings, treatments, and outcomes in 118 cases. J Vet Intern Med. 2020; 34(1): 274-82. Osborne CA, Kroll RA, Lulich JP, et al. Medical management of vesicourachal diverticula in 15 cats with urinary tract disease. J Small Anim Pract. 1989; 30(11): 608-12. Osborne CA, Johnston GR, Kruger JM, et al. Etiopathogenesis and biological behavior of feline vesicourachal diverticula. Vet Clin North Am Small Anim Pract. 1987; 17: 697. Hampton A, Ford A, Cox III RE. Effects of music on behavior and physiological stress response of domestic cats in a veterinary clinic. J Feline Med Surg. 2020; 22(2): 122-8. Agut A, Carrillo JD, SolerM, et al. Cystitis glandularis in a cat. J Feline Med Surg. 2013; 16(4): 363-5. Adamama-Moraitou AA, Paitaki CG, Rallis TS, et al. Aspergillus Species Cystitis in a Cat. J Feline Med Surg. 2001; 3(1): 31-4. Briscoe KA, Barrs VR, Lindsay S, et al. Encrusting cystitis in a cat secondary to Corynebacterium urealyticum infection. J Feline Med Surg. 2010; 12(12): 972-7. Gunn-Moore DA, Shenoy CM. Oral glucosamine and the management of feline idiopathic cystitis. J Feline Med Surg. 2004; 6(4): 219-25. Bradley AM, Lappin MR. Intravesical glycosaminoglycans for obstructive feline idiopathic cystitis: a pilot study. J Feline Med Surg. 2013; 16(6): 504-6. Dorsch R, Zellner F, Schulz B, et al. Evaluation of meloxicam for the treatment of obstructive feline idiopathic cystitis. J Feline Med Surg. 2016; 18(11): 925-33. Osborne CA, Kruger JM, Lulich JP, et al. Prednisolone therapy of idiopathic feline lower urinary tract disease: A double-blind clinical study. Vet Clin North Am Small Anim Pract. 1996; 26: 563–9 Wallius, BM, Tidholm, AE. Use of pentosan polysulphate in cats with idiopathic, non-obstructive lower urinary tract disease: a double-blind, randomised, placebo-controlled trial. J Feline Med Surg. 2009; 11: 409–12. Buffington CAT, Westropp JL, Chew DJ, et al. Clinical evaluation of multimodal environmental modification (MEMO) in the management of cats with idiopathic cystitis. J Feline Med Surg. 2006; 8(4):261-8. Lund HS, Sævik BK, Finstad ØW. Risk factors for idiopathic cystitis in Norwegian cats: a matched case-control study. J Feline Med Surg. 2016; 18(6): 483-91. Gunn-Moore DA, Cameron ME. A pilot study using synthetic feline facial pheromone for the management of feline idiopathic cystitis. J Feline Med Surg. 2004; 6(3): 133-8. Frank D, Beauchamp G, Palestrini C. Systematic review of the use of pheromones for treatment of undesirable behavior in cats and dogs. J Am Vet Med Assoc. 2010; 236(12):1308-16.
