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Putnam North Animal Hospital
Feline Lower Urinary Tract Disease (Idiopathic)
The Basics 
Feline urinary syndrome (FUS), feline idiopathic cystitis (FIC), and feline lower urinary tract signs or disease (FLUTS/D) are interchangeable names given to the same cluster of urination-related symptoms that cats often display when they experience bladder problems. These symptoms include straining to urinate, frequent urination, blood in the urine, urinating outside the litter box, pain while urinating, and urinating small frequent volumes. The unifying theme in these symptoms and syndromes is that there is no infection, no bladder stone, no behavioral cause, and no identifiable defect in the urinary system. In other words, FLUTS/D is a disorder of inflammation and pain that makes urination uncomfortable for cats but that has no defined cause. It is a very common problem in cats.

A cat is known to have this disease when he/she shows some or all of the symptoms described above in the absence of all other urinary disease processes. Therefore, a series of tests is always necessary to try to identify other problems, such as a bladder infection or bladder or kidney stone, which might cause symptoms similar to FLUTS/D but which would require specific treatment (certain antibiotics, or stone-dissolving medications or diets, or even surgery) to alleviate an identifiable problem. Tests that are used for assessing urinary problems in cats include a complete blood panel, urinalysis, x-rays, urine culture, and abdominal ultrasound. When a cat has symptoms of urinary difficulty and these tests produce normal results, then FLUTS/D is considered to be the cause.

The characteristic problem of FLUTS/D is inflammation of the urinary bladder (cystitis). The protective mucous layer that lines the inside of the urinary bladder is deficient in cats with FLUTS/D, which allows the harsh chemicals of the urine to contact the deeper tissues of the bladder, causing irritation of the bladder wall. While much is known about the symptoms and characteristics of cats with FLUTS/D, the exact cause of the disorder remains unknown. In this manner, FLUTS/D is almost identical to a similar urinary syndrome, interstitial cystitis, which occurs in humans, especially middle-aged women.

Diagnosis
First and foremost, it is essential to determine if a cat with these symptoms has an identifiable and treatable disease that can be eliminated using appropriate treatments (antibiotics for a bacterial infection, diet therapy or surgical removal for stones, etc.). This requires the tests described above. Without these tests, inappropriate medications and unsuccessful outcomes (symptoms persist or worsen, adverse reactions to medications) are common.

Second, if the tests are negative, which confirms FLUTS/D (by exclusion), other potential causes of inappropriate urination need to be eliminated from suspicion. A simple and vital preventative step you can take is to make sure that the household has several litter boxes (one for each cat, plus one additional box) and that they are entirely cleaned daily. It can be useful to observe your cat urinate to make sure the cat squats (not standing and marking vertical surfaces) and to observe the volume of urination. Is the puddle the size of a quarter? Is it like a cup of water spilled? This information will be extremely useful to the veterinarian in assessing the possibility of FLUTS/D.

Third, a factor that is commonly felt to cause or worsen FLUTS/D is stress. This may be identifiable (construction in the home, recent move, a new baby, puppy, or kitten in the home), or it may be more subtle. Reducing and removing stress when possible will often help or even eliminate symptoms of FLUTS/D.

Finally, if the stress initiator cannot realistically be removed, then there are some medications that may be beneficial.
Often symptoms will resolve on their own within a few weeks, independent of any medication or changes in the home. The difficult problem is that symptoms often come back. Some cats can have a bout of FLUTS/D that lasts a couple of weeks and resolves on its own without treatment and never have a problem again. Other cats with FLUTS/D develop symptoms every couple of months and have problems for weeks on end each time. Your cat may be on either end of this spectrum of severity or somewhere in the middle.

Treatment
Increase water intake. Ways of encouraging cats to take in more water include: providing plenty of clean and fresh water sources; making sure that bowls are cleaned regularly and water is changed frequently (at least twice daily); providing a diet that encourages water intake (with s/o index) and wet cat foods; and providing a source of moving water (purpose-made cat water fountains or just leaving a faucet that is accessible to the cat to drip several drops per minute). The goal behind increasing water intake is to dilute the urine, which is less irritating to the inner lining of the bladder surface.

Psychological therapy involves identifying and reducing or removing stressors in the environment. Separating cats into different rooms of the home can be useful if the cats have a tendency to fight or don’t seem to get along. Providing a perch near a closed window so a cat can be distracted by the outdoors also can be helpful but can lead to other problems if outdoor cats frequent the area.

Hormonal or pheromone therapy can be of benefit in reducing stress. We like the product Feliway which has a diffuser for room use and spray for smaller area use. In addition, there are many natural stress relievers such as Rescue Remedy for pets. It is an herbal based therapy in which you give drops orally or add it to the water. It is always important to discuss with us what products you are considering using because even though these products are “natural”, they can have serious medical effects.

Joint products such as glucosamine and chondroitin supplements as well as PSGAG products (Adequan) have shown some promise in helping to decrease the inflammation in the bladder wall. This is because the mucous layer of the bladder lining and the protective fluid of the joints are very similar chemically. Use of glucosamine and chondroitin or Adequan therapy in cats with FLUTS/D shows some promise, but it is not a wholly curative therapy.

Non-steroidal anti-inflammatory drugs have been theorized to aid in cats with FLUTS/D by directly reducing the inflammation of the bladder and/or providing pain relief. A very limited number of these drugs is tolerated well by cats, essentially all by veterinary prescription only. Be careful to NEVER give an anti-inflammatory pill or syrup to a cat if it is a human medication; many of these are toxic to cats, and have been fatal with just one dose. Even prescription non-steroidal anti-inflammatory medications designed for cats may cause adverse side effects including gastrointestinal irritation, gastric ulceration, and kidney damage. These medications should be administered only after consulting with us, at appropriate doses, and with frequent recheck to monitor for signs of adverse side effects.

Anti-anxiety and psychotropic drugs are available for cats, and these also have shown some promise for treating FLUTS/D. These may be appropriate for some patients when other efforts to relieve stress and anxiety are unsuccessful. We will work with you to determine the best medication to try and monitor your pet’s response closely. Occasionally, some patients will not respond to one of the medications but respond well to another. Many of these medications can be compounded into a topical form that can be applied to your cat’s ear or other skin location. This way you do not have to force a pill down your cat every day.

DOs
Test for, and eliminate the possibility of, different urinary diseases that could produce symptoms that mimic FLUTS/D but actually are entirely different and require completely different types of treatments.
Try to make realistic and reasonable adjustments to your household to reduce stress.
Provide plenty of clean litter boxes.
Give an appropriate diet designed to help the urinary system (we can help you choose).
Try to increase water intake, provide clean fresh water, and wet cat foods.
Consider trying “de-stress” hormones or pheromones or natural herbal formulas as part of the treatment plan.
Consider glucosamine and chondroitin or Adequan supplementation.
Consider nonsteroidal anti-inflammatory therapy. Follow-up monitoring is important with these drugs.

DON’Ts
Don’t give up. Often, symptoms will resolve on their own and may never come back. Give your cat some time to heal.

When to Give Us a Call
Recurrence of symptoms.
If symptoms change (urinating larger volumes, foul-smelling urine, worsening signs of pain, etc.).
Signs of secondary side effects of medications including poor appetite, vomiting, diarrhea, and lethargy.

Signs to Watch For
We may ask you certain questions about what you see your cat do. Knowing the answer to these questions can be very helpful in determining the severity of FLUTS/D, or even whether an alternate cause is the problem instead.
How is your cat actually urinating? Squatting or standing? Small amounts or large? Blood? Odor worse than normal?
Where is the cat urinating? On the bed? In the laundry, etc.? In one particular place or all over the home?
When is the cat urinating? When you have guests? During the day or at night, etc.? This information can help with the initial diagnosis and, of course, is useful for monitoring how the problem is evolving—deteriorating or improving.

Routine Follow-Up
Follow-up should be tailored to the specifics of each cat. Some cats will need more frequent rechecks (for example, if taking daily medications). Others will respond quickly and will need few if any rechecks. We can provide guidelines for rechecks that are appropriate for your individual cat.