Feline lower urinary tract disease (FLUTD) and urinary obstructions (UO) are common medical reasons for cats to visit the veterinarian. FLUTD can be chronic and frustrating for cat owners. Urinary obstructions can be life threatening if the obstruction is not removed. Emergency veterinarian Dr. Christine Klippen talks about what to watch for at home and how your veterinarian can help.
Welcome, Dr. Christine Klippen
[00:01:05] Dr. Lancellotti: Welcome everyone to today’s episode of Your Vet Wants You to Know. I have a very special guest with me today, Dr. Christine Klippen, who is going to be talking about Feline Lower Urinary Tract Disease and Urinary Obstruction (FLUTD and UO). I’m very excited to have an expert on to talk about these important diseases that we see in cats, because I think it’s something that a lot of cat owners should be aware of. So thank you very much, Dr. Klippen, for being here today.
[00:01:31] Dr. Klippen: Thank you so much.
[00:01:32]Dr. Lancellotti: Tell us a little bit about yourself, your background, and why this topic is important to you.
[00:01:38] Dr. Klippen: I am an emergency veterinarian and I have been one for about 12 years. I work at a very large referral center in Washington DC, and unfortunately, this is a condition that I see walk through my door at least half a dozen times a week. Not a lot of people know about it, and it can be a potentially devastating (as well as frustrating) disease. So, I’m really pleased to be able to share a little bit more information, especially for some of the newer pet owners that are out there.
What is Feline Lower Urinary Tract Disease?
[00:02:11]Dr. Lancellotti: That’s great. Can you tell the listeners a little bit about what Feline Lower Urinary Tract Disease (FLUTD) and urinary obstructions are? Give us a look inside the body at what’s happening in these cats.
[00:02:25] Dr. Klippen: FLUTD refers to a bunch of different signs that we may see in a pet. We may notice straining in the litter box. An owner may notice blood in the urine of their pet, frequent small urinations, as well as inappropriate eliminations (urinating outside of the litter box). Whereas, a urinary tract obstruction is actually a potentially life-threatening condition where the urethra is blocked and will not allow the passage of urine.
[00:02:57] Dr. Lancellotti: For our listeners, let’s give a brief anatomy lesson of what we mean when we say urinary tract. What organs does that involve?
[00:03:05] Dr. Klippen: The urinary tract will consist of the kidneys, the ureters (thin little noodles that connect the kidney to the urinary bladder), and then when the urinary bladder contracts and empties, urine leaves the body through the urethra.
An "Umbrella" term for many conditions
[00:03:25] Dr. Lancellotti: What kind of different disease processes will cause FLUTD and UO?
[00:03:32]Dr. Klippen: There are actually a number of different disease processes that may be present causing the clinical signs. So, some of the things that people will automatically jump to are urinary tract infections, but we know that the actual incidence of urinary tract infections in male animals, as a whole, is actually pretty low. so it’s not usually the first cause. Other potential causes that we may see include crystals within the urine. It’s almost like having little diamond shards within the bladder that irritate it and cause that contraction and those clinical signs. We can see bladder stones (accumulations of some of those crystals that can block the urethra), but an overwhelming condition that we see, very commonly, is called Feline Interstitial Cystitis (FIC). This last category will actually represent almost 2/3 of all patients with urinary signs.
[00:04:35]Dr. Lancellotti: So, how are they going to know that it is Feline Interstitial Cystitis, rather than some of these other things like a urinary tract infection or bladder stones?
[00:04:48]Dr. Klippen: FIC is actually a diagnosis of exclusion. We run specific diagnostics to try to figure out a cause, and if we are not seeing evidence on our diagnostics, then we are usually left with the diagnosis of that FIC.
A Consequence of Chronic Stress
[00:05:12]Dr. Lancellotti: Why would you say FIC occurs in cats?
[00:05:16] Dr. Klippen: FIC is thought to be a result of a consequence of chronic stress in a cat. Stress can be from a number of different reasons (other cats, changes in the environment, etc). So, let’s say you’ve added new baby to the household, a new partner has moved in, you’ve moved to a new place, made changes to the diet- and this can happen even for those cats that have been hospitalized and gone home.
Charlie, who missed his owner.
[00:05:46]Dr. Lancellotti: Do you have any stories, of cats in particular, that were stressed for a certain reason, that wound up getting a urinary obstruction?
[00:05:55] Dr. Klippen: A number of years ago, I met this lovely little tuxedo cat named Charlie. He had a lovely little British owner. Charlie was quite the big cat. He was about 27 pounds. Obviously, food and his mealtimes were quite important to him. I was practicing, at the time (down south), they were never prepared for winter storms because they just didn’t happen. I remember there was a storm that occurred that shut down the city with ice and snow and the city didn’t have salt trucks, so the owner was unable to get home for a couple of days to see Charlie. And once she was able to make it home, Charlie thanked her by becoming urinary obstructed. Then, it became the added stress of her navigating these unsafe roads to get to me in the emergency room, where he ultimately spent the rest of the weekend with me and did just fine. But that was definitely a story that I remember because the owner was so lovely, and this cat was such a giant cat that missing a meal was quite stressful for him.
[00:07:15] Dr. Lancellotti: I bet. Poor guy. He must’ve been so hungry and (I’m sure) relieved when he was able to get back home eventually.
[00:07:21] Dr. Klippen: Yeah.
Signs of Urinary Obstruction
[00:08:31] Dr. Lancellotti: What are some changes that a pet owner might notice at home that would be concerning for a urinary obstruction?
[00:08:38]Dr. Klippen: Signs of a urinary tract obstruction can sometimes be really challenging. Sometimes, owners call and they’ll report that their pet looks like they’re constipated, so they look like they are straining to have a bowel movement in their litter box. They may vocalize, they may notice small frequent urinations in the litter box, blood in the urine. They may notice that their cat is licking their penis Sometimes, they may say that they’re not eating, they’re hiding, or even having pain with light touching of their belly, or if trying to pick them up.
[00:09:12]Dr. Lancellotti: Those are all really good things to watch for, but I know a lot of times, cats are very stoic and it’s hard for owners to tell.
[00:09:22] Dr. Klippen: Because it is so challenging, I will always tell people to be on the lookout. Making sure that you are cleaning the litter box on a daily basis. If you’re not seeing clumps of urine in a 12-18 hour period, then your index of suspicion should start to go up. If they are going in and out of the litter box with any signs of discomfort (the vocalization, straining, etc.), if pet owners notice that their cat has never sat and licked themselves (specifically licking of their penis or their perineal region), those are the red flags that something is going on and they should have them checked out.
Testing your Veterinarian may recommend
[00:10:06] Dr. Lancellotti: Once the cat is at the vet, what type of tests might be recommended, and what information would those tests give the veterinarian and the pet owner?
[00:10:16] Dr. Klippen: With either a urinary obstruction or even a suspected urinary obstruction, if we’re not quite sure just yet, the veterinarian may want to get a urine sample to look at the cells under the microscope (to look for signs of an infection, crystals, etc). They may do some blood work to see what their kidney values and what their serum electrolytes are doing. Sometimes, they may do some imaging of the abdomen, as well. They may try to take an x-ray or they may use an ultrasound to look to see if they see anything abnormal within the bladder.
Prognosis and follow up with no obstruction
[00:10:54]Dr. Lancellotti: If the animal does not have an obstruction, and we’re just looking at those FLUTD signs, what can the owner expect as far as prognosis? What’s the outcome for most of these cats?
[00:11:08] Dr. Klippen: The good thing is that FLUTD signs in a non-obstructed cat should resolve in about 85% of cats within about 2-7 days. Our goals of treatment are to attempt to minimize the discomfort of the condition and the potential risk for obstruction.
[00:11:32]Dr. Lancellotti: And how about if the animal’s not getting better within those 2-7 days?
[00:11:38] Dr. Klippen: If an animal is not getting better, then I do think that it is really important to reevaluate the diagnosis. I have seen, in my career, little stones that can be missed. And so, it may not necessarily be the first thing that your veterinarian may jump to (in regards to doing imaging), but again, if the signs are not improving, consider doing some sort of x-ray or ultrasound to make sure that you’re not missing something.
[00:12:07] Dr. Lancellotti: Yeah, I think rechecks are super important, especially if an animal’s not getting better. Communicating with the veterinarian and figuring out as a team what the next step is, so that the animal can improve, is going to go a long way towards making that animal more comfortable.
What if there is a urinary obstruction?
A hospitalized cat receives intravenous fluids to help remove built-up waste products from his bloodstream, and a urinary catheter allows urine to flow to relieve the obstruction.
Dr. Lancellotti: Now, once there has been a diagnosis of a urinary obstruction, what different treatment options are available for those cats?
[00:12:31] Dr. Klippen: So, treating the obstruction is, first and foremost, the most important thing that we’re going to do, because this is the life-threatening condition. Your veterinarian may recommend sedating these cats to pass a urinary catheter to relieve the obstruction. Some cats will receive intravenous fluids to dilute out those kidney waste products if they have elevated serum potassium levels. Some people will reach for antibiotics if their diagnostics indicate that there is an infection present, and then potentially antispasmodic medications that target the urethra to help with the discomfort associated with the disease.
[00:13:15]Dr. Lancellotti: You talked a little bit before about high levels of potassium and how that could affect the heart. Are there ways that’s monitored in these cats with urinary obstructions?
[00:13:26] Dr. Klippen: Yes. If we have patients that have really elevated potassium levels, there are medications that we can give them to help protect their heart. Sometimes, these types of patients are going to be hospitalized in a larger emergency facility, because they may need things like continuous ECG monitoring around the clock. If they are having any life-threatening difficulties in regards to blood pressure, they may be hospitalized in a little bit more of an intensive care unit.
[00:14:06] Dr. Lancellotti: And hopefully we don’t get to that point, but it’s nice to know that there are emergency facilities and critical care facilities that are able to provide that level of care for these really sick patients.
Environmental Factors for Chronic Lower Urinary Disease
Dr. Lancellotti: Let’s go back a little bit to the pets that don’t have a urinary obstruction. Let’s say they just have these signs of FLUTD, and they are still able to urinate, but it’s just not quite comfortable for them. How would you address treatment of those cats?
[00:14:33] Dr. Klippen: Most of the time, if we are presented with a cat who is not obstructed, I really want to recommend outpatient therapy, because we know that stress is a big component of the condition. So, getting these cats home to their own environment is really important. Specific treatment of cats with FLUTD is usually pretty multifactorial, and we may reach for things like medications to help control any sort of discomfort that they’re currently having, but we also may make recommendations on treating the environment as well.
[00:15:12]Dr. Lancellotti: Yeah, this is great. This goes back to the episode that we had with Dr. Harris, when she talked about inappropriate elimination in cats in the home, so I think this really ties in very nicely for making environmental modifications. She had mentioned in that episode, that Ohio State University has really good information on FLUTD, and I know you had given some information on Cornell University Feline Health Center has information as well. Can you talk a little bit about some of the different environmental modifications that pet owners might use to make the home more spa-like and less stressful for these cats?
[00:15:55]Dr. Klippen: One of the rules of thumb that we very commonly talk about is the litter box 1+1. What that means is that each cat in the home should have their own litter box, plus (an extra) one. In my household, I have 2 kitties, so consequently, I have 3 litter boxes. Some cats are very specific in regards to the types of boxes that they have, some cats don’t like covered litter boxes, and some cats don’t like litter boxes that have a heavy perfume smell to their substrate. Other things that are really important in the environment are allowing cats to do those cat-like things that they are used to. Having the ability to get up high and to potentially look out the window are stimulating their brains and stimulating some of those sensory modalities that they sometimes take for granted because cats are easy keepers. But, looking at it from your cat’s perspective- if you know that a neighborhood cat’s coming and peering in the window, maybe setting something up could prevent that cat from bothering yours. Looking at where you’re placing your litter boxes- so, if it’s next to a furnace that turns on at certain times a day, that might be scary. That will spook a cat and then they are correlating it with stress. If you are moving to a new house, giving cats the ability to have their own space and very slowly begin to explore can help prevent a stressful sort of change. One thing that has been recommended with a lot of my family veterinarians that I work with- let’s say you’re introducing a new baby to the household (because that can definitely be a sense of stress). Before the baby is coming home, taking some of the swaddled blankets that have touched the baby (the new scent) and bringing them into the environment, will give the cats the ability to introduce themselves to those smells before you have a new squalling beast in your home that is an interloper.
[00:18:18]Dr. Lancellotti: Give them a chance to adjust before their whole lives are turned upside down. Tell us a little bit about pheromones, because I use a lot of pheromones within my hospital and I think it’s really helpful for decreasing stress of pets when they come to see the vet. But how can pet owners use pheromones at home?
[00:18:38] Dr. Klippen: A lot of the pheromones that are out there, specifically (the one that we use in our hospital quite frequently) Feliway, can come in both a spray form as well as a plug-in, and these can be used in smaller rooms (especially the plug-ins). So if you have a small room, this can be put in there to give that sense of calm to these cats. If you are bringing a cat to the hospital, you can use the sprays on bedding and those kind of substrates. It doesn’t last as long as the plug-ins, but for some families who have high stress within their household, whether it’s inner-cat aggression or, lots of other things that could be going on, it’s just one more thing that they can use in their arsenal to try to help mitigate the level of stress that may be felt.
Health questionnaire for environmental modification
Questionnaire published in: Westropp, Jodi L., et al. “Chronic Lower Urinary Tract Signs in Cats: Current Understanding of Pathophysiology and Management.” VETERINARY CLINICS OF NORTH AMERICA-SMALL ANIMAL PRACTICE, vol. 49, no. 2, Mar. 2019, p. 187–+
Water and Diet are helpful
Image courtesy of Amazon
[00:19:37] Dr. Lancellotti: Overall, it sounds like there’s not just one thing that can be done to make these cats less stressed. There are a lot of different approaches, and often times, using multiple approaches will help to bring that stress level below the threshold where they start to get lower urinary tract signs. There is a handout in the notes to help pet owners evaluate their cats environment. You can go through and download that handout and look and see what is it that your cat is experiencing and how can you adjust things to lower their stress level. What about water? Do we have to do anything as far as changing their water or changing their diet?
[00:20:17] Dr. Klippen: I am a big proponent of cats having access to additional water sources. They make little fountains that will continuously circulate that will encourage cats to drink more. Some pet owners may decide to transition to canned diets as well, because my rule of thumb is “solution is always dilution.” There are some prescription urinary diets that are out there that your veterinarian may make recommendations for, especially if during those diagnostics they identified any types of crystals that were in the urine, because the goal of those diets are to help prevent those crystals from forming, and therefore hopefully, prevent a flare of that FLUTD.
[00:21:13] Dr. Lancellotti: I know for skin, with my specialty being dermatology, I see a lot of pet owners who try to change the diet around using over-the-counter diets in order to control the skin disease. Tell me a little bit about the use of over-the-counter diets for urinary tract signs. Is that something that may be helpful or do they need the prescription diet?
[00:21:33] Dr. Klippen: I really don’t believe that the over-the-counter urinary diets are able to change the pH enough to be able to have the cause that we’re looking for and I don’t think there’s been any sort of proven benefit of feeding those. So, yes, I think that the prescription diets are really key, especially, if they’ve been identified to have urinary crystals or be prone to those urinary stones again from the diagnostics.
[00:22:03] Dr. Lancellotti: So we want to use something that’s got some evidence-based research behind it.
Healthy Weight
Dr. Lancellotti: Tell me about weight. Is there anything that we can do as far as keeping these pets at a healthy weight that will change the possibility of this occurring?
[00:22:17] Dr. Klippen: A lot of our Feline Lower Urinary Tract kitties are considered overweight to obese. So when you look at the age group, as well as their body conditioning, a good majority of them are overweight to obese. Weight loss is very important for a number of different reasons, but may help decrease the incidence of having these flares in the future, so it’s good to have our kitties at a good acceptable body condition.
[00:22:51]Dr. Lancellotti: Yeah, this is just one of a number of different diseases that will benefit from having a cat at a healthy body weight, rather than being overweight to obese.
Relapse is Possible
Dr. Lancellotti: What other prevention strategies can pet owners take to help to prevent this from occurring?
[00:23:07]Dr. Klippen: FLUTD and urinary obstructions are super frustrating diseases. Unfortunately, there is no “cure” to prevent it from reoccurring again. As we talked a little bit about nutritional, we talked a little bit about water consumption, weight loss, treating the environment- these are all considered multimodal. So, there are lots of different approaches to try to keep the clinical signs to both, a minimum, as well as increasing that disease free interval.
[00:23:41]Dr. Lancellotti: So, if an animal has a urinary obstruction and it gets treated, how likely is it to recur quickly?
[00:23:50] Dr. Klippen: When they’ve looked retrospectively with controlled studies, they have found that the recurrence rate in these patients are usually within the first 7-30 days (pretty soon after being discharged from the hospital). Unfortunately, it can be as high as up to 25% in the first 30 days. So, even once an animal has been cleared to leave the hospital, really looking at the changes and some of the interventions that can be employed at home, will hopefully prevent further concerns in the future.
Medications for anxiety
[00:24:29]Dr. Lancellotti: know this has a lot to do with stress. Do you consider this to be a situation where using anti-anxiety medications might be considered?
[00:24:38]Dr. Klippen: I think that behavioral medications definitely have their place, but they may not necessarily be used for cats on their initial presentation. If we are having cats that, while addressing their environmental needs, don’t resolve their clinical signs, and we’re continuing to have flares, then this might be something that we consider. Personally, I had a cat for a number of years that needed to go on behavioral medications because it didn’t matter what I did to try to keep him in his little safe bubble. He would have little flares here and there, so I ultimately reached for behavioral medications. It did help, but it’s not usually my first go-to with these guys.
Feline lower urinary disease takeaways
[00:25:26] Dr. Lancellotti: So environmental modifications, make a stress-free environment, give them more mental stimulation, and then if things aren’t changing, consider adding on an anti-anxiety medication. What are some of the big takeaway points that you want pet owners to remember? If they have a cat at home that has had an episode of FLUTD, or has been obstructed before, what is it that they can take away from today’s episode?
[00:25:54] Dr. Klippen: FLUTD and urinary obstruction can be really frustrating diseases, both for cat owners, as well as veterinarians who are treating the disease. We hear you. I think that’s a really important aspect- that we hear your frustration. We feel for you and we’re empathetic to your concerns, as well as your cat’s concerns. Again, it comes down to a team-based approach. If your cat has been urinary obstructed or has had a flare of the FLUTD, I think vigilance is key, so these are the cats that I would second guess leaving by themselves to go away for a two or three day holiday. These are the ones that I would consider having someone (a pet sitter or a trusted family member) either staying in the home or checking in on their pets, because you never know what is going to be the trigger. The handout that I provided for this podcast gives us a lot of perspective from a cat’s eye view that we maybe wouldn’t have thought of previously. So, really looking at things from a cat’s perspective and seeing if you can make any sort of changes to limit the chance for a reoccurance.
[00:27:24] Dr. Lancellotti: That’s perfect. Those are all really great suggestions. I love it. Thank you so much, Dr. Klippen.
[00:27:28] Dr. Klippen: Thank you.
[00:27:30]Dr. Lancellotti: Many family veterinarians are comfortable managing cats that have had FLUTD and UO, but you can find the link to find a critical care veterinarian near you on the website, if you would like to consult with a specialist if your animal is hospitalized. You can also view the references for today’s show, as well as the handout to evaluate your cat’s environment in the show notes on the website. If you have had a cat that has had an issue with FLUTD or UO, I would encourage you to join the Facebook group, Your Vet Wants You To Know, so you can talk with other pet owners and tell us your experience. What’s worked for you, in making your cats environment less stressful? I’d love to hear you share those stories with other pet owners.
Scratching the Itch
Dr. Lancellotti: I always end each episode with a segment called Scratching The Itch. It’s a short segment that is designed to highlight something, either a human interest story, a product, or a website that just provides relief or makes you feel good. Hence, scratching the itch. And so I was wondering, Dr. Klippen, if you have something to share on our Scratching The Itch segment today.
[00:28:37] Dr. Klippen: I do. So, with COVID, and with us all being trapped at home and spending a lot of our time on our computers, as well as being in our environment with our pets a little bit more- if you don’t work outside of the home, a lot of people have really enjoyed these monthly subscription kits that you can find. Not only for themselves, but their pets. One of my colleagues came up with something that was what we, as veterinarians, may recommend for a new pet owner- a specific type of product. February is traditionally dental month and so she created a monthly subscription kit for products that were chosen by veterinarians for pet owners. And the name of her kit is Pawkit Vet. She can be found on Instagram, Facebook, and then she also has her own website that does have links to blogs for various health topics, as well, that dog and cat owners may encounter.
[00:29:51] Dr. Lancellotti: This is really adorable. I’m actually just looking at the website now, while you’re talking, and I love these boxes. There’s so many subscription boxes available. I always wonder like, what am I getting in there? Is it really worth it? Is this something that I trust for my pet? And I love that a veterinarian has actually taken the time to curate things that we recommend on a regular basis and they’re not prescription items, they’re just really good tools to have as a pet owner. This is fantastic. Thank you so much for sharing this and thank you for coming on and sharing all this great information with pet owners. I truly appreciate it.
[00:30:49] Dr. Klippen: Thank you so much for having me.
[00:30:51] Dr. Lancellotti: For all of our listeners, I look forward to your next visit with Your Vet Wants You to Know.
References:
- Westropp JL, Delgato M, Buffington CT. Chronic Lower Urinary Tract Signs in Cats: Current understanding of pathophysiology and management. Vet Clin North Am Small Anim Pract 2019 Mar;49(2):187-209
- https://www.avma.org/resources/pet-owners/petcare/feline-lower-urinary-tract-disease
- Feline Health Center at Cornell University: https://www.vet.cornell.edu/departments-centers-and-institutes/cornell-feline-health-center/health-information/feline-health-topics/feline-lower-urinary-tract-disease
- The Indoor Pet Initiative at Ohio State: https://indoorpet.osu.edu/cats
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