FLUTD - Cats Straining to Urinate, Owners Straining to Keep Sanity
It is a familiar situation; your beloved cat suddenly starts
to urinate on the carpet. Or a pillow perhaps? Boyfriend's favorite sweater?Knowing that at any minute our bodies might
meet that familiar cold wetness, we begin to lose sympathy fast despite the
fact that we know that our cat might not be able to help it. Perhaps our
thoughts even turn to options that we don't want to admit.
Inflammation of the bladder, also known as cystitis, is one
of the main causes of inappropriate urination. The nerves within the bladder
are designed to tell us when we need to pee. So when the bladder wall and its
nerves become inflamed, not only do we experience pain but also experience the
sudden urge to pee. This sudden and often distressing urge will occur despite
the fact that the bladder is often near empty. The nerves do not know how else
to process the inflammation. The constant straining to urinate enhances the
inflammation, and thus a spiral of disease begins.
The disorders associated with bladder inflammation (cystitis)
are grouped as disorder known as FLUTD or Feline Lower Urinary Tract Disorder. This
article will cover the various causes of FLUTD and then focus on the main
disorder of FLUTD which is also the most frustrating for owners.
Other diseases can cause inappropriate urination too. Some
of them include increases in urine volume (see Article: Drinking Too Much?),
neurologic or anatomic abnormalities, urinary incontinence and primary
behavioral disorders (true marking, etc...). It is not always easy to differentiate
FLUTD from these other causes, but in general the inflammation of the bladder
leads to small urine spots on the carpet and other horizontal surfaces. This
can help differentiate FLUTD from these other causes.Here we will focus on cystitis. Many cats
with cystitis are often thought of having behavioral issues. These issues may
even overlap. Addressing any underlying FLUTD can be an important step in
solving any behavioral issues.
While cats have lots of personality, it is not nefarious. When they urinate in places they are not supposed to they may be telling us something like "I need help" or "I am upset and in
discomfort" or that they just have to pee really, really bad. They are not doing
this out of anger.
What are the signs of FLUTD?
The signs of FLUTD all stem from the inflammation of the
urinary bladder. The rest of the cat is usually quite normal which can
sometimes lead to the suspicion that the cat is just 'doing it on purpose'. The
following are the signs of FLUTD. Please note that a cat suffering from FLUTD
may have one, two or all of the following signs:
Difficulty Urinating (dysuria) or straining to
This may sometimes look or even lead to difficulty
defecating (pooping). Sometimes inappropriate pooping can occur as the cat
tries so hard to pee. Thus some cats with FLUTD are mistaken as just being
Increased frequency of urination (pollakiuria)
You can see your cat using or trying to the
litter box, or your boyfriend's sweater more often than when the cat was 'normal'.
If your cat has a chronic problem with FLUTD,
then sometimes our first clue will not be inappropriate peeing but just
noticing that the cat is using the litter box more often. This can be
Blood in the urine (hematuria or haematuria)
This can sometimes show as a pink tinge
This may be a consistent finding or just
Crying or howling (vocalization)
They may cry as if in pain or trying to 'tell
This can also be a sign that a complete
obstruction of the urethra (tube that connects the bladder to the outside world
through the penis or exiting the vulva).
Inappropriate urination (periuria)
Sometimes the cat will do it right in front of
the owner as if they are trying to tell them something; and they are!
Complete obstruction of the urethra (Blocked
The urethra is the tube that connects the
bladder to the outside world. It ends at the penis or vulva.
This is a medical emergency. Cats with FLUTD,
especially male cats, are at high risk of this.
When obstructed, the urine builds up in the
bladder and will shut the kidneys down. This will be fatal if not quickly
addressed and treated.
Who gets FLUTD?
Any cat. However we will see it more commonly in young and middle aged (under 10 years of age) cats.
What diseases does FLUTD include?
As we talked about, FLUTD is not so much a disease as a
disorder that encompasses several diseases. The diseases causing FLUTD are:
FIC (Feline Idiopathic Cystitis)
Idiopathic is a fancy medical term for 'we don't
know'. We use it when a disease
exists, that we can describe and localize but do not understand its origin.
Thus FIC means bladder inflammation for reasons unknown. We do know some of the predisposing factors
as we will cover shortly.
FIC often includes 'urethral plugs' and urinary
crystals. Urethral plugs are small clumps that are made of crystals, protein,
inflammatory cells, etc... that can clot and obstruct the urethra.
In young cats (under 10 years) FIC is
responsible for 55 - 75% of all FLUTD cases.
Bladder stones form when crystals form within
the urine and coalesce into an actual stone. They can look and feel just like
pebbles you would find in a riverbed. There are several different types of
stones. Finding out which type is an important part in preventing recurrence.
This is actually a relatively rare cause of
FLUTD in young and middle aged cats.
Many cats are presented for 'signs of urinary
tract infection' and have antibiotics prescribed. Due to the often short cycles
of signs with FLUTD, cats will appear to 'respond' to the antibiotics and an
infection will be presumed to have been present. If we miss the presence of
FIC, we can not only delay addressing the real problem but also increase the
incidents of finding cat pee outside the litter box.
There are several types but luckily this disease
is not as common as the other types of FLUTD.
What tests do I need to figure out which FLUTD disease my cat has?
These are the typical tests used to evaluate a cat with
Urine Culture and Sensitivity
Urinalysis. The urinalysis will evaluate if the pet
has a disorder of increased water consumption, if the cat is not drinking
enough water, look for the presence of crystals, pH levels (which can help with
diet selection - see further down), presence of inflammation and more. While a
urinalysis can sometimes evaluate for an infection, this test can often be
ambiguous and a urine culture is recommended.
Urine Culture. A urine culture and sensitivity will
test for whether or not a urinary tract infection ispresent. It will
take the urine and try to grow any bacteria out of it. If a bacterium is grown,
then the bacteria is identified and usually tested against several different
antibiotics to facilitate the proper choice of antibiotic.
Radiographs (X-Rays) . X-Rays will evaluate for most
types of bladder stones and be able to rule out other problems such as abdominal
tumors, organ enlargement, kidney stones, etc... It cannot evaluate for bladder
Ultrasound. Ultrasound is superior to radiographs for
bladder evaluation as it can visualize all types of bladder stones and is a
great method to evaluate the bladder wall for cancer (X-Rays cannot do it).
Often times due to availability or cost, this test may not be initially used.
If you have access to it though, it is a great test.
Your veterinarian may recommend all or just a couple of
these tests. Your veterinarian may also recommend blood tests. Every case is
individual so I would recommend that if you have a veterinarian that is
familiar with FLUTD, follow their advice.
Let's talk about everything but FIC for a moment.
Why separate the other causes from FIC? FIC is a main cause
and unlike the others has a more complex management. Much of the frustration of
FLUTD is based solely on FIC. Have all the acronyms gotten you confused?Don't worry, it is confusing sometimes but it
will become clearer as we go on.
Bladder Stones. When bladder stones develop, they can
be very distressing. The most common treatment of bladder stones is surgical
removal of the stones. It is important to have the stones analyzed as the
mineral composition of feline bladder stones can vary. The most common are types
are struvite (magnesium ammonium phosphate) and calcium oxalate.
Infection.Urinary tract infections are rare in young and middle aged cats with
FLUTD. In US studies, it is reported that only 1-3 % of the cats with FLUTD
have urinary tract infection. Older cats (greater than ten years of age)
with FLUTD are much more likely to have infectious causes. Infections can also
accompany cats with bladder stones and cancer. To avoid unnecessary
administration of antibiotics and the missing of FIC, proper testing is
Bladder Cancer. While several types of cancer can
cause bladder tumors, the most common form is Transitional Cell Carcinoma.
Unfortunately this tumor is very aggressive. Referral to a veterinary
oncologist for workup and management is recommended. Luckily prospective
studies have shown that cancer accounts for less than 2 percent of the causes
FIC - Feline Idiopathic Cystitis
Again, FIC is bladder inflammation for reasons unknown and
it comprises the majority of the FLUTD cases. In fact, the two terms FIC and
FLUTD have sometimes been interchanged. The reason is (just to make this as
completely confusing as possible) that FIC has also been
referred to as 'Idiopathic FLUTD'; meaning that it is FLUTD without a known
cause such as stones, infection or tumor.
Another way of looking at this is that any cat with cystitis
that does not have bladder stones, an infection or cancer may be considered to
have FIC or 'Idiopathic FLUTD'. For some simplicity here, we will just call it
FIC and leave FLUTD to comprise all the causes of bladder inflammation. The
rest of this article will focus on FIC, its causes and treatment options.
Why do cats develop FIC? What causes it?
"Research over the last 30 years has failed to find a
consistent cause for the inflammation in these idiopathic cases. However, a
recent hypothesis suggests that FIC is seen when a susceptible cat is placed in
a provocative environment; and results from alterations in the cats nervous and
endocrine systems, leading to exaggerated arousal and inability to cope with
environmental stresses." - Daniella A Gunn-Moore. Professor of Feline Medicine,
University of Edinburgh.
While we do not know the exact cause of FIC, we do know many of
the factors that can make FIC worse. The following is a list of some
Stress, in any form.
Multiple cat households
Reduced exercise cats
Indoor litter box
Restricted access outside
Breeds: Persian, black and white domestic short
It occurs equally in males and females however
males are at much higher risk for the medical emergency situation of a complete
Autumn and early spring
This is not a reason not to neuter your cat! I
debated about taking this fact out for this reason but in the interest of being
thorough it was left. Being neutered alone is not enough to create FIC.
According to Dr Daniella A Gunn-Moore, "FIC is seen most
frequently in overweight male cats, often of a nervous predisposition, that
live in multi-cat households, and are fed dry cat food." Despite this, when we
look at the other possible scenarios, male and female cats appear to have
similar frequency of FIC. Also if you have a Siamese cat, then you will be
happy to hear that FIC is not commonly seen with them.
Complete Urethral Obstruction
One of the biggest concerns, besides the random peeing
throughout your house, is the complete obstruction of the urethra by 'urethral
plugs'. The formation of crystals (from diet, urine pH, infection, breed
predisposition, inflammation) and inflammatory compounds (proteins, mucoproteins, blood
clots, bladder cells, inflammatory cells) can combine together to form clumps.
These clumps can clog or 'plug' up the urethra. Since the male cat's urethra is
longer and narrower, especially at the end, males are much more likely to
By definition, cats with FIC, have a consistent level of bladder
inflammation and thus have inflammatory compounds released into the urine. This
inflammation can also affect pH may promote crystal formation. This is how
urethral plugs and crystals are intertwined with FIC and why FIC cats are at
risk for obstruction.
The moment the obstruction occurs, an emergency is present
and the longer it exists without medical care, the lower the chance of
survival. If the obstruction is handled quickly, the prognosis is usually good.
However, if the obstruction is not alleviated, the cat will die.
What if my cat gets obstructed? Your cat must immediately
(even if at 2 am) have a urethral catheter placed at a veterinary hospital.
Typically diagnostics testing and hospitalization will also accompany the
For cats with FIC, addressing and managing them quickly not
only will make your cat happy and you happy but may avoid an expensive and life
threatening obstructive event.
How do we treat FIC?
Increase water consumption.
Feed canned food. "Of all the treatments evaluated in a
controlled clinical study, the only one that has been associated with a
statistically significant improvement in clinical signs is feeding moist food." - Dr S. Dru Forrester.
As time goes on, more and more nutritionists recommend
canned cat food in general. First of all canned food has a higher water
content, leading to higher water consumption and a decrease in the
concentration of the urine. High urine concentration makes bladder inflammation
worse. Secondly canned food has a higher protein to carbohydrate ratio than dry
food. Have you ever eaten a protein bar? They are not that tasty. The reason is
that in a dry form, carbohydrates taste better than protein. That is why cereal
is made of carbs and not protein. Thus, in the interest of taste, dry cat food
(kibble) has a lower protein to carbohydrate ratio than many clinicians would
like for an obligate carnivore (an animal that must eat primarily meat) like a
cat.(Note: there is occasionally the opinion that
dogs are also carnivores because they are also in the same phylogenic Order
called Carnivora as the cat. However dogs are omnivores (diet consists of both
meat and plants) and not a carnivore. The Panda Bear is also in the Order
Carnivora.) There is also concern that dry food for cats might be a
predisposing factor for feline obesity and diabetes.
Part of what we love about cats is personality. Personality
also usually implies preferences and cats have lots of them! One of their
preferences is drinking quality water that is moving. Cats will prefer moving
water, like that out of a babbling brook or a kitchen sink. They also like
filtered water. Thus the use of a cat fountain with filtered water is
recommended. You can purchase cat fountains not only at pet stores, but often
at Walmart and Target as well as online.
Stress Reduction - "But my cat is the happiest, pampered cat ever! How could he be stressed?"
Domestic cats were domesticated from the African Wildcat Felis
silvestris lybica about ten
thousand years ago. Today, this Wild Cat holds a solitary territory of 3 km2.
You have a big house right? 3 km2 is approximately 500 acres!So when you put them in a house
or apartment and they will feel a little cramped all by themselves. Thus there
is a low level of 'crowding stress' which is present for all domestic cats.
Then add in a
second cat, and unlike dogs who share, cats will split the territory. There
will be imaginary lines drawn throughout the household. For this reason, behaviorists
recommend and 'Land of Plenty' and to achieve this recommend that the number of food bowls, water
bowls, litter boxes and vertical perches be one more than the number of cats.
Thus if you have 3 cats, it is recommended that you have 4 of each that are
equally spread out around the house. If you have four food bowls sitting next
to each other, this does not count; they are all considered to be in 'one cat's
territory' and the other cats eating on one of the cat's good graces. This can
be a little stressful despite however congenial they may act towards each
other. Think about living with some of your extended family on a permanent
basis in a smaller house or apartment. It might not appear to an outsider that
anyone was stressed, but how would you feel?
I know what you are
saying, "There is NO way I can have that many food bowls, water bowls and
litter boxes in my home!" Don't worry. This is an 'ideal' not a necessity. If
there is any evidence of cat stress, then you might consider adding in or
splitting up the location of food bowls, litter boxes, etc...
Another way of reducing stress is aroma therapy, and you
thought cats liked being pampered before!It might not exactly be aroma therapy but it
is similar; it is the use of a synthetic pheromone called Feliway, which is
made by Ceva Animal Health. This pheromone, F3, is one of several fractions of
the feline facial pheromone complex. Feliway "serves to decrease perception of
threat and increase a sensation of safety within the home." - Daniella A
Gunn-Moore. Professor of Feline Medicine, University of Edinburgh.
Feliway comes in two forms - a spray and a diffuser. While
the spray is useful for specific locations and situations, the diffuser appears
to work better in the management of multi cat households. Click here for the
official website: Feliway.
There are both prescription and over the counter diets that
are designed for cats with FLUTD. The over the counter brands will often state
something like, "For Urinary Tract Health" and will gear towards acidifying the
urine. Some diets will have increased salt content. This increase in salt is
designed to increase thirst and thus increase water increase. The feeding of a
high salt diet, especially on a long term basis, is controversial. Especially
in cats that might have disorders of the kidney, heart or have increased blood
The acidification of the diet and the mineral content,
particularly magnesium, is dependent upon the type of crystal that is primarily
being seen. "In the case of oxalate stones this includes feeding less
acidifying diets that are not magnesium restricted, while the opposite is true
for struvite stones." - Daniella A Gunn-Moore. Professor of Feline Medicine,
University of Edinburgh. Thus some basic testing with your veterinarian is a
good idea before we start changing pH
and magnesium levels.
One example of a prescription FIC food is Hill's Science
Diet c/d. It has moderate acidification and moderate magnesium restriction. C/d
also has vitamin B6 and potassium citrate to help inhibit crystal formation.
The addition of Omega 3 Fish Oils, specifically the DHA portion, helps reduce
bladder inflammation. For more information on fish oils, click here: Essential
Information on Essential Fatty Acids. It is important to know that Science Diet
preserves the vast majority of all of their foods with only all natural
preservatives using tocopherol (from soy beans, and is a source of vitamin E),
rosemary extract and citric acid. Eukanuba, Royal Canin and Purina also have
foods for FIC. In general I recommend prescription canned foods over the others
if your pet has FLUTD.
Whether using a prescription diet or an over the counter
diet, a canned food is preferred over dry. Unfortunately one study showed that
cats with FIC are three times more likely to prefer to eat dry food exclusively
than other cats.
No, this is not what you think. Put the duct tape down.Put it down... right now.
GAG stands for Glyco Amino Glycans. Yep, it is another big
word that is condensed into an acronym. We just can't seem to get away from
them. If it makes you feel better, I have left a few out.
GAGs are necessary for life in all vertebrate animals and
are used within the connective tissues, including the bladder. You might
familiar with a couple of them called Glucosamine and Chondroitin. These typically come from cow cartilage. As these
types of GAGs are also common in the connective tissues of joints, they are
often supplemented for people with arthritis or who are in high impact
activities like running.
Some people get a condition called Interstitial Cystitis or
Painful Bladder Syndrome IC/PBS. It is characterized by a lack or damage of GAG
layer in their bladder walls. It has some similarities to Feline Interstitial
Cystitis (FIC) and, for this reason, it is theorized that the disruption in the
GAG layer integrity of the cat bladder may have a role in FIC. While there have
been reports that the supplements may help, the only randomized controlled
clinical trial could not find that the supplementation helped. More study is needed to understand if GAGs
have a role in FIC.
Currently the following GAGs are being used in cats with
In the US it is only available in the human form
Glucosamine and chondroitin sulfate
A popular veterinary form is called Cosequin
which comes as a Sprinkle Cap which allows the owner to place the powder form
on top of the food
It is a precursor to GAGs such as glucosamine
It is sold as Cystease by Ceva Animal Health
As GAGs are nutraceuticals (medicinal extracts from food
sources) and the possibility of side effects is low, many people will try them.
If they work, they are usually safe for long term use. Some side effects of GAG therapy however do
include: prolonged bleeding times (difficulty clotting of the blood), loss of
appetite and possible insulin resistance.
Treatment of Urethral Spasm
With FIC and especially if the cat has had, or is at risk of
having (such as being male) a urethral obstruction the treatment of any muscle
spasms of the urethra can be helpful. The spasms, which occur from the
inflammation and or pain, involve the muscles around the urethra. They can be
very distressing to the pet. These medications may be
prescribed and sent home, or used while the pet is hospitalized for a urethral
obstruction or not used at all.
Some of the common antispasmotics are:
This is a common choice.
This is an antispasmotic for skeletal muscle,
whereas the other three work against smooth muscle spasms. The spasms seem to
occur in either the smooth and/or skeletal muscles around the urethra. Skeletal
muscle is under voluntary control (like the muscle you use to walk) and the
smooth muscles are under involuntary control like your small intestines.
TriClyclic Antidepressants TCA
This is another treatment type that comes from human therapy
for Interstitial Cystitis (IC). Like GAGs, TCA have been shown to have benefit
in people but the few studies that have been done in cats do not show
resolution of signs. Still, there have been anecdotal reports that
cats with FIC have benefited with these medications. It should be noted that
there have been no long term studies in cats and there is evidence that there
might be an increased risk of recurrence with these medication.
A few other things should be considered when using these
medications. Firstly, in their other uses the benefits of these medications do
not begin until at least four weeks of therapy. Also they can have a number of
side effects including urine retention and elevation of liver enzymes. On the
good note, they may also have the effects of increasing bladder capacity as
well as some anti-inflammatory effects for the bladder.
Common TCA used for FIC
Clomipramine (clomicalm - veterinary, Anafranil)
Pain medication and Anti-Inflammatory Drugs
By themselves, pain medications do not appear to be enough
to work by themselves on FIC. Some clinicians will use NSAIDs (non steroidal
anti inflammatory drugs) which are related to aspirin or celebrex but are safer
in cats. NEVER use human NSAIDs in a cat, they can be fatal. Discuss this medication
with your veterinarian before you decide to use it.
Morphine related drugs have also been used to reduce pain.
They do not reduce inflammation however but might be a good addition to the
treatment regimen if your cat appears to be in any pain.
Common Opiates (medications related to morphine)
Corticosteroids, such as prednisone, prednisolone, and
depo-medrol, have also been used for their anti inflammatory effect as well as
their ability to dilute urine. However, corticosteroids have been shown to be non-effective. As they can have side
effects, they should be used with caution.
Which Medication is best?
I would venture to state that stress reduction and a high
quality canned cat food are recommended in virtually every cat, with or without
FIC. The other therapies, including those not listed here, should be discussed
with our veterinarian to see if it is right for your pet. Occasionally
antibiotics might be warranted where infections have been properly documented. Furthermore, acupuncture and holistic
medications might also be available or recommended by your veterinarian. These
may be very beneficial in the area of stress reduction.
As I have stated in other articles, multi modality therapy
is often the key. By using multiple therapies, we can use less and rely less on
single therapies. Also, using multiple therapies may often have a synergistic
effect, meaning that some therapies work better together than alone.
FLUTD is Feline Lower Urinary Tract Disorder and generally
refers to disorders with bladder inflammation.
Causes of FLUTD
FIC Feline Idiopathic Cystitis
Most common cause in cats under 10 years of age
Urinary Tract Infection
Rare cause in cats under 10 years of age
Rare cause in cats under 10 years of age
Treatment Options for FIC
Increased water consumption
use of canned food
Create a 'land of plenty'
Both prescription and over the counter foods are
The goal of this article is to help shed some light on why a
young cat may have bladder inflammation which can lead to inappropriate
urination within the house. So many cats that have FLUTD end up suddenly being
shut out of the house or worse. Additionally some cats are also put on the
wrong medications, like a young cat with FIC on repeated courses of antibiotics
FLUTD is not only frustrating and difficult on us but also
the cats as well. For a cat to suddenly start urinating in the house there is always
an underlying cause. Remember, they love you as much as you love them and they
were used to using the litter box before. It is just a matter of trying to
figure out the "before what?"
So if your cat does have FLUTD, and you have survived
reading this article, then you have the understanding on what form of FLUTD
your cat might have, what tests you need, and if your cat has FIC you know what
medications to ask your veterinarian about.
Best of luck to you and your feline family members!
"Feline Lower Urinary Tract Disease
(FLUTD)-Cystitis in Cats" World Veterinary Congress 2008. Author: Daniella
A Gunn-Moore. Professor of Feline Medicine, University of Edinburgh.
"FLUTD: How Important Is It?" Western
Veterinary Conference 2007. Author: S. Dru Forrester. Hill's Pet Nutrition,
Inc. Topeka, KS, USA.
"Improving Your Diagnosis and Treatment of
Idiopathic FLUTD" British Small Animal Veterinary Congress 2007. Author J.
Lulich, DVM, PhD, DACVIM. Minnesota Urolith Center, Department of Veterinary
Clinical Sciences, College of Veterinary Medicine, University of Minnesota, St
Paul, MN, USA.
"Feline Lower Urinary Tract Disease (FLUTD):
Making the Most of Nutritional Management" Western Veterinary Conference
2008. Author: S. Dru Forrester. Hill's Pet Nutrition, Inc. Topeka, KS, USA.
"Common Misconceptions in the Diagnosis and
Treatment of FLUTD" AAFP Fall 2008 Meeting. Author J. Lulich, DVM, PhD,
DACVIM. Minnesota Urolith Center, Department of Veterinary Clinical Sciences,
College of Veterinary Medicine, University of Minnesota, St Paul, MN, USA.