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It's Like a Pandora's Box for Your Poor Pet

feline cystitis

Story at-a-glance -

  • Indoor cats are at risk for feline interstitial cystitis (FIC), which is inflammation of the bladder
  • FIC has been dubbed “Pandora Syndrome” because current research suggests it’s much more complex than a single problem (inflammation) with a single organ (the bladder)
  • After anatomic abnormalities and infections are ruled out, the standard treatment for kitties with FIC is to control pain and most importantly, eliminate environmental and metabolic stress

By Dr. Becker

Indoor kitties, unlike cats in the wild, seem to have an inordinate amount of urinary problems, which fall into the category of feline lower urinary tract disease (FLUTD). FLUTD describes a collection of conditions that affects the bladder and urethra of cats. Causes of FLUTD can include anatomic and behavioral abnormalities, cystitis, urinary tract infections, uroliths (stones), neoplasia (cancer), neurologic disorders and trauma.

Urinary tract disease occurs at about the same rate in males and females. Affected kitties are typically between the ages of 2 and 6, and have several things in common:

  • They use an indoor litterbox exclusively (meaning they rarely or never go outside)
  • They're fed a dry food diet
  • They don't get adequate exercise
  • They're overweight or obese
  • They're stressed by their environment

About half the cats that experience one episode of FLUTD will have a recurrence.

Feline Interstitial Cystitis (FIC)

One of the most common FLUTD conditions is bladder inflammation, or feline interstitial cystitis (FIC), also sometimes referred to as feline idiopathic cystitis. About two-thirds of kitties with FLUTD have this form of the disease.

If your cat is dealing with bladder inflammation, he may strain while urinating, and you may notice he's in and out of the litterbox a lot. This is because he's not able to completely empty his bladder in one visit. You may or may not see blood in his urine (sometimes it's visible, other times it's not) as a result of an inflamed and irritated urinary tract. Your kitty might also be in pain, in which case he may cry out while attempting to urinate.

More Than a Simple Bladder Problem

Recent research into FIC emphasizes the importance of stress reduction and environmental enrichment in treating cats with the disorder. In a 2011 study of 12 healthy cats and 20 cats with FIC, researchers observed that healthy cats behave as if they're sick when their routine is altered.1

For example, sickness behaviors like refusal to eat, vomiting and litterbox avoidance tripled in healthy cats whose routines were disturbed. Also of interest: The cats with FIC showed changes at the microscopic level that indicate they are hormonally and neurologically different than healthy cats.

The study suggests that cats with FIC experience significant symptom reduction in an enriched environment. In kitties with the disorder, symptoms improved by 75 to 80 percent when they were fed at the same time each day, their litterboxes stayed in the same location, and regular playtime was encouraged.

Veterinarian Dr. Tony Buffington of Ohio State University, an expert in the role of stress and disease in companion animals, believes FIC is part of a larger disorder that he has dubbed "Pandora syndrome."

"A name like 'Pandora' syndrome seems appropriate for at least 2 reasons," says Buffington. "First, it does not identify any specific cause or organ, and second, it seems to capture the dismay and dispute associated with the identification of so many problems (evils) outside the organ of interest of any particular subspecialty."2

What he's saying is that the disorder called feline idiopathic cystitis can't be accurately described as simple inflammation of a single organ (the bladder). Instead, it appears to be the result of a potentially wide range of problems that extend beyond the bladder and lower urinary tract.

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FIC Involves Complex Physiological and Environmental Factors

According to Gregory F. Grauer, DVM, writing for Today's Veterinary Practice:

"FIC appears to be associated with complex interactions among the nervous system, adrenal glands, and urinary bladder. Environment also appears to play a role in the pathophysiology and, in some cases, FIC is associated with clinical signs related to the gastrointestinal, cardiovas­cular, respiratory, nervous, integumentary and immune systems. These signs tend to wax and wane, similar to urinary signs associated with cystitis."3

Symptoms of FIC directly related to the lower urinary tract include increased permeability of the bladder lining and wall, as well as decreased urine output and frequency of urination caused by neutering of male cats, confinement, insufficient physical activity, insufficient water intake, dirty or poorly located litterboxes, aggression among cats in a multi-cat home, obesity, arthritis and perhaps viruses.

According to Grauer, when we look outside the lower urinary tract, cats with FIC have symptoms of increased tyrosine hydrolase in the brain, increased blood levels of noradrenaline, decreased cortisol levels after ACTH stimulation and increased uroepithelial paracellular permeability. All of these factors contribute to an elevated stress response leading to increased inflammation and decreased bladder and urinary defenses.

The role of stress in kitties with FIC isn't easy to quantify, but there's often a link between symptoms and recent events such as boarding, traveling, a new person or pet in the household, the use of pet sitters or even a change in the weather. Another stressor in homes with more than one cat is intercat aggression due to competition for food, litterboxes, space, etc.

Diagnosis and Treatment

FIC is a diagnosis of exclusion, meaning there are no abnormalities visible on x-rays or ultrasound imaging, and a urinalysis with sediment examination and culture and sensitivity testing rules out a bacterial infection. Kitties with FIC typically have sterile urine, so they do not require antibiotic therapy. Unfortunately, cats with FIC are often given antibiotics, and then when symptoms subsided within five to seven days, everyone assumes it's due to the medication.

However, since the vast majority (around 95 percent) of young cats with signs of FLUTD or FIC have sterile urine, when symptoms subside within a few days to a week, it has nothing to do with antibiotic therapy. It's simply the nature of the disorder that symptoms wax and wane. Controlled studies show that over 70 percent of cats with FIC also respond to placebo treatments.

Unnecessary antibiotic therapy has long-lasting, negative consequences to a cat's microbiome, and in turn, the overall immune system. I strongly recommend declining antibiotic therapy unless your vet has definitively proven (via culture) your cat requires it.

The treatment objective for cats with acute interstitial cystitis is to reduce stress and provide pain relief as necessary. I recommend people with cats prone to recurrent episodes have homeopathic Aconitum on hand and at the first hint of a problem begin homeopathic intervention (remedies vary depending on a cat's specific symptoms), as well as institute flower essences for bladder support and stress.

Stress Reduction and Environmental Enrichment for Cats With FIC

Environmental enrichment to reduce stress is an effective management tool for all kitties, especially those with FIC, and litterbox cleanliness is one of the most important pieces of the puzzle. Litterboxes should be cleaned frequently (scooped at least once daily and fully sanitized at least weekly).

They should be located away from noisy areas, and should give cats easy access to and from them so they don't feel trapped or unable to escape. It's also important to have the right number of boxes (one for each cat in the household, plus one extra), as well as the size and type of litter your cat prefers.

In a multi-cat household, especially, access to more than one source of fresh water and food will help reduce stress, avoid intercat aggression and increase water intake. It's also important that food and water stations are in safe, secure locations. In the wild, cats not only hunt prey, they are prey for other animals. They feel most vulnerable while eating, drinking or eliminating. This vulnerability creates stress when your cat's food dish or litterbox is in a noisy or high-traffic area.

Increased interaction between you and your kitty with FIC may also reduce her stress. Petting, grooming and play that stimulates hunting behaviors may help. Increasing your cat's access to private areas is imperative, especially if there are other pets in the home. Kitty needs her own resting place and a hiding place (sometimes these are the same spot) where she feels untouchable.

It's also important to realize that introducing a new cat to the household is one of the biggest stressors for kitties already in your home, and it can trigger or exacerbate FIC. If your feline housemates are enemies, it's important to take action, and you can find guidance in my recent article on how to stop cats from fighting.

I have also had good success managing anxiety-based physical ailments in kitties with Solutions flower essences. I also suggest using Feliway pheromone spray for multi-cat household with tension, and homeopathic remedies for specific symptoms.

Last but not least, if you're still feeding kibble, I strongly encourage you to transition your kitty to a high-quality canned diet, and then to a fresh food diet. Studies show that moisture-rich diets help reduce the symptoms of FIC. In fact, this is often the most important piece to this frustrating puzzle, along with supplements that help build bladder defenses, including MSM, glucosamine, probiotics and several blends of herbs.

In my experience, a nutritionally balanced, species-appropriate fresh food diet can actually prevent many cases of lower urinary tract disease in kitties because it eliminates dietary and metabolic stress. Choosing foods free from synthetic nutrients, colors and rendered additives, GMOs, as well as minimally processed foods (to avoid feeding AGEs and acrylamides found in all extruded kibble) can also help reduce digestive, and in turn, immunologic stress.

Offer your cat fluoride- and chlorine-free, fresh, filtered water from glass or stainless steel bowls. Consider creating a quiet, ultra-low stress zone for your feline friend, including a room with natural sunlight (no LED lighting), no electrical equipment or routers emitting EMFs, with an optional dark hiding spot to snooze in during the day.