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Persistent bladder infections? This may be the hidden cause

Analysis by Dr. Karen Shaw Becker

pandora syndrome

Story at-a-glance -

  • Cats with persistent feline interstitial cystitis (FIC) may be suffering from Pandora syndrome, which is caused by chronic anxiety
  • Pandora syndrome can occur when a cat’s central stress response system is activated — this system responds “when an animal’s perception of threat exceeds its perception of control”
  • Helping a cat with FIC includes creating a refuge at home, advocating for fear-free veterinary visits and taking steps to avoid caretaker burnout
  • If your cat has recurrent FIC, it’s a good idea to keep specific natural remedies on hand to begin using at the first sign of a problem
  • Also important for these cats is litterbox cleanliness and location, resolving problems between kitties in multi-cat households, feeding an appropriate diet and hydration

If you have one or more feline family members, you may be familiar with the term feline lower urinary tract disease, or FLUTD, which is actually a collection of conditions that affects the bladder and urethra of cats.

One of the conditions under the FLUTD umbrella, and the most common, is feline idiopathic cystitis (FIC). About two-thirds of kitties with FLUTD have this form of the disease. Feline idiopathic cystitis is the technical term for inflammation of the bladder (cystitis) without a known cause (idiopathic).

Your cat's FIC may be the result of chronic anxiety

In many kitties, FIC or other chronic health problems seem to be secondary to a multisystemic disease pattern caused by chronic anxiety.

In 2011, Dr. Tony Buffington, a clinical professor at the University of California, Davis, School of Veterinary Medicine and emeritus professor at The Ohio State University College of Veterinary Medicine, published a study in the Journal of Internal Veterinary Medicine suggesting FIC is part of a larger disorder he labeled Pandora syndrome.1

According to Buffington, the disorder called feline idiopathic cystitis can't be accurately assessed as simply inflammation of a single organ (the bladder) with no identifiable root cause. Instead, it appears to be the result of a potentially wide range of problems that extend beyond the bladder and lower urinary tract. Affected cats can display symptoms related to several organ systems, including:

Lower urinary tract disease


Finicky eating


Excessive grooming



Other medical or behavioral disorders

When a kitty's central stress response system is activated, Pandora syndrome can be the result.

"This system, which incorporates elements of the endocrine, immune and autonomic nervous systems, responds when an animal's perception of threat exceeds its perception of control," writes Dr. Laurie Anne Walden in an article for veterinary journal dvm360.

"Animals respond to chronic stressors in different ways because of genetic factors and traumatic events (including those occurring prenatally) that sensitize the central stress response system to the environment."2

Diagnosing Pandora syndrome

Cats suspected of having Pandora syndrome should receive a complete physical exam and diagnostic tests to rule out other health problems. Buffington recommends that veterinarians investigate the main complaint last to lessen the chance of overlooking a condition that may coexist with the presenting problem.

Buffington uses questionnaires to evaluate a cat's health history and household environment to include adverse early experiences, stress-related behaviors and stressful environmental conditions. He has also developed a list of four criteria that support a diagnosis of Pandora syndrome:

  1. History of adverse experience (e.g. being orphaned or bottle fed, trauma, environmental instability)
  2. Evidence of comorbidities or additional sickness behaviors
  3. Clinical signs that wax and wane in response to changes in the environment
  4. Clinical signs that improve with multimodal environmental modification

The diagnosis is confirmed if all symptoms respond favorably to environmental enrichment.

Click here to find out Dr. Becker's top tips against seasonal pet allergiesClick here to find out Dr. Becker's top tips against seasonal pet allergies

Caring for cats with FIC/Pandora syndrome

Stress reduction and environmental enrichment must be a central feature of treatment protocols for kitties with FIC. "What these cats need more than anything," says Dr. Sarah Wooten, writing for veterinary journal dvm360, "is MEMO (multimodal environmental modification), more water, and dietary changes."3

Wooten created a handout for cat parents to help address the stress their kitties may be feeling when they're ill. She suggests taking the following three steps:4

1. Create a refuge at home — Convalescing kitties need someplace to hide and rest that's quiet, safe and warm. This location should be away from high-traffic areas — bedrooms are good — and contain all the things the cat needs: bed, food, water, a litterbox and favorite toys. Let your cat come and go freely, but if you have children or other animals, keep them out of this area so kitty can rest quietly.

I recommend the secluded getaway is free from WiFi routers, secondhand smoke, synthetic room sprays or other strong odors, and LED/ fluorescent lighting. A quiet, dark, calm space sets the stage for kitties to begin to feel secure in their environment. If your cat doesn't want to use the area, up the comfort level by spraying a feline pheromone like Feliway in her refuge, or add some treats, catnip or a piece of clothing that smells like you.

2. Happy vet visits matter — If your cat has a medical condition that requires frequent visits to the veterinarian, you should make every effort to work with your vet to make the visits less stressful. If kitty's getting poked with needles, there's only so much you can do to manage his anxiety, but here are some basic tips:

  • Leave the carrier out and open at home so he can investigate and get used to it
  • Take him for car rides in his carrier that don't end at the hospital
  • Give him special treats or toys that are reserved for the hospital
  • Try to schedule appointments for the least busy time of day at the hospital
  • Avoid loud reception areas or barking dogs by waiting with your cat in the car (temperature permitting), and asking to be called or texted when an exam room is immediately available

If your kitty gets really stressed out, ask your veterinarian about antianxiety medications or whether the practice team does home visits. Read here for more tips for fear-free vet visits.

3. Avoid caregiver burnout — Caring for a sick pet can be stressful. In addition, your sick cat may pick up on your stress, which is not healthy for either of you. If your kitty needs ongoing care, it's even more important to take care of yourself. You know how flight attendants ask you to put the oxygen mask on yourself before you assist others?

If you're feeling stressed taking care of your cat, talk to someone about it. Make time to do other things you enjoy, try not to stress about your cat, breathe and get plenty of rest. Read here for more recommendations for staying emotionally healthy while caring for a sick pet.

Additional recommendations for stress reduction and environmental enrichment

If your kitty is prone to recurrent episodes of FIC, I recommend keeping 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.

Calming herbs like ashwagandha and valerian can also be very beneficial, as can working with an Applied Zoopharmacognosy therapist who can help provide what your cat is seeking and needing throughout the healing process.

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 consumption. It's also important that food and water stations are in safe, secure locations. Increased interaction between you and your kitty with FIC may also reduce her stress. Petting, grooming and play that stimulates hunting behaviors may help.

As Dr. Wooten recommends above, increasing your cat's access to a private area 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. Creating a secure, outdoor sanctuary (via a catio) can dramatically reduce stress by providing natural environmental enrichment, fresh air and the ability for cats to ground themselves.

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 article on how to stop cats from fighting.

Last but not least, if you're still feeding kibble, I strongly encourage you to transition to a high-quality canned diet, and then to a nutritionally balanced, 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 and glucosamine, as well as proteolytic enzymes and several blends of herbs to naturally reduce inflammation.

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.