C.A. Tony Buffington, DVM, PhD, DACVN
The terms Feline Urologic Syndrome ("FUS") and Feline Lower Urinary Tract Disease ("FLUTD") were coined in the 1970s (FUS) and 80s (FLUTD) to describe the variable combinations of straining, hematuria, pollakiuria (frequent passage of small amounts of urine) and periuria (urinations in inappropriate locations) seen in cats with the disorder. No diagnosis for these clinical signs can be determined in approximately two-thirds of cats with LUT signs; so we refer to them as having feline idiopathic cystitis (FIC).
Based on recent research we believe that FIC may include multiple, complex abnormalities of the nervous and endocrine systems that likely affect more than just the bladder. Enhanced central noradrenergic drive in the face of inadequate adrenocortical restraint seems to be related to maintaining the chronic disease process. These systems seem to be driven by tonically increased hypothalamic corticotropin releasing factor release, which may represent the outcome of a developmental accident. Because of these abnormalities, treatment strategies that decrease central noradrenergic drive may be important in reducing signs of FIC; those that do not address this aspect of the disease seem to be less effective. Until more effective treatments to normalize the responsiveness of the stress response system are available, efforts to reduce input to this system by environmental enrichment seem reasonable.
Environmental enrichment is primary therapy for prevention of recurrence of FIC. This opinion is based on the documented neuroendocrine abnormalities suffered by cats with FIC, and on our clinical experience. Enrichment includes consideration of:
Cats prefer to eat individually in a quiet location where they will not be startled by other animals, sudden movement, or activity of an air duct or appliance that may begin operation unexpectedly. Although canned food may be preferable for cats with FIC due to the increased water content or a more natural "mouth feel", some cats may prefer dry foods. If a diet change is appropriate, offering the new diet in a separate, adjacent container rather than removing the usual food and replacing it with the new food will permit the cat to express its preference. Natural cat feeding behavior also includes predatory activities such as stalking and pouncing. These may be simulated by hiding small amounts of food around the house, or by putting dry food in a container from which the cat has to extract individual pieces or move to release the food pieces, if such interventions appeal to the cat. Also, some cats seem to have specific prey preferences. For example, some cats prefer to catch birds, while others may prefer to chase mice or bugs. Identifying a cat's "prey preference" allows one to buy or make toys that the cat will be more likely to play with.
Cats also seem to have preferences for water that can be investigated. Water-related factors to consider include freshness, taste, movement (water fountains, dripping faucets or aquarium pump-bubbled air into a bowl), and shape of container (some cats seem to resent having their vibrissae touch the sides of the container when drinking). As with foods, changes in water-related factors should be offered in such a way that permits the cat to express its preferences. Additionally, food and water bowls should be cleaned regularly unless individual preference suggests otherwise.
Litter boxes should be provided in different locations throughout the house to the extent possible, particularly in multiple cat households. Placing litter boxes in quiet, convenient locations that provide an escape route if necessary for the cat could help improve conditions for normal elimination behaviors. If different litters are offered, it may be preferable to test the cat's preferences by providing them in separate boxes, since individual preferences for litter type have been documented. For cats with a history of urinary problems, unscented clumping litter should be considered. Litter boxes should be cleaned regularly and replaced; some cats seem quite sensitive to dirty litter boxes. Litter box size and whether or not it is open or covered also may be important to some cats.
Cats interact with both the physical structures and other animals, including humans, in their environment. The physical environment should include opportunities for scratching (both horizontal and vertical may be necessary), climbing, hiding and resting. Cats seem to prefer to monitor their surroundings from elevated vantage points, so climbing frames, hammocks, platforms, raised walkways, shelves or window seats may appeal to them. Playing a radio to habituate cats to sudden changes in sound and human voices also has been recommended and videotapes to provide visual stimulation are available.
Some cats seem to prefer to be petted and groomed, whereas others may prefer play interactions with owners. Cats also can be easily trained to perform behaviors ("tricks"); owners just need to understand that cats respond much better to praise than to force, and seem to be more amenable to learning if the behavior is shaped before feeding. Cats also may enjoy playing with toys, particularly those that are small, move, and that mimic prey characteristics. Many cats also prefer novelty, so a variety of toys should be provided, and rotated or replaced regularly to sustain their interest.
Signs of conflict between cats can be open or silent. Signs of open conflict are easy to recognize; the cats may stalk each other, hiss, and turn sideways with legs straight and hair standing on end up to make themselves look larger. If neither cat backs down, the displays may increase to swatting, wrestling, and biting. The signs of silent conflict can be so subtle they are easily missed.
Because cats do not appear to possess distinct dominance hierarchies or conflict resolution strategies, threatened cats may attempt to circumvent agonistic encounters by avoiding other cats, by decreasing their activity, or both. Threatened cats often spend increasingly large amounts of time away from the family, staying in areas of the house that others do not use, or they attempt to interact with family members only when the assertive cat is elsewhere.
The signs of conflict can result from two types of conflict; offensive and defensive. In offensive conflict, the assertive cat moves closer to the other cats, and to control the interaction. In defensive conflict situations, a threatened cat will attempt to increase the distance between itself and the thing it perceives as a threat. Although cats engaged in either type of conflict may spray or eliminate outside the litter box, we find that threatened cats are more likely to develop elimination problems. The most common cause of conflict between indoor-housed cats that we have been able to identify is competition for resources.
Open conflict is most likely to occur when a new cat is introduced into the house, and when cats that have known each other since kittenhood reach social maturity. Conflict occurring when a new cat is introduced is easy to understand, and good directions are available from many sources for introducing the new cat to the current residents. Clients may be puzzled by conflict that starts when one of their cats becomes socially mature, or when a socially mature cat perceives that one of its housemates is becoming socially mature. Cats become socially mature between 2 and 5 years of age, and start to take some control of the social groups and their activities.
This may lead to open conflict between males, between females, or between males and females.
Treatment for conflict between cats involves providing a separate set of resources for each cat, preferably in locations where the cats can use them without being seen by other cats. This lets the cats avoid each other if they choose to without being deprived of an essential resource. Conflict also can be reduced by neutering all of the cats, and by keeping all nails trimmed as short as practicable. Whenever the cats involved in the conflict can not be directly supervised, they may need to be separated. This may mean that some of the cats in the household can stay together, but that the threatened cat is provided a refuge from the other cats. This room should contain all necessary resources for the cat staying in it.
Conflict with other animals, dogs, children, or adults is relatively straightforward. In addition to being solitary hunters of small prey, cats are small prey themselves for other carnivores, including dogs. Regardless of how sure the client is that their dog will not hurt the cat, to the cat the dog represents a predator. If the cat does not assert dominance over the dog, as often happens, it must be provided ways to escape at any time. For humans, it usually suffices to explain that cats may not understand rough treatment as play, but as a predatory threat.
Because of the dearth of controlled trials, it currently is not possible to prioritize the importance of any of these suggestions, or to predict which would be most appropriate in any particular situation. Appropriately designed epidemiological studies might be able to identify particularly important factors, after which intervention trials could be conducted to determine their efficacy in circumstances where owners successfully implemented the suggested changes.
Once environmental enrichment strategies have been implemented, additional treatments may be considered. In our experience, these approaches are more likely to succeed after the environment has been enriched to the extent possible by the client, and more likely to fail in the absence of environmental enrichment. They are listed in the order in which we consider them.
Feliway® a synthetic analogue of this naturally occurring feline facial pheromone, was developed to decrease anxiety-related behaviors of cats. Although not specifically tested in cats with FIC, treatment with this pheromone has been reported to reduce the amount of anxiety experienced by cats in unfamiliar circumstances, a response that may be helpful to these patients and their owners. Decreased spraying in multi-cat households, decreased marking, and a significant decrease in scratching behavior also has been reported subsequent to its use. Although, Feliway is not a panacea for unwanted cat behaviors or FIC, we have used it successfully in combination with environmental enrichment, and/or drug therapies.
We provide short term analgesic therapy in cases of an acute flare of signs as appropriate, and sometimes recommend pharmacotherapy in refractory cases after all previous recommendations have been instituted to the extent possible, because we have not found a drug that is more effective than environmental enrichment. Because the placebo response also may be mediated by reduction in this drive, differentiating placebo from drugs effects can be difficult. In most studies of human patients with interstitial cystitis, the placebo response rate is in the range of 50%.
Treating the owner
Finally, because decreasing central neural drive in the cat may require reducing the level of arousal of the owner to the situation, as has been reported in humans (parents and children). We try to follow recommendations for improving client satisfaction with our suggestions by attempting to ensure that they leave the encounter with us feeling that they:
1. Were listened to.
2. Received an explanation for the problem that made sense to them.
3. Felt care and concern being expressed by the caregivers and others in the clinic.
4. Left with an enhanced sense of mastery or control over the cat's illness or its symptoms.
Because FIC can be a chronic, frustrating disease, we have found that keeping these four points in mind when communicating with clients is beneficial for the client, pet, and clinician.
Many indoor housed cats appear to survive perfectly well by accommodating to less than perfect surroundings. The neuroendocrine abnormalities in the cats we treat, however, do not seem to permit the adaptive capacity of healthy cats, so these cats may be considered a separate population with greater needs. Moreover, veterinarians are concerned more with optimizing the environments of indoor cats than with identifying minimum requirements for indoor survival.
Further information about environmental enrichment and conflict are available at: http://www.nssvet.org/ici/