Feline lower urinary tract disease (FLUTD) is used to describe any condition affecting the urinary bladder or urethra in cats- the lower urinary tract (LUT). It affects around 1.5% cats presenting in primary opinion clinical practice [1]. FLUTD includes urolithiasis,  infection, anatomical defects, behavioural disorders and neoplasia. However, in the vast majority of cats – over 50% [2], no underlying cause can be identified; for these individuals the term Feline Idiopathic Cystitis (FIC) is used. The difficulties in diagnosing and treating FIC means that inappropriate urination is a major reason for cats being surrendered to animal shelters [3].

Clinical signs and presentation

The most common presenting signs of FIC are the same as for other LUT diseases- difficult or painful urination, abnormal frequency of urination, or urinating in unusual places. FIC is therefore a diagnosis of exclusion, including primary behavioural disorders. The term ‘cystitis’ is actually misleading- no inflammatory response of significance is seen in the bladder of these cats [2]. In addition it is now accepted that cats suffering from FIC ‘syndrome’ have problems scoping beyond the LUT, and thus the term FIC is not accurately descriptive. The current understanding is that FIC is in part an ‘anxiopathy’ which affects other organ systems also, and results from chronic stimulation of the threat centers in the CNS [4]. However, this is unlikely the sole underlying cause.

Epidemiology and signalment

There does not appear to be a clearcut breed disposition towards FIC, it appears to vary according to geography and prevalence of the popular breeds kept [4]. That said, in USA Persians do appear at increased risk and Siamese at decreased risk [5]. This finding was echoed in a Swedish study [6]. Obesity, inactivity, nervous disposition and frequent changes of diet were found to be strongly associated with FIC [7, 8]. Middle aged males (4-7 years) are most commonly affected [9]. In addition cats with FIC have been found to be more likely to live in an apartment than a house, be part of a multicat household, only have access to non-clumping litter, and not have access to a high vantage point [10]. This supports the concept that risk of FIC is a combination of susceptible individuals exposed to provocative husbandry practices and environments.

Resolution and recurrence

In most cases the clinical signs of FIC resolve within 7 days with or without treatment [9].  However a large number of cats (<65%) will have more than one episode within a year [8]. In a small percentage of cats (15%), the clinical signs persist for weeks or even months, and these cats are defined as having chronic FIC (cFIC). Because the signs resolve so quickly, with or without intervention, any treatment given will seem beneficial. This emphasizes the importance of applying evidence based medicine when considering treatment options for cats with FIC. Medicating cats is stressful for them and so should be reserved for cases that truly warrant it.

Treatment strategies

In cats presenting with signs of FIC, thorough history taking is essential, encompassing the home environment and routines as well as clinical presentation. This enables identification of risk factors and helps exclude other differential diagnoses. The clinician can then make appropriate recommendations pertinent to the case.

1. Stress reduction

Multimodal environment modification (MEMO) effectively reduces signs of FIC in indoor cats [11]. MEMO involves instituting changes in the cat’s environment to reduce activation of the stress response system [11]. This includes human and other animal interactions, resource and diet management. The impact of these variables changes between cats and so the best approach is to enrich as many aspects as possible of the environment.

In all cases, an abundance of resources- toys, litter trays (clumping litter in a quiet location), watering stations, feeding, scratching and perching should be provided throughout the home. The general rule of numbers should be one for each cat in the household plus one extra. If there is an aggressive cat in the household, a belled cat safe collar can be used as a warning to more timid cats.

MEMO has been found to result in profound (p<0.0001) reduction in episodes of FIC clinical signs, with 75% of cats showing none in the 10 month period of study [11]. In addition, these cats showed significant decrease in other stress associated behaviours- fearfulness, respiratory signs and aggression.

2. Diet

There are several aspects to consider- nutrient content, moisture content (dry or wet), constancy of diet versus novelty and method of feeding may all play a role. The current recommendation is wet food is better than dry [12] [2] [13]. Clinical diets with micronutrients to support stress and urinary function are better than other standard diets [14]

Royal Canin Urinary S/O diets promote diuresis and encourage water intake; in addition, the high levels of long chain fatty acids EPA and DHA help modulate production of inflammatory mediators in the cell membranes of the bladder wall [15].

Royal Canin Calm food may also be an appropriate choice [16], containing both alpha-casozepine and L-tryptophan.

• • Alpha-casozepine is a milk-derived protein with proven calming responses noted in both humans and domestic animals.
  • L-Tryptophan is the amino acid pre-cursor of serotonin. Serotonin is a neurotransmitter and increased levels have been associated with sleep-revaluation and improvement in anxiety-related sign.

3. Feline facial pheromone (FFP)

The evidence for using synthetic FFP for cats with FIC is still being collected. In a syndrome that has no ‘cure’ a multimodal therapeutic approach is warranted to give the best possible chance of a positive outcome. Communication with owners is key to manage expectations.  Feline facial pheromone has a clear evidence base to support its use in anxiety-related behaviours. It has the additional benefit of environmental application via diffuser, minimizing stress of ‘treatment’ and also targeting all cats in the household- both the dominant bullies and their fearful victims.

4. Glycosaminoglycans

A defective GAG layer in the bladder may be implicated in the pathogenesis of FIC. Supplements on the market to support the GAG layer include active ingredients N-acetyl D-glucosamine and hyaluronic acid. Cystophan for Cats from the brand Protexin is an example of one such supplement; also containing L-tryptophan- administration is via a sprinkle capsule and avoids the stress of daily tableting.

However, there is little current evidence that daily oral tablets or injectable GAGs will reduce recurrence of FIC signs.

Conclusion

FIC is distressing for both the pet and the owner, and given the variety of predisposing factors, it is best to approach FIC on a case-by-case basis. MEMO must always be discussed with owners- and their individual situation and constraints considered. Diet, supplements and pheromone therapy, alongside environmental modification can bring relief and achieve the optimal outcome for everyone.

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References

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15. Parada, B., et al., Omega-3 fatty acids inhibit tumor growth in a rat model of bladder cancer. Biomed Res Int, 2013. 2013: p. 368178.
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Postdate: 3rd May 2020