20 | How to manage those stressed-out bladder cats without getting stressed yourself!

PodcastRenalUrinary
Written By Laura Jones

What if your blocked cat doesn’t have a “real” reason for being blocked?!

 

If they’ve not got a stone, stricture, plug or mass… chances are they’ve got feline idiopathic cystitis, aka FIC. These cats account for more and more of the obstructions we see - with FIC now being the most common feline lower urinary tract disorder.

FIC cats can be really tough to manage as they’re often incredibly stressed, painful, and unhappy in the hospital - and often, we then discharge them to a home environment full of chronic stressors.

Today, we’ll discuss what causes FIC, the signs we see in these patients, and how we can best care for them—both in the hospital and at home.

Let’s start with some A&P…

Only a little bit, I promise. But if we’re going to look at how urinary diseases affect the bladder, we first need to look at how our bladder SHOULD function.

The urinary bladder is divided into 3 main sections - the apex, the body, and the neck. The ureters enter the urinary bladder near to the bladder neck, in an area called the trigone - a triangular-shaped region that sits at the junction of the urethra and urinary bladder.

How is the bladder structured?

The bladder wall is divided into several layers. From outermost to innermost, they are:

  • Adventitia: a fibroelastic layer housing blood supply, nerves and lymphatics

  • Detrusor muscle: a muscular layer that allows bladder contraction and voiding

  • Submucosa: formed of connective tissue; supports the mucosal layer

  • Lamina propria: formed of structural proteins, nerves and vessels, carries blood supply to the urinary epithelium and adjusts the shape of the epithelium as needed

  • Mucosal layer: contains urothelium, aka transitional epithelial cells; these stretch as the bladder fills with urine

  • GAG layer.

The glycosaminoglycan (GAG) layer covers the inside of the bladder wall. It serves as a protective layer, preventing bacteria from adhering to the bladder wall and acidic, waste-product-rich urine from damaging the urothelium and subsequently causing inflammation.

Beneath this GAG layer is the bladder lumen, which fills with urine as the bladder expands.

What is FLUTD?

Feline lower urinary tract disease is not a specific disease—instead, it’s an umbrella term used to describe several diseases that affect the urinary bladder and urethra in cats.

The most common cause of FLUTD is feline idiopathic cystitis, followed by urolithiasis, urethral spasms or mucous plugs, and other causes of obstruction. Less common causes of FLUTD include bacterial cystitis, urethral strictures, urinary tract neoplasia and primary behavioural conditions.

What is FIC?

FIC is an inflammatory disease of the lower urinary tract. As the name suggests, it is idiopathic and has no obvious underlying cause (e.g., bacterial infection, stones, or strictures). It is similar to human interstitial cystitis.

FIC is common, accounting for over 60% of all the FLUTD cases we see, and it can be obstructive (ie causing a blocked bladder) or non-obstructive in nature.

We don’t yet fully understand FIC and the exact cause is unknown. However, we do know that several abnormalities have been identified in cats with FIC, including:

  • An inappropriate physiological response to stress 

  • Changes to the neurons in the bladder 

  • Changes to the structure of the bladder wall - including depletion of the protective GAG layer that lines the bladder.

What causes FIC?

The changes we see in our FIC cats suggest that FIC results from complex interactions between the brain and the bladder. It also suggests that cats are more susceptible to developing FIC when they are exposed to stressful triggers or events, and these triggers can be acute or chronic in nature.

We’ve also identified several risk factors for developing FIC, and these include:

  • An inactive lifestyle

  • Decreased water intake (which results in urine being more concentrated)

  • Obesity

  • Limited outdoor access or no outdoor access

  • Having to use a litter tray indoors.

What signs do we see in these patients?

Spotting FIC based on clinical signs alone can be challenging because most conditions that affect the lower urinary tract cause similar clinical signs.

A good way to narrow down your differentials and get an idea of how urgent your patient’s condition is is to look at their signalment in line with their clinical signs.

For example, FIC is a condition that usually affects younger cats, whereas older cats generally get bacterial cystitis or conditions such as urinary neoplasia.

Male cats are more likely to develop FIC than female cats, and it’s generally seen more commonly in patients who fit into those risk categories we discussed earlier - indoor cats, overweight cats, and inactive cats.

The most common clinical signs we see are dysuria, pollakiuria, periuria and haematuria. Stranguria may also be reported, and if this is the case, we need to take further steps to ensure the patient is not obstructed since this would be a medical emergency.

Because stress plays a huge role in the development of FIC, we can also see other stress-associated disorders, such as overgrooming, lick granulomas, gastrointestinal signs and behavioural abnormalities - though we won’t always see these.

Collecting a thorough history is vital because we need to understand the complexities of the patient’s home life and how we can best help them in the long term. As well as asking questions about the patient’s urination and general health, we also need to know about the home environment, people and other animals in the home, conflict in the home, and the distribution of key resources in the home.

So you’ve admitted your patient. Now what?

Now that your patient is in the hospital, we need to get a diagnosis and begin managing them. If they’re obstructed, of course, prompt triage and then de-obstructing them is vital.

But if they’re not obstructed, or once the obstruction has been managed, we need to determine exactly what’s causing their urinary signs. FIC is, after all, a diagnosis of exclusion - we need to work through a list of urinary diseases to determine which is causing the patient’s signs or exclude them to reach a diagnosis of FIC.

Most commonly, we’re going to be ruling in or out:

  • Uroliths (stones)

  • Strictures (narrowing of the urethra)

  • Urethral mucous plug (an accumulation of proteins, cells, crystals and other debris)

  • Neoplasia

  • Urinary tract infection

Like many of our other medical conditions, we’ll do this through a combination of bloodwork, urine analysis, and imaging.

Let’s talk bloods and urine

Routine biochemistry, haematology, and electrolytes are usually performed to assess electrolyte balance and renal function and look for the presence of other systemic diseases. It’s particularly important in our obstructed cats, who are at risk of AKI and hyperkalaemia and is generally less useful in patients with FIC.

Urine analysis is going to be a really important diagnostic tool. We’ll likely perform a chemistry strip, specific gravity, sediment examination, and bacterial culture. We’ll look for evidence of crystalluria, pyuria, bacteriuria, and haematuria, along with any abnormal cells that could indicate urinary neoplasia.

Then it’s time to do some imaging

Imaging is really important in our lower urinary tract patients. Plain radiography can be used to detect uroliths (assuming they are radio-opaque). Contrast can be added to highlight radiolucent stones, strictures, or other abnormalities, as well as examine the thickness of the bladder wall. 

Ultrasound is another common imaging modality used in urinary patients. It allows us to examine the thickness of the bladder wall, identify masses or uroliths, and examine the upper urinary tract (kidneys and ureters) for any concurrent issues.

So we’ve diagnosed our patient. But what about treatment?

Well, the treatment we select will depend on the cause of the patient’s urinary tract disease. If they’ve got a bacterial UTI, for example, we’ll begin using appropriate antibiotics based on culture and sensitivity results.

If they have uroliths, we’ll either remove them (if needed) or manage them with a dissolution diet (depending on the type of urolith present).

Of course, if our patients are obstructed, they’ll need to be deobstructed, along with any AKI they have managed, as we chatted about in episode 19.

So, that leaves us with medical management for our FIC patients. These should be implemented regardless of whether your patient has obstructed or not, and they should encompass environmental adjustments at home, medical therapies, and potentially dietary changes as well.

Medical management - what are the options?

Medical therapies may not be needed for simple cases of FIC, but they are recommended in patients with obstructions or repeated, severe, chronic FIC episodes. Treatments used include:

  • GAG replacers: These replenish the depleted protective layer in the bladder lining. They contain glucosamine and hyaluronic acid, which are the building blocks of those GAG proteins, and some contain L-tryptophan (a precursor to serotonin) to reduce stress.

  • Analgesia: This is vital to improving patient comfort, minimising urethral spasm, and reducing bladder inflammation. Usually, opioids are given initially, followed by NSAIDs. NSAIDs are beneficial here to reduce bladder inflammation, but we need to first ensure the patient’s renal function is sufficient. So, if they’ve been blocked and have an AKI, hold off on them until renal function improves.

  • Antispasmodics/muscle relaxants: Drugs such as prazosin (a smooth muscle relaxant) or dantrolene (a skeletal muscle relaxant) have historically been used in cats with FLUTD. Whilst they can be useful in patients with urethral spasm, there is no evidence to support their use in patients with FIC.

Let’s talk nutrition

Dietary adjustments are also important in cats with urinary tract disease - but it’s not as simple as putting every patient with urinary signs on a urinary diet.

In FIC, increasing water intake is the most important nutritional (and non-behavioural in general!) factor. By making the urine more dilute, we can reduce bladder inflammation. So, ideally, consider getting your patient on a wet diet and using other techniques to add water intake on top.

We also know that overweight patients are at an increased risk of developing urinary signs, so we want to promote a healthy weight in our patients, too.

What about behaviour?

Behaviour and environmental adjustments are a vital part of treatment, especially at home. But there’s a lot we can do to support these patients in the hospital, too, including:

  • Minimising the sight, sound, and smell of other cats or patients in the hospital

  • Avoiding cats being able to see other cats - covering kennels, avoiding patients directly facing each other

  • Providing familiar resources (eg the same cat litter as is used at home)

  • Using gentle and minimal restraint

  • Using anxiolytics routinely in hospital

  • Using sedation early in challenging situations

Behavioural adjustments should continue at home, too. The veterinary nurse or technician is the ideal person to provide advice and support on this, working with the client to adapt their home environment to meet their pet’s needs and providing ongoing medical care at home. Areas to discuss include:

  • Resource distribution and number in the home

  • Appropriate litter tray facilities

  • How to predict and prepare for acute stressful events in the home

  • Increasing water intake at home

  • How to adjust to a new diet in a way that won’t cause food aversion

  • How to administer medications

  • What signs to look out for at home, including first aid advice in the event of an obstruction


So there you have it—the stress-free guide to managing cats with feline idiopathic cystitis! This can be a challenging condition, and these cats can be so stressed in the hospital that their ongoing monitoring and nursing care are difficult. But with a cat-friendly kennel setup, gentle handling, minimal restraint, and anxiolytics, we can make a huge difference to their well-being in the hospital.

And, of course, this care doesn’t stop at home - and whilst it can be difficult for clients to change things around at home, the support of a veterinary nurse or technician guiding them through it is invaluable. Not just for our clients but also our patients, who will be much happier in their homes.

Did you enjoy this episode? If so, I’d love to hear what you thought - screenshot it and tag me on Instagram (@vetinternalmedicinenursing) so I can give you a shout-out and share it with a colleague who’d find it helpful!

Thanks for learning with me this week, and I’ll see you next time!

References and Further Reading

Laura Jones
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