Complex interaction of local bladder factors and abnormal neuroendocrine function.
Picture courtesy of Mr James Kyffin – Protexin Veterinary (adapted).
CASE REPORT – MR BLU WITH FELINE IDIOPATHIC CYSTITIS
Feline Idiopathic Cystitis (FIC)
What is it?
FIC is a painful condition of the bladder with inflammation and bleeding of the bladder wall, where no other primary cause can be found to explain the inflammatory process. Why it occurs in some cats is not fully understood yet, but it has been extensively researched, particularly as there are many similarities to a human condition called Interstitial Cystitis, a.k.a. Bladder Pain Syndrome, that mostly affects women.
It is probable that FIC is part of a syndrome, with interactions between local abnormalities of the bladder, and dysfunction of the nervous and hormonal systems. Often cats with FIC may suffer other stress-related illnesses, including disorders of the skin, gastro-intestinal system, respiratory system and behaviour, but cystitis is the most common manifestation of stress-induced disease in cats.
What are the clinical signs of FIC?
FIC cannot be differentiated from other causes of (feline) lower urinary tract disease (FLUTD).
All causes of FLUTD can cause some or all of the following:-
- Straining to pass urine
- Blood in the urine
- Urinating outside of the litter tray
- Frequent attempts to urinate
- Vocalising when urinating
- Over-grooming, especially around the genital area, or the tummy
- Behavioural changes, anything from being withdrawn to being aggressive
- Potentially a complete blockage of the urethra (the tube conveying urine from the bladder to the outside) – THIS CAN BE A LIFE-THREATENING EMERGENCY
FIC is by far the most common cause of FLUTD. Other causes include bladder stones, urine tract infection and cancer (see figure 2).
Why do some cats get FIC and others do not?
Several factors have been identified that are linked to an increased risk of developing FIC, as listed below. There is also a strong likelihood that a cat’s start in life has an influence on the disruption of the nervous and hormonal pathways as described above. Kittens that have suffered adverse events when they are very young may not develop the correct balance and interactions between the brain and the pathways down to the bladder.
Factors associated with an increased risk of FIC:
- Between 4 and 7 years of age
- Cats fed only dry food
- Cats housed indoors only
- Cats living in multicat households
Not all FIC cases will tick all or any of these boxes- it can be seen in any type or age, breed or sex.
Because this condition appears to be multifactorial, a very holistic approach to dealing with cases is required.
Mr Blu’s case really emphasises how these multiple factors have to be considered. It also shows how our best intentions are often thwarted by cats’ stubborn natures!
Mr Blu’s predilection factors
- Prefers dry food
- Indoor only
- Troubled past – in and out of rescue centre and foster care, full life history not known
- Very nervous disposition
- Recently rehomed (3months)
Mr Blu’s presenting signs
- Frequent trips to the litter tray
- Only passing small amounts of blood tinged urine
- Urinating on owner’s bed
- Crying when urinating
Mr Blu’s Case Progression:
- Our first visit to Mr Blu was more akin to a zoo vet tending the wild animals. It was very apparent that any attempt to catch and restrain Mr Blu would end badly. He was so afraid and wound up. Considering the impact stress has with the condition we suspected, on balance we felt it better to have a more ‘hands-off’ approach. We observed him closely for some time, and vet Claire felt there was no indication of a urethral obstruction. Claire prescribed a double whammy of pain relief with meloxicam and gabapentin. The former is an anti-inflammatory, the latter acts on pain in a different way, and also acts as an anxiety-buster. A urine sampling kit was provided so his urine could be analysed.
- Once obtained, the urine sample showed lots of blood and inflammatory protein, but no signs of crystals (which can indicate there may be stones inside). It was cultured but only a contaminant bug grew, so this was ignored.
- Mr Blu seemed to get a bit better over a few days, but soon he relapsed.
Mr Blu’s investigations
Because of Mr Blu’s extremely nervous disposition, multiple visits to re-examine and try different tests and treatments were not going to be possible. Thus, we planned to do all the investigations required in one hit. Mr Blu was taken in to Whiteley Village Vets to undergo further investigations:
- Ultrasound of the bladder showed a very thickened bladder wall, and the presence of a dense structure within- with the risk of causing an obstruction
- Blood tests showed there was no kidney disease
- Radiographs – no obvious stones but not all stones show up on x-rays
- Bladder surgery performed – the dense structure seen on the scan was a large blood clot. The bladder wall was biopsied before a good flush through and closure. The biopsy result showed severe inflammatory changes, but no cancer, confirming FIC as the diagnosis.
Mr Blu’s treatments (and difficulties in giving them!)
- Right from the start Mr Blu decided to make our lives difficult! The first treatments prescribed usually go down a treat when mixed into wet food. However, Mr Blu refused to eat any wet food with the meloxicam or gabapentin powder in! He also refused the meds in Easypill putty, Lick-e-lix, cat soups, cream cheese, chicken, you name it! Nurse Emma advised to soak the meloxicam into his dry food, and we ordered in a special chicken-flavoured liquid form of gabapentin to do the same, and fortunately he took to this.
- After his surgery, the primary goals immediately post-op are sufficient pain relief, preventing him from licking the wound, and encouraging water intake. Obstruction at any point is still a real possibility and Ms W was counselled about this.
- Extra pain relief was provided in the form of a patch stuck to his skin, slowly releasing a potent opioid, fentanyl.
- On-going provision of meloxicam and gabapentin soaked into dry food
- A body dressing (Pet Med Shirt) was put on him post-op – its like a Baby-gro – to prevent wound licking, without the stress of wearing an Elizabethan collar
- Wet food continuously provided, although he still showed preference for dry, and multiple water sources were provided at home, including a water fountain, different types of bowls and flavoured waters.
- After the first week post-surgery, Mr Blu was doing well in general. His urine was still bloody for several days, but this was to be expected. The patch and the body-shirt were off, which he was much happier about.
- Now, long term management of the condition was to be addressed. The multifactorial nature of the condition requires a multifactorial approach to management.
- Diet – a special diet called Hills Multicare CD was recommended – this diet reduces the frequency and severity of recurrent FIC episodes. Fortunately, Mr Blu took to the diet well, but still preferred the dry over the wet (Honestly, does he not know what is good for him!!). Wet food was still offered as much as possible, with restricted amounts of dry food (mostly to get medication into him!). As Mr Blu was a bit portly as well- another FIC factor – the low-calorie form of this diet was used.
- Pain relief – the gabapentin was continued for a short while and the meloxicam was continued for a few weeks until he was not showing any signs of problems
- Environmental Modification. This was probably the most crucial aspect for his long-term recovery. Because FIC is a stress-related condition, it is of utmost importance to ensure his environment and ability to express his natural feline behaviour are optimised, so that stress is reduced. Although Ms W was a seasoned cat owner and had provided Mr Blu with everything a cat needs – cat tree for climbing, comfy beds, 2 trays, interactive toys and umpteen ping-pong balls (his particular favourite!), the majority of these resources were all close together in one room. This is fine for the initial period of rehoming a cat- to start with a smaller area, so that it is not quite as daunting for the cat, but now was the time to expand his world. During one of Mr Blu’s post-operative check-up appointments vet Claire and nurse Emma went through the house and made suggestions of things Ms W could do to optimise Mr Blu’s environment. She had already made plans to have a Catio built, and fortunately she is one of our favourite types of clients – she actually acted on ALL the advice we gave! Gold star for Ms W! Here are some of the changes and additions made:
- The cat tree was moved from the corner of ‘his room’ to near the window in the conservatory, a lovely place to perch and observe the birds outside
- Larger litter trays as Mr Blu is quite a large cat. A tray ideally should be 1.5 times the length of the cat’s body from nose to tail base, in length. Separating the two trays apart, placing one in a different room, and getting a third tray for the conservatory was advised – two trays together in one area will just be seen as one ‘latrine’ by the cat. Cats often prefer to urinate in one tray and defaecate in another, or may be very fussy about using a tray if there are any eliminations already there. Ms W was already scooping twice daily, and cleaning them regularly.
- Provision of more water resources in different areas – separating water away from food areas will encourage cats to drink more, and using water fountains as some cats prefer running water. The more water through-put the better – making his urine more dilute, and the more volume of urine in the bladder encourages complete emptying of the bladder when he urinates.
- Provision of more beds in the lounge, especially under a coffee table which he likes to hide under
- Provision of horizontal and vertical scratchers provided at key areas in the house
- Advice about how to play with Mr Blu and what sort of toys and games
- Provision of Feliway plug-ins can help reduce anxiety in some (not all) cats
- The plans for the Catio were in place too!
Mr Blu’s outcome to date
Mr Blu’s urination gradually returned to normal. The meloxicam was stopped. A urine sample was checked after a few weeks and found to be clear of blood, but still more concentrated than we would like for this condition. Ms W was advised to reduce the amount of dry food fed to encourage more wet food intake, she also added water to his wet food.
The catio was completed and furnished with tunnels, climbing and perching areas. Ms found that over time, Mr Blu was becoming more vocal, often meowing quite loudly. She was concerned there was something wrong with him, but vet Claire and nurse Emma studied some videos she sent of this behaviour- the conclusion – he was being a happy cat! Some cats are naturally quite vocal, now that Mr Blu was fully relaxed and coming out of his shell, his true nature was shining through. He was also more playful and slowly becoming more affectionate and tactile – instigating head bumps and strokes during play.
Mr Blu now seems to be a happy, environmentally-fulfilled cat. A word of caution – he will always be at risk of further FIC episodes. Stressful events may bring on an episode, but prior knowledge of this can prevent it – for example by using calming products or medications before a known stressful event.
How was Vet2Cat Home Visiting Service beneficial for this case?
- Initially, Ms W felt she wouldn’t even be able to get him in the carrier, as well as being aware of his extreme nervousness, she really did not want to put him through the carrier-car-vet experience. Even his two post-operative checks were performed at home.
- Vet Claire has advanced qualifications in feline medicine. There are many products out there marketed as supportive therapies for Feline Cystitis. Although giving them is not going to cause harm, and anecdotally some cats seem to improve on them, one has to balance any benefit these products may (or may not) have against the ease (or not) of giving them to the cat! A common go-to first line treatment for episodes of cystitis is antibiotics, but these are rarely required. Their use is not recommended unless indicated from urine culture results, and overuse of antibiotics can lead to resistant infections. Claire’s knowledge took all of these factors into account.
- Assessing the house enabled vet Claire and nurse Emma to provide individualised advice on environmental enrichment.
- Claire and Emma respected Mr Blu’s disposition, and always handled him in a feline friendly manner.