A multimodal approach to feline house-soiling

Feline house-soiling is a complex matter. According to Tammy Sadek, DVM, DABVP (Feline), CEO of Cat Hyperthyroid Radioactive Iodine Services, LLC, in Grand Rapids, Michigan, and a member of the American Association of Feline Practitioners (AAFP) Board of Directors, the condition places a tremendous strain on the human-animal bond. “Unfortunately, sometimes the first time we hear about a cat house-soiling is when someone schedules a euthanasia appointment. This is something we want to avoid.” Sadek offered diagnostic and treatment recommendations for house-soiling during a session at the American Veterinary Medical Association Virtual Convention.

Drilling down on this subject can be difficult, Sadek warned. Clients may be too embarrassed to mention it, and some cats aren’t overtly sick. However, the issue can still be identified during regular wellness visits. That means the veterinary team needs to work closely with clients to recognize this issue and initiate successful management strategies.

Managing client expectations

Help clients understand from the outset the commitment needed to manage a cat with this issue. Certain cases can be resolved quickly by making simple adjustments, such as increasing the number of litter boxes, cleaning/scooping the boxes more frequently, changing the type of litter, or addressing a mobility limitation (eg, arthritis). However, a quick fix isn’t always possible. In these cases, the veterinary team can help set and manage expectations so the client doesn’t lose confidence in the process.

Multiple office visits may be required to address the issue, but telemedicine consults can be an attractive alternative once a medical evaluation has been performed, including a physical exam, urinalysis, urine culture, and sometimes imaging. Instruct the client to use video, webcams, and photographs to capture episodes and information.

House-soiling is frustrating and stressful, but helping clients understand the process can keep them motivated to help correct this problem.

Courtesy of Tammy Sadek, DVM, DABVP (Feline)

Approaching a diagnosis

Accurate diagnosis starts with asking the right questions. To open the conversation, simply ask at the beginning of each visit whether the cat is urinating or defecating outside the litter box. An affirmative answer allows for follow-up questions:

• When did the problem start?
• Have there been any changes in the home (eg, relocation, someone moving in or leaving)?
• How many other pets are in the home? What’s their relationship to the affected cat?
• Where are the incidents happening? What types of materials are being used (carpeting, porcelain, clothing, etc.)? Are they in frequently trafficked areas?
• Do the episodes involve horizontal or vertical surfaces?
• Are the “accidents” small volume or larger volume?
• How many litter boxes are available, and where are they? How often are they scooped? How large are they? What type of litter is being used, and has it changed? What products are used for cleaning the box and the soiled areas?
• Does the cat strain in the litter box?

Keep in mind that everyone involved with this matter is under stress. Owner frustration about the situation, conflict among family members, and concerns about medical costs are likely. The cat is probably stressed by the car ride and office visit, but anxiety may be at the root of the whole problem. “Many of these cats have a high baseline level of stress at home,” Sadek said.

Technicians can help alleviate this stress and reinforce the bond between the client and the practice. Communicating to the client that they are partners in the effort to resolve the situation encourages their participation. “If we don’t bond with the client, the cat is much less likely to receive the care it needs, and we won’t be able to help them,” Sadek cautioned.

When conducting physical exams, use cat-friendly techniques that don’t contribute to further anxiety.¹ Check the bladder for pain and size, but perform a complete exam that doesn’t focus just on the urinary tract. Look for other causes of pain, including dental disease, joint disease, and constipation. Certain cats may need analgesics or sedation to complete an assessment and obtain laboratory samples. Verbalizing exam findings to the client is helpful, as it keeps them engaged and reinforces the value of the exam.

Diagnostic testing should include a chemistry panel and complete blood count as well as a urinalysis. Sadek also recommends obtaining baseline thyroid level for cats over 6 years old. If diarrhea or constipation is part of the problem, check a fecal sample. For the urinalysis, Sadek advises collecting a sterile urine sample via cystocentesis, so a culture, which requires a sterile sample, can also be performed.

Use imaging studies – such as radiographs or abdominal ultrasounds – to identify bladder stones, bladder thickening, renal disease, bladder cancer, or constipation. Arthritis is also sometimes found on radiographs.

Is the cat marking, eliminating, or both?

Noting the cat’s posture can help answer this question. Squatting implies elimination, but the upright position is more consistent with urine marking. Marking is usually done on vertical surfaces, and elimination is more common on horizontal surfaces. Marking normally involves depositing small volumes of urine (or, less commonly, stool), and most cats that mark still use the litter box.

Cats use marking as a form of communication, so they often mark repeatedly in the same places to denote travel routes or areas where encounters with other cats are likely. Anxious cats may mark to boost their confidence and reduce anxiety by making the area smell like them. Sexually intact cats use marking to attract a mate.

Noting the location of the marking can offer clues to the cause. Marking near a window or exterior door suggests that the cat perceives something outside (perhaps another cat) as a threat. Marking near interior doors may indicate conflict among cats in the home. Some cats mark new items being brought into the house, and heat-producing objects (eg, toasters, computers) can become targets as well.

Potential causes

Aside from urinary tract disease, a variety of medical, environmental, and behavioral issues can contribute to house-soiling. Urinary tract diseases include bacterial cystitis, urine crystals, and bladder stones. Some cats that present with signs of cystitis have a type of idiopathic or sterile cystitis that is sometimes referred to as Pandora syndrome, in which stress experienced by that cat’s mother when pregnant can cause the developing kittens to exhibit exaggerated stress reactions later in life. These cats may be nervous and startle more easily, and some develop urinary tract disease.

Other rule-outs include urinary incontinence and any condition that can cause polyuria, such as kidney disease, hyperthyroidism, and diabetes. Conditions unrelated to the urinary tract can also be involved. Cats with arthritis may experience pain when posturing to eliminate or can have difficulty accessing the litter box, especially when it is located in the basement, and may therefore select an alternate location for elimination. Cognitive dysfunction syndrome, diarrhea, and constipation can be components, too.

Environmental factors can involve other pets, humans in the home, and litter box management. To meet cats’ general needs, they must have the following:

• Safe places for resting, eating/drinking, and eliminating
• Key resources (eg, food, litter box) located in multiple, separated areas
• Opportunities for play and predatory behavior
• Predictable and positive interactions with humans
• An environment that respects the cat’s sense of smell

Some cats, in both single and multi-pet households, do not always have these needs adequately met. The resulting anxiety can lead to house-soiling. Cats need places to hide and rest, as well as a way to escape from other pets and humans when necessary. They also need to access a litter box from a “safe” resting place without having to encounter another pet.

Social stressors include children or other pets chasing the cat, loud noises, and visitors. Even boredom or lack of positive attention can contribute to anxiety. “In busy families with kids and other pets, the cat may be at the bottom of the totem pole, as far as who gets attention,” Sadek said.

The litter box itself may be to blame. Cats may avoid using a litter box that’s too small. The box should measure 1.5 times the length of the cat, from nose to tail base. The total number of litter boxes in the home should be 1 more than the number of cats in the home. So, a home with 1 cat should have 2 litter boxes. Sadek also recommends that homes with multiple levels have a litter box on each level. She noted that many cats prefer softer, sandy, unscented, clumping litter, and some do not like scoop-free litter systems or litter box mats or liners. Encourage clients to try different kinds of litter boxes (eg, covered and uncovered) and related products to see what their cat likes. “Respect the cat’s sense of smell and texture preference,” Sadek said. Keeping litter boxes clean can also help, so make sure your clients know to scoop the litter box twice a day and wash with a mild soap weekly.

Multi-modal management

Feline house-soiling is a multifactorial problem. As such, multi-modal management can resolve it effectively in many cases. The steps involve identifying and addressing medical issues, optimizing litter box maintenance and accessibility, optimizing access to other resources, including food, safe spaces, and human interactions, as well as providing environmental enrichment, and reducing conflict and stress:

• Treat medical issues.
• Spay or neuter sexually intact cats.
• Incorporate more vertical spaces, hiding and resting places, scratching substrates, and food puzzles to enhance environmental enrichment.
• Determine whether behavior-modifying medications (eg, fluoxetine, clomipramine) are needed in addition to environmental modifications. In multicat households, more than 1 cat may require medication.
• Provide separate resources, which helps reduce conflict between cats by minimizing forced interactions. In some homes, permanent segregation is a viable solution.
• Increase play time.
• Use pheromone sprays around the home and (if necessary) on new items entering the home.
• Clean soiled areas around the home as well as outdoor siding (if stray cats are spraying outside) to eliminate odors.

Sadek also encourages rewarding positive behaviors. “Don’t punish a cat for house-soiling. Instead, find the cat using the litter box and give it a reward, like canned food,” she said. “And make sure you’re interacting in a positive way with the cat.” Client follow-up visits are important opportunities to assess and adjust treatment strategies. Multimodal therapy can yield a good prognosis, but it’s best to intervene early and for the client to be motivated to make the necessary changes.

For more information, Sadek directed attendees to the American Association of Feline Practitioners and the International Society of Feline Medicine Guidelines for Diagnosing and Solving House-Soiling Behavior in Cats.²

Karen Todd-Jenkins, VMD, is a medical writer and has remained in clinical practice for over 20 years. She is a member of the American Medical Writers Association and One Health Initiative.

References

1. Rodan I, Sundahl E, Carney H, et al. AAFP and ISFM feline-friendly handling guidelines. J Feline Med Surg. 2011;13(5):364-375. doi:10.1016/j.jfms.2011.03.012
2. Carney HC, Sadek TP, Curtis CM, et al. AAFP and ISFM guidelines for diagnosing and solving house-soiling behavior in cats. J Feline Med Surg. 2014:16(7):579-598. doi:10.1177/1098612X14539092