Feline idiopathic cystitis

Sponsored by Royal Canin

Feline idiopathic cystitis (FIC) is the most common form of feline lower urinary tract disease (FLUTD), exceeding other causes, including urolithiasis; neoplasia; anatomic malformations; urinary tract infection; and behavioral, metabolic, or neurological problems.^1-5 In spite of our increased understanding that this is more than just a bladder problem, the term FIC is still in use more than 20 years after it was introduced.⁶ Most veterinary teams are familiar with and confident in diagnosing FIC based on exclusion of other causes of FLUTD. Given the complexity of the disease, the challenge is determining how to proceed once the diagnosis is made. At this moment, a better understanding of risk factors associated with FIC is likely our best option for management and prevention.

Risk factors

FIC has been shown to be associated with numerous risk factors,⁷ but most important is the unique susceptibility cats with FIC have toward environmental and physiological stressors.^7-11 Healthy individuals respond to normal day-to-day stressors with a balanced physiological response. Even in unique, highly stressful situations, a healthy individual is capable of responding to and recovering from stress with minimal to no permanent effects.^6,7,10 In cats with FIC ,^8,9 there exists a derangement in relationships between husbandry practices, the environment, nervous system, adrenal glands, and urinary bladder, resulting in a reduced ability to adapt to environmental and physiological stressors.⁶ Management of stress through multimodal environmental modifications (MEMO) has been utilized successfully in reduction of lower urinary tract signs in cats with FIC.¹²

Additional risk factors have been identified in association with FIC (Figure 1), offering added key targets in our approach to FIC therapy, and emphasizing the need for a multimodal approach.^7,8,10,13 Although some of these risk factors such as genetics, sex, age, and early life events cannot be altered (Figure 1A), others including obesity, diet, water intake, environment, husbandry, and intercat tensions can be (Figure 1B).⁶ An approach to optimal welfare for all owned domestic cats includes prevention of certain risk factors such as obesity and intercat tensions, as well as management of diet and lifestyle.^14-16 Outcomes for patients with FIC can be increasingly positive when these risk factors are managed.

Figure 1. Risk Factors Associated With FIC That A. Cannot be Altered B. Can be Targeted as Part of a Treatment Protocol for Patients with FIC
*5 pillars of a healthy feline environment

Minimizing stress in modern-day households

As a predator and prey species and an obligate carnivore, cats have unique needs. We can guide cat caregivers by helping them understand their cat’s unique needs based on the 5 pillars of a healthy feline environment (Figure 2). Each cat needs to live in a defined territory where they feel safe. To meet the needs of each cat within the house, each individual cat must have free access to their own key resources, including resource options out of sight of other cats in the home. Key resources include food, drinking water sources, litter trays, resting places at different heights, and multiple scratching posts and scratching resources.

Litter box management is particularly critical to avoid house soiling issues and should include the use of unscented cat litter with daily or more frequent scooping; 1 litter box per cat, plus 1 additional box; and distribution of the boxes in various locations around the home.

Cats need opportunities for play and predatory behavior. This includes regular interactive play time with family members, individual play with favorite toys, and use of feeding puzzles. Cats need positive, consistent, and predictable interactions with caregivers. Interactions should be respectful of the cat’s wishes, including avoiding forced physical contact and rough play such as hand play. Caregivers should be advised to allow the cat to initiate and terminate interactions, giving the cat control based on the cat’s emotions and needs.¹⁷

Cats have unique senses that better equip them to stay safe from predators and to hunt prey. Strong odors in the home (eg, cigarette smoke, essential oil diffusers), loud noises, or bright lighting can negatively impact their senses, potentially reducing their sense of safety from predation. Some caregivers may be able to meet all of their cats’ needs according to the 5 pillars, but many (and probably most) fall short of consistently providing this ideal environment. Working with the caregiver to identify deficiencies in the 5 pillars and prescribing MEMO tailored to those deficiencies provides patient-specific changes that serve to minimize activation of the stress response system and thereby reduce lower urinary tract signs.^12,14

Figure 2. The 5 pillars of a healthy feline environment provide a framework from which to evaluate for and correct deficiencies in the environment. The 5 pillars represent every domestic cat’s essential environmental needs and should not be confused with enrichment.

Obesity

Feeding puzzles enhance predatory play behaviors and increase activity.

Weight management programs are ideally preventive in nature, starting with appropriate nutritional guidance, particularly in the first year following spay/neuter, when cats are first vulnerable to obesity.^18,19 Once elevated body weight and body condition score (BCS) are identified, a patient-specific weight loss program is essential. Overweight cats are at increased risk of disease and are more likely to be diagnosed with FLUTD, diabetes mellitus, respiratory disease, skin disorders, locomotor disease, and trauma.²⁰ A weight loss program should be developed in consultation with the caregiver. This includes calculation of resting and maintenance energy requirements, assessment of the caloric density of the current diet(s) and monitoring of actual daily caloric intake.^21,22 In most cases, weight loss programs should utilize a veterinary therapeutic diet formulated for weight management, to avoid the development of nutrient deficiencies when calories are restricted. Strategies for weight loss in the patient with FIC will also include a potential change to a diet tailored to the patient’s FIC. This may include veterinary therapeutic diets that support urinary health while providing additional nutrients that help the cat cope with everyday stressors, such as Royal Canin Multifunction Urinary SO+Satiety+Calm, Multifunction Urinary SO+Calm, or Multifunction Urinary SO Aging 7⁺ +Calm. Canned food provides built-in portion control, and may help with reduction in food intake to promote weight loss.²³ Improvements in feeding strategies can help increase activity and reduce anxiety. For example, the introduction of feeding puzzles enhances predatory play behaviors and increases activity levels.²⁴ In a multicat household, cats should be fed separately with a visual barrier and a distance of at least 6 feet between them.²⁵ Regular nutritional consultations are ideal as diets can easily fail in a 12-month period before the cat’s next preventive care visit. These visits should include assessment of the food, feeding strategies, current intake, BCS, muscle condition score, and body weight. In some cases, consultation with a veterinary nutritionist and/or behaviorist may be beneficial.

The case for increased water intake

Providing water sources that reflect patient preferences promotes increased water intake.

Increased water consumption to promote a reduction in urine specific gravity (USG) is a key dietary therapeutic goal in the treatment of FIC.⁷ Feeding a canned urinary diet can achieve a lower USG with the potential to reduce FIC flare-ups.²⁶ Successfully encouraging water consumption requires identifying patient-specific preferences for fluid intake (Table 1) and ensuring water is managed as a resource (Pillar 2, Figure 2). Diets targeted to reduce USG and/or increase water consumption may include increased moisture content as well as adjustments in ingredients that increase thirst, such as sodium.²⁷ Consumption of canned food promotes additional water intake directly through the diet. In some cases, additional water in small volumes (1-2 tbsp) can be added to each meal. Although the consumption of dry food comparatively limits water intake in the meal, some veterinary therapeutic diets targeted for the treatment of FLUTD, such as the Royal Canin Urinary SO formulations, include dry formulations that promote water consumption.

Table 1. Promotion of Water Intake Includes Evaluating Individual Patient Preferences for Water Consumption

Multicat households: A solitary species living with friends?

Domestication has allowed cats to adapt to living in social communities with humans and other cats. As a prey species relying on small, frequent meals to meet their daily caloric intake, cats are generally considered to be asocial as a species.²⁸ Cats that cohabitate may develop a social bond (“friends”), whereas most cats merely coexist in the same space. These cats may or may not exhibit overt signs of agonistic behaviour (“foes”). “Friends” will exhibit affiliative behaviors including allogrooming, allo-rubbing, tail wrapping, and allo-play (Figure 3). They will sleep in direct physical contact with one another. Affiliative cat-cat behaviors should not end in physical violence or vocalization. Caregivers may not recognize the subtle signs of intercat tension and are often more aware of obvious agonistic behaviors such as vocalization and fighting. Teasing out the history of any existing intercat tension is important to developing a treatment plan for FIC. Assessment for deficiencies in the 5 pillars of a healthy feline environment will help to pinpoint areas of concern.¹⁴ Consultation with a veterinary behaviorist may be needed in cases of intercat tensions.

Figure 3. Signs of Affiliative and Agonistic Behavior in Cats

What about drugs to treat stress?

It is tempting in cases of FIC to consider long-term pharmaceutical therapy as the principal approach to care. We can now see that long-term success is best achieved by identifying and managing treatable risk factors (Figure 1B). This includes identification of deficiencies in the 5 pillars of a healthy feline environment (Figure 2) and correction of these through MEMO.¹² Pharmaceuticals have a role in the treatment of FIC flare-ups and may be beneficial for some patients as a short-term adjunct to reducing anxiety in response to stressors. During periods of FIC flare-ups, when cats are experiencing clinical signs of FLUTD, a multimodal approach to acute pain is ideal. Drug selection should be based on the patient’s signalment and health status and tailored to their specific clinical signs.²⁹ Patient comorbidities should be monitored and managed appropriately to avoid added physiological stress and emotional distress.³⁰ For example, cats diagnosed with degenerative joint disease will require appropriate chronic pain management to manage well-being. All medical, dietary, environmental, and resource concerns need to be addressed prior to or in conjunction with the use of anxiolytic agents. Anxiety will improve with environmental adjustments,¹² but in some cases anxiolytic or antianxiety medications such as tricyclic antidepressants or other behavior-modifying pharmacologic drugs may be needed. Caregivers will need to understand that these may require days to weeks to take effect and will not work in the absence of other management strategies. Behavior modification pharmacologic drugs should be used as a last resort and considered a component of the holistic approach, with the intention of being able to discontinue medications over time.

Conclusion

FIC is a complex disease that involves not only the patient, but the patient’s ability to respond to and cope with stressors in their environment. Given this complexity, a holistic approach to care for patients with FIC is ideal. Pain and related clinical signs need to be managed, as well as any coexisting causes of FLUTD and/or patient comorbidities. Risk factors for FIC such as obesity need to be addressed but, most importantly, deficiencies in the patient’s environment need to be identified, corrected, or modified according to the 5 pillars and MEMO. This type of integrative care for the patient with FIC improves feline well-being and has the capacity to minimize FIC flare-ups.

References

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