Hi, everybody. Thank you so much for joining me. My name's Sam Taylor.
I'm a feance specialist. I work in, referral practise at Lumbury Park, but I also am very fortunate to work with International Cat Care. So I get to think and talk about all things cat, very frequently.
And in this talk, we're going to be thinking about some, tips and tricks around feline lower urinary tract disease. And feline lower urinary tract disease is that, that common condition that probably fills you with a bit of Well, maybe fills you with a bit of dread when you see that on the list, and certainly block cats are a cause of significant stress, I think. I certainly, you know, they, they cause me anxiety when I hear we have a block cat coming in.
Even at referral level we see block cats sometimes if they've been challenging to unblock or recurrent, for example. So in this talk, I can't cover everything, but I'm gonna try and give you some really key take home messages that hopefully be useful for you when you're seeing these cases and we'll talk about some kind of new thoughts and as I mentioned, some top tips. First of all, I want to mention and draw your attention to the 2025 consensus guidelines on lower urinary tract diseases that we produced recently.
And you can see that we've tried to cover lots of different areas of low urine tract disease and also pair this with a. Guide so that you don't have to have those lengthy conversations about all of these conditions and about the environment. We tried to do it for you and so we've got yeah, something you could print off or you can send a link to, and it will just help with having those conversations.
So first things first, before we get started, I'm a little bugbear and we talk about this in the guidelines, and that's about fluttered, or FLUTD as a term. And it is a bit problematic, and I'll tell you why, because it's not a diagnosis, but it tends to be used as such. So we'll sort of say, we've got a cat coming in with FLUTD.
Well, OK, but those are only clinical signs. That's not a, that's not a cause. It doesn't mean they have FIC.
What it means is that they are presented. With this kind of group of clinical signs that are caused by various diseases. And I know this sounds horribly pedantic, but it's, it's useful when you're trying to come up with a diagnosis because we see some assumptions made sometimes about FIC when they have urolithiasis, for example, and vice versa.
So, Think of it as really just a term to kind of describe presenting signs, but it doesn't mean it's a it's a diagnosis. So it's better to talk about lower urinary tract signs, and they are caused by several different lower urinary tract diseases with a. On the end.
So I know this sounds like me being a little bit annoying, but it can help when you're thinking about differentials and thinking about this, not as one disease kind of process, but as quite a heterogeneous condition with lots of different causes. Is that the right word? Another question mark on terminology is FIC.
So we all know FIC it's very, very much recognised by us in the profession as idiopathic cystitis, but there are some issues with with that terminology because some of these cats actually don't have a huge amount of inflammation in their bladder. They have pain from their bladder, but they may not have inflammation. And to owners, the word cystitis really implies a bacterial involvement because that's what they'll be used to from human medicine.
Although humans get FIC as well. Well, not FIC, idiopathic cystitis as well. But it, it might be better to call this condition something like stress cystitis, at least, or feline bladder pain syndrome, so that it's understood as a a multifactorial.
And actually multisystemic disease. So we'll talk about that a little bit later, but just introducing that for owners, FYC is a really, really confusing term. It's been around for a long time, and actually if you look back at some really old textbooks, such as the one that I've got on the screen here, they use some of this terminology, they might use feline neurologic syndrome.
There's, there's lots of sort of different terms that have been used, but we have inherited this one. It might not be the right one. So I've said to you that the clinical signs can be the same amongst several different diagnoses, but there are some clues.
It's important to ask the right questions and history taking is super important in cats with lower urinary tract signs. And distinguishing periurea from urine spraying again sounds like it's not particularly important, but actually there is a bit of research showing that true spraying behaviour with that sort of vibrating tail and stood upright as this cat's demonstrating here is much more indicative of a problem behaviour in response to stress rather than a primary lower urinary tract disease. So that's something to make sure that you ask about if they're talking about urinating in the house, urinating in the house can have lots of different causes as well.
And so ask about what exactly that behaviour is. Always look for other clinical signs. So we know that cats that have FIC that that pathology, is coming from bladder pain generally.
But you can see other signs, such as over grooming, signs of stress. But also, if you have another disease causing lower urinary tract signs, such as infection or urolithiasis, you might have other signs. If you have chronic kidney disease, you might have some weight loss, PPD.
That would be unusual for FYC. So you can see we're using that history taking. And clinical exams to try and just get every bit of information that we can.
And just on that point, you know, presenting signs of urethral obstruction can be a bit confusing for owners. Not all cats use litter trays, and not all cats will demonstrate that strangura that we're so typically recognise. Some owners may recognise visiting the litter tray regularly as constipation and straining to urinate as straining to defecate, or they may simply see that their cat that normally urinates outside is trying to urinate indoors.
They could be just changes of behaviour. So it's worth recognising that owners might give you slightly different information. Let's tell you about a case, and this is a sweet little cat, and I love this little cat.
This is Maverick. Maverick is a 3 year old, domestic short hair, has outdoor access, lives in the UK. He doesn't live with any other cats.
He eats a standard complete diet. Nothing else very exciting about his history. But a month ago he had an episode of dysuria, and he was presented then again a month later with suspected urethral obstruction.
But actually, once he arrived at the clinic, he did pass some urine, so that sort of panic was was over at that point. Now you can see I've got quite a few pictures of Maverick cause myself and his owner got to know each other and trying to to manage his disease, and she sent me some photos of him at home and yeah, bring your own thoughts about the, the location of this litter tray and whether that is clearly in the kitchen, could be in a busy area, don't know what you think. That's the only litter tray that he has available to him.
So this is where that history taking is really, really important. So have a look at these other photos of Maverick. Yes, concerned about his urinary signs, but when we ask a little bit about what he's like, we find that he is a really nervous cat.
And we also find that recently a strange cat got into the house. Fiona got up in the night and there was a random cat in the house. Since then, Mavericks started urinating near that door.
He's very jumpy. And he's watching the cat flap like a hawk. They have changed the cat flap now for a a microchip cat flap, but before that, this other cat had got into the house, and you can imagine that's very traumatic for a sensitive soul like Maverick.
So let's look into his investigation. Well, on exam, he was quite quiet, but nothing else very, very remarkable from his demeanour point of view. But his bladder was definitely sort of a little bit wornnessy, quite sore, but quite empty.
So we did some investigations. We had some hematuria, very concentrated urine, nothing else on the bloods, a negative bacterial culture. And on ultrasound, the bladder did look quite thickened.
So my question for you here to make sure you're, you're awake and I'm keeping you thinking is, have we done all of the workup that we need to do? Can we call this idiopathic cystitis? You were probably thinking that.
I've told you we've got a nervous cat here, presenting with those types of signs. He's had a stressful event. It's very easy to jump to that, that thought that this is FIC.
But this brings me to my first top tip for you, and that's around performing a retrograde study of the urinary tract. And that might be something you don't do particularly regularly in your clinic, but I'm going to try and convince you that all cats presenting, particularly male cats with low urinary tract signs, could potentially benefit from having this type of test done. And that's because if we don't do a retrograde urethrogram, we can't exclude in a patient like Maverick there being some pathology within the pelvic and even penile urethra.
OK, because we've only done an ultrasound, we've only looked at the bladder, we maybe look at a little bit of urethra as it leaves the bladder, but we can't examine the rest of it. And that means that we could give all of the drugs in the world to manage FIC. We could even control all the stress in the world.
But if he does have a small urolith or any filling defects, then That's, not gonna get better. And so, doing a retrograde can be really cheap, and we've got lots of really detailed instructions in the guidelines if this is unfamiliar to you. It feels a bit old fashioned.
We all kind of like doing, ultrasounds and things and CDs, and we don't so much like doing contrast studies anymore, but this is one that is super useful. Also, another of my colleagues, Danielle Garmore, who was an author on the guidelines, really recommends that when the cats are sedated, of course, considering rectal exams to just feel that, urethra, that, that distal and intra pelvic urethra, because you can sometimes even feel a little stone in there. So here's an example of why retrograde studies can be really important.
This is a 10 year old male neutral domestic longhair who has recurrent episodes of dysuria, and he has had some leaking of urine as well. He has had abdominal ultrasound which showed that his bladder was slightly thickened, but no other abnormalities and no urliths. So, he had been previously diagnosed with initially suspected urinary tract infection and then later FIC.
Be given quite a few medications and things. What you can see on this retrograde study, and I'll, I'll just guide you with a, with an arrow here. The first thing to see is we've got this really dilated area of the intra pelvic urethra, and it's got a filling defect in it, and that's it.
That's a urolith. But then also importantly, you'll see just behind my pink arrow, well, just, cordal to my pink arrow, I should say, distally, in, as the urethra is just leaving the pelvis there, you can see a, a, a marked narrowing. And that is a stricture.
So actually what we have in this case is a urethral stricture, then a dilated area of urethra that has a collection of little stones. There's no way this is going to improve or get better, and actually this cat is a perineal urethrostomy candidate and did awesomely after that surgery. So I hope that just kind of illustrates to you, that we need to do these retrogrades in these type of cases.
For Maverick, his retrograde was actually completely normal, so you were right with your instinct that he is an FIC patient. So let's move on and think about urethral obstruction because he had originally presented with suspected urethral obstruction and he'd then passed some urine and my retrograde is normal. So that would lead me to conclude that he had urethral spasm.
And that is a cause of urethral obstruction, but probably not as common as this other term, which again is not really a diagnosis, and that's a urethral plug, and all that means is some gunji material plus or minus some crystals. It's again, not a full diagnosis of why it's happened. We also do see strictures, as I showed you.
Why would they occur? Well, often secondary to urethral catheterization with no criticism of anyone's technique at all. The urethra is narrow and often at times we're placing a catheter, it's inflamed, and we might be sort of butting up against the urea.
Things can happen. And so urethral strictures is something we probably see in referral more often because they come in as recurrent cases. And often they do require surgery such as perine urethrostomy.
Other things you can see, blood clots, post trauma, obviously you see ruptured urethras. So, the most common cause is gonna be around those, those ureus, those plugs, but of course, FIC is a hugely common cause, of urethral obstruction. That's usually due to urethral spasm, but it can have a contribution of blood clots and other materials plus or minus again, some crystal urea, and that's where this complex kind of interplay, comes in, but we will talk more about pathogenesis of FIC.
This particular study here is a study of perineal urethrostomy, generally showing good outcomes from that surgery, but I include it here because they did send the removed parts for histo and found lots, you know, lots of strictures and tears and thickenings and yeah, there can be pathology there that we don't know about. Actually, that FIC figures that we often quote, as I'm quoting here, 65 to 90% of urethra obstruction cases being down to FIC. What I will say is that those are generally quite old papers where ultrasound was not used quite as Frequently and it's very possible that some of those cats had exactly what I described before and a missing of small euralliths.
So I think that's an interesting thing to consider, and I, I'm probably more proactive now at looking for for urliths. And the thing about the urethral plugs is that crystals can play a role, but it isn't the, the sole cause, and that's something else to, to kind of take home, I think. And that means that you can attack one angle and manage crystal urea, but if you don't manage inflammation and potential FIC, then you may not prevent that plug from forming.
I wish it was as simple as just prescribing a urinary diet, but it rarely is. So the other thing, and I've alluded to this, it leads me on to my second tip, and that's about thinking of FIC really as a systemic disease. And what, what on earth do I mean by that?
It's a bladder disease. Well, it is and it isn't, because actually, FIC is, a stress-related disorder that does not just affect the bladder. It's just that signs of a bladder problem are more dramatic than signs of stress from other reason, other areas of the body.
So this brilliant phrase from Professor Buffington, who was an author on the on the guidelines I find really useful. So he describes FIC as the bladder's response to activation of the central threat response system. Well, what on earth does that mean?
It really means that part of the brain that is designed to protect us from danger. And in these cats, that area is probably basically super hyperreactive and activation of that area feeds kind of straight to the bladder, but it will also affect the guts and things, other parts of the body. It's just that we're seeing that.
And so you can see that actually just managing the bladder isn't going to be solving the problem. Now this is a a really busy slide, and I don't expect you to read it now, but this is actually in our owner document that goes with the guidelines, so you can find that if you just even Google the guidelines, you'll find this at the bottom as an extra link and supplementary material. And it really shows the kind of multifactorial nature of FIC, how we have this combination of temperament, which is formed based on genetics and early life experiences.
And then we put this cat perhaps in an environment that doesn't suit it, and it has like maverick cats in the house that shouldn't be there. And there are other factors that have been shown to increase the risk of FYC such as indoor lifestyles, obesity, more than one cat in the home, and of course, changes in the home environment. So have a look at this in a little bit more detail later, but it just kind of shows you that there are lots of things causing it.
Whenever you have a disease with loads of stuff causing it, there isn't gonna be just one treatment and that's what makes it difficult to to manage. You're not gonna give a tablet that sorts it out, and your bladder supplements and the gags and things, you know, alone, in the face of what I've just described, you can see how they won't stand a chance. And that's why it's also hard to study the effect of those those type of treatments.
We need a multifactorial approach, and I illustrate here this idea of kind of a perfect world for cats, which, involves these pillars and the pillars are things that cats really need to be happy in their environment. So you don't need to. Study behaviour or anything.
I'm not a behaviourist, but we're thinking about these principles of a happy feline environment, such as having somewhere to hide, such as having enough litter trays, you know, such as having, an environment that smells OK for you. And that doesn't always mean having lots of plug-in air fresheners and things like this, for example. And we can see a clash between these requirements for cats and our requirements for our living space.
But the bottom line is if you're listening to this as a medic or a surgeon or you know, you just love GP work, we can't get away from discussing the environment when you deal with cats in terms of lots of diseases, whether we want to or not. So my tip 3, I'm gonna jump through some subjects here because I want to make sure that we get, you know, through some really useful stuff for you. And this, I hope you'll, like the retrograde information, will be really useful for your block cats.
So, are you familiar with sacrococcygeal epidurals? Well, the word epidural scares the bejesus out of me because I don't like, I'm a medic, I don't like putting needles near eyeballs and spines and things like this. But actually in this situation, I am convinced that this is quite an easy one to do and I can't do do harm with it or it would be difficult to do so.
And basically this is applying a very caudal epidural that allows you to provide analgesia for that painful bit of blocked cats. There is a bit of nice evidence. I've got a couple of studies here that showed you need less propofol when you use this, and just showing that it, it does effectively block those pain signals from around the penis, you know, when those penises of these blocked cats are so awfully bruised and swollen, and that whole perineal area is causing them so much pain.
This can really break that cycle. Now, the analgesia doesn't last for, you know, a super long time. We can extend it a little bit.
We can use bivvicaine and morphine together, for example. But what it does is it allows you to have complete analgesia to that region, particularly while you're catheterizing these cats and. When they're recovering from that and you want to leave a catheter in situ.
So think about it. I've got a video here, which I'm not going to play, all of, but from one of our fantastic authors on the guidelines. And she, Rachel Corman, who's a feline specialist in Australia, really takes you through the technique, so don't worry about watching this.
I put the link in here, and again, you can just Google, and you should be able to find it. And the Zero Pain philosophy websites also, as well as our ISFM guidelines, show you a little bit more detail about how to do this as well. But you can see Rachel here just palpating the right area, and she takes you through how to apply this block.
Doesn't have to be expensive, and it can make a huge difference to cats that are challenging to unblock. OK. Top tip 4.
Well, on this one, I'm gonna jump subjects a little from FIC and move to urolithiasis and just, emphasise what I already told you, that urolithiasis could be underdiagnosed, particularly if we just look at the bladder. And, calcium oxalate and strevite are the most common. I think in referral, we tend to see much more calcium oxalate.
I'm not quite sure whether that's a UK thing. Strevite in cats is seen without infection. It's not the same as that eight year old golden retriever with a UTI.
And you can see urists that are made of other things. So you can occasionally see ones that are just made of, solidified kind of blood. But calcium oxalate and strevite are gonna be the most common.
And if we diagnose it, we need to look for an underlying cause. Don't always find it. But for example, hypercalcemia, we need to exclude when we find calcium oxalate.
And you can see a few graphs here just showing you the kind of trends in neolith composition. So it used to be that struvite was, was a more common, and you can see that the top data just going up to the end of, well, 2018 time when struvite is more common, and I think calcium oxalate has now kind of come back and overtaken a little bit, and you might see some differences between different countries. So let's show you a case.
Here's a little cat that I saw a few years ago, Rosie, and she's an eight year old rag doll. She has pretty unremarkable background. She lives with a sibling.
Lives indoor only. She's fed a mixed wet and dry diet. She's never been the biggest.
She's always been a bit skinny and doesn't eat particularly brilliantly. But about a month ago, she started to, sort of, show those classic lower urinary tract signs that we talked about. So the strangura, dysurea, and very much a plucky urea, just leaving these little drips of urine here and there, sometimes on the sofa next to the owners where she'd been sitting.
Not so much incontinence, but she would sometimes strain and just produce a little drip in inappropriate places, outside the litter tray. She'd had multiple courses of antibiotics and, you know, things like influxin, she'd had several injections of ervavicin and amoxiclovin. We talk in the guidelines about, you know, the, the likelihood of UTI and, and certainly if you're not getting improvement after the amoxiclab, it's, it's worth considering other diagnoses, and I'm sure you'll, you'll agree that that's, overuse of antibiotics, but I do, you know, I do understand it, and I think it reflects some of our tendency to think that bacterial infection is involved.
But in, in a case like Rosie, she's 8 years old, she certainly could have some risk factors for urinary tract infection. But we wanted to investigate further. On her physical exam, again, another small bladder that's a bit sore, and she passed some bits of urine during the consultation and then that photo that I just showed you is in actually in the consult room on the chair where she sat.
Otherwise, nothing too exciting on her clinical exam. So we've got a problem list that would fit several different diagnoses, really. And your next step is likely to be some, urinalysis, plus some imaging, most likely.
And in this case, you know, the urolith is not hiding away. You can see quite a, a, a large relative for her size. Urolith in the bladder there that looks quite spiky, and the bladder wall is very, very thick.
But interestingly, have a look at her urinalysis here. We can see that her pH is 8. And she has no crystals, really, in her urine.
And that might surprise you because there's clearly a urelith in there. And it shows you how we can get a little bit tripped up with urinalysis. Don't assume that you're going to have a load of crystals when you've got a stone, and also you could in theory, have crystals of a different type to the stone.
We also look at pH quite a lot. We'd like to look at pH for predicting what uroliths are, for example. But remember, pH just in one result can be a bit misleading.
It can be affected by stress, it can be affected by when they last ate. There are lots of factors that can influence pH and that can send you up the wrong kind of wrong direction, of thinking, for example, in this case, well, we've got an alkaline pH of the urine, this must be strevite. Just some other results from Rosie, we did also ultrasound her kidneys and that's always a good idea.
We can learn a little bit from that in that we know that nephroists are more likely to be calcium oxalate than struvite. And she did have some nephroists present as well. So When I talk to and bored you about multifactorial cause of FIC, I have to also say that uroethiasis probably has multiple causes.
So that can be occasionally infection, but not common in cats. Diet, but probably a lot of it genetic. So rag dolls with some, I do see some rag dolls with nasty calcium oxalate stone disease.
So think about all the different aspects that feed into what's happening in that cat's bladder. And I can't get through a sentence without talking about pain and stress, and you're thinking, well, that, yes, I get how that applies to FIC but actually pain and stress can apply to risk of urlithiasis. If you're very stressed in your home as a cat, and there are lots of other cats, and they sit by the water bowl, you don't drink as much, they sit by the list tray.
You don't empty your bladder and your urine sits in your bladder, super saturated, and so perhaps you can start to see that all of these things are interlinked. So diagnosing your urthiasis, well, yes, it is still important to perform urinalysis, of course. And you can find lots of beautiful crystals and things.
We talked about not assuming FIC and the challenges of urine pH. Radio density is very useful, so often. Taking a radiograph, even if you've identified a stone on ultrasound can be helpful.
And there is actually an app. If you look up the Minnesota Eurolith app, you'll find that you can enter some details about the case, and it will give you an idea of what the stone may be made of, and that's really useful. It's for dogs and cats.
So what about urolithiasis with block cats? Well, we've already talked about the importance of imaging the whole urethra, and that's also an important decision making factor when you think about urolithiasis management because you might identify urlis in the bladder, but if you miss them being further back and you do a cystostomy, you're not going to solve that dysuria. And so this is a beautiful photo from Rachel showing an absolutely wonderful kind of collection of, of, radioaic uroliths going all through, the urethra and into the bladder.
So with Rosie, well, we did do a cystoomy. She was clearly very uncomfortable, and yes, you could argue, well, hold on, you didn't know that wasn't struvite, and you could have dissolved it with diet. Well, you might be right, but I knew that this cat was in quite a lot of discomfort with this stone, and if I get it out, I can work out what it is.
And these are the type of sometimes difficult decision making around your lists, particularly sisterliths. So in this situation, we removed that one big one and some smaller urlis. Sometimes we'll biopsy the bladder wall.
Little bit of thought that we could get some bugs that live in the walls, so the urine culture's negative. We treat them with antibiotics and just kill the ones on the surface, and then the next round kind of comes forward. So sometimes in this situation, I will culture the, the bladder wall.
The reason we did histology was that it was really quite thickened at surgery and Yes, still, that diffuse thickening makes it unlikely to be anything apart from inflammation, but we had that opportunity. So once she recovered, she felt so much better. They're obviously causing so much irritation to her bladder.
And actually they were calcium oxalate with her. This is her result here, so it shows you that, these were calcium oxalate, and not a, not a hint of anything else really. So that was despite her having no crystals and having a slightly alkaline pH.
She wasn't hypercalcemic, but I mentioned the importance of, of checking that and that we do see these certain breeds, but we can see any cat with these. With calcium oxalate, what always worries me is the recurrence, the recurrent nature of it, because there's probably a genetic predisposition to it. So with Rosie, well, water intake's going to be hugely important, and you can go in with things like potassium citrate, to reduce the acidity of the, of the urine because actually I did multiple urinalysis or urinalysis on her, and she did have more acidic urine most of the time.
We can use and should use a commercial diet for stone prevention, but any wet diet is better than dry food. And sometimes transition for a cat like Rosie, who doesn't eat very brilliantly and never has, can be difficult. So think about the whole case and using some appetite stimulants.
So with Rosie, she, as I mentioned, responded really well, but sadly, she decided to move some of the nephroists that were in her renal pelvis into her ureter. And so she had a dilated ureter and some hydronephrosis at one point, and she was very challenging. This cat just.
Clearly produced so many stones. One kidney was sort of out of action, but she did live with management for several years. We didn't place subs and things.
It wasn't what the owner wanted to do. And to be honest, she had still more stones in her renal pelvis. She was quite a difficult case.
OK. Let's move on to a different area of urinary tract disease in cats, and that's incontinence. Now, this is something you'll be much more familiar with seeing in a, you know, in a 10 year old female Labrador than you are in cats.
And that's the point. It is rare. But if it occurs, it should raise that big red flag that they might have pathology in the urethra.
We sometimes jump to think it's neurological, but actually, neurological causes of incontinence in cats should always be accompanied by Or almost always accompanied by some hind limb gait changes or some other neurological signs. So do your neuro exam and if it's normal, I would say that it's more likely to be a urethral pathology. Here's a case.
This is bear. He's a very fluffy 3 year old domestic long hair. He's indoor outdoor.
He has this brilliant history that you sometimes get from owners that they say that he's friends with one of the cats outside and they see them on the fence sitting together. But when actually they describe this, they're sitting sort of with their backs to each other and they probably hate each other. Remember, cats are not good at communication sometimes, and we're really bad at interpreting it and owners will often think that they're friends with cats that they actually wish were dead.
So in his case that that perhaps is true and he has some stress factors. Anyway, he is one of these cats that you don't want to see on your consult list. He's had recurrent urethral obstructions.
He's been catheterized several times, and now he's come in again partially obstructed. The vet was not able to pass the urinary catheter and he then the panic sort of was, was over a little bit because he passed some urine in the cage overnight. And he is also a cat that's quite challenging to handle in the clinic.
He doesn't particularly like being messed about with because he's been in multiple times with urethral obstruction. So he came to us and took a really good history from the owner, and this is where asking those questions about the urination behaviour can be helpful. So the owner mentioned almost quite casually that since he'd been casterized a month ago, he'd actually been leaking a sort of jet, kind of a squirt of urine in his bed overnight when he was asleep.
During the day he strained and passed some urine, but it was quite a big volume overnight that was an incontinence presentation, and they said he would be completely asleep and then almost to they on one occasion had seen urine kind of squirt out from his bladder. As I say, he's, he's not one to like being examined, but generally didn't find too much apart from a slightly sore bladder, but he didn't particularly like any form of, of examination. I certainly couldn't do a cystoconscious.
So, where are you gonna, where are you gonna start? I'm sure you want to do some urinalysis. I'm sure you want to do some imaging.
Which imaging do we want to do? Well, probably the same rules apply as mentioned before, in that a combination of radiography and ultrasound. And Analgesia hasn't had any analgesia, and he's had lots of messing about with his back end.
So we ultrasounded him, he had some sediment in his bladder, some blood. So always check the penis as well. This photo always reminds me to check the penis so you can just see on the end here a little great little plug poking out.
And actually we did a we did a CT, but I will, in hindsight say that I could have done a retrograde urethrogram. I think because he was so difficult to do a neurological exam on, I was sort of thinking, we are, maybe I need to be a little bit more thorough here, but what we found, I would have found as a filling defect on, on retrograde. But the arrows are illustrating a nice line of kind of calculli and sandy sediment that we can see in the intra pelvic urethra again, so not visible on ultrasound.
So he had a partial urethral obstruction, and I think what was happening was when he was very deeply asleep, it was like the valve gave way and the urine could pass so that spasm sort of went off and, and the urine could, could go past. So he, you know, was really struggling with that and dysuria when he was conscious. Now, in his case, there was, you know, real obstruction there, we could not move those stones, they were absolutely wedged into the wall of the urethra and so he went for a perineal urethrostomy.
He did very well. Perilineal urethrostomy is not without complications and it's certainly not the solution to all block cats, but in some situations where there is no choice, particularly like with bear, but bears a classic example where, Doing the perinealrotomy does not solve any stress fractures or stress factors, sorry, or, urolithiasis tendencies. And so he's a cat that, yes, we solve some things with that surgery, but we don't solve everything at all.
And so he had to be on a wet diet. We looked at his water intake, all sorts of things, tried to reduce his stress. And mention water intake a couple of times now and actually any lower urinary tract disease will benefit from lowering the urine SG ideally to less than 1035, and that's surprisingly hard in cats.
They're not very good at drinking, but if we look at evidence-based advice around lower urinary tract disease, then from small studies, I do admit they're not massive studies. It does seem that lowering the urine SG is very, very beneficial for cats with idiopathic cystitis. It will also help obviously eurolithiasis, CKD, all sorts of things.
Basically, get cats to drink. And there are lots of ways you can do this, and we talk about it in, both guidelines and the owner information. And we have a separate document as well that you can send your clients to, whatever their disease, about getting cats to drink a bit more, because, as I say, I don't like to point out faults in cats, but they're not very good at drinking.
You could try some other things. So, Purina Hydracare, have you been lucky with this? I had one memorable client who I recommended it to.
They bought tonnes of it for lots of money, and the cat wouldn't even lick one drop of it. But some cats love it, like this cat that you can see here, and it has been shown to reduce urine SG and it's essentially a sort of thickened kind of flavoured water product, hydration supplement. So it's something to consider.
Yeah, this cat apparently really had a great effect on the urine SG. OK, we're moving into our last few top tips here. And this one, you, I'm sure know already.
We've talked a little bit with Rosie about use of antibiotics in cats with low urinary tract signs. Well, low urine tract signs related to infection are uncommon, but it will vary according to the population that you're looking at. And so my decision on this will vary according to that population.
So I might think differently about, of course, a 15 year old cat as I would compared to a 3 year old cat like Maverick. So if we look at the prevalence of urinary tract infections in cats, it's a little bit skewed by where those studies were done and whether they were, how they were detecting that bacteria. But some do think we are under underestimating the prevalence of urinary tract infections.
A complicating factor is this phenomenon called subclinical bacteria. So if you're not aware of this, this is basically when bugs are present, you can get a positive culture, you could even have an active sediment, but the cat does not show any signs. That's in contrast to UTI where they have the presence of bacteria but are also clinical signs.
OK, so this is it, why is this important? Well, it's important because we need to interpret our culture and urinalysis in context of clinical signs. Why don't we just treat them all with antibiotics and get rid of the bugs, whatever, just to be safe?
Well, the reason is that we know that treating subclinical bacteria urea has a negative, increased negative effects in humans, side effects from, antibiotics and other morbidities, plus encouraging resistant infections, and I have certainly seen that in cats, cats that have had, Genuine UTI's and then episodes of subclinical bacteria or the other way round, had lots of different antibiotics and you can end up with a a resistant bug. Again, young, healthy cats are not gonna have either subclinical bacteria or UTI. There are risk factors.
And that's particularly around chronic kidney disease, diabetes, things like this, bit of conflicting evidence in hyperthyroidism, or cats like Bear that have had PU surgery, . We've had a few other risk factors of being female and being older. So we need to interpret our, our urine results thinking about the signalling of the case.
We always used to think that if you lowered the SG, and I would get asked this sometimes, well, you're telling me to low lower the urine SG in some of these urolith cases, but aren't I gonna mean, isn't that gonna mean that they're more likely to get a urinary tract infection? But it's simply not, not that, it's simply, simply not that simple. Low urine urine SG in studies is not a consistent risk factor for, subclinical bacteria urea or UTI because there's more going on than that.
This whole thing about host defences, And lots and lots of other factors. The most common causes of infections are E. Coli, Eococcus, staphs, things like this.
But enterococcus might be something to make you sort of think, could this be subclinical, because Eococcus likes to be subclinical, OK? And it also likes to sometimes colon, colonise kind of sub-vis if you've ever had managed a cat that's come back from referral with a sub. And just remember, a reminder, while I've got you, I still see lots of results coming through with nitrites and leukocytes and SG from sticks, and they're not useful in cats, so you shouldn't be interpreting leukocytes, particularly nitrites and the SG can be hugely inaccurate because they're human, human dipsticks.
So when do we treat? How do we know whether we treat or not? Well, as I mentioned, the evidence from humans is that treating subclinical bacteria could cause an increase in morbidity.
And we think the same is probably true in cats, and so we should only be treating them if we've got clinical signs, or you can see some other factors here that might influence your decision making. It can be really difficult in older cats that you're not completely sure whether they have signs or not, i.e., you're worried you're going to miss it and they go outside and things like this.
Err on the side of caution, monitor body weight, monitor creatinine in CKD patients, and just get as much information as you can so that you can interpret that info. And I suppose if in doubt, if they're not showing urinary tract signs, don't culture them because you know you're gonna have problems interpreting that result. And you can read the ISA guidelines, if you're not familiar with that, have a Google, and it will show you, I've taken this quote from there about the treatment of subclinical bacteria that we, we don't generally want to, to do that, and that we're now thinking we use shorter courses.
And there's some good evidence that antibiotics are a type of drug that people don't complete the course with cats because it's difficult to give them medication. And a lot of these drugs are twice a day. So compliance, compliance, compliance, help your clients.
To give them. OK. Top tip 8.
Well, we're getting to the end here. Don't worry. Don't overinterpret crystal urea.
Now, I mentioned the role of crystal urea in, urethral plug formation, and that's certainly possible, but as I mentioned, it's not the whole story. And by that, I mean, crystal urea can happen in normal cats that never show any sign of urinary tract disease for their whole life. If they're fed a dry diet, they're gonna have concentrated urine that's super saturated.
We're gonna see crystals. It doesn't mean it's a problem unless they have low urinary tract clinical signs, for example. We can also see crystals form when we leave that sample around.
We don't send it off to the lab straight away. So definitely see this in vitro, crystallisation by the time it gets to the lab, and you should really take that into account. So again, interpreting according to the case, but ideally performing some in-house sediment exam.
And I know that's difficult in a busy clinic, but if you see what I see here on this, this was from a cat that came into me with some recurrent obstruction issues, you know, this is packed with strevite. And I know I checked this as soon as it came out, the cats, and so I know that that's something I'm going to need to, to deal with. OK.
Top tip 9. Well, I've told you that you can't get away with avoiding the behaviour conversation with FIC cats, and probably with all lower urinary tract, cats. But I've tried to help you, with this lower urinary tract, guide for owners.
But it's not just, sort of fluffy behaviour stuff. It's about evidence as well. And if you look at evidence around FYC in cats, you'll see it's really difficult to study, and, and there's some conflicting results.
But this particular study, and you'll hear, let's talk about this term memo, which is multimodal environmental modification. And that's because this was a really important study that showed you could reduce recurrence of FIC if you optimise that cat's environment, increase their water intake, and had lots of conversations about, with the owners about how to improve that home environment. So the aims of our, our behaviour approach to cats with urinary tract disease is about improving their owner understanding.
Of course there are owners that just want to come in and get some antibiotics and have the problem sorted, of course. But that's, that's gonna be difficult because that isn't gonna sort this problem and they're gonna need to come back in and, actually it's more expensive in the long run. So I won't spend a long time talking about this slide, and I've mentioned pillars and resources multiple times, but it's something that doesn't always happen in lots of cats' lives and can make a huge difference.
We will get cats with recurrent FIC referred, and we had one not long ago, 4 cats in the household, 1 litter tray, you know, so there's easily something that we can pounce on and change and improve. And owners won't instinctively know that. Nobody likes having millions of litter trays around, and they don't particularly like hearing that if you've got 4 cats, you should have at least 5 litter trays, that's a lot of litter trays unless you've got a massive house.
So these can be difficult conversations. In the guidelines, we try to help here as well, and we've got a questionnaire to, to try and, you know, help you. Actually, this questionnaire is about cat friendly clinic, but we've also got a questionnaire as part of our guidelines to prompt some conversation about these things.
And of course, your approach is going to change according to the case and motivation of the client. Reviewing the cat's environment, as I mentioned with that litter tray anecdote, can be illuminating. It can show you quite a few things.
So you can see here, in the, from the guidelines, we've got this kind of diagram talking about some of those key factors and how house maps can help. So where are the litter trays? You know, are they in awkward positions in busy places?
Could it be as simple as just providing more and locating them appropriately? And my final top tip, well, is something that again I've touched on before with when we were talking about urolithiasis, and that's that stress can affect all lower urinary tract disease. It affects drinking, eating habits, voiding habits, and, you know, it, it really can cause these urinary signs to develop in the case of FIC.
But imagine if you have an FIC male cat, and then they don't drink enough, and then they get crystal urea, then we end up with the urethral plugs. So there are lots of sort of factors here that can work together, and create that kind of perfect storm, but stress, stress is one of them. So let's go back and apply some of what we've learned to Maverick.
Well, let's bring it all together. He's got a high USG he's on a dry diet and I, I don't need to tell you that he's got stress at home and outside. So how are you gonna treat this poor guy?
Well, the first thing to say is get the timing right. We don't want to make huge environmental or diet changes during a flare up or during an obstruction. No obstructed cat should go home with a urinary diet.
It's not the time. And some of these cats are so sensitive that they will get so upset by just a diet change that they can get FIC. They're really bit special case, some of these, little cats.
Analgesia, analgesia, analgesia, these are hugely painful conditions, whatever the cause, and actually analgesia could prevent spasm. And non-steroidals have a place here. We get nervous around non-steroidals and blocked cats, quite rightly, and of course you're not going to use them in an asotemic patient or a patient with volume deficits, but there are lots of cats that would really benefit from it after that period of time or some of the FIC cases.
With Maverick could start to have a discussion about diet and water intake and kind of look, start to explore what might be preferred wet foods. Remember he didn't have any crystals, not madly worried about a urinary diet. I just want to get that USG down.
And we can provide some immediate emergency behaviour advice. He's gonna watch that cat flap, but let's give him an elevated location to do it from. Let's give him some more litter trays, and they've got that microchip cat flap.
So here's little Mav. He did really well. He continued on some gabapentin, which is another useful drug for these type of conditions.
We slowly made some changes to try and dilute his urine. He was drinking out of a pint glass, and the owner kept removing it because they thought it was a bit gross. Obviously we're vets, so we didn't think it was gross, and I'd drink quite happily out of a glass that cat's drunk out of.
But I did encourage them to keep that pint glass and maybe use another one for themselves if he wanted to drink out of it. Also, something else is being proactive in cats with recurrent obstructions and recurrent urinary tract signs. I have a few that I manage remotely.
I haven't seen them for a long time because if they have an episode, we'll talk to them. Talk to the owner, obviously gauging if they're severely unwell, they're gonna have to come in, but if they've had a stressful event, for example, then a non-steroidal could head off an episode, but obviously that requires lots of good kind of communication and and awareness of adverse effects. OK, I'm gonna stop there and just do a selfie plug for cat friendly clinic, which is obviously important for reducing stress within your clinic environment.