Good evening everybody and welcome to a Thursday night members webinar. My name is Bruce Stevenson, and it is an absolute pleasure and an honour to be chairing tonight's session with such a distinguished presenter as Daniela Gmur. So for those of you, that don't know Daniela, I, I think that would be practically nobody, but Daniela, has a list of qualifications and titles behind her name.

That would take the whole webinar to read out. But she graduated from the Royal Dick Veterinary School at the University of Edinburgh, with the Dick vet Gold Medal in 1991. After a few years in small animal practise, she joined the Feline centre, the University of Bristol, and initially was, as the feline Advisory Bureau scholar.

And then later on as the DA feline, feline fellow. And then she completed her PhD studies in feline infectious peritonitis in 1997. After a short period as a lecturer at the veterinary in veterinary pathology at the University of Bristol, she returned to Edinburgh to establish the feline clinic and become professor of feline medicine in 2006.

Daniela is interested in all aspects of feline medicine and something that's not on her bio that she mentioned to me just before we went on air. She was put on this planet to make cats' lives better. And I think that says it all.

Daniele, if, you'll forgive me if I don't read out the long list of achievements and awards. I think everybody, that's on tonight knows you and if they don't, they certainly can go and research, the immense impact that you have had on our profession and leading us forward. In our striving to help cats.

So without further ado from me, it's over to you. Thank you, Bruce. That, that's lovely.

And you're right. The, the only introduction that I ever feel for myself is, yeah, I'm, I'm, I'm the batty cat professor and I was put on the planet to help cats. So hopefully, everyone's got themselves got themselves comfy, got a glass of wine or a nice jam of whiskey.

I don't get mine until afterwards. And then we're gonna talk about, well, Pussy pussy's part two is the way I've colloquially turned this webinar. Now, it's brand new.

So, I have no idea how long it's gonna take. So we might kind of crash into a bit of a wall at the end and speed up. It's just you never quite know with cases.

I want to talk about diagnostics first and then cases. So, anyone who was with me last time when we were talking about FLETD, feline lower urinary tract disease, so that's any cat which showing signs of bladder inflammation. And last time we talked about the, the causes and we're really focused on stress cystitis or idiopathic cystitis, and then we really talked about the management of that, and unblocking pussycats as well.

So, we're gonna take really focus this time on diagnostics and then cases. My thank you as always, to the webinar vet for organising these webinars. I was saying before and chatting to somebody earlier today.

I love these webinars. Everything works so well. You're, you're such a, a great group of people.

It's always a, a real honour to come and spend time with you. Thanks to the dick, of course, I've just realised I have not stuck the dick on the front of my slide. That shows you how brand new this talk is.

I had finished writing it last night. Oops, nothing like up to the wire. So apologies to the dick for not sticking them on the front, but thankfully, I'm still here at the deck after 22 years, I think.

And then I'm gonna stick a little thank you to Siva because Siva drew me these purple pussycats a few years ago and they still have me use them whenever I like. And for that I'm grateful because I think they're just fabulous. OK, OK, I'm now being dumb and blonde and my slides.

Thank you. There you go. So you'll remember this slide where we were talking about causes.

And that the vast majority of cats with signs of cystitis are less than 10 years of age, because the majority of between kind of 4 and 7 years of age. And the vast majority we see are feline idiopathic cystitis, which really needs to be renamed now. It is feline stress cystitis.

Certainly, we know it is triggered by stress. It may be that it's initially caused by potentially an infection that we don't yet recognise. We certainly know that the wiring in these cats' brains has all gone wrong for, things that have happened to them around kitten hood, etc.

So stress cystitis and different studies will put it anywhere between 55% and 75%. The urethral plugs, that's gonna be about 20%. I remember that I talked about the fact that plugs are just the inflammation of FIC added to urethral spasm because of the pain.

And the role of crystals is really not important here other than the fact they get stuck in the sticky protein matrix, you know, just, you know, if you scuff your knees and you get that kind of the, the, the crusty bits, it goes wet and then gets crusty. Well, this is the same thing that's clocking up in these poor cats urethras. So the crystals make it worse, but they're not a course.

Obviously, if you've got a lot of crystals, then you've got an increased risk of stones. That would be my next one along there. It's only about 20% of stones.

And in the younger cats, then, urinary tract infections, UTIs really don't form a major player. Certainly in the research world, or sorry, referral world, then they're always less than 5%. In Sweden, for some reason.

Which I think's really fascinating because of course Sweden is Sweden they see a lot more bacterial UTIs. And of course, they're one of the countries that has got a real moratorium on using antibiotics. So I suspect there's some kind of something related in there.

So the take home really is major causes of cystitis in the cat. It's gonna be stress cystitis causing at least 75%. When we're talking about all the cats, and that's important.

So if you remember this graph, you the kind of the lilacy colour is the cat's less than 10 and the kind of the maroony colour are the older cats, then we're really talking the fact that they're actually PUPD cats, because they're PUPD because they've got chronic kidney disease, hyperthyroidism, or diabetes, they have got low urine specific gravity. Well, not as concentrated as it was. They've all got some reason for circulating, .

Things that are causing neutrophils to not be very happy. So azotemia, thyroxine, or glucose, all of those make newts go there, and unhappy neutrophils mean you can't fight your infections properly. In case of chronic kidney disease, obviously you've got your urinary tract immunocompromised as well.

And then diabetes, you got that lovely glucose to metabolise as a bacteria. So lots of reasons why cats with PUPD are going to get lower urinary tract infections and present with cystitis. Now, clearly you don't just have these things happen on your 10th birthday.

So it's just these are diseases of older cats, and so you need to think about these in the older pussy cats. And you do see stones and infections together in older cats. Obviously, neoplasia is gonna be much more of an older cat thing as well.

And then in obstructive ones, there's a few papers I've distilled into this, some people would still argue it, but certainly this is what we see now, maybe, maybe, maybe, maybe, a, a really good general practise review on this might give you a slightly different result. But certainly the papers that are out there and from our clinic, plugs would be about 60%. Spasm with stress cystitis, about 30%.

So putting those two together, yeah, that 90% of cats that are getting sent to referral practise are obstructed because they're stressed. That's a really interesting thing to be thinking about. Stones only make 10%.

Yeah, neoplasia. I've seen 3 cases in my life of prostatic adenocarcinoma. I've seen one where a shotgun pellet was wedged in the pelvic in pelvic urethra.

That was either a lucky or an unlucky shot. I'm not sure which one you'd count there. But you start seeing more of these weird stuff.

We've had one case of malacolachia. Isn't that a fabulous word? Malacolachia.

Apparently it means soft and hard or something like that at the same time. It's a weird thing. It looks like urethral urothelial carcinoma, what we used to call transitional cell carcinoma.

Does it annoy everyone else as much as it annoys annoys me that things keep changing names? I liked transitional cell carcinoma as a name. TCC easy to write.

Now I've got to write urothelial carcinoma, and I can't spell it apart from that there's not a good acronym for it. But Malakaplay it looks very, very similar. Only it's actually non-fective macrophages due to a really weird, it's normal infections, but just behaving in a really strange way.

So if anyone's more interested in that, then, then ask me afterwards, real funky disease. But it's fun, there's a few, few reports coming through on that now. So that is just to remind you the thing diseases we're looking for.

So we're now talking investigation. As little cat desperate for us to sort things out. We're gonna think about signalling.

We're gonna think about the household, we're gonna think about history. We're then gonna focus on clinical signs, then we're gonna talk, talk very short bit about bloods, dip into ECG just for a bit of fun. We're gonna talk about scans and more imaging.

I'm really just gonna do one picture on cystoscopy because I'm guessing most people haven't got access to it, certainly not in a way that you can do in cats. It's pretty limited on cats. Things we can do with it now with dogs, it's just that vava voom, it's just stunning, but we could talk about that later and ultimately bladder biopsy.

I really think it's worth me taking a few minutes here. The reference at the bottom is one from, it's getting old now that 2001 and it is a US paper, but they're looking at almost 3000 cats. So it's, it's a nice big study, and I've added in some of the ones that I've distilled from other papers, but that's the paper that's the main paper and yeah, I know I should say his name and I'm sorry that I can't, but I can't even work out where to start.

And that's pathetic of me. So age, something's pretty obvious. So young congenital disease.

And then if you dip down below on breed, you're particularly looking at Persians and Manxes here. Manx, yeah, we all know we don't see very many, thankfully, but they've got an autosomal lethal, dominant gene that can result in obviously taillessness and the extent. Of their taillessness, that's a really weird word, taillessness.

The more severe it is, the more likely they are to have problems with urination, defecation, constipation, hind limb mortal mobility, etc. And they may develop or may be born with spina bifida. So not surprising that we do see Manxes with congenital urinary tract defects, but the Persian comes in there too.

And when you read US stuff by Persians, they mean Persians plus, they call them Himalayans. A Himalayan is a colour point Persian. So just one that's, if you look across at this little guy, this is actually a rag doll, but he's colour pointed, so it's the tips of him are darker.

And a person is just a Persian, Himalayan is a Persian cat with colour pointed tips. And we do see more congenital urinary tracts in them. And I think that is, that is an important one to, to remember.

The other one I've put there for young, if you go back up to the I should use my pointer, shouldn't I, oxalate stones. This is becoming a biggie, and I want to take a moment on this. This is a beautiful cat called Charlie.

He is a rag doll. I had a rag doll in last week called Milo. He was sorry, week before last.

He, 10 months old, 11 months old, 11 months, and he was referred in with over 4 months of hematuria. As soon as I read the referral letter, I looked at my resident and went oxalate stones, and my resident went. No, he's a baby.

I said, no, put money on it. It's oxalate stones. You can buy me a cup of tea if it's, if, if I'm right, and I'll buy you a coffee if it's wrong.

And of course, it was oxalate stones. His whole kidneys were full of them. His ureters were full, but not yet obstructing, and his bladder was just a bag of stones.

Why did I know? It's because I have seen so many. Baby rags, baby rag dolls with oxalate stones now.

It is heartbreaking because they, hematuria, and they're painful. They get grumpy, and it's not surprising. My youngest one I've seen was only 8 weeks old.

And that's Henry. He fell off his climbing frame and landed on his side. Thankfully, it wasn't me on duty, that night.

It was, Kerry Simpson, who, when she was still with us, she's now working down south. And thankfully it was her that was on, she's much better at emergency stuff than I am. And this poor little kitten, when he fell off his climbing frame, one of the spiky oxalate stones in his kidney ruptured his kidney.

So he had a ruptured kidney, so he then got blood and, pee all through his abdomen. A little 8 week old baby. Thankfully, they got him sorted.

John Moseley repaired the kidney because Kerry demanded that he repair the kidney. She said he's gonna need both of them. He's got stones and he's only 2 months old.

And he's still alive now. He has turned into a bit of a grumpy baby because he comes to see us so often. So please watch out for those guys.

More mid age, then obviously, you know, 2 to 7 would be FIC and urethral plugs, which is obviously the same condition and we classically say 4 to 7 is FIC. The reason you're not gonna see it in babies is it is a disease of social maturity. In order to feel stressed about your position in society, you have to be aware of your position in society.

So we really don't see FIC in cats that are younger than 2 because they're not socially mature at that point. That is quite important. I do get referred quite a few cases where people presume FIC and they're only 1 year old, and it's just not gonna be that.

Stones you see coming in a little bit later, other than the the oxalates, then obviously the older ones, UTIs as I've already mentioned and the plasia. Gender, obviously the boys, boys and girls can be equally affected. The boys seem to get everything more, particularly neutered ones other than UTIs and incontinence.

That's not surprising. They've got that long urethra. And the girls, you can see they've got predispositions to to UTIs and, and neoplasia, which I suspect partly as a response to, to chronic, inflammation.

And then the breeds I've already mentioned, rags in a big way, Persians in a big way. These are my two major breeds that I see, with bladder problems. We really don't see Russians very much in this country.

They're not a common breed. We don't see many abbeys in this country either. So what about the household history?

This is Uber, Uber important because if you don't get this, you could easily miss what's going on. And owners never give you the right answer. They, they tell you what they think they think is true.

It's almost certainly not true. You've really got to ask some kind of drilling questions to get here. The number of cats in the household, they'll probably get that right.

And the relatedness, they'll say, oh yeah, all the cats get on well. But you've got to drill down to, OK, how many will actually give each other washes? How many will actually curl up and cuddle?

Because just cause two cats will sleep on the same bed, but with a metre between them, they're not a group. It's just that bed is a key resource. So you really need to find out what the key resources are.

Number of feeding stations and the types of diet, etc. Wet food versus dry food. They're all being fed dry food.

Remember that is 90% not water. I only 10% water, as opposed to wet food, which is 90% water. So that will make a big difference to what you're gonna be looking at.

And not just where the food feed bowls are, you know, it's how many feed bowls, and yet, where they are as well. Drinking stations, more people are giving cat food soups, more people are giving, you know, things that aren't, you know, things like cat milk, etc. Things that aren't water.

So you need to know about those two. A number of litter boxes we could spend a whole lecture on that and we'll all die of boredom, like that might be quite interesting. But it's really important.

The classic was a household, which you might get to, with, 17 cats. And I asked about number, but I know you're all gasping and the thought of 17 cats, it gets worse. We'll see if we get to that.

Then the, the, the problem is that, oh yeah, yeah, they knew that you had to have a litter tray per cat and one extra. So they had 18 litter boxes, all in the box room. OK, guys, have a quick think.

How many litter boxes? How many litter box stations did they actually have? Yeah, one, because it just took one cat that wants to be grumpy with the others, and he could block access to the room with all the litter boxes.

Also things with the litter box lids, because some cats like that, it's a little bit of privacy, but sometimes you'll get the more, grumpy cat, the more aggressor will sit on the top of the litter box and smack the butt of the cat that it wants to beat up when it's going in and out. So. All of that is really useful.

I find photographs and maps are really good. I'll get to my map in a minute. But the photographs are really important because owners always say that, yes, they're very clean with the litter boxes and things.

And I just ask for general photographs of all the resources. And you will be amazed. I get pictures where litter boxes, literally, there is shit up all the walls.

It's disgusting, and the scoop is left in there. Oh, just gross. And they think they're doing a good job.

It just makes you think, I don't want to ever go around to that house for tea. So really important that all the things on this list, we need to find about, find out about, they're all more static things. We then need to find about potential stressful events that could be involved with this cat, that they get a new cat, a new dog, a new child or new house.

. Then you don't just think about what's been happening in the house. If the cat has access outside, you need to think about outdoor stresses, and it's not just that they have access outside, because if the cat can see outside, there's one little cat, I went and did a house visit on little Chloe and her litter box was the conservatory, and there was a low wall just outside and She obviously needed to pee, and I had a look in the conservatory, and there were 3 cats stood on the wall, sat on the wall, just beside the conservatory, looking in, waiting for the floor show to start. Not surprisingly, she didn't want to go.

I just literally moved her litter box into a cupboard under the stairs. She went straight in there. Nice sound of pee came out.

Makes you want to go for a pee. And she came out with such a smile on her face. I was like, yay, thank you.

I just didn't want the audience. So all sorts of things like that, you're gonna need to consider. If not immediately when you're seeing the cat in, because it could be a block cat, you haven't got time to all this discussion, but you got to get there at some point.

And then what else can we think about in the history? Well, has it been black urea, so increase in frequency. Periurea, we're gonna come back to, so that's you pissing around, your appropriate urination.

Has there been blood in it? Difficult urination, urethral obstruction. The ventral grooming, and this is not always just grooming over the tum.

Sometimes this is, this one, this picture from Keith. The cats groomed all the way down the inside of her legs and on the inside of her tail. And we had this very funny banter.

It was like he was going, it'll be fleas. I went, it's a bladder, fleas, bladder. Actually, it turned out she got bit both.

But you, you see this cats will rub their bladder as best possible because it's painful. And actually, they'll over groom. The society in humans that deals with interstitial cystitis, which is human, idiopathic cystitis, is called the Institial cystitis and Periulva Pain Society.

Doesn't that sound like something you want to be a member of? And the, the little journal that comes out is called the We Ray of Hope. We spelled W E E I think's great.

So what it gives you the indication of the perineal pain, it shows it's not just bladder, OK? It's pain in the whole perineal area and sterile prostatitis is the same condition but in, in men. And so that's important we think about that in cats, the pain comes way, way, way before the blood.

So by the time we're dealing with the blood, this cat's been in a lot of discomfort for potentially a long time. Altered behaviour, they tend to get very friendly with other cats when they've got kind of a perennial tingle that feels a little pleasant. And then they get grumpy when suddenly they're, nope, it's switched over and now painful.

And if they don't block, it is usually episodic. So you're looking to get this kind of history out of them. There's one of my little maps on the corner, just one of nicked from internet.

But then what you overla on that is when you're trying to work out whether the periura, the inappropriate urination, is it medical or behavioural, so there's the when and the where. So let's start with the wear. The wear is where it is in relation to the wall.

So spraying is classically the cat is standing, as you can see on, on the left. So the pea hits the wall and dribbles down. One caveat male cats with urethral pain will often stand up.

OK, that that caught me out once, so they'll stand because they've got painful, particularly post stones damage. They'll pee standing up for a while. Well as the inappropriate urination, they're gonna be sitting peeing on a flat surface.

But then you want to think about the, the where, as in not just on the wall or on the floor, where in the, the building. So if the cat is asleep in the lounge, but then when they need to pee, they suddenly run upstairs to pee in the, on the airing clo in the cupboards in classically, it's clothes in the dirty linen bin. That is behavioural.

Whereas if it is beside the litter box, that's usually actually that they're arthritic and they can't get into the box, or the box is just manky and they need it cleaned. Doorstep? Mm, that's a tricky one.

It could be that they're old and arthritic, and they can't get out of the litter, but they can't get out of the cat flap, or it could be behavioural that they, Don't want to get outside because there's another cat kind of aggressing on them, you know, bullying them out there. So, you know. Where they are is important.

But what you do is you get the owners to fill out one of these, just get them to draw out their, their flat, their house, put in the essential key resources, and then put little X marks the spot, all the places, the cat pees, and how often it moves. Because with stress cystitis, it's likely to move and they tend to have favoured places they go to when they're stressed. And then that's the when has something very stressful happened or if you had a visitor, etc.

Etc. Or is it the count out cat outside and then it could be hard to work out what the pattern is. Whereas with inappropriate urination because they've got cystitis, their bladder will calm down and they'll pee in where they should, and then they'll have a, a flare of the idiopathic cystitis, and then they're going to feel painful and they're going to move.

So you get, it moves every few days or every few weeks. But what I think's really important number is that the history of hematuria, it's in over 90% of behavioural peruric cases. So you know what, this stuff crosses over and back, but it's important to try and get a handle on this.

Then, is it cystitis or is it polyuria? But you can tell that's gonna be crossover cause these are old cats and factor in the arthritis. Is it that they can't get into the litter box?

Is it they can't get out of the cat flap? I've had owners confuse it with constipation, where the cat is straining when it's actually constipated, and then it's just passing a little pee because they're straining so much so they're trying to poop. So your physical exam should tell you that.

And then concurrent disease, abdo pain in pelvic disease that usually makes a little bit more of an investigation. And then whether you need to do a full investigation or you know, just kind of pat on the head, you know, have some painkillers and come and see, well, we'll take that on a little flow diagram that I've got in a second. So here we go.

First question, when you practical approach, physical exam, so we're starting the physical exam now, obstructed or not. If yes, I remember, most of these are gonna be stress, then you're gonna deobstruct. So that goes back to busy pussy lecture number one.

Don't forget your rectal exam. If you came away with anything from that, it is, you have got the most impressive piece of kit and it hangs on the end of your wrists, just wrap them in plastic, and they are so gifted. And you would never think to not do a rectal exam in a blocked dog.

So unless your fingers are fatter than your average cat poo, then you need to do a rectal on a block count. Wait till it's anaesthetized. If your fingers are bigger than your average cat poop, then you know what, some find someone else in the practise who's got little hands.

Do your imaging, etc. And you're likely to end up that it's stress cystitis somewhere along the line. We'll come back to that.

And then, if not obstructed, then what age are they? If they're older, then you're gonna look at urine and blood, find out what the USG is, find out what their systemic diseases, or whether they've got local neoplasia, etc. If they are younger than 10, then you're going to be looking at addressing all the things we talked about for stress cystitis, so reducing environmental stress, finding out the number of social groups, making sure you've got the requisite number of key resources, etc.

Think about your plugin feely ways, your classic and your friends, then changing the diet to a wet version of ideally a prescription diet designed for stress cystitis and or stones, antispasmodics. And sides, maybe some of these other things. Normally what would go is Think about this, treat as this proved in 2 weeks, you know what, it was FIC.

If it wasn't, yeah, maybe you'll need to do some more work. So, other clinical signs we need to be thinking about body weight is important. Remember, stress cystitis cats are much more likely to be overweight, also much more likely to be black and white.

I've never published it, but take it from me, I'm much more likely to be black and white. In one study of 40 cats I did, 75% were were black and white, and other people doing similar studies have seen the same thing, which none of us got around to publishing it. Obviously a real full full physical, particularly in the older cats.

Find out what else is wrong. You don't wanna just be addressing the bladder when there's other stuff going on. Retinal examine are older cats because you do need to know what the systemic blood pressure is.

And if you haven't got easy access to a blood pressure machine, you know what I'm gonna say, Please get easy access to a blood pressure machine. Take the time train up nurses to do this for you. But a retinal exam, you know, a quick retinal will actually give you a good idea about whether or not the cat is too, as well it's got significant hypertension, and I've just realised there's a picture I wanted to put in here.

It's called the Epi Epit or Epiam. Look up Epica. It's a new handheld, very low light wattage video camera can record video and stills of the retina, and then you can post them to anyone who knows how to read them for you.

Ah, it's gorgeous. It's revolutionised our place. I just love it.

Epica, I must put it in, in this talk. And then trying to decide whether or not they are obstructed or not. Obviously, the major thing is palpation of the bladder.

Do have a look at the penis and the prep you sometimes there's a little stone in there that you can just milk out at the end or there's that plug, you just milk that out and actually unlock them, problem solved. . Then you know, sometimes you can't palpate the bladder.

They're very fat. That can make it tricky. Could the bladder be ruptured?

Maybe you're gonna have to go to ultrasound with those guys. Maybe cardiac dysrhythmia, you know what I'm gonna ask you, and this is Oliver on the bottom, and he's in and out of his litter box because he's a, a chronic recidivist, keeps recurring, stress cystitis. So first question guys, let's see if the polls work.

If they don't, don't worry, we don't have to do them, so we've got plenty to to to discuss without it. So I think Bruce is gonna read the questions for me. Is that right?

Yeah, right, guys. You know how this works. I don't think we've got any new people on tonight.

So simply just click on the answer that best suits you and we'll give you about a minute to answer this one. But what are the most likely ECG changes for a cat with obstructive FLUTD? Four options, just simply click on the one that you think is the most important one.

And as soon as we've given them some time to vote, what we'll do, Daniela, is we'll just close the poll and we'll reveal the answers and you'll be able to see the percentages as well. Perfect. But we give you another 15 seconds, folks.

Remember that all the voting is anonymous, so don't be shy. A couple of stragglers coming in and then we've closed the poll and now we'll just share those results quickly. Oh, you guys are good.

Well, 45% of you are good. It's, yeah, it's those tall T waves, that's pathhenemonic. And actually, for those people who said tall tes and tachycardia, which is the second most prevalent, you know what, you're not wrong, because occasionally you do see tachycardia.

Classically, hypo, kalemia. Will cause bradycardia, but just occasionally I've been caught out. First one that was tachycardic.

I was really confused. So yeah, the, the clue is that horrible tall, very dominant T wave. You often lose the P waves altogether.

But yeah, tends to be bradycardia, tends to be dysrhythmic. But remember, it doesn't relate to the potassium level per se, because it also depends what the calcium level is. If the calcium is low, Then that is gonna make a big effect.

In fact, I think we'll go to the next slide and talk a bit more about that. Yeah, trying to decide about obstructed or not. So let's look at serum chemistry.

Yeah, the urea, creatinine and phosphorus, they're gonna go up as you'd expect in kidney disease. But let's think about the electrolytes. So the potassium, because it's not getting cleared, is gonna go up.

It's the high potassium that really makes your heart sick, but it's when you combine that with low calcium. And what's really weird is, oxalate stone forming cats, unblocked ones, then at least a third are going to have hyper, so high calcium. But when these cats block, block for any reason, whether it's oxalate stones or stress, then you get hypocalcemia.

And it's that low calcium that really tickles the heart to go with the, the high potassium. So I've certainly seen this one cat, I remember him very well, Murphy. You know, he had a potassium, I think it was, I think he was 11.3.

I didn't believe it. I said, that's wrong. He, he should be dead.

He wasn't well. I mean, but he wasn't dead. And I've seen cats with, you know, kind of like 6.8 that have been really bratty dysrhythmic.

It's to do with the speed of the block obstruction and what the calcium is doing. And it's those two things that are important. Then you might want to look at your analysis.

There was a nice study that showed the bloodier the pee, the worse, and the longer the obstruction. That's a little bit of a no Sherlock finding, but it's a useful thing to think about. And then sometimes like this cat at the bottom, this cat is an old cat who's got, I remember it was a spinal lymphoma, you can see chronic, colonic obstruction as well as a massive atonic bladder.

And I couldn't feel this cat's bladder. And yet she was obstructed because she'd got that obstipation. But it took the X-ray for me to be able to tell what was happening.

So sometimes you do need to, to look a bit further about that. I put this slide in before, but it's just there to remind you. You really need to know what the calcium's doing with these guys.

If they're blocked, it's very likely to be low. If they're not blocked, then, particularly if they've got calcium stones, calcium oxalates. It's quite like to be up, and then you need to find out why, cause you might be able to cure it really simply by getting the, the owner to not put the psoriasis cream on, last thing at night and then cuddle the cat, because it could be that that's all that's required is for the cat not to be cuddled with psoriasis creamed arms.

I've also cured them really beautifully where, owners have got lots of house plants and the cats are house plant chewers. And I've gone, hm, could you take the plants away or switch them to something that's not got vitamin D analogues in it, or put them outside of the cat's reach. The neoplasia, we don't see as much as we used to, and that tends to be head and neck carcinomas, so particularly, .

Oh, squamous, squamous cell carcinoma of, the, the, the mouth, but you can see it with them anywhere but just not so likely with lymphoma and you don't get the perianal stuff in cats. Cats don't like that sort of thing. Remember, chronic kidney disease, the total calcium might be really quite high, but the ionised is not that likely to be high.

And idiopathic is becoming much more of a thing, probably related to diet change. Genetics seems to play a role there too. Granuloma, how dare you not think of it?

If we're in Britain, I see so much like 5 advice calls today about TB or potential TB cases in cats. It's like, boring. Yeah, they're great cases, you know, I love them.

So you need to find out what this cat's calcium's doing and if it's tall, screwy, you need to find out why. Then you want to look at Pete? So, OK, we're all taught that in order to get the idea of our culture, you need to do sister andesis.

Yeah, that is by far the best thing to do. And if you could do it like we're doing it with this pussycat, this is, ginger lang ginger, yeah, I, yeah, he's not at all stressed by it. That's great.

I think we're seeing and hearing about more side effects because more and more and more people are doing systos all the time. But it is now well recognised and has been published a number of times now about vago vagal reflexes when you do a cystocentesis and a cat. We all know that you do a systo and then they always need to pee straight away.

I trained ginger because he was acromegalic and I did a systo every time he came to see me about the 3rd time I did it because I would do the systo and then hand him a litter box just on the consult table cause I knew would need it. You know, the 3rd time I went to do the cisto, he just stepped into the litter box and peed, and I just caught it in the, the tube. And so from then on, each time he came in, I offered him a litter box and he'd pee for me.

And the students were just like, Wow, she's trained the cat. Like he trained himself. So, yeah.

Cysto is great, but just remember, it is not always benign. You can get Vega, vagal reflexes. They will collapse.

They go very, very bradycardic, hypotensive. The vast majority, providing they're reasonably healthy when it happens, will then get up looking rather shocked, but they'll get back up again. But, last year I was contacted by two very experienced vets who had done cystos and the cats had died.

One was a bladder tear, which had resulted in, where it's a bladder and, and aortic tear, and the other one was a vaovagal and a very dehydrated cat that was agitated. So what I do more now with particularly my elderly cats where I want lots of litter box. I want lots of urine samples.

I want them very regularly. I'm monitoring to see what the USG is doing. I'm monitoring to see what the prone is doing.

I'm looking for bugs, etc. And you know, chronic kidney cancers, bladder count, diabetes, etc. I don't want them.

I don't want to be sing them all the time and I don't actually want to see them as frequently as I want to see their pee. So I get the owners to They keep a litter box, which is their clean litter box. So it's been sterilised with disinfectant, etc.

Rinsed with hot water, drained upside down, left to dry. And then we use Medica, which is this beautiful stuff. It looks like sand, and the pea just sits on the top.

It is sterile, just comes that way. It's not advertised, as it, but it is. And the cat goes in there, scraps around, has a pea, the owner grabs me, grabs it for me and brings it in ASAP.

I can tell you the vast majority of those pea samples are sterile, because most self-respecting cats do not have shit all over their paws. What you sometimes get if the cat's feet aren't as clean as you'd like, is you will get very low grade mixed bacteria. Fine, there's no UTI.

But what you see every now and again is either pure heavy growth, or low grade mixed bacteria, and then one bacteria where there's a much, much heavier growth. So both of those latter things say, OK, I think we've got a UTI here, and either it's clear enough that you then you can treat or you then can get the cysto. So I just wanted to take that moment, you know, to think about it.

You know, we're very quick to do Systos, and they're not totally benign. So, you know, it's just taking a step. Things to look at at.

You do this all the time. I really don't need to say very much. I wanted to mention lipid, which got a nice picture of lipid, because this will confuse some people.

It is completely normal for cats to spill lipid. They store it naturally in their proximal convoluted tubules, so it falls out, particularly when they're, for example, diabetics, metabolic activity, etc. So the pee will look cloudy on ultrasound, and the urine may look cloudy when you've taken it out.

And then you look at it under the microscope and you've got lots of different size, little refractile bodies. And the littlest ones, as they warm up on the centrifuge stage, they start wriggling, and they look like bugs, and they're not bugs. OK, so just as a thought for that.

And then on dipsticks, the number of people who keep telling me 2 or 3 + on the leukocytes. The leukocyte pad is to do with a protein that you get in it's a urea. So, no, I've lost it, it doesn't matter.

It's a protein that humans only get in their pee when they've got bacteria. But cats and dogs have that protein in their pee anyway. So the leukocyte pad is irrelevant.

That's one comment and the other thing would be about ketones, and you know that the dipsticks do not pick up beta hydroxybutyrate, which is the most important one. But we're talking about bladder disease here. So most importantly, we want as fresh as possible because I want to be looking for crystals, when actually, ideally, I'd like them one still warm, which I can't always have.

But with my block cats, clearly, I can have them warm because I've just collected them from the cat. Oh, what I would say is I did a little study. I never got around to publishing it.

You can't publish everything. Where I looked by ultrasound on every cat that that was an obstructed cat. I did a cysto, say 100% of those get some degree of euro abdomen, providing it's not infected, they are fine.

I think I mentioned that in the last lecture. Things you might see, we've got bacterial infections at the top. This one here is horrendous.

This is filamentous E. Coli. To get them to do that, well, on this occasion, this cat was given effervescent, so convenient, every 2 weeks for 9 months.

When it was resistant to effervescent. Yeah, it's a really good way to really generate an interesting resistance on bacteria. I should change the initials here because it's clearly not TCC anymore.

That's urothelial carcinoma. And renal cast tells you you've got a lot more happening than just bladder disease. Remembering that the blood pad on, The dipstick will pick up, yes, pure blood, it will also pick up haemoglobin, it will pick up myoglobin as well.

So you gotta remember that. And then crystals I really wanted to point out, if the cat is on dry food and it's got good healthy kidneys, 100% of cats are gonna have crystals. OK, they're super concentrated.

Super concentrated. They've got lovely long loops of Henley. So I don't want to hear that there's loads and loads of crystals and that the diet's been changed every two weeks to accommodate that.

It, it really doesn't tell me anything. The only thing on this whole page that tells me something is bilirubin, because that shouldn't be there in a cat. And then if you've got a cat that's got stones, then I'm gonna be going, OK, it's got bladder stones or, kidney stones or urethral stones, and then I might be interested.

But you know what? I'm actually not because I can tell you that over 95% more of renal and urethral stones are oxalates. And once they start forming stones in their kidneys, they stop forming them in their bladder.

So you rarely see any crystals in cats that have got oxalates, that have got stones in their, in their bladder, or, once they've gone up to their kidneys or ureter. And you regularly see an oxalate stone in the bladder and then you've got strovi crystals because you just change the diet. So not the most useful.

So let's look at ultrasound. There's a few little things I wanted to talk about here. I'm gonna speed up.

I want to get to my cases. Don't forget to look at the kidneys because it could be that the reason the cat's bladder is cats having problems is because it's bleeding and we see blood causing clots in the bladder, causing dysuria pretty frequently. This one at the top is a polycystic kidney cat.

So obviously this is a Persian. And we've got a perirennal pseudocyst as well as all these cysts. Here, we've got a big stone being passed down from the kidney and there's a cyst in this kidney.

And I wanted to remind you that you could only see the proximal urethra on ultrasound. If you want to know what the distal urethra is doing or the intra pelvic urethra, stick your finger up the bum, you won't find it otherwise or you need a contras study. What we can now do as well, if we want to look at where the ureter or jets are, if we've got we think it's renal hematuria, we want to find out which kidney is bleeding.

It's pretty difficult to do in the cat by cystoscopy, we can do a bubble study now, something with something called Sonoy. And we inject these bubbles into the blood and then you they should stay in the blood. And if you, if the kidney is bleeding, you can see these bubbles coming out into the kidney, into the bladder, it's stunning, ask me about it if you're interested.

Things you're gonna need to look for. Really take a bit of time on your bladder ultrasound. Here, we've got a dissecting cystitis.

It's not good. This is the same cat. We have a dissecting cystitis and it's already transformed into a transitional a urothelial carcinoma.

Here we can see a stone, we know it's definitely a stone because we got shadowing. Oh, this is a fabulous, hideous one, this poor cat. Actually, like a plachia looks exactly the same.

When you get these horrible, horrible infections. You see it with pseudomonas, you see it with Proteus. I've seen this with coini bacterium where you get these really intense revolting inflammatory, buildups in.

And then radiography, one take home, if there's only one take home here, guys, it's tell me what the kidneys are doing. I get so many cats sent to me for recurrent bladder problems, and they've had their bladder radiographed and no one's ever included the kidneys. Please let me know what the kidneys are doing.

Here, we have got stones in one kidney, probably a stone in that one you can't really see, and we got stones in the bladder. So the minute that this cat was assessed for bladder stones, I know there's one in the kidney as well, and this kidney is small, this one's big, big kidney, little kidney, and we've got stones. This is an oxalate cat.

I really need to chase down the calcium. And it doesn't matter what I do with the bladder, I've got to think about those kidneys. Good observation.

We didn't used to see, we didn't used to think cats had lost penises. And then suddenly we got digital imaging, and suddenly 40% of them have, you know what, I don't doubt that 100% of cats have penises. We'll simply see them as the imaging gets better.

So, other things to think about. Some things are are easy. So if we look at the bottom here, you can see big kidney, little kidney and stones in both.

So this is a cat again that was referred him for bladder problems. Same cat, little kidney, big kidney. Yeah, so we know we're in a dealing with something else.

This cat is a pretty screwy image and now I'm looking at it, it's not at all clear. This is a big kidney. And then this bit here.

Is actually the ureter coming down to a stone. And it was sent in because they really didn't know what they were looking at, and now I'm looking at it going, I'm not sure it's that clear, but this is a big kidney and this is a huge ureter. I know it looks like a piece of gut, doesn't it?

Well actually isn't a piece of gut. We did have to do an IVU to prove that to ourselves. What have I got here?

Little kidney, big kidney, oh yeah, that's right, little stone here. So if you'd only concentrated on the bladder, you might have missed that little guy. This is not got contrast.

This cat has got, you look at this little tiny kidney, one huge kidney. Again, this is oxalates. This kidney is hypertrophied, and it may be, might have hydronephrosis because this side might be blocked as well.

I don't think so on this one. I think he came in as a bladder. But this kidney is obviously pretty redundant.

One of my residents call the calls these popcorn kidneys, which I think's great. So then, contrast studies. I don't know how many of you still do these.

I really like them. I have to have a fight with the images to do them. Important, something's wrong in this picture, this is an old one.

This is not how a perineal prep. This should be an aseptic prep because it was sterile before I got there. I'd like it to be afterwards.

And I don't use clamps. I don't use, Babcockes or anything like that. I don't use Foleys.

I just use the pressure of the contrast media. And I find that if I use standard cheap urinic catheter, and then either straight through a bung onto a 10 or a 20 mil syringe, actually between a fiver and a 20, it's fine, or a stock cock. The What I find it's, it's the question is how much air or CO2 or contrast media of any form, can you put into this cat's bladder?

And why that's important is like this little cat, her bladder only took 10 mLs total, and it's already up into her kidney. So, and yeah, I know she didn't have a, she wasn't emptied out first. Oops.

Obviously, if you got access to CO2, it's sterile, a lot more sterile, and, you're less likely to get airembboli, but it, it's not a major thing. But by, I take the air out, or, sorry, I take all the pee out, and I know how much pee I've removed, I can safely put that volume of either air or contrast back in. But I actually do it very much by feeling for the bladder as much as possible.

And some of these cats are so fat you can't feel the bladder. So I know that if I put air in at the point where when I push the plunger a bit and then let go of the plunger, it then pushes back. That is the right pressure.

I'm not gonna cause damage. So I don't use the set volume. I actually do it by Replacing how much pee I've removed, really empty that bladder and empty it completely, and then put your air in.

What I, I then take my view, my, my negative contrast. I then literally only draw up 5 to 6 mLs of Conra 280 or Omnipe 300. I don't like the diluted stuff.

I think it doesn't stick to the bladder wall very well. And I literally just put a couple of mLs in, and then I roll the cat round, and then I take my other views because that's just enough to coat the wall. Of the bladder, it won't drown out stones.

If you put in more than that, you will miss all your stones. So things you might see. So here's one being referred into me, and this is a pre and look, there's a little stone here, very easy to miss.

Negative contrast. You can see there's a diverticulum. You still see that little stone.

It's only when you pass the catheter, you can then see, oh, hang on. And actually, to be honest, I could feel it. Then we've got like this, is this a stone?

No, I think, well, to be honest, I couldn't decide whether it was a stone or an air bubble. It's up for debate. We can debate that one.

Air bubbles, really easy to get. So sometimes it can be really hard in, as in that previous one, to decide whether it's, air or stones. These ones are pretty obvious that they're, that they're air, except what about this little guy?

He actually is a stone. Again, it's about, if you've got fluoroscopy, it's much, much easier to see, but I know most of you aren't gonna have access to that. And then this is quite good.

This is, I'd left, or actually, it wasn't me. I am going to blame a resident. It was a resident.

They called me and said, oh, he's got a thickened bladder wall. And I looked at it and said, it's not bright enough. You must have left some pee in there.

And he said, no. And I said, Well, can I try? And I got maybe about 6 or 7 mLs of pee out and then I've put contrast back in and you can see now we've removed the thickened bladder wall.

We've got a nice thin bladder wall and it was just because it was getting diluted with pee. So if it gets diluted with pee, it will look like a thickened bladder wall. Don't push too hard.

Idiopathic cystitis cases can be really scarred. Here we can see, air, sorry, my, there's my pointer. Air is leaking into the bladder wall and retroperitone nearly.

This one, I got 3 mLs of air in this one. The bladder wall is so thick. And this one, this is great, isn't it?

There is no hole in this bladder. This is idiopathic cystitis and the bladder wall is just so damaged and it's just leaking out. Nothing much here, so I'm gonna skip through, diverticulum, diverticulum with stones.

These are urachal diverticulum urachal remnants. This is a very typical idiopathic cystitis one, not very exciting. Some stones with a thickened bladder wall.

Stones, you can see, this is why you don't want to put too much con positive contrast in. You'll drown your stones, little bit of a stricture there. This is a lovely, what would have been called the TCC before.

And you can see the amount of contrast. I should have put the vet who gave this to me. I'm sorry, I, I'll find her name and put it on.

Perfect amount of contrast has been added there to just highlight the mass without drowning it. And then don't forget your retrograde urethrography here is completely normal urethra. Here, do not use those anymore.

We've got a bit of a. Stricture or spasm at the prostate. Here, prostate and is she a arch prostate.

These a place, there is a natural thinning there anyway, but it can get quite exaggerated. This is a cat that somebody has tried to catheterize and it's gone through, torn and formed this little, a little diverticulum. And remember I talked through last time, the importance of straightening the urethra.

This is always where you see trauma. If you have access to fluoroscopy, then it really aids interpretation of retrograde urethrography. But it's also to do with the feel of how it feels when you flush them.

This is a little girl cat. She had a stone that was used acting like a ballcock. Here's just a lovely, stricture spasm, and I can't tell looking at this, whether this is a stricture or a spasm.

Strictures tend to be pretty short, which this is pretty short. Spasms can be short or long. But when you do a rectal, you'll feel that muscle being really tense.

And then this is a kind of funky one, which is just in there for fun. IVUs, I'm not gonna say much because this is talk about bladders, but if you've got oxalate, if you've got bladder stones, and they are oxalates, or the calcium is increased and then you're gonna find out those stones are oxalates when they come back from analysis, please make sure you get the kidneys into the imaging. And if you're not sure what you're seeing, if you got an ultrasound, yay, go for ultrasound.

But if not, consider an IVU to find out whether or not you might be having partial obstruction. And that's why the, the, the cat might be being off colour, etc. And until they get complete bilateral obstruction, they're not gonna tell you.

And then I love this one. This is a, one that was sent in to me. It's a big kidney, little kidney again.

Both kidneys have got stones. And then they said, I think I can see the, the left ureter. And I went, what?

And they said, yeah, yeah, I think I can see it. And this is the, it's right at the beginning of an IVU and it was like, really? But yeah, you can see it, massive ureter.

It's great, great pictures. And then if you're lucky enough to have access to CT, which I know more and more of you are, if you got access to the, humane mouse trap, you know, a little oxygen box that they can just sit there, then you can actually get the slices straight through the kidneys. You can see the size of the kidney, whether there's stones, the size of the pelvic dilation, etc.

Out and their toes look adorable, as does the tail. And then more and more of you will be heading in this direction and certainly with the dogs, we're doing much more of that. By way of biopsy.

I think the most important one would be, an aspirate. And I think that's really important. So we do a, a transurethral aspirate.

What I would say if you're taking stones out, please, please, please. No, don't just remove the stones. If the bladder is at all thickened, take that bladder, a little piece of it, and culture it.

You could have a deep wall infection. That might be why this cat keeps getting problems, and dehito. So, oh, well, timing's crappy, isn't it?

But we'll skip through the cases. We might, we, we'll skip the polls, I think, because clearly I'm supposed to be finished already. So, Ollie, you can then go through these at you in a leisurely pace and work them through as well.

So Ollie is one of, if I can just interrupt you for a minute, please don't worry about the time. Those people who need to leave are welcome to leave. You just carry on going.

This is absolutely riveting and fascinating, and I would put some money on it that nobody's going to be leaving. So please just carry on. OK, thank you, Bruce.

If it but tell if people need to go, please go, but then this will be there, you can come back to it. But I'll be able to tell who's getting bored, tired, or just has to go and feed the kids because, they, nobody asks some polls, but we can then stop the polls. So this is Ollie.

He came to see me when he was 4. He's had recurrent hematuria, and he's now non-productive, timid, big painful, big painful bladder, and his prep use is inflamed. So let's have a quick question.

What do you think? What is the most likely cause of Ollie's urethral obstruction? Do you want to read them out, Bruce?

Right, let's get that pole launched quickly. There we go. So what is the most likely cause of Ollie's urethral obstruction?

Bacterial urethritis number 1, urethral plugs number 2, FIC number 3, urethral stones number 4, and urethral neoplasia number 5. So simply just click on the answer that you feel best suits your, your opinion and then we'll give you another 30 seconds or so to answer it and then we'll reveal that. Yeah, I think 30 seconds a good compromise.

Yeah. But, everybody is, is on the go here, really nice. So that's it.

And, there we go. You guys are fabulous. You don't actually need me here at all.

Yeah, it's spasm is gonna be a big one, followed by plugs. That the balance of, of how you voted is just gorgeous. Perfect.

So, yeah, it's actually, it depends on the papers, but the most important is you get those two in there. So it's either way, he is gonna be a stress cap. And so we really, really need to be dealing with his stress.

Yeah, we've got to get him unblocked and everything that entails, but then we got to deal with his stress. So his investigation, here's what we see. Now I know what I said the numbers were, but have a look, see what you've got there.

Quick, quick look at that. What type of crystals do you think they are? OK, so you've seen the bloods, rest ofbiche was normal.

So, ready for another question? Oh, now you get to see two radiographs first. There's his plane.

And there's this other plane. I might be being a bit too quick for you, but you always go back and have a look. So from what we've seen.

Do you want to change your mind? So what do you think of the poll now, Bruce? Right, let's run that poll quickly and from that, what do you think it is?

Number 1 is bladder neoplasia, 2, oxalate stones. Number 3, struvites, 4 struvites and UTI, and number 5 is urethritis. And what do we want now?

Everybody's playing the game nicely. Quick voting now. So, everybody's still here and still listening to you.

Right, there we go. Oh brilliant. Yeah, there's, there's, if we, if I close that and we slip back.

Will it let me? But let me Yeah. Yeah.

We've got stones above the bladder. If you've got stones above the bladder, yeah, 95% are gonna be oxalates. And the other clue, I'm sure most of you noticed, he's hypercalcemic.

OK. So the fact that he's hypercalcemic immediately should make you think oxalates. So, yeah, and numbers to start with, said he was gonna be a stress cystitis count.

But You know, common things commonly, but we do see oxalates, and we are seeing more and more. So, actually, when he was anaesthetized on the rectal, I could feel that stone, and I propulsed it back into the bladder. So what do we do then?

Well, at this point, obviously, you guys would go and do useful stuff, like get the stone out for me, but you really don't want to see me doing surgery. So I got out of markers to, to take the stones for me. And this had been happening, remember, for quite a while, and that bladder wall's pretty thickened.

So I wanted histology of the bladder or just a little slice, and cultural and sensitivity because while the urine in these guys is almost always sterile, particularly if they've had a urethral catheter for obstruction before, they can have a deep wall infection. You can get these little bladder wall microabscesses. And they're an absolute bugger, because it, they don't shed into the pee.

I've seen Carini do that a couple of times, but I've actually seen E. Coli do it, which I was really pissed off when I had an E. Coli that did it.

Cause it was like, why couldn't I get this cat to recover? It was because it was a deep wall infection that had become pretty resistant. So, and then I'm gonna put him on anti-spasmodics because you know me, that's what I really want to do.

And I really feel that spasm in his urethra because of the pain of the stone, is an important thing to deal with. And, and I'm not convinced that he's not a stress cystitis as well, but too often go hand in hand. Remember, you're gonna investigate his calcium, and we found, you know, his and I was high, total was high, PTH, PTHRP, vitamin D metabolites, all boring, boring, boring, and that probably costs you the most of about 400 quid to run all of those, which it does frustrate me that it's so expensive.

So what are we going to do? We've got stones, we really want to reduce the urine concentration, so increase fluid intake, whichever way you can. So if they're like running water, yeah, but deal with all those key resources, try to get them onto a wet diet, but remember we've got the specific diets, which I think's the next picture.

Yeah. So remember that you're in USG you're looking for, you're looking for less than 1035, 10:35 or less. So you want to be thinking about these diets.

So classically you're looking at at the Purina, sorry, I'm looking at Hills Multicare, I'm looking at your your real can urinary SO or the Purina STOX. These are the three that are classics for FIC. And for reducing oxalate and strovi stone formation.

They can't dissolve them. They dissolve through rights a bit. What I would say is that the royal cannon, I get my point back, the royal cannon and the Purina both worked out how to drop the specific gravity by increasing sodium chloride content.

So I know it's been shown to be safe in normal cats and even in older cats, but Ollie at the moment, his kidney function's fine, but I didn't do an STMA on him, because we didn't have it then. If I had done his STMA, I'm pretty certain it probably would have been increased. So I don't want to go with a high cal high sodium, sodium chloride in a cat that I think's got a high risk of developing kidney disease, and he has.

So, My options are for his bladder to try and reduce the specific gravity and to reduce more oxalate formation, then CD multicare or CD urinary support is good. You could go with the Purina NF. It's got the calcium restriction that we used to have with Hills XD for those of you remember that one.

Or the the increased fibres are pretty interesting because they seem to have a positive effect on calcium. I suspect that, you know what, this disease is new to us from 15 years ago, maybe 20 years ago, our first case is 15 really. I suspect we'll work out what the cause of this is and resolve it within the next 5.

So, as I always say, anything we lecture on today, give me, I'll do it again in 5 years. Half of what I tell you won't be right, won't be right anymore. So it's why we always all have to do CPD, including us.

And with, with Ollie, it didn't matter what I did. I could not get his calcium down. So he did end up on a lodge night.

And I, I really can't think, I, I've probably got at least 30, maybe, yeah, at least 30 cats on the launch night at the minute. So bisphosphonate, it paralyses the, osteoclast, so you don't get bone reabsorption. Ultimately, it increases bone fragility, although it's given for osteopenia, but osteoporosis, it's a long story.

But these cats, I don't think are gonna live long enough for, for that. I think we're gonna see that in decades with humans and we're not gonna see decades in cats. I start with just 10 megs, every 7 days.

The worst in theory, you're supposed to give it on I'm starved with just a tiny bit of food. It can be very damaging to the oesophagus. Oh.

00, note to self. Bruce, I haven't got a pen close by. Can you remind me afterwards or Dawn if she's in the background, I want to ask Nick Bova about reformulation of a laundry night.

Excellent. You can add it to that list that he's already got. Yeah, exactly.

And then the delegates who are listening, this is a a spoiler. We're gonna tell you all about a new company that's making really fabulous reformulation for reformulated drugs. So, not for you guys, it's for the cats and the dogs and the horses.

. But I think allogenate would be a great one because it's incredibly acidic, and it really can cause, problems. So I actually let people give it with food and I just accept that I've got to give it more frequently and we seem to get a balance of it like that. And you monitor how frequently you need to give this by getting the, the blood calcium back into a normal range.

But it's a bit of a big drug. So that was our Olly and Ollie is still doing fine, but he does live on his . Yeah, on his bisphosphonates.

So he's a real quickie. This is Hamish. He's 10, when I met him, he's a bit depressed.

Siamese, one of 2, dysuria, then hematuria. It's been going on for 4 months. He's bright.

He was depressed in the hospital. Bladder is kind of mid-sized, painful, you know, he cried when I palpated his bladder. So, ready for another pole?

10 year old pussycat. So we're on that 10 year old cusp, so let's go 10 years or older, think of things like that. So what's the most likely differential?

And our choices are Bruce. What is the most likely cause for hyme's hematuria? Number 1 is bacterial bladder or urethral UTI.

Number 2, bladder or urethral stones. Number 3, bladder or urethral neoplasia. Number 4, renal or urethral stones, and number 5, systemic clotting.

Remember there's a quick poll, 30 seconds and then we'll close it. So let's get voting. 5432.

And I had to throw an old one in for you. Here we go. I, you guys, spot on.

Absolutely. The top choice, at least 50, yeah, 50%. I love the numbers.

It's almost like you guys have actually decided amongst you who is gonna vote which one. So you get the same ratios that we actually come out as their prevalence. Like, that's fabulous.

Yeah, you're expecting a UTI. He's a 10 year old, so we're really thinking about the risk of, chronic kidney disease, diabetes, hyperthyroidism. But we do see stones in these guys still.

We obviously do see neoplasia, and I love the fact that it's even Stevens on that one. And then we see some weird things. And, yeah, no one thought clottings, which, yeah, it doesn't fit.

So Oh, didn't we just do that? But I put it in twice. I told you I wrote this thing like late last night.

Oh yeah, yeah, there you go. Yeah, I'm being stupid. There you go.

And then, as I say, the, the, the ratios, as you'd suggested, and then I've put in Malacoplachia. If anyone hadn't wondered what I was saying, but yeah, Malaoplaia. It's a great name.

And so now we recognise what this is, we're seeing it more frequently and, hearing about it more frequently, it looks just like you've got a TCC. But it's a TCC with a UTI and if you get a TCC and a UTI, let me know and maybe we get the slides reviewed, because if it is malaplachia, you've got a much better chance of resolution. What did we find with Hamish?

Well, we checked his blood pressure and his bicam, etc. Because he's an old pussycat. His creatinine, urea, etc.

Etc. All good. Here's your analysis.

He's not concentrating as well as I'd like him to, but it's not hideous. He's got an E. Coli, and, OK, that's the most common UTI.

And then we've got this on his ultrasound, and then we've got a double contrast as well. So the top one is just an ultrasound and of course the probe is on his tummy, tummy side, and then flipped over and you've got double contrast. So there's some air in there that's particularly around the edges of the bladder.

And then positive contrast here. So you've got something on the dorsal aspect of his bladder. Further investigation.

Now the quickie, do you want to read it out for me, Bruce? Yep, let's get that poll launched and then we can start voting and And get it going. Sorry, I've just got a massive storm going on here, so there's a slight delay.

Right, how best to investigate? Number 1, per urethral suction aspirate. #2, transcutaneous FNA.

Number 3, UTI treat the UTI first as mass could result spontaneously. And the last one would be surgical biopsies. And what do we think?

Oh, it's interesting. It is so interesting. Come on, folks, this is great.

Cause I, I would actually say there's not a right one with this. That one. Right, there we go.

OK. So we, I, I agree completely. We don't know, looking at this, that this isn't, inflammatory debris.

And you saw how big some of the inflammatory debris is that I see in these guys, and it can cause horrible obstruction. So yeah, I definitely think, let's take things gently, unless he's obstructing, then let's get rid of this antibiotic, there's some infection first. And I know I'm stealing your time, but I want to tell you just a sec, cause I just, it sprung into my mind.

My, my own old little cat, she had small cell lymphoma of her pancreas and her small intestine, and she had it for 4 years. At one point, she got a UTI. It was an E.

Coli UTI. And when we went to do a cysto for urine culture, we couldn't get one. The bladder was solid.

We ultrasounded it, it was solid. We aspirated it. It was small cell lymphoma.

Thankfully, it wasn't me that did it. And this is the proverbial week. This is my team, because I was actually on holiday.

It's on annual leave. They didn't tell me. They knew I was back the next day, and they figured, hm, OK.

Well, let's start treating for, they got tiny little drip of urine and it looked buggy. So they said, well, there's a there's a UTI there, so let's treat for that. She had an E.

Coli UTI. That bladder was read out as small cell lymphoma. We, she was clinically completely better in 7 days, 7 days of antibiotics, but obviously I gave her more than that because I was thinking I've got a cat that's got cancer everywhere now.

When we re-ultrasounded her to a month later. Guess what, bladder? Completely normal.

And she wasn't troubled with it again for the next 2.5 years. She lived for 4 years with small cell lymphoma of the pancreas and bowel.

Small cell lymphoma is not like normal cancers. It's there because you've got an inflammatory focus. If you can get rid of the inflammatory focus, it goes away.

It's a bit like malacoplachia, but malacoplaia is macrophages. Funky, hey. OK, so What did we do?

Actually, I'm gonna slip back for a sec. So transal aspirate is where we went next. The reason for not doing a transcutaneous FNA, which didn't get high votes, which I agree, you would be risking if that is a TCC or its new name, you risk tracking it down an either path.

And surgical biopsy just seems a bit big at this point. So, section of the mass, what do you think? Yeah, it's a urothelial carcinoma.

I was so depressed, but you can see those cells are, you know, they're not that irregular. So treatment for Hamish. We need to think about, remember, he's got a UTI so it's got to be cultural and sensitivity because you've got an infection there, you've got an infection and a mass, so we really want it to be, you know, all of the things as listed.

And moxil and caveolinate was the right choice for him, and he took it well. Nowadays, you know what? I've got doxycycline that I'm want, actually, dox is pretty good for bladders, and I will use it with bladders.

My preference would be amoxi and clavulinate in the vast majority of, of UTIs. We know that, on a, a blind test, so to speak, that's gonna get at least 83% of, cat UTIs before you get the culture result. So what about urothelial carcinoma?

If it's a surgical one, drop it out. The problem is they're often not. If they're near the trigon, then clearly you're gonna stuff the ureters, and that's not gonna work.

And in, while in the dog, they tend to be in the trigon, the cat, they much more likely to be diffuse, and we often see them. So if you slide down to just below here. This was, we, we gathered together 11 cases and pussycats, 3 of them had had FIC for up to 5.5 years, and these were FIC with really thick bladder walls.

So this makes sense. You know what cats are like, you inflame them for any length of time and the inflammation will turn into neoplasia. So kind of not so surprising.

Work has been done with peroxicam, but we did work with meloxicam. It's much more titratable, cats will drink it off the spoon, etc. So, that's why we, we opted for that.

In dogs, I should have put the reference at the bottom, my apologies, but in dogs, come on, point. In dogs, there was one paper which is 34 cats, dogs, sorry, lesser species. And their life expectancy or mean survival time was 180 days.

Ours was actually better. So we've had one cat who her bladder TCC disappeared. I kept her on meloxicam because, you know, I was worried and ultimately she died of a squamous cell carcinoma in her nose.

So, Means survival for us, or sorry, one year survival with 34%, so not, not bad, definitely worth considering, this isn't something you just go, I'm sorry, euthanasia. Unfortunately, with Hamish, we weren't so lucky. We only got 2 months, which wasn't so good.

And then let's quickly skip through Bert. So, Bert, Persian, one of 18 cats. You, yes, I mentioned him already.

He's at 2 years, hematuria, dysuria, perio, bad episode at the present. And I think he's also suffering from the fact he's on a pretty loud carpet. He's overweight as we expect these guys to be.

Nothing very large. He's got a big painful bladder. So, really quickly, a 12th vote.

Bruce, could you do the honours for me? Right, let's get that poll going. What is the most likely cause of Burt's urethral obstruction?

Bacterial urethritis, urethral plug, urethral spasm or FIC, urethral stones, or urethral neoplasia. What do we think, guys? Yeah, I think we're gonna have 100% on this one.

Well, we know we could go. I'm cheating. I can see the results before they come out.

Alright, there we go. OK, yeah, well, I, I'm with you guys. It's, it's gonna be plugs or spasm, which, let's be honest, it's FIC whichever way you look at it, isn't it?

Absolutely. Come on, please. Oh, it's, he's having sleep.

I think your thunderstorms come to get me, Bruce. There we go. Yeah, he's a spasm, and actually, you've seen his radiograph.

Look at that. Lovely title spasm. Oh, and as soon as I put my finger up his bum, this little piece of muscle here literally felt like a little piece of Arnold Schwarzenegger.

It was like, oh, to talk could be. All I had to do was massage that. You know, just relaxed.

It's great. And you can see on the, the contrast, you know, just beautiful clean walls. Really concentrated pea.

Yeah, of course, it's true rights. When you pee is over 1050, you're gonna have stones. You're gonna have, sorry, not stones, you're gonna have crystals.

That would be normal. He does not have stones. He has crystals.

And it was sterile. We're not surprising, you can't really grow bugs when you've got a USG of over 1050. So, diagnosis and treatment.

OK guys, here's a quickie. Bruce, can you be my gorgeous assistant? Right, so let's get this poll running quickly guys, nice and, and fast.

What is likely to be the most effective way to manage both stress cystitis long term, oral gags, tricyclic antidepressants, decrease the stress, decrease his urine SG, and rehome him. Let's see what we get. That's what I'm really curious about.

And I always give you real cases cause, you know. I don't need to make them up. I get sent them anyway.

You get enough of them. Yeah, absolutely. Another couple of seconds and then we'll close that poll.

Sometimes I think people think I make them up, but no, it's a real, yeah. There we go. Reduces stress.

I, but I'm with the 16% of you that says rehome him. Do I really think that somebody who's got 18 persons is ever gonna be able to reduce his stress? I can see 20% saying antidepressants, but remember what I feel about antidepressants.

It's OK for a temporary where, you know, we've got a a a short transition for something. We might be got a building work or a holiday or something, moving house, but I really don't think leaving cats long term on antidepressants is the right thing. I think we should, if we can't sort their environment out, then we need to sort it out permanently by, by rehoming.

So, see, I forgot to close. You see, confused myself. I'm very easily confused.

There you go. So, management for stress cystitis, we need to reduce urine concentration, and we need to reduce cat stress. Reducing urine concentration below 10:35 will reduce the bladder pain.

It will reduce the signs of cystitis. It will usually prevent them almost completely. Certainly in the two studies have been published, including my own, it's nearly, you know, it, I think mine was 94%, the other one was like 83% or something.

So, you know, it's, it's really good. Get the urine concentration down. The bladder at least is not adding to the stress.

But that doesn't mean the owner can then forget that the cat is stressed because that cat is still stressed as hell, just because it's not being blood all over the place. So, options reduce the urine concentration. Yeah, we can do that with food and food or water.

I've put the oxates or stre rights in because if you're getting a lot of crystals, that's not gonna help. It can make it worse, and risk making the plugs worse. We're gonna need to think very quickly about cat stress and we've got the others, and I'm really underlining monitoring cause that's so important.

You're in concentration. We talked about this when we would end up in fizzy pussy part one. So got these diets, they are absolutely life sparing.

They're not physiological, but they are life sparing, which are life saving, which is really important. Obviously, you really need to, to work hard on getting the cats to drink more. Some of them don't.

I do have some of these cats on sub-Q, regular sub-Q, fluids. If that doesn't stress them out, then that's a pretty good way. They are cats that really won't do anything other than eat dry food.

They're just not willing to, to drink. Think about those key resources. So you need to find out how many groups of cats you need the only owners to be honest about the groups of cats.

You need to really reduce all that stress that we talked about at the start. And there is, the little book that I wrote with Sarah. It's on her website, which is Caprofessional.com.

I do not get a penny from it, by the way, that it was my gift to, to Sarah was a wedding present. So just here, that's me. That's kind of a weird pre wedding present, isn't it?

But you know what, it works. So, really think about these cats and their stress. So you need somebody in, in your clinic who's willing to spend time with the owners and to get this and to go through everything.

And I often find that my nurses have got more patients at this and they really enjoy it. They can spend the time and they're good at it. Other things that can help.

So the indoor cat initiative, which is a higher state uni. I love these things. These are the cat it pro products.

There's all sorts of cat toys, it's a water fountain, trees, feeders, you name it, they make it all. Think about if you're making changes in diet, do it gently. Think about fill away products, the classic to reduce anxiety, feel away friends to stop anxiety and and problems between cats, particularly in a household of 18 Persians.

And, yeah, no, no, they get on fine. Nobody hisses at each other, but that doesn't happen when you've got that many cats. Owner stress, say, in my, one of my studies that was 40 owners, 39 owners of cats with stress cystitis volunteered that they were on tricyclic antidepressants or serotonin reuptake inhibitors.

39. The 40th, she should have been. So these owners are very stressy.

They are looking for a very intense relationship with their cats, and sometimes that is not the relationship that the cats are wanting. And I've already mentioned about thinking about outdoor activities affecting on the cats. By way of other potential drugs or interactions, I do like zilking or you've got the same product effectively in these two diets.

This binds, the NMDA receptors that is not addictive. There's some studies that show this works, which is good. I do have my reservations about TCAs, antidepressants, etc.

But they in the right place then, and if it's that or death, you know. Taxes, yeah. Although I do worry that some of these guys would actually prefer not to be alive.

That's really miserable, some of them, in which case you really need to think about rehoming. I love smooth muscle relaxants. I just love, love, love Prazolin.

Absolutely great. Some of these guys are really, really twitchy in their spasms, and that could be girl cats too. Remember the data I showed you about gags and the fact that these guys really don't work.

All right. There is no statistical evidence that they work, and we've got at least 5 good studies now. Does it mean that they never work?

No, it could be that in individual cats they do. And I won't take a cat off them if they've already gone on them or if the owner's determined. But I don't expect them to work and then think about analgesia, etc.

So let's finish a little with, let's finish with but I still half an hour extra. I'm really sorry, guys. It's, it's, this is a virgin talk, you see, that's what happens when you put them together and you have no idea how long they are.

Not very professional of me. I, I really apologise. So put him on fluids, you can see he's a bit pissed off.

Now, should I have catheterized him? Actually, maybe I should have put that as a spot question because one massage of his pelvic in pelvic urethra, and he was peeing, it was a spasm. It is not a benign thing to leave a catheter in.

Now, what I would do with him. I would probably give him, a few hours of IV fluids cause he was on IV fluids while he recovered from his anaesthesia, to have him on nice high levels. I'd probably give him some, some cues as well.

And I'd send him home on Prazoin high dose and see how we get on. If his kidneys were worrying me, then maybe I'd keep him in overnight. With the Prazoin on the high dose fluids, make sure he pees for breakfast, as long as he's peed in the morning, then I'm gonna get him out of the building, at least on a week of Prazoin.

Remember that stops the bounce back. I want to feed him a wet diet, preferably one that's a prescription diet. I really want to reduce the stress.

I want these guys, the, the owners had heard about, gags, really wanted them, and home monitoring. I mentioned about really important to get the owner engaged. She really said she was, she was doing everything for him, etc.

Etc. Etc. She swore to me that she had it all under control.

And he came back looking like this. Yeah, I hope you've all gasped. I couldn't tell if he was blocked or not.

I couldn't feel his bladder because his coat was such a mess. So yeah, I was not at all pleased. I had to shave him before I could actually assess him.

He's now kind of a dairy cat. I don't. Not the best thing to do to a stressed cat, but I, I think he's probably more comfortable like that than he was.

She really pleaded with me and so I did put him on amitriptyline, she was moving house and I thought, OK, let's try. He escaped from the van when they were unloading. And, he didn't run away for very long.

She was moving into a, a, a place near a barn. He moved into the barn temporarily, but just too much of a posh cat. He moved back in, but only into her, scullery.

He would not go back into the main house. And she ended up putting a chair out there for her to sit in. He had all of his key resources.

And she spent time with him every day out there almost every day. So he eventually got rehomed effectively, but kept his owner. So as far as he was concerned, that was the right outcome because he then had all his key resources and he was no longer stressed.

So hopefully, that's been useful for you. Only a half an hour extra. I really give you my humble apologies, but I hope this has been a useful, exercise for you.

There's a useful resource that you can go back over. Obviously, I'm very happy to take any questions you have, but absolutely appreciate that you've probably got to go off and Other things. Huge thank you to the webinar vet for hosting this webinar and all of these webinar series for Dawn in the background, organising everything, for Anthony, for keeping everything going as always, for Bruce, who I've only met today, who's just been an absolute gentleman, and always to you guys for spending time, for agreeing with me that to spend time.

Talking about cats of an evening when we've all got other things to do. We're all busy people. I, I, I'm really honoured that you'd spend time with me.

Thank you very much. Daniela, thank you so much for your time and I'm sure that everybody will agree with me. It was more than worthwhile.

You are amazing, and we are really so happy to have you in our profession and leading us and guiding us in our knowledge of cats. I think the reinforcement of that to me was that, even though we ran over, we only lost one person out of the audience. So that's testament to, to your lecturing and to the knowledge that you've shared with us.

So thank you so much for your time. You're very, very welcome. Thank you.

We do have a couple of questions coming through, but most of the comments that are coming through are, are about how amazing the webinar was. Excellent, informative webinar. Thank you so much.

They really, really are very, very pleased. One quick question that I just wanted to ask you, folks, we're not gonna have time to go through all of them, but the one from Gordon just said, oral gags are ineffective, but what about cartrophin? Unfortunately, I'll tell you what, I will direct you back to Pussy pussy one.

There are now 23 studies using Cartrafin in some version, so one was systemic, so, subQ injections on the 1 to 5, 10 day cycle. And that was a 6 month study and there was absolutely no statistical difference between the groups. There's another one where it was given already, that was the Elmoron study, that was 144 cats and they were each followed for a year, and again, no statistical difference.

So Gordon, I think that the short answer is, go back and watch the first webinar again. And I think like all of us, we're all gonna watch them over and over because there's so much valuable information in there that it's just hard to, to be making notes and, and concentrating while we're going through. Daniela, thank you so much.

For your time and I cannot wait to see you back on the, the next list of webinars. It's been an absolute honour and a pleasure, to everybody who's attended. Thank you for staying to Dawn in the background.

Thanks very much. And from all of us on this side, thank you and good night. Good night, everybody.

Take care.