Blood in the urine is a common finding in cats with litter box problems. What most people don't realize, however, is that this blood is usually from inflammation, not a true bacterial urinary infection, especially in younger cats. Most of the time this inflammation, called idiopathic cystitis, results from a combination of stress, insufficient water intake, diet, and a genetic tendency toward lower urinary tract disease. Sometimes, however, especially in older or debilitated cats, a true bacterial infection is involved that requires appropriate antibiotic therapy. These infections can involve both the bladder and the kidneys and can be very painful. Kidney infections can also damage the kidneys and cause kidney failure.
Many cats with cystitis run back and forth to the litter box frequently or may lick their urethral area excessively. They may strain to urinate because of the discomfort. Male cats that are showing any of these signs need immediate veterinary care as they may have a complete urethral obstruction, which is fatal if left untreated.
Some cats have a urinary diverticulum, a pouch that occurs when the urachus (the tube running from the bladder to the umbilical cord in the unborn kitten) does not seal and wither away after birth. This urachal diverticulum can predispose cats to cystitis. It is thought that antibiotics do not penetrate well into this pouch and bacteria along with other toxic substances are able to persist long term in the pouch.
So why do we see so many cats with inflammation in their bladder? A lot of research is being performed to investigate the causes of cystitis in cats.
Domestic cats evolved in the desert, with a diet of small game such as rodents, other small mammals, lizards, and birds. They had a very active lifestyle with a substantial amount of exercise often needed to catch their prey. They lived independently outside, in small family groups, and in colonies with the freedom to move about over fairly large spaces. These cats and social groups tended to develop certain territories, with some migration of cats back and forth.
In society today, cats are usually confined inside homes, often in relatively small spaces, and may share the home with other cats in closer quarters than they would choose. This increases their stress levels, just as overcrowding increases our stress levels.
Many indoor cats are relatively inactive and become obese. Obesity contributes to inactivity, and so a vicious cycle occurs. These less active cats tend to drink and urinate less frequently, and irritating substances in the urine are able to have longer contact with the bladder lining.
As a society we tend to feed grain-based commercial dry cat foods, often with fish added as a palatable protein source. Although these foods may be nutritionally complete, cats are carnivores, and their bodies require meat to work properly. Some cats appear to be more genetically sensitive to dietary issues and stress, and are more likely to develop cystitis than other cats.
"But, Doc, I gave my cat an antibiotic and she got better, and now the infection must be back again because she is going outside the box again!" Cystitis is a chronic, cyclical and often self-limiting disorder. This means that, frequently, improvement will be seen in a few days whether any treatment is given or not , and then relapse occurs a few days or weeks thereafter. The key is to get a definitive diagnosis of idiopathic cystitis, and then treat the underlying inflammation both directly as well as addressing and reducing the instigating causes.
Some cats, particularly male cats, may develop a life threatening urethral obstruction due to mucous inflammatory plugs, excessive urine struvite crystal formation, or small calcium or struvite bladder stones. These cats will die if their urethral obstruction is not relieved by placing a urinary catheter.
Proper treatment may not completely prevent flare-ups, but it usually reduces the frequency, severity and duration of the episodes. Treating with antibiotics without a urine culture is not recommended, since most cats do much better long term by using appropriate medications and environmental and dietary changes to reduce the inflammation. In addition, using antibiotics when bacterial infections are not present increases the chance for antibiotic resistant bacteria to develop making true infections much harder to treat later. Besides, medicating most cats can be a little challenging- why give these medications unless they are really needed?
Diluting the urine is an integral part of treating cystitis. Feeding a canned food diet that is high in meat protein and low in grains and other carbohydrates is particularly helpful. Mix water with the canned food to form a slurry or "kitty soup" and to encourage the production of a dilute urine.
Pain medication can be very helpful in keeping the cat more comfortable when inflammation is present. Managing the discomfort reduces the risk that the cat may eliminate outside of the box. DO NOT use over the counter pain medications- these are poisonous to your cat. Prescription pain medications are available and are usually effective and relatively low risk. Most pain medication is considered to be off label for use in the cat and owner consent should be obtained before use.
Male cats who have urinary tract blockages (and very rarely female cats as well) need to be treated initially with a urinary catheter placement, pain medication, fluid therapy, and diet changes. If the urinary blockage reoccurs, or does not resolve well initially, a surgery called a perineal urethrostomy can be performed to make the urethra wider.
Treatment of Cystitis
Treatment of cystitis focuses on addressing the causes of the cystitis as well as treating the symptoms. Think of it as managing a chronic health concern rather than curing a one time illness. Your cat must be evaluated by a knowledgeable veterinarian to develop an appropriate cystitis treatment plan and adjust it for the particular needs of your cat. Changing to and continuing with an effective diet, reducing stress and making the litter box attractive, and managing the bladder inflammation are all needed for successful treatment. If urinary tract stones are present, they need to be dissolved with a stone dissolution diet or surgically removed. If the stones remain, the cat will contiue to experience pain, inflammation and usually the litter box problems.
Many lower urinary diets have been developed that are helpful in producing urine that is less likely to be irritating and less likely to develop crystals or stones. The canned forms of these foods, especially when mixed with additional water to form a "kitty soup" type slurry, are especially effective at improving urine quality.
Increasing the amount of water consumed helps dilute the urine and dissolve or prevent the formation of crystals. Adding ice cubes to the water bowl, especially during hot weather, can improve the cat's interest in drinking. Many cats prefer running water to drink. Although many people leave faucets dripping for their cats to drink from, commercial pet fountains are also available and readily accepted. Distilled water in the pet fountain helps prevent minerals from building up and corroding the pet fountain.
Most of the over the counter non prescription foods that may include "promotes urinary health" on their labels are less effective than the prescription products in many cats. The small increase in cost you pay for the prescription lower urinary diets purchased from your veterinarian will usually save you significant amounts of money in reduced medical costs to treat acute flare ups of the urinary issues, not to mention cleaning and aggravation of your home if litter box issues reoccur. Some well known manufacturers of lower urinary prescription foods include Hills, Royal Canin, and Purina.
Reducing environmental and social stresses on the cat is another essential component of treating cystitis. Making the litter boxes as attractive as possible to the cat, offering multiple litter boxes, increasing the space available to the cat, improving the quality of interactions between cats, and also giving more positive attention to the cat are all helpful.
What medications can be helpful for treating cats with cystitis? Obviously, if a true bacterial infection is present, an appropriate antibiotic must be given for an adequate length of time. However, for idiopathic cystitis, usually medications are directed towards reducing the bladder inflammation directly or indirectly.
Medications targeted to reducing inflammation in the bladder itself include veterinary "nutraceuticals " containing glucosamine and chondroitin sulfate such as Dasuquin and Cosequin, and pentosan polysulfate sodium (Elmiron), which is thought to adhere to the bladder wall cell membranes and thus buffer the cell from the irritating compounds in the urine.
Medications that target the bladder indirectly are anti-anxiety medications that help reduce stress. Current research is finding that the bladder and colon are closely linked neurologically, and that both organs are extremely sensitive to the impact of increased stress hormones. Consequently, reducing stress reduces the negative neurological stimulation of the bladder and the colon, and thus reduces inflammatory changes.
Pain medication is extremely helpful both in quickly making the cat more comfortable and in encouraging the cat back to using the litter box. DO NOT give your cat human over the counter or prescription pain medications! These are poisonous to cats! Cats are missing certain enzymes that process these drugs. There are some prescription medications that can be used under the supervision of your veterinarian.
Many of the medications used to treat cats for cystitis and other health concerns are not approved for use in cats, although they are used routinely. Any medication can have potentially significant side effects, and consequently care must be taken with their use. Meloxicam, buprenorphine, gabapentin and tramadol have all been used in certain cases, always with informed consent and monitoring by your veterinarian for potential side effects.