FLUTD/FUS Feline lower urinary tract disease

FLUTD/FUS Feline Lower Urinary Tract Disease

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FLUTD

Question: Dear Dr. Mike,

I am very confused and concerned about my 3 year old neutered cat. A little more than a year ago, he began urinating frequently, with discomfort and in very scant amounts. I live in a very small town, but took him to the vet here. He prescribed an antibiotic and said there appeared to be no blockage and his bladder was empty... this seemed to help a little, but about a month later, the same thing happened. Over about the next 6 months, my vet prescribed 4 or 5 different antibiotics, told me to try an acidifying food - science diet, but because he never improved, and kept getting worse, finally recommended I take him to a specialist. (He never collected urine, but would take his temperature, and externally feel his bladder, which he said felt "thickened".) Anyway - I took him to a feline specialist in a town 3 hours away...

By this time, he looked pretty bad and had been losing a lot of weight... he is an average size cat and was down to 8 1/2 pounds... I think his usual weight was somewhere around 11 or 12 pounds. (you could see his hip and shoulder bones and his chest bone(?) stuck out.) He would urinate very frequently, and would mee-"howl" around the house for no apparent reason all of the time. He strained to urinate and defecate. His stools were very infrequent, small and soft, but he would have to strain and push to even pass one... He licked his penis all of the time... Often biting at it - it was usually red or purple on the end. He makes noises when he licks himself and seems as if he is in pain.

That doctor performed many blood tests, x-rays, sono-grams, urine analysis, etc... and said that his bladder was very thickened, there was blood in the urine, but no evidence of crystals, no tumors and nothing apparently wrong with his bowels (?). He discussed very thoroughly the history and causes of FLUTD, which in essence seemed to be in either great debate, or "unknown". He told me to change his diet to CDS, wet and he prescribed ovaban (5mg per day) (which he did say not a lot of vets use anymore - but felt that short term use could be beneficial) for 7 days and 1 capsule of cosequin for 30 days, then 1/2 a capsule for another 30 days. After the 7 day treatment of ovaban, he was showing no improvement, so the vet said to continue it for another 10 days. My kitty greatly improved, began eating again and gained weight. He urinated much less frequently and in much greater amounts... (the clumps of urine were previously so small they barely held together and were often difficult to "scoop" - but after the ovaban, they were a little smaller than a hard boiled egg would be.) This progress began to decline pretty quickly after he stopped taking the ovaban, and we repeated the treatment (10 days worth) 2 months later (he had stopped eating the wet CDS and was not showing much interest in any food... - even the dog food he used to love and try to steal from the dog, he wouldn't touch). He finished this treatment about 2 weeks ago, and is doing ok...

Currently, he still licks himself often and bites at his penis. It still looks irritated. He is an inside-only cat. He does not appear to bathe himself. He just hasn't been acting like himself for the last several months. I would say he seems generally depressed and in a little bit of constant pain. His weight looks ok right now, but he does not eat as much as he did when he was taking the ovaban. He will urinate on a plastic bag if there is one on the floor (he NEVER used to use anything but the litter box). He eats about 1/2 can of CDS a day and has free choice of dry food (I have given him lots of options on the dry food and the one he eats now is Purina one... ) I am not giving him the cosequin anymore.... (not really vets orders, I just didn't think it was helping and worried that maybe that's why he stopped eating the wet CDS) - (I also tried all different kinds of wet acidifying foods - CDS was the only one he would eat)... He still meows around for no apparent reason sometimes, but not at all like he used to. He has begun sleeping with me again the last couple of days. (Oh - lately (the past several months -probably around the time we started the ovaban/cosequin treatments,) he would lay and sleep on the floor - which I thought was pretty strange. He used to always sleep "up" on something... the couch, a chair or bed, or on top of a piece of furniture...) I started giving him distilled water last week (when I read your comments on it) and tried to mix it with his wet food but he didn't touch it. He still has very scant and small stools. He seems to want outside a lot. I'm not sure if I should let him out. We live out in the country - (no danger of traffic) but he is declawed in the front. He loves to eat stringy things and I'm afraid he would eat a lot of grass - which would upset his stomach and I just don't know if he needs any more problems.

OK- my questions... what do you think about the ovaban and cosequin treatment? Are there any other treatments you would try... I was wondering about the Amitriptyline - could you tell me about the pros and cons of that drug and what its purpose is. Also - recently I discussed a perineal urethostomy with my vet. My kitty has never been blocked and there are apparently no crystals present - but his penis has been irritated through all of this.... Do you think a P.U. could help? Also - I didn't ask him what the negative side to a P.U. is? (Aside from the enormous cost!) I think my vet is great and I really trust him, but thought I would get a second opinion before I considered the P.U. since it is such a costly procedure that is not "guaranteed" to work. And - what would be the pros and cons to letting him outside and do you think I should?

My cat is so great, I love him so much and I hate that he is in pain... Are there cases of FLUTD that are so severe they require putting the animal to sleep? I don't want him to suffer, and want to try whatever might help, but it's getting very frustrating and expensive....

thank you so much for your help!

Dawn

Answer: Dawn-

The use of amitriptyline for cats with FLUTD is based on reports that it has helped with interstitial cystitis in people. This is also true for the use of glucosamine products. We haven't had too much luck with oral glucosamine/chondroitin products but have a couple of feline patients that seem to be responding to the use of Adequan, which is an injectable medication. I think that the product showing the most benefit in humans is Elmiron (Rx). Hydroxyzine, an antihistamine, is reported to help some cats, as well.

Amitriptyline is usually given once a day, at night, at dosages between 5 and 10mg/cat. It can cause sedation but the most serious side effects are urine retention and decreases in the numbers of neutrophils and platelets. So far, our experience has been that serious side effects are not very common, though.

Perineal urethrostomy (PU) surgery should be considered a last resort, I think. I did this surgery pretty frequently early in my career but have not had to do one for several years. Most cats did fine with this surgery but it has the potential for really serious complications, including an inability to urinate -- and it can be hard to correct a problem once it occurs.

I have not tried pain control, but piroxicam may also be helpful since pain is part of your cat's problem.

The other thing to consider is further diagnostic work. An exploratory surgery to examine the bladder and to get biopsy and culture samples may be helpful. It may also help to have dye contrast X-rays to look for bladder abnormalities but I would recommend having a veterinary radiologist or veterinary internal medicine specialist do these studies, as I think they can be hard to interpret. You may have to consider traveling to a veterinary school or large referral center for this type of diagnostic work.

This can be a really frustrating situation. I have two or three cat patients who have been to more than one specialist and still have occasional problems with pain or urinary tract disorders.

I can find dosages for you if you and your vet would like to pursue any of these options. I really do think additional diagnostic work might be the best next step, though.

I have not ever tried megestrol acetate (Ovaban Rx) for feline lower urinary tract disease. I am not sure why it would help but have a hard time arguing against success. On the other hand, this is a medication that has a high potential for serious side effects in cats, so it has to be used with that risk in mind (it induces diabetes pretty frequently and mammary cancer, even in male cats, occasionally). That risk has to be weighed against the improvements you have seen in his comfort level but if an alternative medication can provide the same comfort level it may be better to change medications.

I am not uncomfortable with having patients with FLUTD who are inside/outside cats -- but I do think it is really important to find them at least once a day and make sure they are OK, since a urinary blockage in a male cat is a serious problem and can cause a cat to die. Some cats are much more comfortable urinating outside and some drink more when allowed to be inside/outside cats, which also helps. If he roams or hides from you outside, that wouldn't be a good situation with the FLUTD.

Good luck with this.

Mike Richards, DVM 7/7/2000

FUS diet

Question: Hello, I have two male cats, one is 11 yrs. old and the other is 6.

The youngest one has problems with (FUS). My vet suggested Science Diet maintenace diet (dry food) for Seniors. I can buy it at the petstore. It supposedly contains the lowest amount of magnesium and ash available on the market, and is low calorie. My vet has told me that it's ok to have the older cat on this diet also. I am not particularly fond of Science Diet, so I've tried Innova, and Eukenuba, but each time the FUS would return to the youngest cat. Meanwhile, my older cat has bouts of throwing up. He seems to do this when we've been gone, and his schedule changes.

I am concerned first of all, about having the older cat on this diet being he is throwing up easily. He does go for maybe a week without throwing up, but I usually see where he has about once per week.

Secondly, is there something else I could or should be doing to correct the FUS problem in the younger cat rather than feed him this diet?

Both cats are over weight.

I was reading your June 2000 newsletter, and it prompted me to write with my concerns.

Any help or suggestions would be greatly appreciated.

Thank you

Regards, Peggy

Answer: Peggy-

For cats that have repeated bouts of FUS (FLUTD) dietary control is the best option. It is possible to use d,l-methionine or ammonium chloride to try to keep the urine acidified and then feed a diet that doesn't cause urinary acidification, however this just doesn't seem to work quite as well, just based on our attempts to substitute this therapy for dietary control. I can't really explain why, though, since I am pretty sure that these are the ingredients that are used in the urinary acidification diets to achieve urinary acidification.

Eukanuba makes veterinary diets that acidify the urine and so do other cat food companies, so there are a lot of choices in foods. If you keep working with your vet you should be able to find one that is OK with you, OK with your vet and that works for both cats. It may take a little time to figure out which one really does all this, though. If you can't find one, you can try a diet that works for the older cat's GI problems and use the urine acidification medications and see if that works.

Mike Richards, DVM 6/10/2000

Feline Urinary Tract Disease and distilled water

Question: Dear Dr. Mike:

Could you please give us any information you have as to whether distilled water could help prevent Feline Urological Syndrome, especially crystals and blockages in cats, more particularly male cats. If distilled water does help prevent FUS, would a water softener installed in a home be as effective. Also, if distilled water does help, how does it help?

Also, are there any foods you can buy at a pet store that help prevent FUS. We understand that a food low in magnesium will help. If this is true, what percentage of magnesium? We have a couple of overweight cats (both male and female) that we have been feeding CNM - OM Formula made by Purina (which is a diet formula) because one of them had a problem with FUS. We fed all of them this formula because of the difficulty separating them, and we were under the impression that feeding this to the cats that were not overweight would not hurt them. Is this true? When we bought more of this cat food, it stated on the bag that it was a new formula. I started feeding these cats this new formula, and one of the cats that is not overweight started having diarrhea. I called a number on the bag and told them of this problem and they stated that nothing had changed in the formula except they starting using wheat germ or wheat flower (I don't remember which) and also stated that some cats have problems with this. Can you suggest another type of food (possibly that we can buy at a pet store) that is similar to CNM - OM Formula? We are considering switching to Science Diet - Light Maintenance Formula which is as close to the percentages of protein, fat, fiber and magnesium as we can find:

Science Diet CNM - OM Formula

Crude Protein: min. 35.0% min. 32.0%

Crude Fat: min. 7.0% min. 6.0% max. 9.5%

Fiber: max. 10.0% max. 14.0%

Magnesium: max. 0.07% mg. max. 0.1%

Is Science Diet a good choice to help prevent FUS?

Also, we leave a bowl of dry food for these cats out at all times. I now realize that they are eating too much food and am considering limiting how much they eat. Will it hurt them to just start putting out limited amounts of food about three times a day considering they have always eaten as much as they liked?

Any information you can give us is greatly appreciated.

We just wanted to take time to also say that we find VetInfo very informative and are very appreciative of your articles that almost always gives us information we use. Thank you so much and keep up the good work!

Shirley and Mike

Answer: Shirley and Mike-

I think that using distilled water sometimes helps a lot with feline urinary tract disorders. But I think that it helps because some cats are more willing to drink it and therefore are less likely to get dehydrated and the urine concentration is likely to be more dilute, which discourages crystal formation. I don't know of any specific benefit to distilled water other than this.

I don't know of any study showing an increased risk of lower urinary tract disease associated with the use of water softeners. They do add sodium to the water but I don't think that has a bearing on crystal formation.

Low fat or low fat/high fiber diets don't help with weight loss if they are fed free choice. Cats just eat enough of these diets to get the calories they want. You do have to limit the amounts fed if you are going to see weight loss. Since this works for any diet you chose (limiting the amount fed), I don't use weight loss diets too often in my practice.

I don't think that it is a good idea to use a diet that helps to prevent feline lower urinary tract disorders (FUS, FLUTD) unless you are sure one of your cats has this problem. The reason for this is that the diets that are proven to work do so by causing a lowering of the urine pH. This can lead to the formation of calcium oxalate stones. If your cat is known to have FLUTD then this risk is worth taking. If your cat doesn't have this problem it isn't necessary to use a diet that actually increases the risk of another problem.

Magnesium may or may not have an impact on FLUTD but the current thinking is that there is no effect or that the effect is very minimal in most of the literature. Acidifying the urine is the approach that seems to work best to limit problems with FLUTD. There are a lot of diets that do this. Purina and Alpo both make grocery store brands with this effect and there are numerous specialty diets available through your veterinarian, too.

The best approach to weight loss is to ask your vet to recommend an amount of food to feed after picking out the diet you want to use. Ask for a total daily requirement and then divide it up any way you want. Your cats would appreciate three or four small feedings as that more closely matches their natural eating pattern. Watch carefully to be sure the bigger cat isn't mugging the smaller one for its meals.

Hope this helps some. If you need clarification of anything, don't hesitate to ask part of the question again.

Mike Richards, DVM 2/16/2000

FLUTD - Adding water to food

Suggestion: I feel the need to share with you something that might help other cats owners with this dreadful syndrome. I have a male cat three years of age. He has had this problem for over a year. We have tried everything from changing of the diet to flushing out his bladder. I needed to let you know something we have discovered that so far seems to be doing the trick. Adding water to the s/d wet . He was also taking Clavamox twice aday and Baytril. THE MOST IMPORTANT PART OF THIS IS THE FORCING OF 40cc's of water everyday. Slowly he was weaned onto a mixture of w/d and s/d both dry and wet. Eventually to a diet of w/d wet and dry. The Baytril was stopped but the clavamox continued. He is doing well now and I check his p/h reading's at least once a week to make sure it doesn't go higher then 6.8 (not always easy to do) He is now on a diet of just s/d wet and dry THE 40cc's of WATER EVERYDAY and 1 tablet of Clavamox every other day. This may not work for everyone but it sure has helped my guy out up till now. I truly believe the 40 cc's of water everyday is the real trick to this. I have found out that cats with this type of condition need to have extra extra water to keep everything flowing freely.

Hoping this will help out others. Michele

A: Michele

There is evidence that adding water to the diet, even just using canned foods rather than dry foods, does help with feline lower urinary tract disorders (FLUTD). So this is a good suggestion. Many cats will eat canned food with water added to it, which may be enough to help with the problem, too.

Thanks!

Mike Richards, DVM 8/22/99

FLUTD / FUS and PHIL

Q: I am in dire need of help and advice for my cat Phil. Phil is extremely special to me & is an an extraordinary cat and companion. Phil has an extreme recurring case of FLUTD or FUS. My vet has been very helpful and has kept Phil with me through many scares, but I fear his condition is getting to a critical point. PLEASE HELP !!!

He is a bit over 5 years old now (born approx 1/93) and was neutered (8/93). He developed the first symptoms of FUS and partially blocked at under a year old 10/93). He was switched to Feline c/d food at that point. He had no problems for about a year when he blocked again (1/95). He blocked again after about another year and was fine after that until this past September, 1997. He blocked and when cleared there were many crystals & definite cystitis.

At this point he was put on Feline s/d but blocked again after 1 month, was unblocked, and blocked again the next day - no stones were seen in the bladder by x-ray, but again there was many crystals ("sand"). I decided then to have a P.U. (Perineal Urethrostomy) performed (10/97). He healed nicely & was kept on the s/d food but blocked again less than 2 months after the surgery. The crystals were analyzed as being calcium oxalate. At this point, Phil was put on Eukanuba PH-O. He has since blocked again twice, partially in January and completely just last week.

I am thoroughly worried. Has anyone had a similar experience??? Does anyone know of any other foods that might be better for him??? What should be my next course of action. I need to find a cure for my baby!!! I don't have a lot of money and am unable to afford extensive visits to specialists. As it is I have spent a lot of money on emergency visits. I am begging for some advice because I cannot even begin to think of having Phil "put to sleep".

I cannot even express my gratitude for any helpful advice. I have searched the web quite extensively and while there is a lot of info on FLUTD / FUS, there seems to be no specific information for a case as bad as Phil's is.

Thank you for your time and concern.

Bret

A: Bret-

There is a recent article on dogs with calcium oxalate stones in the February 1998 issue of the Compendium of Continuing Education. Most of the article appears to relate to cats pretty well based on other things I have read. From what I can gather, it is necessary to remove all calcium oxalate stones because they can not be dissolved and leaving even small stones makes recurrence very very likely. An X-ray of your cat's bladder to determine if any stones are present would thus be a good idea. If there are stones, they have to be removed, even little ones. Then you can try to prevent the recurrence of these stones. The recommendations are to avoid diets that acidify the urine. I am not personally familiar with the Iams diet but I think that it a diet made so that it does not acidify the urine. You may want to check on this to be certain. Alternatives are Hill's k/d diet and Purina NF. Get your cat to drink as much water as possible. The best way to do this is to feed canned food and to add as much water to it as you can without destroying its palatability to your cat. Adding potassium citrate to the diet is advocated by some veterinarians, too. It is also important to prevent infection of the bladder as much as is possible, especially if there are also struvite crystals or a history of struvite problems. On the Veterinary Information Network someone mentioned that Kirk's Current Therapy XII has a good chapter on this problem but I am at home and that reference is at work. Your vet is likely to have it, though. It might be worth reading it or asking your vet to review it. One last thing, for what it is worth. Somewhere I saw a reference to risk factor for bladder stones in cats that listed an entirely indoor existence as a risk factor. While I think it is prudent in many instances to keep cats indoors, I guess this is something that could be changed if the condition warranted it. I have no idea how much it would help to be allowed outdoors and you would obviously have to assess how much risk being outdoors represented and weigh all risks before considering letting an all-indoors cat have access to the world at large.

Your letter was interesting to me because we are dealing with a very similar case in our clinic. We saw a very small stone on X-rays and did exploratory surgery to remove it and then couldn't find it. We flushed the bladder and examined the bladder and just couldn't find a stone. We took biopsy samples from the bladder and the pathologist thought that a stone was probably present based on the type of inflammatory changes. We are really hoping we flushed it out and just missed it since we were using suction at the time. Follow up X-rays did not show a stone in the bladder and so far things are OK. This cat had blocked on 5 or 6 occasions prior to surgery. It is only a few weeks post-surgery at this time so we are holding our breath and hoping that the problem won't recur.

Mike Richards, DVM

Feline lower urinary tract disease (FLUTD)

Q: Dear Dr. Mike: I recently took my 2 year old, neutered male cat to the vet. I noticed that he was having trouble urinating and was trying to go all the time, even in unusual spots throughout the house. The vet suspected FUS, but after examination saw that his blood work was normal (though he did detect some crystals) and his bladder was not enlarged. He put him on antibiotics and told me to switch to Science Diet C/D. It's been 5 days now and he still seems to have the same problems. This evening in fact he even threw up violently. He's scheduled for another vet visit in 2 days. My questions for you are:

1) Could this condition be something other than FUS?;

2) Is this the course of treatment that you would go with?;

3) and are there any cat foods out there over the counter that would work equally as well without the large expense of the Science Diet products?

A: Becky- The symptoms do sound like feline lower urinary tract disease (FLUTD) which is what the "new" designation is for feline urologic syndrome (FUS). The name change is proposed because it is now recognized that there are a number of possible problems and that urethritis may be as important as cystitis in this disease syndrome.

Infection is only one cause of FLUTD. I usually try to eliminate it first, just like your vet. When that doesn't work I look for other causes of the problem. In many cats, the urine is sterile but the discomfort is still present. Crystal formation has traditionally been thought of as the reason for this but inflammation for other reasons has recently been recognized as an important factor in this condition. Currently, when cats do not respond well to antibiotics it is common practice to try various anti-inflammatory medications to attempt to relieve the clinical signs of discomfort. Amitriptyline (Elavil Rx) is used for this due to side effects of its normal use as an anti-anxiety medication that are beneficial to the lower urinary tract. DMSO (dimethyl sulfoxide) is also used in some cases. More recently there has been interest in using the glycosamines (GAGs) to relieve inflammation. It may be beneficial to consider using Arthroflex, Glycotabs or other GAG type products to see if they will help. At present I don't know why the inflammation occurs so we are just treating the symptoms which seems to work well enough in many cases.

I have not seen a comparison study of the various diets available for cats with FLUTD but I suspect that the diets that acidify urine and are available in the grocery stores and pet stores are probably effective. Of course, in the absence of any data that is just my best guess.

Mike Richards, DVM

Last edited 06/19/05