Clinical
Feline lower urinary tract disease:
predisposition, causes and nursing care
Abstract
Feline lower urinary tract disease (FLUTD) is a common problem in veterinary
practice. The causes of and predispositions to FLUTD are often misunderstood
and this can lead to recurrence within patients.
Sex, weight, diet and stress have all been suggested as factors that increase
the risk of a cat developing FLUTD. Males would appear to be more predisposed
to FLUTD than females and are regularly over represented in studies of FLUTD
cats. Obesity also seems to be a predisposing factor with larger cats more likely
to experience FLUTD. However cats that are fed a dry diet do not appear to be
significantly more likely to develop FLUTD when compared to those fed a wet diet.
Stress would seem to be the most significant inciting factor in the recurrence of
FLUTD with much research conducted in this area.
Key words: FLUTD, predisposition, weight, sex, diet, stress
F
eline lower urinary tract disease (FLUTD)
affects a large number of domestic cats and
is thought to account for 410% of feline ad-
missions to the veterinary surgery (Nelson and Cou-
to, 2009). FLUTD can affect the bladder or urethra
(Gunn-Moore and Cameron, 2004), and is charac-
terized by the presence of one or more clinical signs.
These are:
zz Pollakiuria (abnormally frequent urination)
zz Haematuria (blood in urine)
zz Dysuria (difficulty passing urine)
zz Stranguria (straining to urinate)
zz Partial or complete urethral obstruction (Nelson
and Couto, 2009).
FLUTD can be categorized into two broad categories:
cause known; or idiopathic, cause unknown. Known
causes of FLUTD include uroliths (normally struvite or
calcium oxalate), trauma, bacterial infection, anatomi-
cal abnormality, neurological disorders or neoplasia
(Gunn-Moore, 2003a). However it is thought that in
around 55% of cases of FLUTD the cause is feline idi-
opathic cystitis (FIC) (Saevik et al, 2011).
The aim of this report is to examine the research
into the predispositions to FLUTD. The relevance of
such in reducing the suffering of those inpatients
with FLUTD will also be discussed.
Karen Woolf RVN BSc (Hons) DipAdvCB is Head
Nurse at Melton Veterinary Practice in Suffolk, UK
406
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Causes of FLUTD
FLUTD disease is normally categorized into idiopath-
ic of unknown cause, or known cause, these groups
can further be divided into obstructive and non-ob-
structive (Table 1).
Uroliths
Uroliths, which can cause urethral obstruction, nor-
mally form due to the presence of crystals in the urine
(Lane et al, 2004). Struvite crystal, seen in Figure 1,
used to be the most common urinary crystal seen in
cats (Hostutler, et al 2005). However since the late
1980s when diets to dissolve struvite became com-
mon place on the market and magnesium in most
commercial cat foods was decreased, calcium oxalate
levels have increased (Hostutler, et al 2005). Calci-
um oxalate causes uroliths that cannot be dissolved
by diet and have to be surgically removed (Figure 2)
(Cannon, 2007).
The presence of these large uroliths does not always
lead to obstruction, non-obstructive FLUTD can be
caused by uroliths and in these cases examination
of a urine sample will normally locate crystals and a
contrast bladder x-ray may be indicated.
Urethral plugs
Urethral plugs, another possible cause of urethral
obstruction, normally consist of crystals and mucoid
material (Lane et al, 2004). The mucoid material is
mostly protein and is thought to be material that is
leaked from the bladder wall as a result of inflamma-
tion (Gunn-Moore, 2003a). In male cats a urethral
plug can result in obstruction causing a build-up of
waste products in the blood that can lead to collapse
and death within 4872 hours if not treated (Shaw et
al, 2006).
Predispositions to FLUTD
Gender
Lane et al (2004) states that male cats tend to be more
affected by obstructive disease due to the narrow size
of the urethra in comparison to the female. Gough
and Thomas (2010) also suggest that males are more
predisposed to FLUTD however Nelson and Couto
(2009) and the Feline Advisory Bureau (2011) suggest
the disease is equally prevalent in males and females.
September 2012 Vol 3 No 7 The Veterinary Nurse
 Clinical

tive FLUTD. The study was a retrospective review of

Table 1. Causes of FLUTD and the percentage of cases that they account for
medical records; it is possible that symptoms, recur-
Causes of FLUTD Percentage of occurrence rence, or any other information could have been left
off the medical records which could obscure the data.
Non-obstructive FLUTD
Saevik et al (2011) also suggested a predisposition to
Anatomic defeats 10 males as a sample of 119 cats with FLUTD contained
88 male cats (73.9%). However, as the researchers
Behavioural problems 9
themselves noted, it is possible that the over repre-
Neoplasia 12 sentation of male cats is because more owners of male
Infection 18 cats attend the veterinary practice the research was
conducted within. In the authors opinion, as the re-
Obstructive FLUTD search used no control group, no measurement of sta-
Urethral plug 21.0 tistical significance could be made to compare male
and female sub-populations in this study, and the sug-
Uroliths 11.8
gestions made by this study cannot be verified.
Uroliths and bacterial infection 11.8 The over representation of male cats in research may
be due to the fact that they are more likely to become
Idiopathic causes 55.5
obstructed, due to the length and narrow diameter of
FLUTD, feline lower urinary tract disease. Data from: Roura, 2010; Saevik et al, 2011 the urethra (Lane, et al, 2004). In addition, the over
representation of males within research and practice
Cameron et al (2004) conducted a study looking at could simply be because owners are more likely to no-
environmental factors associated with FLUTD and tice a male cat that cannot pass urine compared with a
found that when compared with the control group, female cat that is struggling to pass urine.
the group with FLUTD contained more males. The
result was significant however males were generally Weight
over represented in both the treatment and the con- Gough and Thomas (2010) suggest that overweight
trol group. In this study two controls were used, one cats are more likely to suffer from FLUTD than cats
from the same household as the treatment group and with a normal weight. This theory is backed up by
one from a completely different household. Both the research conducted by Defauw et al (2011) which
control groups contained more cats than the treat- found when comparing a treatment group with
ment group. Defauw et al (2011) also looked at possible FLUTD to a control group, that the treatment group
predispositions in cats with reocurring FLUTD. They were significantly heavier (5.5 kg 1.5 compared with
compared age and gender between the treatment and 4.7 kg 1.5). Cameron et al (2004) also suggested from
control groups, and found no significant difference in their research that overweight cats were more likely
recurrence between male and female cats, however, to be found within the treatment group for FLUTD.
they did find males were more likely to have obstruc- However in both studies weight was the only meas-
Figure 1. Struvite crystals. Figure 2. Calcium oxalate crystals.

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 Clinical

urement taken, no comparison of body condition

score was made meaning that the cats could have
been above average weight but within a normal body
condition score. In both pieces of research males
were over represented within the treatment groups,
which could have affected the average weight of the
treatment groups, males generally being heavier than
females.
Palm and Westropp (2011) suggest dietary fats are
involved in the formation of calcium oxalate stones
and this could be one of the reasons FLUTD is seen
more regularly in obese cats. However the research
was conducted in humans and rats and there are in-
sufficient experimental data to support the sugges-
tion that the same would occur in cats.
Most studies seem unable to outline why obesity
could cause FLUTD, however as obesity is a growing n Dry diet n Both n Wet diet
problem in veterinary practice the author suggests
that obese patients suffering from recurring FLUTD
Figure 3. Diet of cats at the start of a clinical
be placed on a weight reduction diet when possible as
trial (data from Gunn-Moore, 2003b).
part of their FLUTD management plan.
suggest that an animals diet should be changed to
Diet predominantly wet if FLUTD is diagnosed.
Gough and Thomas (2010) state that a dry diet is a A number of different studies have been conduct-
predisposing factor and Nelson and Couto (2009) ed into diet and FLUTD. A study by Gunn-Moore

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 Clinical
Table 2. Diet of cats affected by FLUTD (data from Buffington (2007)
Number of cats Diet type
41 Dry diet
3 Canned only food
26 Canned and dry food
6 Prescription canned food for struvite
18 Dry prescription food to dissolve struvite crystals
(2003b) indicates that dry food could be a cause with
more cats with FLUTD being fed dry food at the start
of the study (Figure 3). This does not prove that dry
food causes FLUTD however the study suggests that
dry food could be an aggravating factor. Saevik et al
(2011) support this finding, with cats with FLUTD
in their study being fed significantly more dry food.
However Saevik et al (2011) note that the fact that the
population of cats with FLUTD are fed more dry food
may be due to the fact 87% of the general feline popu-
lation is fed only dry food.
Defauw et al (2011) studied the risk factors for
FLUTD and found that when compared with a con-
trol group, a group of cats with FLUTD were not fed
significantly more dry food. This supported Cameron
et als 2004 study which found that cats with FLUTD
are not more likely to be exclusively fed dry food.
Buffington (2007) studied a small group of cats and
the findings of this study did suggest that diet plays a
significant role. Table 2 shows the results. As Table 2
indicates the study found a significant number of cats
with FLUTD were fed solely dry food. However in this
study it was also found that cats on prescription food,
to dissolve struvite crystals to reduce FLUTD still suf-
fered from it, the significance of this was not investi-
gated. Buffington et al (2006) did look at the impor-
tance of prescription diets and recurrence of FLUTD
in an earlier study, finding that 11% of the cats that had
more than one episode of FLUTD were fed canned
food only, compared with 39% that recurred when giv-
en a dry prescription food to reduce struvite crystals.
Although some success may be seen with prescription
diets to dissolve struvite, Palm and Westropp (2011)
suggest they increase the likelihood of calcium oxalate
forming which would cause recurrence of FLUTD.
Stress
Multi-cat households, indoor living and lack of en-
richment have all been linked to reoccurring FLUTD.
Buffington et al (2006) conducted an observational
study that found that patients with lower urinary
tract diseases were considered in the eyes of the own-
ers to be more fearful and nervous. Saevik et al (2011)
410
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supported the findings of the Buffington study with
more of the affected group showing depression ac-
cording to the owners (Figure 4). Other studies such
as Defauw et al (2011) also support the idea that fear-
fulness and nervousness increase the risk of FLUTD
reoccurring. However all these studies rely on owner
perception as well as, in some cases, being retrospec-
tive. Retrospective studies can sometimes be un-
trustworthy. The fact that the researcher was asking
owners to remember the behaviour and events that
occurred to their cat months ago means that some
events may be remembered incorrectly. Defauw et al
(2011) also suggested that a few events such as house
moving and restriction to the outside world were sig-
nificantly higher in cats with FLUTD. However not all
stressful situations were significant, a new baby for
example was not seen as significant in the study, sug-
gesting only severe stress is a contributory factor.
Buffington (2007) suggested that visits to the veter-
inary practice could be considered a stress factor. He
studied one cat and found that when a urine sample
was obtained before the animal travelled to the prac-
tice and during its visit the pH had changed from 6.1
to 7.6. Shaw et al (2006) suggest struvite grows bet-
ter in a pH greater than 7.2 this would suggest that
veterinary visits increase the risk of reoccurrence.
The reason from the increase in pH of the urine was
not revealed by Buffington (2007) in his study. So al-
though pH increase and stress seem to be linked it
is unknown why. The study was only conducted in
one cat, however, so it is difficult to generalize to the
whole cat population.
Multi-cat households are often blamed for FLUTD
especially when conflict is seen between two or more
members of the feline family (Caney and Gunn-
Moore, 2004). Feline Advisory Bureau (2011) suggests
that stress is a flare factor and that bullying within a
multi-cat household is often to blame. Seawright et
al (2008) conducted a case study that supported the
suggestion that multi-cat stress is a factor in FLUTD.
The study looked at one male cat with reoccurring
FLUTD finding the cat had been exposed to a serious
stressor, moving house, as well as being in conflict
with cats within the household.
Behavioural therapy was introduced in this case
and the cat was provided areas that he could urinate,
hide from the other cats in the household and have
free access to resources (Seawright et al, 2008). The
FLUTD did not reoccur until the owner changed
the cats environment by removing some of the be-
havioural modifications. The study does indicate
that stress was a factor in this case however as only
one animal was used it cannot be generalized to all
animals. Gunn-Moore and Cameron (2004) also sug-
September 2012 Vol 3 No 7 The Veterinary Nurse
 Clinical

gested stress was an issue and introduced the use of

feline pheromones to reduce stress, finding in this
study that owners reported less signs of cystitis than
they had previously.
The physiological reason for stress causing FLUTD
has been investigated heavily in recent years. Al-
though the theory is still a working one the main
idea is that sensory neurons are stimulated in the
brain as a result of stress, this causes a release of sub-
stances from the nerve endings in the bladder wall
(Feline Advisory Bureau, 2011). This in turn causes
swelling, pain and an alteration of the protective gly-
cosaminoglycan (GAG) layer that lines the bladder
(Feline Advisory Bureau, 2011). Stress either acute or
chronic can cause inflammation of the bladder, un-
treated substances within the urine can excerabate
the inflammation and cause clinical signs of FLUTD.

Nursing the cat affected by FLUTD:

inpatient and outpatient care
Cats affected by FLUTD are often difficult to nurse in
the veterinary practice. The importance of stress as a
factor cannot be over looked. FLUTD sufferers may
benefit from being treated with pheromones during
their stay, the importance of gentle handling of the pa-
tient and keeping them in an area of the practice away
from stressors, such as dogs and loud noises, should
also be considered. It would also be of benefit to ask
owners to look at stress factors within the household
and keep a diary on the occurrences of these in the
household to see if a correlation can be seen between
certain stressors and the clinical signs of FLUTD.
Visits to the veterinary practice can often be con-
sidered stressful for cats; noise from dogs in the wait-
ing room and veterinary examination are both stress
factors. Once FLUTD cats are sent home it may be
beneficial to monitor progress through home urine
testing and telephone consultations with owners
rather than getting these patients back into practice
as this may increase the risk of reoccurrence.
Diet should also be looked at both within the prac-
tice and once the pet goes home. Currently most prac-
tices will suggest a prescription diet to change the pH
and decrease the risk of struvite crystals. However the
research seems to suggest that it is more beneficial to
place the patient on any wet food so that the water in-
take of the animal is increased. A wet version of the
prescription diet may therefore be the answer to cover
both problems. However no significant increase in oc-
currences of FLUTD in cats given only dry food is seen
in most studies and as changing food could be consid-
ered a stressor, a factor more likely to cause reoccur-
rence, it is suggested less importance should be placed
on diet (Cameron, et al 2004; Defauw, et al 2011).

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 Clinical

gested to owners when the cats are discharged. Using

70
nurses to weigh the animals and advise on diet and
n Control n FLUTD group
exercise in outpatient weight clinics would be one
60
way to help decrease reoccurrence in obese animals.
50 However the effect of changing diet and these visits
on the cats stress level should also be monitored to
40 ensure no increase is seen.

30
Conclusion
20 FLUTD is caused by a number of different factors and
a number of predispositions have been looked into.
10 Gender, weight, diet and stress are all considered
predisposing or flare factors and research reviewed
0
Depressed Normal condition Mildly depressed Severely depressed
in this report suggests that the importance of these
factors varies.
Data from: Saevik et al (2011) Advising clients on reducing stress and keeping
weight at an optimum level would appear to be the
Figure 4. Owner perception of feline mental state in the feline most important factors. Although dry food may not
lower urinary tract disease (FLUTD) animals compared with animals be a significant factor, as many studies suggest, it may
unaffected by FLUTD. still be beneficial to suggest cats are fed predominate-
More than one study suggests obesity is a signifi- ly wet prescription food.
cant risk factor. In animals with FLUTD it is recom- Although a lot of research has been conducted into
mended that weight control or weight loss is sug- the significance of stress in recent years further re-
search is required. Research looking solely at diet as
an inciting factor also seems to be lacking in recent
Key points years and the author would suggest, due to the im-
zzFeline lower urinary tract disease (FLUTD) can be both obstructive and non ob- portance placed on it as a factor in veterinary prac-
struction, obstructive causes should be treated as an emergency. tice, this is a significant area for research. VN
zzObstructive FLUTD is more likely to occur in male cats.
zzWeight loss in overweight cats suffering from FLUTD should be advised. Conflict of interest: none.
zzStress appears to be an important factor and should be reduced to avoid re-
occurance. Acknowledgements: thanks to Finn Pathologists Vet-
zzCats that have suffered from FLUTD will benefit from an increased water intake. erinary Laboratories for providing the photos.

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