Feline Lower Urinary Tract Disease

(Feline Urologic Syndrome)

CLINICAL SIGNS DIAGNOSTICS
• Tachycardia (>220) or, • PCV/TS
• Bradycardia (HR<160) • Electrolytes (Na and K particularly)
• Vomiting • Biochemistry
• Stranguria • Urinalysis (once unblocked)
• Haematuria • +/- Radiography, Ultrasonography
• Pollakiuria

PATHOPHYSIOLOGY
Feline Lower Urinary Tract Disease (FLUTD), or formerly Feline Urologic Syndrome (FUS), is typically seen in 1-
7 year old indoor and overweight male cats. More recently, it has been associated with a stressful event or
environment leading to changes in the patients urogenital tract, not to mention inflammatory signaling and
gastrointestinal status. Though there is no single leading cause, contributing factors have been attributed to a
longer and tapering urethra compared to females, formation of distal plug from inflammatory components
(mucus, protein, cells), uroliths, crystalluria, infectious vs sterile cystitis, and increased sympathetic tone to
the proximal urethra. Despite these, the majority are identified as idiopathic and given the name Feline
Idiopathic Cystitis (FIC).

On presentation, FLUTD is typically associated with immediate palpation of a distended bladder, however,
this can vary in size. Patients with cystitis typically have a completely empty bladder. Palpation of a medium
sized, but turgid bladder in such a patient is a likely indicator of urethral obstruction and treatment is
indicated. When in doubt a focussed urogenital ultrasound scan can be useful.

The first treatment priority is assessment and stabilisation of the patients cardiovascular status. Bradycardia
(HR< 160) is a critical finding and immediate treatment of hyperkalaemia is required. The magnitude of
hyperkalaemia was previously thought to correlate with the severity of clinical signs, but this has recently
been disproven. Multiple pathological processes contribute to poor cardiac output and sudden death in
FLUTD patients, so the current recommendation is to treat aggressively when there are signs of bradycardia
and ECG abnormalities rather than tailoring treatment to the magnitude of hyperkalaemia.

The effects of bradycardia are considered 2-fold, a reduction in cardiac output and reduced organ perfusion,
and its compensatory increase in sympathetic drive and vascular tone, resulting in improved pressure but
reduced blood volume, both of which reduce GFR further.

The reduction in GFR consequently leads to a direct reduction in renal tubular flow and other electrolyte
abnormalities. Once relieved, normal kidney function typically resumes, though post-obstructive diuresis
(POD) can occur (polyuria). This latter process is not well understood, though is possibly related to osmotic
diuresis from elevated urea, high tubular sodium and water retention, and the inability for ADH to have an

Guidelines: Class 1 (C1) – Definitely perform (good evidence)

Class 2 (C2) – Consider performing (some evidence)
Class 3 (C3) – Do not perform (unsound evidence and/or deleterious)
AES – Protocols\Excellence Program\FLUTD Page 1 of 6
 effect from loss of the medullary concentration gradient as a result of increased tubular flow after relief of
the obstruction. UOP, ins/outs and frequent weighing of the patient are required to ensure the patient
maintains normovolaemia.

Regardless of the cause and ease of unblocking the urethra, the recommendation is to leave the urinary
catheter in place for at least 24hrs. This allows time for reduction of inflammatory effects on the bladder wall,
reduction in effects of sympathetic drive, monitor effects of possible POD, reduce crystalluria, and allow a
change in urinary characteristics from a possible infection. It is well-known struvite crystals form in alkaline
and high Magnesium (Mg) environments, and a high suspicion for an infectious cystitis should be considered
as urease-producing bacteria cleave urea to ammonia causing an increase in pH.

TREATMENT
INITIAL MANAGEMENT
UNSTABLE Patient (hyperkalaemia vomiting, obtunded, HR <160)
• Place IV Catheter
• Analgesia – care with contributing to worsening demeanour/respiratory drive (C1)
o Methadone 0.2-0.3mg/kg IM, or
o Buprenorphine 0.01-0.02mg/kg IM or IV
• Treat Shock by administering 10-15ml/kg boluses of crystalloid fluid until improvement in
cardiovascvular status (max 60ml/kg- usually 10-30ml/kg required)
• Treat Hyperkalaemia – monitor with ECG during treatment
o Calcium Gluconate 10%: 1ml/kg over 10 minutes (C1)
(max effect in 3-5mins)
o Glucose: given at 0.5g/kg (1ml/kg 50% glucose diluted 1 in 4) (C1)
(max effect in 30mins)
o +/- Insulin: 0.25-0.5 IU/kg IV or IM (C2)
(max effect in 30mins)
*NB: glucose MUST have been given first
*NB: 2.5% Glucose MUST be added to IV fluid (50ml of 50% added to 1L crystalloid)
o +/- NaHCO3: 1ml/kg (only if absolutely necessary), pH <7.2 and HCO3 <12 (C2).
Bicarbonate should be administered slowly >30min
• Relieve urethral obstruction and place indwelling urinary catheter under appropriate sedation
*Avoid isoflurane due to vasodilating effects on an already CV compromised patient (C1)
o Fentanyl 3-5ug/kg IV (0.3-0.5ml/5kg Cat, assuming 50ug/mL) +
Midazolam 0.2mg/kg IV (0.2ml/5kg Cat, assuming 5mg/mL) - same syringe (PREFERRED)
o Ketamine 2-4mg/kg IV (0.1-0.2ml/5kg Cat, assuming 100mg/kg) +
Diazepam 0.3mg/kg IV (0.3ml/5kg Cat, assuming 5mg/ml) – same syringe
(Only if NO Cardiac concerns)
o +/- Alfaxan PRN (1-2mg IV boluses as required)
o provide flow-by oxygen during procedure due to mild hypoventilation
o have intubation equipment at the ready
o no anaesthetic if moribund on presentation. In this situation, stabilising cardiovascular
status and enabling bladder decompression should be the first priority, and placing an
indwelling catheter performed without anaesthetic (local infiltration of prepuce) or delayed
until the patient is stable. Bladder decompression can be achieved without sedation by
Guidelines: Class 1 (C1) – Definitely perform (good evidence)
Class 2 (C2) – Consider performing (some evidence)
Class 3 (C3) – Do not perform (unsound evidence and/or deleterious)
AES – Protocols\Excellence Program\FLUTD Page 2 of 6
 unblocking with a 22g IV catheter, or by cystocentesis.

STABLE Patient (normokalaemic, no vomiting, HR >160)

• Analgesia on presentation
o Methadone 0.2-0.3mg/kg IM
o Buprenorphine 0.02-0.03mg/kg IM or IV
• Fluid therapy
- Bolus crystalloid fluid as required (approx. 5-10ml/kg initially and reassess) (C2)
- Provide at least 1-2hrs fluid therapy prior to giving an anaesthetic agent (C1)
• Anaesthesia +/- Sedation (C1)
o Fentanyl 3-5ug/kg IV (0.3-0.5ml/5kg Cat, assuming 50ug/mL) +
Midazolam 0.2mg/kg IV (0.2ml/5kg Cat, assuming 5mg/mL) - same syringe (PREFERRED)
o Ketamine 2-4mg/kg IV (0.1-0.2ml/5kg Cat, assuming 100mg/kg) +
Diazepam 0.3mg/kg IV (0.3ml/5kg Cat, assuming 5mg/ml) – same syringe
(Only if NO Cardiac concerns)
• Induce with alfaxalone (5-15mg IV) and intubate. Maintained with 1-2% isoflurane, FiO2 100% at 1L/min
• Place in dorsal vs lateral decumbency and clip perineal and preputial area and clean with aqueous
chlorhex (0.05%), flush penile tip/prepuce with 3x with 5ml of aqueous chlorhex
• Pull the back legs cranially or keep as lazy caudal
• With sterile gloves on, expose penis tip and instill 2% Lignocaine gel into the prepuce (C1)
• Use a 20-22g IV Catheter tip and 10ml sterile saline solution to flush the tip of the penis
*Avoid excessive catheterization due to risk of urethral trauma/tear and stricture formation\
• If the obstruction is not in the tip then flush the entire urethra with a TomCat catheter (do not use as an
indwelling catheter, C3). Make sure you straighten the urethra (once 2-4mm inside urethra pull
prepuce caudally, then dorsally in parallel with the table top to straighten out the urethra)
• Place 2% Lignocaine gel throughout the length of the urethra with the TomCat catheter (C2)
• Place a 3.5FR x 12-14cm indwelling TomCat indwelling Urethral catheter/attach Little Herbert and secure
in place to prepuce (C1)
*Do not use a stiff Tomcat or feeding tube as an indwelling due to risk of pressure necrosis, C3).
*Slippery Sam TomCat catheters are known to separate under duress and can be lost into the bladder
• Flush the bladder with 20ml warm saline until it runs clear (remember to ‘jiggle’ the bladder as
performing flushing) (C2)
• Attach secured closed collection system and secure to the tail. Allow for tail movement and possible
pulling at the prepuce (C1)
• Leave urinary catheter in place for at least 24hrs if marked initial bladder distension to prevent further
bladder wall trauma (C1)
*NB: urinary catheters will cause irritation to the urethra and urothelium and subsequent haematuria so
removal as early as possible is preferred, though without compromising morbidity from re-
catheterisation if removed to early

MEDICATIONS TO BE DISPENSED
• Analgesia
o Buprenorphine 0.01-0.02mg/kg IV or SL q8-12hrs (C1)
• Muscle relaxants: started 24-36hrs after urinary catheter is placed only

Guidelines: Class 1 (C1) – Definitely perform (good evidence)

Class 2 (C2) – Consider performing (some evidence)
Class 3 (C3) – Do not perform (unsound evidence and/or deleterious)
AES – Protocols\Excellence Program\FLUTD Page 3 of 6
 o Dantrolene 1mg/kg PO q12hrs for 7 days (skeletal muscle) (C2)
o Prazosin 0.5mg PO q12hrs (0.25mg if <4kg) for 7 days (smooth muscle) (C2)
*reduced rate of recurrence within 24hrs (24% compared to 18%)
*Do NOT use phenoxybenzamine (increased recurrence rate vs no meds) (C3)
• Consider anti-inflammatory (NSAID or steroid) if CVS stable 30min prior to removal of urinary catheter to
reduce inflammatory effects on bladder wall only (no change to recurrence rate or duration of
hospitalization) (C2)

FURTHER TREATMENT & MONITORING

1. Fluid therapy: initially 5-10 ml/kg/hr if euvolaemic & no contraindications then modify on the basis of
urine output, PCV/TS, electrolytes and hydration status (C2)
2. Modify IV fluid rate to exceed urine output (for a 5kg cat, 5% dehydration = 10 ml/kg/hr). May require
higher IV fluid rates as long as patients cardiovascular and respiratory status tolerates it, reassess rate
regularly (C1)
3. TPR q4hrs initially, then extend to q6hrs (C1)
4. Assess urine output q4hrs (C1)
5. Monitor weight q4hrs due to risk of post-obstructive diuresis (C2)
*Post-obstructive diuresis is an abnormally high UOP (outs>ins) that continues for 12-24hrs after
bilateral ureteral blockage. Unknown cause, but patients can become hypovolaemic if not monitored
6. PCV/TS/electrolytes q8-12hrs (C2)
* Perform sooner if concerned about obstructive diruresis vs acute kidney injury vs hyperkalemia on
presentation.
7. Feed wet food only and allow access to fresh water at all times (NO biscuits) (C1)
- c/d or s/d preferred. Consider kangaroo, tuna, sardines, fish (60-70% water content), add tepid
water to biscuits
8. Place in quiet, dark environment and spray cage with feliway (C1)
9. Leave urinary catheter in for at least 24hrs until urine is clear (C1)
10. Diagnostic imaging should be recommended to the owner at admission (ie: either contrast radiography
or US for uroliths vs neoplasia) (C2)
*90% sensitivity if combined (77% US if used alone)
11. Consider need for analgesia and anti-inflammatory drugs (C1)
12. Whilst patient is in hospital, perform urinalysis at placement (t=0) and then every 24hrs for possible
bacteriuria and pyuria (C1). Start antibiotics (ie: cephalosporin) as indicated if bacteriuria is present and
send away urine for MC&S (C2)
*Bladder size must be checked immediately prior to discharge and transfer to the primary vet for
ongoing management
13. Avoid antibiotics (unless bacteriuria confirmed), prolonged corticosteroids or bethanecol (C2)
14. Consider sending urine for MC&S on presentation and including after catheter removal (C2)
*Bacteriuria reported in 33% cats with urinary catheter in place >48hrs

COSTS AND HOSPITALISATION

• Hospitalisation time to expect: 2-4 days
• Costs whilst hospitalized: $2500-4000

Guidelines: Class 1 (C1) – Definitely perform (good evidence)

Class 2 (C2) – Consider performing (some evidence)
Class 3 (C3) – Do not perform (unsound evidence and/or deleterious)
AES – Protocols\Excellence Program\FLUTD Page 4 of 6
PROGNOSIS AND RISK FACTORS
• Recurrence rate is 24% 24hrs following discharge (22% reported at 6mths). This is reduced to 18% if
Prazosin is given prior to discharge. This is also reduced if 3.5FR is used over 5FR catheter size
• Recurrence rate reduced if the urinary catheter was left in place >32hrs
• Bacteriuria occurs in 33% patients with if the urinary catheter is kept in place longer than 48hrs
• Feline Idiopathic (Interstitial) Cystitis is the most common reason for an obstruction (50%), followed by
urethral plugs (25%), uroliths (20%) (Struvite vs Calcium oxalate), infection, urethral spasm, neoplasia
(eg: TCC, LSA), abdominal mass, pelvic/sacrocaudal fractures, neurogenic (dysautonomia), diverticulum,
iatrogenic
• If >10yrs old, risk of neoplasia increases dramatically
• Significant risk of FLUTD developing if the patients weight is >5kg, less litter trays and allowed to remain
indoors
• Consider referral for Perineal Urethrostomy if LUTD occurs for a 2nd time

REFERENCES
1. Drobatz, K., Costello, M. (2010). Feline Emergency and Critical Care Medicine Pp281-288
2. Roger A. Hostutler,
 Dennis J. Chew, Stephen P. DiBartola. (2005). Recent Concepts in Feline Lower
Urinary Tract Disease. Vet Clin Small Animal 35: 147–170
3. Silverstein, D., Hopper, K. (2009). Small Animal Critical Care Medicine. Saunders Elsevier. PP 638
4. Buffington, C.A.T. (2011). Idiopathic Cystitis in Domestic cats – Beyond the Lower Urinary Tract. JVIM 25:
784-796
5. Hetrick, P.F. & Davidow, E.B. (2013). Initial treatment factors associated with feline urethral obstruction
recurrence rate: 192 cases (2004-2010). JAVMA 243(8): 1140-1146
6. Segev, G. et al. (2011). Urethral obstruction in cats: predisposing factors, clinical and clinicopathological
characteristics and prognosis. JFMS 13: 101-108
7. Huggonard, M. et al. (2013). Occurrence of bacteriuria in 18 catheterised cats with obstructive lower
urinary tract disease: a pilot study. JFMS 15(10): 843-848
8. Cannon, A. Evaluation of trends in urolith composition in cats: 5230 cats (1984-2004). JFMS 231(4): 570-
576
9. Buffington CA, Westropp JL, Chew DJ, et al. (2006). Clinical evaluation of multimodal environmental
modification (MEMO) in the management of cats with idiopathic cystitis. Journal of Feline Medicine and
Surgery 8 (4): 261-268
10. Griffith CA, Steigerwald ES, Buffington CA. (2000). Effects of a synthetic facial pheromone on behavior of
cats. J Am Vet Med Assoc 217: 1154-1156.
11. www.vin.com. (2007-2013). Veterinary Information Network

Guidelines: Class 1 (C1) – Definitely perform (good evidence)

Class 2 (C2) – Consider performing (some evidence)
Class 3 (C3) – Do not perform (unsound evidence and/or deleterious)
AES – Protocols\Excellence Program\FLUTD Page 5 of 6
 *Use of any of this material is not for retail or public disclosure. It is intended for personal use and knowledge only

Author(s): Dr Courtney Reddrop

Reviewed: Dr Michele Rebelo, Dr Gerardo Poli
Date: 9th Nov 2015

Reviewed#2 : Dr Rob Webster

Date: 21 June 2018

Guidelines: Class 1 (C1) – Definitely perform (good evidence)

Class 2 (C2) – Consider performing (some evidence)
Class 3 (C3) – Do not perform (unsound evidence and/or deleterious)
AES – Protocols\Excellence Program\FLUTD Page 6 of 6