Exam 4 - Feline Interstitial Cystitis

Question 1

what is FLUTD?

Answer 1

feline lower urinary tract disease - signs associated with lower urinary tract disease (stranguria, pollakiuria, dysuria, hematuria, & pyuria) due to many underlying etiologies

Question 2

what is FIC?

Answer 2

feline idiopathic cystitis - syndrome resulting in lower urinary tract signs caused by complex interactions between the urinary bladder, nervous system, adrenals, husbandry practices, & cat’s environment

Question 3

what are some examples of causes of lower urinary tract disease in cats?

Answer 3

FIC, UTI, urolithiasis, urethral plugs, urinary tract neoplasia, trauma, stricture, anatomic defects, neurological defects, & behavioral disorders

Question 4

how is FIC diagnosed?

Answer 4

diagnosis of exclusion!!!

Question 5

what are the characteristics of FIC?

Answer 5

signs of lower urinary tract dysfunction & clinical signs in other organ systems

waxing & waning signs associated with stressful events

resolution of signs following effective environmental enrichment

Question 6

what is the most common cause of lower urinary tract signs in cats?

Answer 6

FIC

Question 7

what is the cause of FIC?

Answer 7

etiology is unknown!! proposed that the mucous layer containing glycosaminoglycans & glycoproteins is disrupted (the layer that normally provides a barrier for the urothelium) so cats with FIC have a decreased concentration of urinary glycosaminoglycans

when a susceptible cat is housed in a deficient environment, FIC is more likely to occur

Question 8

what nerves provide sensory innervation to the bladder? how does this relate to FIC?

Answer 8

pelvic & hypogastric nerves with neurons in the submucosa

release of substance P from the neurons can result in vasodilation, release of inflammatory mediators, & contraction of smooth muscle

Question 9

how can decreased urine volume & frequency be a cause of FIC?

Answer 9

increases contact time of highly concentrated urine with the uroepithelium

decreased water intake may result from reluctance to drink water, confinement, impaired mobility, or intercat aggression

decreased urination may result from litter box preference, dirty boxes, confinement, or intercat aggression

Question 10

how does stress contribute to FIC?

Answer 10

plays an integral role in FIC

FIC cats have an altered HPA axis characterized by exaggerated catecholamine release & blunted cortisol response

Question 11

what are some examples of how may a cat with FIC present to your clinic?

Answer 11

non-obstructive self-limiting disease

frequent recurring episodes

chronic persistent episodes

urethral obstruction

Question 12

what signalment of cats are commonly affected by FIC?

Answer 12

middle aged (2-7 years old) cats have an increased risk, neutered/overweight cats, being housed indoors, & high levels of stress

in cats <1 year old - UTI or urolithiasis more likely

Question 13

what is the most common sign of urinary obstruction in cats?

Answer 13

non-productive straining in the litter box +/- vocalization

Question 14

T/F: episodes of FIC often resolve within 7 days with or without treatment

Answer 14

true

Question 15

why do you need to inquire about previous episodes of lower urinary tract signs if you have a cat presenting with stranguria?

Answer 15

recurrence rate of FIC episodes is up to 45% in 6 months in male cats with obstructive uropathy

39% within 12 months in cats with non-obstructive uropathy

Question 16

what may be seen on physical exam in a cat with FIC?

Answer 16

bladder may feel small & thickened

if urethral obstruction - bladder will feel turgid, enlarged, & painful, patient may be dehydrated or volume depleted, & may be tachycardic due to pain or bradycardic due to hyperkalemia

after a long standing obstruction - bladder can rupture

Question 17

why do you need to be careful when evaluating a urine dipstick on a cat?

Answer 17

the dipstick will yield false positives for leukocytes in cats - look at the sediment

Question 18

when should you do a urine culture for a cat with FIC?

Answer 18

sample by cystocentesis

should be performed if there is pyuria/bacteriuria, recurrence of clinical signs, evidence of chronic kidney disease, prior urinary catheterization, or perineal urethrostomy

Question 19

why is efficacy of therapy complicated when managing a cat with FIC?

Answer 19

clinical signs usually resolve after 1-7 days

Question 20

what is management of FIC aimed at?

Answer 20

reducing rate of recurring signs, reducing severity & duration of signs, & reducing the risk or urethral obstruction

Question 21

what is your first line therapy for all cats with FIC?

Answer 21

stress reduction!!!!!

Question 22

how is environmental enrichment used for managing cats with FIC?

Answer 22

very important for indoor cats - enhance interactions with owners & predictability of interactions

minimize conflict - belled collars on cats in the home & potentially separate cats

add resources to the home - toys, food & water sites, etc

gradual changes

Question 23

how is litter box management done for cats with FIC?

Answer 23

aimed at promoting frequent urination & decreasing stress - at least one box is uncovered & all boxes placed in easily accessible quiet locations

of litter boxes = # of cats + 1

Question 24

what kind of litter do cats prefer?

Answer 24

clumping, sand like litter

Question 25

how is feline facial pheromone used for stress management in cats with FIC?

Answer 25

nonvolatile molecules that influence social & reproductive behavior shown to decrease stress in cats during hospital visits

Question 26

how is diet management part of treating FIC in cats?

Answer 26

consider if a diet change would be too stressful!!! transition will need to take place gradually over weeks to months allow cat to self select by placing new food in a different container beside the current food increase their water intake - canned food diets, adding broth to dry food

Question 27

what is the current standing on using anti-inflammatory drugs for treating FIC?

Answer 27

no difference in rate of recurrent urethral obstruction or recovery from clinical signs in cats with FIC treated with meloxicam vs a placebo prednisolone not effective in reducing severity or duration of FIC signs

Question 28

what cats are more commonly affected by urethral obstructions? why?

Answer 28

male cats - narrow urethra

Question 29

what usually causes urethral obstructions in male cats?

Answer 29

urethral plug - composed of protein matrix with some WBC/RBC less commonly due to a stone (tumors & strictures rarely cause obstruction)

Question 30

what is seen on physical exam of a blocked tom? what parameters do you need to get?

Answer 30

bladder is enlarged, turgid, & painful & tip of the penis is often discolored vital parameters & blood pressure if obstruction has been present > 48 hours, patient will be SEVERELY ILL

Question 31

what should make up the immediate medical therapy for a patient with a urethral obstruction?

Answer 31

establish iv access - need to start isotonic crystalloids/bolus shock dose if needed, & correct % dehydration over 12-24 hours + maintenance stat data collection - pcv, total protein, electrolytes, venous blood gas, & ecg (monitoring for sinus bradycardia - ventricular tachycardia & arrest may follow) extended database - collected when possible based on patient stability (urinalysis & culture collected once obstruction is alleviated) may need to do a decompressive cystocentesis

Question 32

how is a decompressive cystocentesis done? what are the risks?

Answer 32

use a 25 or 22 G over the needle catheter with a 3 way stop cock & large syringe to perform a single cystsocentesis to remove as much urine as possible to reduce pressure in the bladder & increase GFR extravasation of urine, trauma to the bladder wall, possible collapse (thought to be a vagal response)

Question 33

what is the purpose of giving calcium gluconate to a blocked tom?

Answer 33

decreases cardiac membrane potential threshold - cardiac protectant! does not decrease serum potassium levels - need to monitor an ecg during infusion (0.5-1.0 ml/kg IV over 2-5 minutes)

Question 34

how is regular insulin & dextrose fluids used to manage hyperkalemia in a blocked tom? how is it done?

Answer 34

insulin shifts potassium & glucose intracellularly 0.25-0.5 U/kg IV regular insulin & then 0.5-1.0 ml/kg of 50% dextrose IV dilute dextrose in saline 1:4 then begin a 2.5% dextrose CRI monitoring bg & potassium every hour to start

Question 35

how is albuterol or terbutaline used for treating hyperkalemia in a blocked tom?

Answer 35

beta-2 mediated stimulation of Na-K-ATPase pump moves potassium intracellularly

Question 36

what are contraindications for giving bicarb to a blocked tom when needing to treat hyperkalemia?

Answer 36

encephalopathy, liver disease, or hyperosmolarity

Question 37

T/F: it is okay to give calcium gluconate & sodium bicarbonate at the same time to a blocked cat with hyperkalemia

Answer 37

false - don't do this

Question 38

when would you give sodium bicarbonate to a blocked tom with hyperkalemia? how would you give it? what does it do?

Answer 38

if pH < 7.2 or CO2 < 12 mmol/L - HCO3 = weight X (12-patient HCO3) X 0.3 & give half the dose IV over 5 minutes & repeat if needed helps to shift potassium intracellularly in exchange for hydrogen ions

Question 39

what are your sedation & analgesia options for blocked toms?

Answer 39

butorphanol IV +/- midazolam ketamine IV with diazepam IV/midazolam IM propofol +/- isoflurane

Question 40

how should a blocked tom be unblocked?

Answer 40

sterile procedure when placing ucath (wear sterile gloves) & apply sterile lube to the tip of the catheter clean penis/prepuce with povidine/iodine obstruction is alleviated via hydropulsion with saline & only gentle pressure should be applied to the catheter

Question 41

how is a male dog that is blocked from a urolith unblocked?

Answer 41

patient positioned in lateral recumbency with the penis extruded use urohydropulsion through a red rubber catheter to try & propel the stone back into the bladder so that a cystotomy can be done instead of a urethrotomy after obstruction is alleviated, collect urine from the catheter for urinalysis empty the urinary bladder

Question 42

how is a tom cat blocked by a urethral plug unblocked?

Answer 42

position cat in dorsal recumbency at the edge of the table & massage the tip of the penis gently to remove any distal plugs extrude the penis & extend it parallel to the spine to stretch out the flexure in the distal urethra use an open ended tomcat catheter, a 12 mL syringe, & saline to hydropulse can add lube/lidocaine into the saline

Question 43

what kind of indwelling catheter options do you have?

Answer 43

needs to be soft & flexible red rubber, slippery sam, or foley catheter for dogs

Question 44

how is an indwelling catheter placed?

Answer 44

measure the length of it to be passed to avoid forming a knot on itself suture it in using a tape butterfly & attach the catheter to a closed collection system usually leave it in for 48 hours - this allows the bladder to remain empty & recover from detrusor atony, lets urethral swelling decrease, & provides access if a re-obstruction occurs

Question 45

what is the benefit of using a closed collection system after placing an indwelling urinary catheter?

Answer 45

slows the rate of ascending bacterial infections allows detection of obstruction of the urinary catheter allows measurement of urine output - post-obstructive diuresis is common

Question 46

what is the most important thing to do after unblocking a cat?

Answer 46

PUT AN E COLLAR ON THEM

Question 47

what monitoring management is done after unblocking a cat?

Answer 47

check urine output every 4 hours & adjust fluid rate as needed to compensate for the post-obstructive diuresis - if urine isn't flowing, check the line for patency with sterile saline & palpate the bladder

Question 48

what medical management is needed after unblocking a cat?

Answer 48

buprenorphine or other analgesia +/- alpha-adrenergic antagonists to manage urethral spasm (prazosin) avoid abx when ucath is in place because it will predispose them to developing a resistant urinary tract infection potassium supplement as needed urine should be clear with little sediment before the catheter is removed!!!!

Question 49

after removing a urinary catheter, what should you consider if the cat is unable to void urine?

Answer 49

re-obstruction due to urethral inflammation or urethral plug/clot re-obstruction by a stone (obtain rads if not previously done) urethral spasm urethral strictures do not develop until 7+ days after urethral trauma has occurred

Question 50

after removing a urinary catheter, what should you expect to be going on if the cat is able to void urine?

Answer 50

signs of UTIs will persist as expected for several days client must closely monitor at home for signs of re-obstruction manage them the same as FIC

Question 51

T/F: 45% of cats reobstruct either soon after being unblocked or within 6 months

Answer 51

true

Question 52

when may you pursue an elective perineal urethrostomy? what are the risks?

Answer 52

may be done in a male cat with a high risk of recurrent re-obstruction doesn't decrease the risk of clinical signs due to FIC - increases susceptibility to UTIs

Question 53

T/F: FIC is considered to be a neuroendocrine disorder & not a primary bladder disease

Answer 53

true

Question 54

what are the risk factors for cats developing FIC?

Answer 54

middle aged, overweight, indoor only, living with another cat with conflict, fed a dry diet exclusively, & equal sex distribution

Question 55

is there any association with risk of developing FIC with the age of neutering?

Answer 55

nope

Question 56

what are the 2 components of the stress response of FIC?

Answer 56

exaggerated sympathetic nervous system - increased norepinephrine blunted HPA axis - less cortisol

Question 57

what is MEMO?

Answer 57

multimodal environmental modification litter box management, synthetic facial pheromone, escape areas

Question 58

what crystals are commonly found in urethral plugs?

Answer 58

struvite

Question 59

what are the big consequences of urethral obstruction?

Answer 59

azotemia, pain, hyperkalemia, & acidosis

Question 60

what causes pre-renal azotemia? what about post-renal?

Answer 60

pre-renal: marked decrease in renal blood flow (dehydration) post-renal: AKI, obstruction of urine outflow from the kidney

Question 61

if you see this on an ecg of a blocked tom, what are you concerned about?

Answer 61

hyperkalemia!!! causing bradycardia & increased resting membrane potential

Question 62

what is seen on ecg commonly in patients with hyperkalemia?

Answer 62

long p-r interval, prolonged QRS, tall t wave may even lose p waves

Question 63

when is an indwelling urinary catheter indicated?

Answer 63

if the patient needs time for inflammation to reduce maintains a patent urethra keeps the bladder empty

Question 64

how long do strictures take to form after urethral trauma?

Answer 64

7+ days