Exam 4 - Feline Interstitial Cystitis Flashcards
what is FLUTD?
feline lower urinary tract disease - signs associated with lower urinary tract disease (stranguria, pollakiuria, dysuria, hematuria, & pyuria) due to many underlying etiologies
what is FIC?
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
what are some examples of causes of lower urinary tract disease in cats?
FIC, UTI, urolithiasis, urethral plugs, urinary tract neoplasia, trauma, stricture, anatomic defects, neurological defects, & behavioral disorders
how is FIC diagnosed?
diagnosis of exclusion!!!
what are the characteristics of FIC?
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
what is the most common cause of lower urinary tract signs in cats?
FIC
what is the cause of FIC?
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
what nerves provide sensory innervation to the bladder? how does this relate to FIC?
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
how can decreased urine volume & frequency be a cause of FIC?
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
how does stress contribute to FIC?
plays an integral role in FIC
FIC cats have an altered HPA axis characterized by exaggerated catecholamine release & blunted cortisol response
what are some examples of how may a cat with FIC present to your clinic?
non-obstructive self-limiting disease
frequent recurring episodes
chronic persistent episodes
urethral obstruction
what signalment of cats are commonly affected by FIC?
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
what is the most common sign of urinary obstruction in cats?
non-productive straining in the litter box +/- vocalization
T/F: episodes of FIC often resolve within 7 days with or without treatment
true
why do you need to inquire about previous episodes of lower urinary tract signs if you have a cat presenting with stranguria?
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
what may be seen on physical exam in a cat with FIC?
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
why do you need to be careful when evaluating a urine dipstick on a cat?
the dipstick will yield false positives for leukocytes in cats - look at the sediment
when should you do a urine culture for a cat with FIC?
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
why is efficacy of therapy complicated when managing a cat with FIC?
clinical signs usually resolve after 1-7 days
what is management of FIC aimed at?
reducing rate of recurring signs, reducing severity & duration of signs, & reducing the risk or urethral obstruction
what is your first line therapy for all cats with FIC?
stress reduction!!!!!
how is environmental enrichment used for managing cats with FIC?
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
how is litter box management done for cats with FIC?
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
what kind of litter do cats prefer?
clumping, sand like litter
how is feline facial pheromone used for stress management in cats with FIC?
nonvolatile molecules that influence social & reproductive behavior
shown to decrease stress in cats during hospital visits
how is diet management part of treating FIC in cats?
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
what is the current standing on using anti-inflammatory drugs for treating FIC?
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
what cats are more commonly affected by urethral obstructions? why?
male cats - narrow urethra
what usually causes urethral obstructions in male cats?
urethral plug - composed of protein matrix with some WBC/RBC
less commonly due to a stone (tumors & strictures rarely cause obstruction)
what is seen on physical exam of a blocked tom? what parameters do you need to get?
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
what should make up the immediate medical therapy for a patient with a urethral obstruction?
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
how is a decompressive cystocentesis done? what are the risks?
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)
what is the purpose of giving calcium gluconate to a blocked tom?
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)
how is regular insulin & dextrose fluids used to manage hyperkalemia in a blocked tom? how is it done?
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
how is albuterol or terbutaline used for treating hyperkalemia in a blocked tom?
beta-2 mediated stimulation of Na-K-ATPase pump moves potassium intracellularly
what are contraindications for giving bicarb to a blocked tom when needing to treat hyperkalemia?
encephalopathy, liver disease, or hyperosmolarity
T/F: it is okay to give calcium gluconate & sodium bicarbonate at the same time to a blocked cat with hyperkalemia
false - don’t do this
when would you give sodium bicarbonate to a blocked tom with hyperkalemia? how would you give it? what does it do?
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
what are your sedation & analgesia options for blocked toms?
butorphanol IV +/- midazolam
ketamine IV with diazepam IV/midazolam IM
propofol +/- isoflurane
how should a blocked tom be unblocked?
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
how is a male dog that is blocked from a urolith unblocked?
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
how is a tom cat blocked by a urethral plug unblocked?
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
what kind of indwelling catheter options do you have?
needs to be soft & flexible
red rubber, slippery sam, or foley catheter for dogs
how is an indwelling catheter placed?
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
what is the benefit of using a closed collection system after placing an indwelling urinary catheter?
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
what is the most important thing to do after unblocking a cat?
PUT AN E COLLAR ON THEM
what monitoring management is done after unblocking a cat?
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
what medical management is needed after unblocking a cat?
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!!!!
after removing a urinary catheter, what should you consider if the cat is unable to void urine?
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
after removing a urinary catheter, what should you expect to be going on if the cat is able to void urine?
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
T/F: 45% of cats reobstruct either soon after being unblocked or within 6 months
true
when may you pursue an elective perineal urethrostomy? what are the risks?
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
T/F: FIC is considered to be a neuroendocrine disorder & not a primary bladder disease
true
what are the risk factors for cats developing FIC?
middle aged, overweight, indoor only, living with another cat with conflict, fed a dry diet exclusively, & equal sex distribution
is there any association with risk of developing FIC with the age of neutering?
nope
what are the 2 components of the stress response of FIC?
exaggerated sympathetic nervous system - increased norepinephrine
blunted HPA axis - less cortisol
what is MEMO?
multimodal environmental modification
litter box management, synthetic facial pheromone, escape areas
what crystals are commonly found in urethral plugs?
struvite
what are the big consequences of urethral obstruction?
azotemia, pain, hyperkalemia, & acidosis
what causes pre-renal azotemia? what about post-renal?
pre-renal: marked decrease in renal blood flow (dehydration)
post-renal: AKI, obstruction of urine outflow from the kidney
if you see this on an ecg of a blocked tom, what are you concerned about?
hyperkalemia!!! causing bradycardia & increased resting membrane potential
what is seen on ecg commonly in patients with hyperkalemia?
long p-r interval, prolonged QRS, tall t wave
may even lose p waves
when is an indwelling urinary catheter indicated?
if the patient needs time for inflammation to reduce
maintains a patent urethra
keeps the bladder empty
how long do strictures take to form after urethral trauma?
7+ days
