Feline idiopathic lower urinary tract disease (FLUTD) Flashcards
1
Q
Synonyms - FLUTD
A
- idiopathic FLUTD
- feline urologic syndrome (FUS)
- feline interstitial FLUTD (FIC)
2
Q
CS - FLUTD
A
- straining
- haematuria
- pollakiuria
- periuria
- CS referrable to LUT (stones, UTI, neoplasia)
- licking penis/prepuce
- inappropriate urination
- vocalisation, hiding
- signs of urethral obstruction
3
Q
Dx - FLUTD - old cat
A
- UA + culture
- other diagnostic tests (renal function, hyperthroidism)
- imaging
4
Q
Commonest cause - FLUTD
A
- idiopathic FLUTD:
- diagnosis of exclusion
- CS spontanteosly resolve in 3-7 d
- recurrence common (39% in 18 months)
- subset have chronic dz
5
Q
Risk factors - FLUTD
A
- persian
- aged 2-6 years
- spayed/castrated
- obestiy
- decreased activity
- dry cat food
- stress
6
Q
Aetiology - FLUTD
A
- OLD THEORY: infectious agent (bacteria, virus, mycoplasma), crystalluria, urachal diverticula
- NEW THEORY: interstitial cystitis (neurogenic inflammation, mucosal defects), neuroendocrine imbalance
7
Q
Outline relationship between UTI and FLUTD
A
- bacterial UTI documented in
8
Q
Outline relationship b/w mycoplasma and ureaplasma with FLUTD
A
- aerobic bacteria
- fastidious growth requirements
- several studies fail to culture these from feline idiopathic FLUTD
- osmolality of feline urine inhibits growth
- PCR based detection unsuccesful in finding them
9
Q
Outline relationship b/w viral infection and FLUTD
A
- BHV-4, calicivirus and feline syncytia forming virus (FSV) most commonly implicated
- virus-like particules ID in 38% crystalline matrix urethral plugs
- could explain episodic signs and recurrence in stress
10
Q
What is the significance of crystalluria and FLUTD?
A
- DISRPOVED (i.e. no relationship b/w the two)
- struvite crystals common in normal cats
- struvite crystals found in >50% cats with FLUTD and in the same proportion of young cats w/o CS
- crystals cannot directly damage urethra or bladder mucosa
- crystals a risk factor for urolithiasis
- stones are a potential cause of FLUTD, account for 15-20% cases
- not directly injurious
- tx = oxalate
- adverse effects from acidification
11
Q
How common are urethral plugs?
A
only in 18% cats with urethral obstruction (probably related to diet)
12
Q
What is a vesicourachal diverticula?
A
= out-pouchings of bladder apex
- associated with CS of FLUTD, especially when obstruction occurs
- develop d/t increased intravesicular pressure and are the result not cause of the dz
- microscopic urachal remnants common
- macroscopic diverticula develop secondary to increased intraluminal pressure
- heal spontaneously within a few weeks if obstruction relieved
13
Q
What is interstitial cystitis (IC)?
A
- unknown aetiologies, humans (women)
- analogies b/w human IC and idiopathic LUTD
14
Q
Compare idiopathic FLUTD and human cystitis
A
- young cats and young women
- CATS and humans = dysuria and pollakiuria
- CATS and humans = sterile urine
- CATS = haematuria, HUMANS = few RBCs
- CATS and humans = glomerulations
- CATS and humans = increased bladder permeability
15
Q
What are glomerulations?
A
= pinpoint haemorrhages in bladder wall
- documented in most cats with idiopathic FLUTD
16
Q
Outline neuroendocrine imbalance
A
= current popular theory but evidence sketchy
> NEUROGENIC INFLAMMATION: local stimulation of sensory neurons (C fibres) –> pain, but in addition causes release of SP from local nerve endings which may have a multitude of effects including release of histamine from mast cells, mm contraction and vasoconstriction
- inadequate GC restraint
- excitatory SNS outflow is unchecked
- cortisol response to ACTH is less in cats with FIC than controls
- cats with IC have small adrenal glands
17
Q
Signalment - idiopathic FLUTD
A
- male, pedigree, longhaired, overweight, the cat which tries to remove itself from stressful situation rather than the aggressor
- NOT SIGNIFICANT: diet, outdoor access, fear of strangers, fear of sounds
18
Q
2 components of idiopathic FLUTD
A
behavioural and physical
19
Q
How do antispasmodics work?
A
- anticholinergic
- decreases detrusor contraction
- efficacy not demonstrated
20
Q
Discuss anti-inflammatory agents in FLUTD
A
- GCs: efficacy not demonstrated, CI with azotaemic animals and if urinary catheters in place
- NSAIDs: no difference in duration of CS with meloxicam vs placebo
21
Q
Discuss amitriptyline in FLUTD
A
- tri-cyclic antidepressant
- anti-cholinergic, anti-histamine, anti-inflammatory, analgesic effects too
- common for human IC
- used for idiopathic FLUTD
- reports in chronic cases promising but placebo show acute FLUTD episodes more likely to develop UTIs and relapse
- SIDE EFFECTS: urine retention, sedation, liver enzyme elevation
- STUDIES: –> urolith development in some cats, placebo controlled trials showed no improvement, increased UTI risk, increased short term recurrence rate
22
Q
Outline synthetic GAGs in FLUTD
A
= pentosan polysulphate and cystease
- one theroy of IC/ iFLUTD is that there is a deficient GAG layer
- GAGs overly bladder epithelium, possibly protecting the cells form noxious substances in urine (high osmolality, protons)
- theorised that if layer deficient, an inflammatory response could occur
- idea is that there are deficient GAGs in bladder wall in human IC (but unknown if these reach bladder and if felines with FLUTD are deficient in GAGs)
23
Q
What is cystease?
A
- N-acetyl glucosamine (a GAG precursor)
- GAG precursor
- UK
- placebo trial: no overall benefit significant but improvement reported in many patients
24
Q
Outline feliway in FLUTD
A
- no significance vs placebo but v small study
25
Outline diet in FLUTD
- only thing that DOES seem to make a difference
- feeding canned (less likely) vs dry diet (more likely to have another episode)
- difficult if always eat dry food
- new hill's formulation in wet and dry form
26
How to increase water intake?
- add water to food
- flavour water with tuna juice/similar?
- drinking fountains? (no proof)
- hill's diet? (study to be released)
27
What is MEMO?
= Multimodal Environmental Modification
1. avoid punishing cat
2. canned food, increase water intake
3. unscented water intake
4. improved litter box management
5. environmental enrichment
6. increased interaction with owner
7. identification and resolution of conflict
28
Summarise - FLUTD
- idiopathic FLUTD common
- typically self-limiting (unless obstructed) but recurrence common
- no tx proven uniformly effective (strongest evidence for diet change and environmental management)
29
How to approach the FLUTD patient?
+/- UA, +/- imaging (1st time)
- UA and imaging (repeat offenders)
- wet food and drinking fountains
- behavioural and environmental modifications
- (synthetic GAGs)
- (amitriptylline)
- analgesics? (butorphanol/buprenorphine)
30
How to differentiate spraying from behavioural peeing
- SPRAYING: males and femlaes, cat marks vertical surfaces with squirts of urine, tails usually quiver
- PURELY BEHAVIOURAL: marking owner's clothing, bed etc
31
Cause - FLUTD
- Older cats (>10 years): cause generally ID
| - Young cats - tends to be idiopathic - cause harder to elucidate
32
How to investigate an older FLUTD cat?
- urine sample (SG, dip-stick, sedminent exam, culture)
- if no UTI identified and this is first case of FLUTD --> image the LUT to r/o neoplasia and urolithiasis
- Then consider it idiopathic
33
Condtions that predispose to UTIs in cats
- CKD (v common)
- hyperthyroid (v common)
- DM
- urolithiasis
- bladder tumours
34
Cause - young cats with FLUTD
- >65% cases you can't ID an underlying cause thus idiopathic
- will tax your clinical and communication skills!
35
T/F: over-zealous tx to prevent struvite crystals may result in calcium oxalate stones forming instead
True
36
Outline the neurogenic inflammation theory as a mechanism for IC/ iFLUTD
- known that stress may precipitate/ aggravate iFLUTD in cats
- preliminary work suggests inappropriate stiulation of SNS or derangement of HPA may occur in this condition
37
Name 3 new proposed mechanisms for IC/ iFLUTD
- Neurogenic inflammation
- deficient GAG layer
- sympathetic overactivity
38
Why are a huge # of tx proposed for iFLUTD?
None work very well
39
How can you reduce feline stress?
- difficult!
- minimise overcrowding (feline and human!)
- many clean litter-boxes in different areas of the house
- feliway diffusers
- ICC website useful
40
What tx are not recommended for FLUTD?
- urinary acidifyers (uroease, ammoniu chloride) since all brand cat foods are sufficiently acidifying
- steroids (placebo controlled trial showed no benefit, CI with obstruction and urinary catheters anyway)
- ABs (unless UTI documented)
- sx (bladder biopsy not required for dx)
41
Approach - young cat + 1st episode FLUTD
- PE (r/o obstruction)
- Hx (r/o behaviour, ID stress triggers)
- UA: if possible, difficult as cats have v small bladders and often resent palpation, measure SG as if high then dz probably idiopathic or perhaps a stone
- Educate owner: nature of condition and signs of obstruction (if male)
- Tx: environmental changes, canned food, water fountain
42
Approach: young cat + recurrent FLUTD
- same as for first episode, PLUS:
| - imaging (r/o urolithiasis and other causes of FLUTD)
43
Approach: young cat + recurrent FLUTD + getting deperate
- same as for first and recurrent episode, PLUS:
- consult with behaviourist
- oral analgesics (butorphanol) during episodes
- sometimes use amitriptyline/other behaviour-modifying drugs out of deseration if owner is at point of euthanasia
- minority of cats - tx doesn't work
- sometimes worthwhile repeating imaging because cats that previously had idiopathic signs will develop stones.
