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Recurrent cystitis - afternoon reading!

Discussion in 'Cat Health and Nutrition' started by Ceiling Kitty, Apr 26, 2014.


  1. Ceiling Kitty

    Ceiling Kitty Hides away from much through humour...

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    Very interesting-looking article in this month's Journal of Feline Medicine and Surgery, which just dropped through my letterbox...

    Based on a quick flick through, it seems that a new condition called 'Pandora Syndrome' has been proposed to represent cats with chronic, recurrent cystitis bouts that are thought to be related to other conditions (medical or behavioural).

    I shall report back once I've read it. :D
     

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  2. Cats cats cats

    Cats cats cats PetForums VIP

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    Hurry along now :) I like your technical posts :thumbsup:
     
  3. buffie

    buffie Mentored by Meeko

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    Hoping against hope here that this may help to shed some light on Meeko's on going urinary probs,probably wont but I live in hope :)
     
  4. Paddypaws

    Paddypaws PetForums VIP

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    I will be reading your update with great interest too.
     
  5. Ceiling Kitty

    Ceiling Kitty Hides away from much through humour...

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    Oks I've done my best to summarise the gist of the paper here - just say if I've not made something clear.


    Right, I'll start by saying that this article focussed on cases of chronic, recurrent cystitis without any other diagnosed underlying cause. Cats with bladder stones and crystalluria, for example, did not apply; their disease needs to be addressed with regards to urine modification first as they are more likely to have a true urinary disorder. Get that fluid intake up and, if necessary, modify the urine pH as appropriate.

    FYI, LUTS in this case stands for 'lower urinary tract signs'. These include blood in the urine, difficulty or pain urinating AND - importantly - inappropriate urination in the house; ie not just the 'medical' symptoms.


    Where we are now - nomenclature of recurrent feline cystitis


    The ever-changing terminology for recurrent cystitis in cats can be confusing. If you do any reading on the subject, you'll find all of these names mentioned, and generally they refer to the same condition. I know it confuses me sometimes. I was taught 'FLUTD' (feline lower urinary tract disease), which according to this article was en vogue in the 1980s and 1990s, even though I was taught in the 2000's.

    Initially, the condition was called FUS (feline urological syndrome). In 1984, FLUTD was proposed as a better term BUT the full name was 'feline lower urinary tract disease with heterogenous causes', which emphasised the multitude of causes, but I guess FLUTDHC was even more of a mouthful so the last bit unfortunately got dropped. Technically, FLUTD covers ALL feline urinary tract disease, including tumours, UTI, bladder stones etc.

    In 1999, the research bods proposed another name change, this time to FIC. Beware: FIC can stand for TWO different things, which are differentiated as follows:
    - feline INTERSTITIAL cystitis - cystitis in which there is no UTI or crystals/stones, as proven by urine tests, and in which there are haemorrhagic lesions on the bladder wall as proven by cystoscopy (sticking a camera into the bladder).
    - feline IDIOPATHIC* cystitis - the same, but without the scope test performed (most cases in practice will fall into this category as we don't scope all that many bladders, to be fair). It probably is the same, but you just can't prove it without the scope.

    *idiopathic is the medical word for 'unknown cause'.

    From this point on, FIC in this post refers to feline idiopathic cystitis.


    Previous thinking on FIC


    I'd never heard of the 'brick paradigm' before, but this is what the authors said leads to many diagnoses of FIC. This theory is that everything was fine until something happened (the 'brick' struck) - an injury, an infection or a stressful event. This, they say, is not accurate in many cases. In fact, these cats have probably had lots of other things going on mentally and/or physically, and it may even have a congenital component (more on that in a bit).

    Basically, studies have shown that cats with FIC seem to have other abnormalities in the rest of the body which make the bladder just another unfortunate victim of a systemic disease. We knew this before (well, at least I did) but it doesn't seem to be as widely known yet; hopefully this will change. This article went into loads more detail than I was aware of, though.

    In a nutshell: FIC is NOT a bladder disease!!!

    Previous research findings that support this:
    - cats with FIC have significant differences in the way their bodies synthesise and release neurotransmitters, the natural chemicals that are involved in the nerve response to pain etc.
    - the nerve cells in certain spinal nerves of cats with FIC are 30% larger than in 'normal' cats.
    - the sympathetic nervous system ('fight or flight' system) of cats with FIC seems to be more active.
    - the long-term stress response of cats with FIC is also altered - their adrenal glands produce less cortisol when stimulated, so they seem to have an inadequate response to stress.

    Moreover, cats with FIC often have other illnesses going on at the same time. Examples include GI disease, heart disease and behavioural disorders. Some of these occur before or during the LUTS rather than afterwards, so they are not caused by the LUTS. There has to be something else going on. The same thing has been noted in human patients with interstitial cystitis.

    So, FIC has already been considered a whole-body neurological/hormonal condition, rather than just a bladder disease, but why does that happen?


    Genetic causes?


    No genetic predisposition to FIC has been found. However, the authors believe that it can be the result of a 'developmental accident' associated with stress to the mother. Stress hormones crossing the placenta during pregnancy affect the development of the stress response systems in the fetuses, leading to exaggerated stress reponses in adulthood.

    They also suspect a link with adverse experiences early in life, such as being orphaned. Most individuals recover from such things without problems, but it is estimated that 5-20% will go on to remain vulnerable and develop chronic disorders (based on human studies). Therefore, the owners of cats suffering with recurrent cystitis should always be questioned about the early history of their cat, if it is known, to see if there have been any traumatic early life experiences that could now be making them more prone to problems.

    This is the DOHaD (developmental origins of health and disease) paradigm, which seems to be much more accurate than the brick paradigm we saw earlier when it comes to diagnosing and treating FIC.


    'Pandora syndrome'

    This is a proposed name for a new syndrome in cats with chronic recurrent LUTS in the presence of other disorders (GI disease, skin disease, behavioural issues etc). It avoids pinning down the diagnosis to the bladder and, I quote: "...seems to capture the dismay and dispute associated with the identification of so many problems ('evils') outside the organ of interest..." I guess they're thinking Pandora's Box.

    In conjunction with the new name, the authors have proposed some tentative diagnostic criteria to identify cats with Pandora syndrome. Remember that this will only apply to cats without other bladder disorders; those with bladder stones/crystals, tumours, or UTIs secondary to kidney disease and the like already have a diagnosis. They are not likely to be suffering from Pandora syndrome or FIC.

    Proposed criteria for diagnosis of Pandora Syndrome
    - presence of LUTS and other disease - GI disease, skin problems, hormonal conditions, immune disease such as tumours or FIV/FeLV, respiratory conditions and behavioural issues.
    - evidence of early adverse experiences such as orphaning or being abandoned.
    - clinical signs that wax and wane in severity associated with events that trigger the abnormal stress responses in the nervous system.
    - symptoms that improve when the environment is modified to reduce these stressful events.

    The authors were keen to mention that any cat can suffer LUTS in association with a stressful event such as building work or a change in carer etc - but there is a difference between 'stressed healthy' cats and 'Pandora syndrome' cats. The stressed healthy cats are responding in a predictable way to an obviously stressful events (after all, we all get stressed sometimes, especially by major life changes); cats with Pandora syndrome are extra sensitive to their surroundings.

    This little chart they printed shows that an environment can be unsuitable at both extremes - it might be deficient (too few litter trays, unstimulating indoor environment, neglect) or it could be way too crazy (too many cats, frequent changes in household routines, people or furniture etc). Cats with Pandora syndrome are only able to handle a much narrower range of environmental changes than healthy cats... but any cat can get sick if exposed to an extreme enough change, same as people.

    Credit to the authors and JFMS for this:

    [​IMG]


    So, where do we go from here?

    The authors emphasised the importance of more detailed history taking for cats with recurrent LUTS not attributable to stones, UTI etc. As vets and owners we need to delve deeper into the history and general health of the cats, looking for anything that might suggest we're dealing with more than a bladder issue. They have created some forms for vets and owners to fill in to this effect, but they are only published online - I've checked the online journal but the paper issue was only delivered today so I don't think they've quite uploaded it yet. I'm keen to have a look once it appears.

    On the research scene, they also made a plea for researchers to include more background information about the FIC cats they are studying in their papers, which would enable further investigation into possible links with background and concurrent diseases.

    They briefly discussed differentiating the 'stressed healthy' cats, who are otherwise fine but have just come up against something major that's upset them, from the Pandora syndrome cats. Basically, in a young otherwise healthy cat with a first episode of LUTS, it is likely an acute episode of FIC or a 'normal' response to a stressful event. Of course, the possibility of UTI or crystals also needs to be explored as these cats could have genuine bladder disease. But they are less likely to have Pandora syndrome.

    It's the cats with recurrent episodes of FIC, those with other diseases or older cats (more than eight years old): it is more likely. The authors stressed that we still need to rule out other causes - you wouldn't want to miss UTIs, tumours or bladder stones, after all - but if all the tests are coming back clear and the cat is still suffering then Pandora syndrome should be considered: dig deeper and find and treat any other diseases. Be aware that these cats cannot handle stress as well as 'normal' cats and need even more care with their environment.




    Overall I found this very interesting. I'm not sure how successful they'll be in getting their new name, 'Pandora syndrome', introduced into general practice. Time will tell. But the thoughts behind it apply nonetheless.

    There are a few loose ends I want tying up, and will have to think about more or look in to. At the moment, we see more LUTS in cats who are overweight or fed a dry diet. If crystals etc have been ruled out, could these cats be suffering from Pandora syndrome? Does increasing water intake or weight reduction make any difference for cats whose bladder disease is essentially a result of a systemic neuro-hormonal disorder? Or is there something else going on?

    A lot to think about, anyway.
     
    #5 Ceiling Kitty, Apr 26, 2014
    Last edited: Apr 26, 2014
  6. buffie

    buffie Mentored by Meeko

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    I need time to try to digest all this , but it does give me food for thought and in fact I will be asking Meeko's vet the next time I see him.
    I do remember when the blood in his urine was picked up at the Royal(Dick)Veterinary College I'm sure the specialist said that there may be a connection between Meeko's IBD and the blood in his urine.
     
  7. debsue

    debsue PetForums Member

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    That is really interesting, thankyou
     
  8. Lilylass

    Lilylass PetForums VIP

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    Thanks Shoosh - I also really enjoy your (to use CCC term as I haven't got a better one!:)) technical posts

    It's nice to have things explained in depth, in a language I can understand :eek:



    I've popped a thread on the dog H&N board as don't want to hijack this one - if you get a sec, I'd really appreciate your thoughts...
     
  9. Dumpling

    Dumpling PetForums VIP

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    Really interesting post Shoshannah, thankyou for posting! :)
     
  10. meal2

    meal2 PetForums Newbie

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    Thank you. Food for thought having a cat that has had bouts of bloody cystitis and developed skin problems.
     
  11. Kitchen Maid

    Kitchen Maid PetForums Member

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    I only joined today and have just caught up with this thread. So I want to start by saying Hi to one + all and especially to Shoshannah for his post on recurrent cystitis which I will keep in my 'Cat Info' folder.

    Our cat is 11+half years old and originally belonged to my mother who had to go into a care home in March 2013. Blackie was the runt of a litter born to a farm cat and if Mum hadn't said she'd have him, he was going to be pts because all the others in the litter had been found homes.

    Blackie had a rather traumatic time last year until we decided to adopt him and seemed to settle well - at least that's what we thought.

    But in early April this year he had his 1st bout of FIC (I won't go into the trauma of all that save to say we were told he was 24 hours from death). We were warned it would recur and so it did in mid-June but we got him to the vets in good time.

    He's now on the Hills c/d stress diet, mixed with 1 tbs of water with each feed, along with Cystophan.

    I feel like we're living on a knife's edge half the time - wondering when the next bout might happen and if we'll catch it in time. I can't describe how relieved I am coming downstairs in the morning to see he's urinated in his litter tray :)

    Thank you again for your post.
     
  12. Polski

    Polski PetForums VIP

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    You have my sympathies, I know what its like to be constantly watching the litter box! I have a cat, Jasper, with recurrent cystitis but I'm pretty good at spotting the early signs now, luckily.

    Jaspers is stress related, and by stress I mean anything from not scooping the litter before he wants to use it in the morning (all 7 cats prefer the tray under the basin in the bathroom!) to introducing a new food (not stopping his usual just offering some as well as his usual!) If I close my bedroom door when I'm in there without letting him in i'll see early signs, if he doesn't get to go out once a day (indoor cat) Now not going out might be his choice because its raining but I'll still see the signs of cystitis coming on...he didn't go out today because it was raining and he's peed up my front door in protest. Still eating so hopefully just a protest pee! He squats for his pees in the litter boxes but loves to spray his pee outside and this was sprayed up my door.

    Jasper is quieter with humans and almost stops eating if he's stressed and that is my cue to spend the day in my room one to one with him. Doing this I've avoided the vets for a couple of years now albeit very narrowly on a couple of occasions. It would help if he would eat wet food but he won't touch it (well, he recently started having a chunk, like 1 chunk, here and there but its nowhere near enough) but he does drink plenty (he does 4-6 tennis ball sized clumps in the litter a day as well as the outside spray...told you I was a litter box watcher!:biggrin5:)
     
  13. OrientalSlave

    OrientalSlave Shunra Oriental Cats

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    Guess what Google found? :)

    Pandora syndrome: Rethinking our approach to idiopathic cystitis in cats
     
  14. Kitchen Maid

    Kitchen Maid PetForums Member

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    Sympathies to you too Polski ... Jasper sounds like one very stressed cat!

    The article posted here by Shoshannah made very interesting reading … not least because the local vet who treated Blackie for his 1st bout said Blackie met all the criteria for FIC - there was blood in his urine, no crystals or stones, male, neutered, slightly overweight, 11 years old - but most of all, he perceived Blackie to be a very highly strung individual. We always thought the cat had an abnormal stress response to the slightest noise or movement . He was also the runt of a litter born to a farm cat. If my mother hadn’t decided to have him, he was going to be pts as all other kittens had been rehomed before him.

    Blackie lived for 10 years in a very quiet house - my mother is a widow and had few visitors except when we came down to stay. We tried to ‘make friends’ with the cat, but all we got was ‘the stare’ and then he’d run off or the paw would come up with claws showing - we knew when to retreat! For the most part, he looked one miserable cat.

    Even the lady at the cattery where he had to stay for 2 months last year said he would be difficult to rehome because of his temperament quite apart from his age. However, we decided to adopt him when Mum had to go into a care home. It was a huge change for him - and we thought he’d coped much better than we expected - he became much less feisty and for 10 months there seemed to be no problems at all.

    As Mum has settled well into her care home in N Somerset, this necessitates us going down to stay for a couple of months at a time in her house so that we can get things done to the house and also visit Mum. I know this is not ideal for a cat with an abnormal stress response in spite of liberally spraying Feliway and dosing him with Zyklene. The 3rd time we made the journey I put his basket on my lap and this definitely seemed to have the effect of calming him - he hardly made a sound during the 3 hour journey.

    Now I fear that the constant changing of environment every 2/3 months, has brought on his FIC and I feel very guilty about it. Unfortunately there isn't anyone I could ask to come in and feed/look out for him for that amount of time. The vet said its obviously not ideal, but better for him to be with us all the time than in a cattery for 2 months. While I appreciated what he said, it was of cold comfort.

    At the moment, Blackie is undergoing treatment for scratching fur off both sides of his neck and making his skin bleed. I wonder if this is also stress related - the vet said if the latest injections don't work, then she's suggesting a blood test. She's also suggested putting him on Zyklene on a permanent basis.

    Still we've grown to love him (something I didn't think possible 18 months ago!) and will do all we can for him, given the difficulties of having to shuttle between 2 homes at the moment.
     
  15. Ceiling Kitty

    Ceiling Kitty Hides away from much through humour...

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    :)

    The author of that link is one of the authors of the JFMS article, he's the main vet proposing the 'Pandora Syndrome' name for the condition. :)


    You're welcome Kitchen Maid, and I is a girlie. ;) I know my name doesn't make it that obvious. :)
     
  16. Kitchen Maid

    Kitchen Maid PetForums Member

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    ^^^

    :eek: Oops...my bad ... apologies Shoshanna.

    Anyone who likes /loves ginger + white cats is a friend of mine. Still much missed after over 20 years is the one my Mum had for 18 years .. a female ginger/white - the most friendly, silly cat I've known - she had a habit of trying to stand on her head in the corner of a room. Also very partial to men for some reason :blushing:
     
  17. Ceiling Kitty

    Ceiling Kitty Hides away from much through humour...

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    Aren't we all? :D
     
  18. Fang

    Fang PetForums Junior

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    This sounds just like my cat, Kitchen Maid.

    My cat is now on a fully wet grain-free diet with added water/broth and, touch wood, is peeing regularly at the moment. He's also on Cystease once or twice a day and I expect this to be permanent. We have Feliway diffusers plugged in around the house too.

    However, he's been quite jumpy and out of sorts recently and has scratched his skin around his head and neck leading to hotspots. He's being treated for these at the moment, if it comes back, it may be time to investigate food allergies. In the meantime, is it worth getting some Zylkene to help to relax him? Is it ok to give this along with the Cystease? Or is it excessive to give both along with the Feliway?
     
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