By Kim Campbell Thornton
Urinary tract disease in cats takes many forms and can be frustrating to veterinarians, clients, and surely cats themselves, even if they can’t say so. One of the common features of urinary tract disease, whether it originates in the upper or lower urinary tract, is hematuria—blood in the urine. But it often isn’t detected until later in the disease process, after the cat is already experiencing clinical symptoms and discomfort or pain.
At the EveryCat Health Foundation symposium in Gainesville, Florida, last July, Kelly St. Denis, DVM, who specializes in treating cats, spoke on hematuria detection and how it can be used to promote urinary tract disease prevention and management. “The ability to detect hematuria early in the disease process gives caregivers a powerful tool which allows them to seek veterinary assistance early,” she says.
But hematuria is just one aspect of urinary tract disease. Dr. St. Denis also discussed predisposing factors, including one of the most powerful: stress. Providing owners with information about home detection of hematuria and how to recognize early behavior signs can help you and the client be more successful in managing the disease, keeping cats happier, healthier, and more comfortable.
Upper and Lower Urinary Tract Issues
Acute, congenital, and chronic conditions of the kidneys and the ureters include infections, kidney stones, stones in the ureters, pyelonephrosis, neoplasia, and more. Among the risk factors for upper urinary tract disease are exposure to lilies or other toxins, and breed, for instance, Persians and polycystic kidney disease.
In the lower urinary tract, conditions include feline interstitial cystitis, uroliths, crystalluria, infection, cancers, and bladder polyps, as well as other conditions. Probably all of them can be associated with hematuria, St. Denis says.
Take urolithiasis. Some cats may have it only once in their lives while others may have multiple episodes, depending on a variety of factors. It’s one of the conditions that is going to cause hematuria.
Bladder stones accumulate and increase in size. Hematuria is a common side effect.
No matter what type of urinary tract disease a cat has, hematuria is likely to be a common denominator. Some factors more than others can be associated with hematuria, but all have the potential to lead to it.
Other Causes of Hematuria
Diseases of the urinary tract aren’t the only causes of hematuria. When urine is drawn by means of cystocentesis, it can cause a small amount of bleeding. That can interfere with the interpretation of whether blood is present in the urine, St. Denis says.
Hematuria in urine collected by free-flow samples can also have causes unrelated to urinary tract disease, she adds. Conditions that may lead to blood in the urine include a cat being in estrus; trauma; vascular disease that is causing bleeding in the bladder; urinary tract parasites; coagulopathies; and toxins.
Early Detection
Blood in the urine can be detected microscopically or on chemistry test strips if a cat is brought in early enough, but usually cats aren’t brought to the clinic until blood is macroscopically or grossly visible: pink-tinged urine on the client’s carpet, frank blood in the urine, or even blood clots.
For cats at risk, St. Denis recommends that clients use a hematuria detection product called Blucare. The granules are sprinkled in the cat’s litter and turn blue if there is blood in the urine, even if it’s not yet detectable by the naked eye. Even a change to light blue is considered significant, St. Denis says. The blue color remains for 48 hours, enabling clients to bring the cat to the clinic in the early stages of the problem or alert them to recurrence.
In multicat households, granules can be added to the cat’s favorite litter box. Another option is to separate the cats so they each have their own litter box, with the client checking litter daily. Granules can remain in litter for 30 days before new ones are added.
Other Physical and Behavior Changes
Even without use of Blucare or color-changing cat litter such as Pretty Litter that can indicate problems, clients can learn what to look for in the litter box.
“Cats should be urinating about 30 to 40 ml/kg per day,” St. Denis says. “We try to make our caregivers aware of what their cats’ normal clump sizes are. Our caregivers should be aware of when things are changing, if clumps are getting bigger or smaller, but it’s also beneficial if they know if there’s hematuria.”
Certain changes and behaviors can alert the observant cat caregiver. House soiling is one of the earliest signs of feline urinary tract disease. But owners don’t always see that as a signal to take the cat to the veterinarian. In a 2016 telephone survey of 281 households owning 455 cats, researchers found that 26 percent of all cats in the study were reported to have urinated or defecated outside of the litter box at some point in their lives, but only 31.7 percent of cats with house-soiling behavior were evaluated by a veterinarian. The behavior resolved in 56.7 percent of the cats but persisted in 43.3 percent.
“I wonder, if they had granules in the litter that detect blood, would they have taken the cat to vet? Because probably a lot of these cats had some sort of medical problem,” St. Denis says.
Other clues clients should be aware of are PU/PD; straining to pass urine; vocalization during urination, usually indicating pain; smaller volumes of urine—so smaller clump size—and, in the case of serious kidney disease, failing to produce urine.
Cats with urinary tract disease may also overgroom themselves, particularly on the belly but also elsewhere on the body. St. Denis recalls a patient who always had a groomed belly. She recommended abdominal radiographs to the owners—who reliably brought the cat in every six months for her senior checkup—but they insisted the cat had always been nervous.
“Finally, one day she came in with hematuria and I noticed she was now grooming a number of other places besides the belly. I said, ‘Okay, now we really need to do some imaging.’”
The radiographs turned up not only a large bladder stone but also osteoarthritis in multiple joints. Using diet to dissolve the calcium oxalate stone was unsuccessful because of its size and it had to be removed surgically.
“If you’re seeing those cats that are grooming their bellies, don’t just chalk it up to them being nervous or having some kind of OCD problem,” she says. “You really need to get into the question of are they in pain. I wish I had had Blucare with that cat because I couldn’t convince them to do an x-ray. If I could have sent some Blucare home, they would have found the hematuria at some point and we would have found that stone a lot faster.”
FIC Risk Factors: Stress Is at the Top
One of the urinary tract conditions that is most distressing to cats and their owners is FIC, because it has so many risk factors. Stress, obesity, lifestyle, age, diet, sex, and the presence of other cats are among the factors influencing a cat’s risk level for any type of lower urinary tract disease, but FIC stands out. It used to be thought that certain cases of the disease were idiopathic, but St. Denis says studies have shown consistently that stress is integrally involved in the pathogenesis of FIC—now known as feline interstitial cystitis rather than feline idiopathic cystitis.
FIC doesn’t just encompass the bladder. It can affect the whole body, the result of complex interactions between the nervous system, urinary bladder, adrenal system, husbandry practices, and the cat’s environment. Many cats unable to deal with normal stress can also have gastrointestinal signs or immune system depression that makes them susceptible to infection. They may have a genetic predisposition that affects their ability to deal with normal day-to-day stressors. Cat guru Tony Buffington, DVM, calls them “sensitive cats in a provocative environment.” It can be especially important for these cats to live in a Fear Free home environment.
Age is another predisposing factor. Cats at risk are between two and seven years old. If they live in a multicat household, the presence of other cats may be stressful for these patients. A sedentary indoor lifestyle, carrying excess weight, or being a neutered male cat are factors as well.
Diet matters. Cats on a urinary maintenance diet may be less likely to develop LUTD. Cats eating only dry food are going to have a higher concentration of urine, putting them at increased risk. Cats who are prone to dehydration because of poor water intake, hypertension, hyperthyroidism, or diabetes are also at higher risk.
But what also matters is where cats eat. And in a multicat household, where they should be eating is away from each other. For clients whose cats eat side by side, apparently happily, this may be hard to believe, but St. Denis says they should be eating in separate areas, out of view of other cats. Eating together is stressful for them.
“When a cat hunts, they get a mouse. To get enough for them, they have to get multiple mice per day. They don’t want to share. So when we ask them to eat within sight of each other, share bowls, or beside each other, even if they’re swapping bowls and it looks like they’re having fun, they’re actually stressed,” she says. “Dr. Buffington recommends that cats should be at least six feet apart and have a visual barrier between them when we’re feeding them.”
Water should be placed away from food bowls as well. Cats don’t want to drink where they eat or eliminate and doing so can be stressful for them.
Diagnosing FIC
Not surprisingly, this is a diagnosis of exclusion. It’s necessary to rule out stones, crystals, and other conditions.
It’s not unusual for cats to have more than one condition, St. Denis says. “They might have a bladder stone and FIC or crystals and FIC. I always go by the principle of treating what you see and then see what’s left, because sometimes you’ll still be left with FIC.”
Diagnosis typically starts with a urinalysis, checking clinical chemistry, urine-specific gravity, and sometimes culture sensitivity and urine protein creatinine. If the client’s finances permit, ultrasound-guided urinalysis allows a peek into the bladder. Send out urine right away, St. Denis says.
“We do have evidence to show that if we let it sit, or we send it to an external lab, there is an increased chance that we’re going to have struvites develop. We can also have bacteria that might be in there multiply, increasing the chance that we’re going to misdiagnose a UTI. Even refrigeration can increase false positives.”
The condition can wax and wane and it can be acute or chronic. Try to identify what’s going on in the household that might be predisposing the cat to a flareup. Cats become stressed when their environmental needs aren’t met (that indoor sedentary lifestyle); they must compete with other cats for resources; a new pet, baby, or other significant person joins the household; their environment changes because of a move to a new home; their schedule changes because of a family member’s new job; they receive meals at set times instead of having free access to food; or they must eat in the presence of other cats.
Where does hematuria detection fit in with FIC? Ninety percent of FIC patients have hematuria.
Treatment
It’s all too easy to reach for antibiotics when clients ask for them or signs seem to indicate infection. But without confirming the presence of an infection, antibiotics can do more harm than good. And without getting on top of a case of FIC, cats end up with a chronic disease.
When St. Denis has patients that are prone to FIC, she and clients work together to prevent flareups caused by stressful events. Clients call if they are moving, they’re going to a summer vacation home with the cat, a child is leaving for or coming home from college, or they are facing other potential upheavals in a cat’s life.
“We would maybe put the cat on some medication to try and preemptively avoid having a flareup,” she says.
Early detection is an opportunity to be proactive before the disease and accompanying pain advance. Caregivers know their cats best, but cats are innately private creatures. Educating clients about the risk factors for FIC, the subtle early signs, and the option for early detection of hematuria can empower them—in a good way.
“We want to get people involved in their cats’ care,” St. Denis says. “This is another way we can help them be an active part of the cat’s team rather than just telling them what they need to do.”
This article was reviewed/edited by board-certified veterinary behaviorist Dr. Kenneth Martin and/or veterinary technician specialist in behavior Debbie Martin, LVT.
