Sample Topic

Feline

Feline Idiopathic Cystitis

Summary

  • Characterized by clinical signs of lower urinary tract inflammation for which an underlying cause is not identified
  • Considered the most common cause of feline lower urinary tract disease (FLUTD); occurs in approximately 2/3 of cats with signs of lower urinary tract disease who are < 10 years of age
  • Etiology is multifactorial and involves pathways outside of the urinary tract; chronic stimulation of the body’s stress response, release of stress catecholamines and chemical mediators activate the nervous and endocrine systems, contributing to neurogenic bladder inflammation
  • May present with or without urethral obstruction; obstruction is most common in young, male, overweight cats
  • In cats with non-obstructive form, clinical signs may resolve within 2 to 3 days with no therapy; however, rate of recurrence is high
  • Diagnosis is based on history, signalment, environmental risk factors, and exclusion of other common causes of lower urinary tract disease (e.g., urocystoliths)
  • Treatment is aimed at reducing the severity and frequency of clinical signs; response to therapy may be inconsistent
    • Multimodal environmental modification (MEMO)
  • Client education and communication are critical to successful management
  • Prognosis is variable; frequent recurrence increases the risk of euthanasia or rehoming/surrender

Causes and Risk Factors

Causes

  • Multifactorial; underlying cause is often not identified
  • Environmental or physiologic stress (particularly chronic stress) activates the body’s stress response, releasing stress catecholamines and chemical mediators that activate the nervous and endocrine systems, contributing to neurogenic bladder inflammation
  • Decreased excretion of urinary glycosaminoglycans, increased bladder permeability, increased serum catecholamine levels, and increased excitability of bladder afferent neurons have been reported
  • Role of viruses as a cause of lower urinary tract disease remains unclear
  • Environmental and behavioral stressors thought to play a role

Risk Factors

  • Obesity
  • Nervous disposition
  • Genetics
  • Decreased activity
  • Environmental stressors; may include but are not limited to:
    • Indoor housing
    • Litter box placement or substrate (non-clumping litter may increase risk)
    • Frequent diet changes
    • Dry food diet
    • Diet changes
    • Owner work schedule
    • New animals or people in the house
    • Moving to a new home/location
    • Multiple cat household

Signalment

  • Often young to middle-aged cats
  • Males predisposed
  • No breed predilection

Differential Diagnosis

Diagnosis and Screening

General Points

  • Diagnosis is based on history, signalment, environmental risk factors, and exclusion of other common causes of lower urinary tract disease (e.g., urocystoliths)
  • Clinical signs vary in severity; may wax and wane
  • Signs may be exacerbated by stress
  • Many cats have resolution of clinical signs without therapy; therefore, diagnostics may not be necessary in a young cat with a first occurrence of clinical signs
  • Bacterial urinary tract infection is rare in young, otherwise healthy cats; cats with perineal urethrostomy, repeated catheterizations, or underlying metabolic/endocrine disease may be at greater risk of infection

Signs and History

  • Hematuria
  • Dysuria
  • Pollakiuria
  • Stranguria
  • Periuria
  • Inappropriate urination; owner may misinterpret as urine marking/spraying
  • Overgrooming (abdomen, perineum, rear legs ) due to pain
  • Hiding
  • Behavioral changes, including aggression
  • Urethral obstruction possible
  • A detailed environmental history and timeline of onset of clinical signs should be considered as part of the initial assessment

Physical Exam

  • May be normal
  • Abdominal pain possible; prepubic hair loss may indicate presence of bladder pain
  • Findings will depend on the presence of an underlying disease process

Laboratory Tests

  • Routine laboratory tests
    • Complete blood count and biochemistry panel
    • Urinalysis
      • Should include sediment examination
      • Hematuria
      • Crystalluria
      • Pyuria
      • Specific gravity is often concentrated; isosthenuria should prompt investigation for underlying systemic disease (e.g., chronic kidney disease)
      • Urine should be evaluated within 30 to 60 minutes of collection to ensure reliable results

  • Urine culture
    • Should be considered for cats with:
      • Recurrent bouts of clinical signs (> 2 episodes)
      • An underlying medical condition
      • Prior history of urethral obstruction

  • Thyroxine level
    • Should be considered for any cat > 8 years of age
    • Cats with hyperthyroidism may demonstrate polyuria; may be mistaken for lower urinary tract disease

Imaging

  • Abdominal radiography
    • Will aid in identification of radioopaque uroliths

  • Abdominal ultrasonography
    • Should be considered in older cats (>10 years of age) that have signs of lower urinary tract disease
    • Useful in identifying bladder abnormalities such as polyps, stones, blood clots, debris, or neoplasia

  • Contrast cystogram/cystourethrogram
    • May be considered in cats with recurrent episodes of lower urinary tract signs or those who are unresponsive to therapy
    • May identify mass lesions, radiolucent calculi, thickening of the bladder wall, or urethral stricture (specifically in males)

  • Cystoscopy
    • Can be performed in female cats and males that have undergone perineal urethrostomy
    • Referral to a veterinary specialist should be considered
    • Allows direct visualization of the bladder and urethra, with collection of biopsy samples if needed

Treatment

General Points

  • Many cats may have resolution of clinical signs within 2 to 7 days without therapy; however, recurrence of clinical signs is common, often within 12 months
  • Multimodal environmental modification (MEMO) involves adjusting resources (e.g., food and water stations, litterboxes, toys, etc.) to reduce stress and improve the cat’s sense of control
  • Therapy should be initiated for patients with recurrent signs of lower urinary tract disease
  • There is no consensus on the optimal treatment for cats with idiopathic cystitis; transitioning to a moist diet, effective environmental enrichment (see Other Therapies), and use of a multipurpose therapeutic urinary diet have the highest levels of evidence
  • Treatment is aimed at reducing the severity and frequency of clinical signs
  • Response to therapy may be inconsistent
  • For cats receiving daily oral medication, the stress associated with being medicated can exacerbate the condition and complicate assessment of therapeutic response
  • For many medications, high-level studies demonstrating efficacy are lacking

Medications

  • Antibiotic therapy
  • Analgesic therapy
    • Short-term options include:
      • Buprenorphine 0.01 to 0.03 mg/kg IV, IM, or PO (buccal/transmucosal) every 4 to 8 hours
      • Butorphanol 0.2 to 0.8 mg/kg IV, SC, or IM every 2 to 6 hours; or 1.5 mg/kg PO every 4 to 8 hours
      • Tramadol 1 to 2 mg/kg PO every 12 hours
      • Robenacoxib 1 mg/kg PO every 24 hours, up to 6 days

    • Long-term options include:
      • Gabapentin 5 to 10 mg/kg PO every 12 hours

  • Antidepressant/mood modifiacation therapy
    • May be considered for cats that do not respond to nutritional or environmental therapy; can take weeks to note improvement so not indicated for acute management
    • If ineffective, drugs should be weaned over 1 to 2 weeks and not abruptly discontinued
    • Options include:
      • Gabapentin 5 to 10 mg/kg PO every 12 hours
      • Amitriptyline 2.5 to 7.5 mg per cat, PO every 24 hours
        • Efficacy is variable
        • Treatment should be initiated at the low end of the dose range
        • Side effects include lethargy, weight gain, and urine retention
      • Clomipramine 0.25 to 0.5 mg/kg PO every 24 hours; up to 1 mg/kg PO every 24 hours
        • Use in combination with behavior modification therapy
        • May cause sedation
      • Fluoxetine 0.5 to 1.3 mg/kg PO every 24 hours
        • Can help reduce urine spraying
        • Demonstration of therapeutic response may take up to 8 weeks
        • May cause a decrease in appetite; urine retention has been reported
      • Alprazolam 0.125 to 0.25 mg per cat, PO every 8 to 12 hours
        • Although idiosyncratic hepatic injury has not been reported with alprazolam, use oral benzodiazepines with caution in cats
      • Lorazepam 0.125 to 0.25 mg per cat, PO every 12 to 24 hours
        • Alternate dosage: 0.05 mg/kg PO every 12 to 24 hours
        • Start at the low end of the dose range
        • May cause sedation or paradoxical excitement
        • Although idiosyncratic hepatic injury has not been reported with lorazepam, use oral benzodiazepines with caution in cats

  • Glycosaminoglycan therapy
    • Controversial; significant benefit has not been demonstrated, and presumed efficacy has been variable
      • N-acetyl glucosamine 250 mg per cat, PO every 24 hours

  • Medication for cats with urethral obstruction
    • In addition to treatment aimed at removing the obstruction, medical management of urethral spasm may be considered; efficacy is variable
    • Options include:
      • Prazosin 0.25 to 1 mg per cat, PO every 8 to 12 hours
        • May cause sedation and/or hypotension
      • Phenoxybenzamine 2 to 4 mg per cat, PO every 12 hours
        • May cause sedation and/or hypotension

Surgical Interventions

  • Cystotomy may be required for patients with urolithiasis
  • Perineal urethrostomy may be considered for male cats with recurrent bouts of urethral obstruction

Other Therapies

  • Environmental enrichment/multimodal environmental modification ( MEMO)
    • Goal is to increase the cat’s sense of control, and reduce perceived threats
    • Has been found to decrease the clinical signs of idiopathic cystitis and lower the rate of recurrence
    • Removal of environmental stressors is recommended whenever possible
    • Environmental enrichment recommendations include:
      • Providing safe havens (e.g., climbing posts/perches, secure hiding spots, window perches) spread throughout the house
      • Provide different types of scratching surfaces (e.g., horizontal and vertical, different substrates and textures, different heights and locations)
      • Rotate toys regularly, to discourage boredom
      • In multi-cat households, provide separate feeding areas, multiple water locations, and multiple litter boxes (at least one box per cat and one more litterbox than the number of cats); litter box size, locations, and substrates may need to be changed as well
        • Litterboxes should be in separate rooms, and not side-by-side
        • Scoop boxes daily (at least)
        • Unscented, sandy-type litter is generally preferred, but additional types and textures can be offered to discern the cat’s preference
        • Most cats prefer an open litterbox, but different types can be offered, to determine the cat’s preferences
        • Size: the litterbox should be at least 1.5 times the length of the cat, minus the tail
        • Owners should be mindful of potential obstacles (e.g., stairs) and deterrents (e.g., appliances, air vents or ducts) that can contribute to stress and/or hinder accessibility
        • Older cats, or cats with mobility limitations may benefit from a litterbox with shallower edges, or a cut-out section for easier access
      • Increased activity (e.g., leash-walking, interactive play time, positive-reinforcement training)
      • Provide food puzzles and/or toys that encourage expression of predatory behavior
      • Provide positive human-cat interaction (e.g., grooming, petting, playing)
      • Avoid using heavily perfumed or noxious smelling substances for cleaning, or in the home in general
      • Whenever possible, routines should be stable; e.g., feeding should happen at the same times each day

  • Nutritional therapy
    • Can be a component of a multimodal approach, but is unlikely to resolve the condition as a monotherapy
    • Acidifying diets are not recommended for cats with idiopathic cystitis
    • Feeding a moist diet (>70%) has been associated with a decreased risk of recurrence of clinical signs
    • In the absence of concurrent medical conditions, a multipurpose therapeutic urinary diet should be considered
    • For patients with concurrent urolithiasis, diet composition must be determined on a case by case basis
    • A change in the diet should not be attempted until the cat is well; transition to a new diet over 3 to 5 days
    • Weight management should be a therapeutic goal, as obesity contributes to disease risk and likelihood of recurrence

  • Feline synthetic facial pheromone therapy
    • Use of pheromones has been reported to reduce anxiety and may be of benefit to some cats with this disease; if used, should be combined with other therapies
    • One spray in affected area once daily
    • A room diffuser may be considered as well

Follow-up

General Points

  • Client education and communication will be critical for successful management
  • Owners should be instructed about how to interpret feline behaviors and recognize signs of stress

Diagnostic Follow-up

  • Will depend on any underlying diseases

Therapeutic Follow-up

  • Follow-up phone consultation should be conducted within 2 weeks of initial evaluation to assess response to therapy
  • Cats receiving fluoxetine may take up to 8 weeks to demonstrate a therapeutic response

Prognosis

  • Variable; client communication is critical for successful environmental management
  • In a Level 3 survey, 70% of affected cats recovered and experienced few recurrences or none at all Increased frequency of recurrence increases the likelihood of euthanasia or rehoming

Evidence

Guidelines and Consensus Statements

  • Taylor S, Boysen S, Buffington T, et al. 2025 iCatCare consensus guidelines on the diagnosis and management of lower urinary tract diseases in cats. J Feline Med Surg. 2025 Feb;27(2):1098612X241309176. Level B Article
  • Carney HC, Sadek TP, Curtis TM, et al. AAFP and ISFM Guidelines for Diagnosing and Solving House-Soiling Behavior in Cats. J Feline Med Surg. 2014 Jun 25;16(7):579-98. Level B (IND) Article
  • Ellis SL, Rodan I, Carney HC, et al. AAFP and ISFM feline environmental needs guidelines. J Feline Med Surg. 2013 Mar;15(3):219-30. Level B Article

Systematic Reviews/Meta-analyses

  • Frank D, Beauchamp G, Palestrini C. Systematic review of the use of pheromones for treatment of undesirable behavior in cats and dogs. J Am Vet Med Assoc. 2010 Jun 15;236(12):1308-16. Level B Abstract

Randomized, Controlled Trials (RCTs)

  • Panchaphanpong J, Asawakarn T, Pusoonthornthum R. Effects of oral administration of N-acetyl-d-glucosamine on plasma and urine concentrations of glycosaminoglycans in cats with idiopathic cystitis. Am J Vet Res. 2011 Jun;72(6):843-50. Level 2 Abstract
  • Kruger JM, Conway TS, Kaneene JB, et al. Randomized controlled trial of the efficacy of short-term amitriptyline administration for treatment of acute, nonobstructive, idiopathic lower urinary tract disease in cats. J Am Vet Med Assoc. 2003 Mar 15;222(6):749-58. Level 2 Abstract

Other Studies or Reviews

  • Defauw PA, Van de Maele I, Duchateau L, et al. Risk factors and clinical presentation of cats with feline idiopathic cystitis. J Feline Med Surg. 2011 Dec;13(12):967-75. Level 2 Abstract
  • Cameron ME, Casey RA, Bradshaw JW, et al. A study of environmental and behavioural factors that may be associated with feline idiopathic cystitis. J Small Anim Pract. 2004 Mar;45(3):144-7. Level 2 Abstract
  • Jones BR, Sanson RL, Morris RS. Elucidating the risk factors for feline lower urinary tract disease. N Z Vet J. 1997 Jun;45(3):100-8. Level 2 Abstract

  • Plumb’s Veterinary Drugs (online database), Tulsa, OK: Brief Media; 2025. Accessed April 9, 2025. Level 3
  • Buffington T, Delgado MM. Feline idiopathic/interstitial cystitis. In: Cote E, Ettinger SJ, Feldman EC, ed.’s. Ettinger’s Textbook of Veterinary Internal Medicine. 9th ed. Philadelphia: Elsevier; 2024:2171-8. Level 3
  • Krause LR, Li E, Lilly ML, et al. Survey of veterinarians in the USA to evaluate trends in the treatment approach for non-obstructive feline idiopathic cystitis. J Feline Med Surg. 2024 Aug;26(8):1098612X241260716. Level 3
  • He C, Fan K, Hao Z, et al. Prevalence, risk factors, pathophysiology, potential biomarkers and management of feline idiopathic cystitis: an update review. Front Vet Sci. 2022 Jun 21;9:900847. Level 3
  • Papich MG. Papich Handbook of Veterinary Drugs, 5th Edition. St Louis, MO: Elsevier; 2021. Level 3
  • Eggertsdóttir AV, Blankvandsbråten S, Gretarsson P, Retrospective interview-based long-term follow-up study of cats diagnosed with idiopathic cystitis in 2003-2009. J Feline Med Surg. 2021 Oct;23(10):945-51. Level 3
  • Amat M, Camps T, Manteca X. Stress in owned cats: behavioural changes and welfare implications. J Feline Med Surg. 2016 Aug;18(8):577-86. Level 3
  • Lund HS, Sævik BK, Finstad ØW, et al. Risk factors for idiopathic cystitis in Norwegian cats: a matched case-control study. J Feline Med Surg. 2016. Jun;18(6):483-91. Level 3
  • Forrester SD, Towell TL. Feline idiopathic cystitis. Vet Clin North Am Sm Anim Pract. 2015 Jul;45(4):783-806. Level 3
  • Shreyer TA, Buffington CAT. Mulitmodal environmental enrichment for domestic cats. . In: Bonagura JD, Twedt D, ed’s. Kirk’s Current Veterinary Therapy XV. Philadelphia: Elsevier Saunders;2014:909-14. Level 3
  • Buffington CAT. Idiopathic cystitis in domestic cats--beyond the lower urinary tract. J Vet Intern Med. 2011 Jul-Aug;25(4):784-96. Level 3
  • Elliott DA. Nutritional management of the lower urinary tract conditions. In: Ettinger SJ, Feldman EC, ed.’s. Textbook of Veterinary Internal Medicine. 7th ed. St. Louis: Saunders Elsevier; 2010:696-701. Level 3
  • Westropp JL, Buffington CAT. Lower urinary tract disorders in cats. In: Ettinger SJ, Feldman EC, ed.’s. Textbook of Veterinary Internal Medicine. 7th ed. St. Louis: Saunders Elsevier; 2010:2069-86. Level 3
  • Forrester SD, Roudebush P. Evidence-based management of feline lower urinary tract disease. Vet Clin North Am Small Anim Pract. 2007 May;37(3):533-58. Level 3 (IND)
  • Westropp JL, Kass PH, Buffington CA. Evaluation of the effects of stress in cats with idiopathic cystitis. Am J Vet Res. 2006 Apr;67(4):731-6. Level 3
  • Buffington CAT. External and internal influences on disease risk in cats. J Am Vet Med Assoc. 2002 Apr 1;220(7):994-1002. Level 3
  • Buffington CA, Chew DJ, Kendall MS, et al. Clinical evaluation of cats with nonobstructive urinary tract diseases. J Am Vet Med Assoc. 1997 Jan 1;210(1):46-50. Level 3

Additional Reading

  • Colombino E, Cavana P, Martello E, et al. A new diet supplement formulation containing cranberry extract for the treatment of feline idiopathic cystitis. Nat Prod Res. 2022 Jun;36(11):2884-7.
  • Naarden B, Corbee RJ. The effect of a therapeutic urinary stress diet on the short-term recurrence of feline idiopathic cystitis. Vet Med Sci. 2020 Feb;6(1):32-8.
  • Kruger JM, Lulich JP, MacLeay J, et al. Comparison of foods with differing nutritional profiles for long-term management of acute nonobstructive idiopathic cystitis in cats. 2015 Sep 1;247(5):508-17.
  • Buffington CA, Westropp JL, Chew DJ. From FUS to Pandora syndrome: where are we, how did we get here, and where to now? J Feline Med Surg. 2014 May;16(5):385-94.
  • Bradley AM, Lappin MR. Intravesical glycosaminoglycans for obstructive feline idiopathic cystitis: a pilot study. J Feline Med Surg. 2013;16(6):504-6.
  • Frank D, Beauchamp G, Palestrini C. Systematic review of the use of pheromones for treatment of undesirable behavior in cats and dogs. J Am Vet Med Assoc. 2010 Jun 15;236(12):1308-16.