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Cats with FLUTD usually present with signs of difficulty and pain when urinating, increased frequency of urination, blood in the urine, urination outside the litter tray and in inappropriate places, or even complete obstruction to urine outflow. It is now known that certain nerves within the bladder can be stimulated, either by the brain (in response to stress), or by local triggers within the bladder (such as inflammation, bladder stones, concentrated urine, infection etc).
Stress plays a very important role in triggering FIC and it has been shown that cats that are predisposed to getting FIC show exaggerated arousal and response to stress. Bladder stones (uroliths) can vary in their composition, with struvite and oxalate forms being most common in cats. Thick protein matrix may cause urethral obstruction without evidence of crystalluria (crystals in the urine). So far, no bacterial, fungal or viral organisms have been consistently shown to cause FLUTD.
The different causes of FLUTD may occur individually, or in various interacting combinations. Although, inflammation without crystalluria can result in obstruction with protein matrix, it more typically causes bloodstained urine and signs of pain when urinating. Most cases of non-obstructive FLUTD are self-limiting, usually resolving within five to 10 days. Unfortunately, few treatments for FLUTD have been investigated by well-controlled experimental studies. As more drugs are tried, the list of those that are either unhelpful, or even harmful, is growing.
The list of medications and interventions that have been considered for the treatment of FLUTD is far too extensive to be included in this article. Stress plays a key role in FIC; it has been identified as a 'flare factor' that can precipitate a recurrence of clinical signs.
Thankfully, a number of diets are now available that are specially designed to increase water turnover despite being dry diets; so those cats that will not eat wet food can now be treated more appropriately. Do not feed an acidified diet if the urine is acid and struvite uroliths are not a problem.
While controlled studies have not yet been performed, some cats do appear to derive benefit from using GAG supplementation. Observant owners may notice that some cats show mild signs before the onset of an episode of FIC. Where urethral spasm has been shown to be causing a problem, specific spasmolytic drugs may be beneficial. Tricyclic antidepressants (such as amitriptyline) have been used in some very severe or chronic cases of FLUTD. While some painkillers may reduce the severity of the pain, they are rarely sufficient to significantly reduce the clinical signs of FLUTD. Urethritis is most commonly caused by a bacterial or viral infection but there are also non-infectious causes of urethritis.  It is often classified as gonococcal or non-gonococcal urethritis. The same bacteria that cause bladder and kidney infection, can also infect the lining of the urethra. Irritation of the lining of the urethra may be caused by certain soaps and spermicidal creams. Conditions which cause an inflammatory response like arthritis and Steven-Johnson syndrome can also cause urethritis.
While the condition can be seen in cats of any age, it is most frequently seen in middle-aged, overweight cats, which take little exercise, use an indoor litter tray, have restricted access outside and eat a dry diet. However, while research over the last 30 years has failed to find a consistent cause, a recent hypothesis has suggested that FIC may result from alterations in the interaction between the nerve supply, the protective (glycosaminoglycan [GAG]) layer that lines the bladder, and the urine. Over the last few years, pet food companies have focused on designing diets that help to dissolve struvite stones. They are composed of varying combinations of a protein matrix (various proteins and cells from the bladder and blood) and crystalline material (most typically struvite). However, where crystalluria is also present, the crystals may become trapped within the matrix and add to the obstruction. However, it is still possible that an organism that is very difficult to grow could be involved.
For example, the formation of urethral plugs may result from concurrent, but not necessarily related, disorders, such as the simultaneous occurrence of urinary tract inflammation and crystalluria. While crystalluria is usually clinically silent, if persistent, it may predispose to the development of bladder stones, and these in turn can lead to urethral obstruction and bladder inflammation.
However, if the cat is not currently showing signs of FLUTD, repeating the investigation when the cat is showing signs may reveal more obvious disease. However, most affected cats have episodes of clinical signs, which recur with variable frequency. Most recommendations are therefore based on uncontrolled clinical observations and personal opinions. Of those treatments that have been critically assessed, corticosteroids and certain antibiotics have been shown to have no beneficial effect, except in those rare cases where bacterial infection is present and antibiotics are actually required.
This paper therefore describes the current most successful current approach to the management of FIC, which is aimed at addressing the factors that are believed to underlie the disease, including the nature of the nerve supply into the bladder, the content of the urine, and the protective GAG layer. Identified stressors include abrupt changes in diet, environment, weather, overcrowding, owner stress, or the addition to the household of new pets or people. Providing a safe, clean area in which the cat can urinate, reducing overcrowding or bullying, and reassuring the cat as much as possible may achieve this.
Previously, much interest has been placed on changing the acidity, magnesium and calcium content of the urine. It relies on the assumption that GAG supplements gain access to the bladder and attach to the defective bladder lining.

They have been found to be beneficial in the treatment of humans with interstitial cystitis, and in a number of cats with FIC; however, they should always be used with caution. The best results are gained by instigating a number of changes, including reducing stress, feeding a wet diet, replacing GAGs and, if necessary, relieving urethral spasm or giving tricyclic anti-depressants.
Treatment of primary bladder neck obstruction in women with transurethral resection of the bladder neck.
The standardization of terminology of lower urinary tract function: Report from the standardization Sub-committee of the International Continence Society. Refining diagnosis of anatomic female bladder outlet obstruction: Comparison of pressure flow study parameters in clinically obstructed women with those of normal controls.
Bladder outlet obstruction index, bladder contractility index and bladder voiding efficiency: Three simple indices to define bladder voiding function.
Abnormal electromyographic activity (decelerating burst and complex repetitive discharges) in the striated muscle of the urethral sphincter in 5 women with persisting urinary retention.
Factors predictive of urinary retention after a tension -free vaginal tape procedure for female stress urinary incontinence. While there are many conditions that can result in signs of FLUTD, the vast majority of cases are idiopathic (i.e. Where inflammation is triggered by the nervous system, it is termed neurogenic inflammation.
It has been suggested that defects in this protective layer may result in increased bladder wall permeability, allowing noxious substances within the urine to cause inflammation. Unfortunately, while this has resulted in a decline in the incidence of struvite stones, there has been an increase in oxalate stones. The protein matrix is believed to 'leak' from the bladder wall as a result of inflammation. It is therefore the protein matrix that is of primary importance, rather than the presence of crystals per se.
While obstruction most typically results from the formation of urethral plugs, it may also be caused by the passage of small bladder stones, or from pain-induced urethral spasms.
It often includes taking blood samples to rule out systemic disease (for example, generalised disease such as kidney failure or diabetes), followed by collection of a urine sample. It is interesting to note that many cats which are believed to have a purely behavioural problem have a history of having had blood in their urine at some time in their past. Also, since FLUTD is usually self-limiting, many treatments may appear to be effective when they actually have no positive effect.
Stress associated with urination can be particularly significant, such as an unsuitable position or content of the litter tray, competition for the litter tray, aggressive behaviour by other cats while the cat is trying to use the litter tray or when urinating outside etc. Use of Feliway (a synthetic feline pheromone) as a plug-in 'air freshener' can also help reduce anxiety.
However, it is now believed that the single most important factor is the rate of water turnover.
GAGs may also be of benefit because of analgesic ('pain killing') and anti-inflammatory properties. Supplementation can begin with a higher dose at the time of initial presentation and then be reduced to a maintenance level.
Signs may include increased grooming of the hind-end, or inter-cat aggression initiated by the FIC sufferer.
They act as anti-depressants, and also have direct effects on the bladder where they can increase bladder capacity, and have anti-inflammatory and 'pain killing' properties. In the majority of cases when tailored to the individual cat, this will reduce or prevent further clinical signs. Examples of viruses which cause urethritis are human papilloma virus, herpes simplex virus and Cytomegalovirus. Besides, the management of bladder outlet obstruction in females is perhaps as complex as its diagnosis.The etiological factors for outlet obstruction are more diverse in females than in males. Delayed treatment of bladder outlet obstruction after sling surgery: Association with irreversible bladder dysfunction.
FLUTD occurs equally in male and female cats; however, neutered cats are more susceptible, and the risk of urinary tract obstruction is greatest in males. It has been shown that some cats with FIC have reduced levels of GAG within this protective layer. The cause of this inflammation may be neurogenic, idiopathic, or secondary to infection, cancer or bladder stones. The urine will be assessed for its concentration (specific gravity) and for the presence of crystals, protein, red and white blood cells, and bacteria (infection).
In severe cases, it can be helpful to ask for your cat to be referred to an animal behaviour counsellor.
The aim is therefore to increase water turnover and dilute any noxious components within the urine.
However, while these compounds have shown some positive responses in humans with interstitial cystitis, controlled studies in cats are currently lacking. Secondly, the Urodynamic criteria, so well researched for the diagnosis of Bladder outflow obstruction in the male, are not applicable to the female bladder outlet due to a different pressure flow relation. While it is not known whether or not the defect is actually caused by the inflammation, its presence is believed to exacerbate it. From human studies, it appears that there are differences in the relative efficiency of different GAGs to produce positive effects, and the same is likely to be true in cats. The instigation of increased reassurance, feeding wet food, use of Feliway etc at this time may help to reduce the severity and duration of the episode, or prevent it from occurring altogether.
Lastly the dynamics of voiding in females also is more complex than in the males, presumably due to mobility of the bladder neck and proximal urethra as well as due to the action of pelvic floor movements and fasciae over the urethra.

Older cats, particularly those with renal failure, have an increased risk of bacterial infection. This approach can also be used if a stressful episode is anticipated, such as a visit to the vet, a stay in a cattery, or builders in the home.
Besides, presence of pelvic organ prolapse adds a different dimension to the dynamics of voiding in females. The innermost intrinsic smooth muscle sleeve has a longitudinal orientation, and is noradrenergically innervated. Its role in the continence mechanism remains debatable to date.The striated urethral sphincter or the so called Intrinsic Rhabdosphincter is a definite mass of striated muscles which have a circular orientation. This is thickest in the central portion of the urethra and its thickness tapers of towards the bladder neck and towards the external urethral meatus.Indeed this muscle is made of "slow twitch" striated fibers, which are capable of prolonged contraction. The reason this muscle is thickest anterierly is because it is oriented in a number of bundles and some of its bundles wrap the urethra from the sides and then become incorporated into the anterior and lateral vaginal walls.Although it's an intrinsic urethral muscle, it is supplied entirely by the pudendal nerve. The third component is of course the muscle mass of the pelvic floor which essentially surrounds the external rhabdosphincter but is made mainly of "fast twitch" fibers like other skeletal muscles.
But since it presents in such a peculiar way that unless precisely diagnosed it can be confused with infravesical obstruction leading to retention. Typically it affects young women from 13 to 30 years, who present with insidiously developing painless urinary retention, which may harbor over 1000 mls at a time. However hallmark of diagnosis is strictly neurophysiologic abnormalities of the external urethral sphincter. This muscle must be precisely accessed by concentric needle electrode and its electrophysiological response should be analyzed. Audio signals arising from these activities typically produce the noise of "whales in the ocean". Other significant findings of Fowler's syndrome are abnormally high static urethral profile pressure and increased volume of the intrinsic rhabdosphincter on Ultrasound or MRI. This syndrome is named after Clare Fowler, who described electrophysiological responses of the urethral rhabdosphincter in young women in urinary retention of unexplained nature. These young girls fail to relax the pelvic floor, but instead contract the entire pelvic floor musculature in an intermittent manner.
This results in interrupted flow, straining to void, very high intravesical pressures and a whole cascade of phenomena that may follow an organic obstruction. Indeed, the obstruction is entirely functional and can be demonstrated well on multichannel Urodynamics with or without video [Figure 5]. It is postulated that the female urethra may be susceptible to atrophic senile urethritis compared to senile vaginitis as a result of oestrogen deprivation.
However there is no conclusive evidence that the Hormone Replacement Therapy (HRT) either systemic or topical has any significant role in the management of Bladder outlet Obstruction in females. Sheer mechanical dilatation of the urethra can offer relief of a stricture in the short term but has a high recurrence rate. Empirical urethral dilatation is a popular mode of treatment but has no evidence of support in the literature.Urethral obstruction arising from iatrogenic reasons such as surgery for stress urinary incontinence deserves a special mention.
Colposuspension procedures such as Marshall Marshetti and Krantz operation had a higher incidence of producing bladder outlet obstruction, presumably due to the element of fixity of the urethra to the back of the Symphysis Pubis. Incidence of obstruction occurring after Burch procedure is comparatively low, since the Urethra remains significantly mobile.
Current day use of tension free mid urethral slings, too, has a low but significant incidence of bladder outlet obstruction. Since there is no way of knowing the "Optimum" tension (or laxity) in the sling at the time of surgery, some incidence of overcorrection is likely to occur. The patient usually presents with increasing difficulty in passing urine and sometimes with complete urinary retention. Division of the sling in midline below the urethra usually settles the matter and curiously without affecting the continence. Division of the sling must be considered within three weeks of initial surgery in order to avoid permanent features of urethral distortion, which may arise from progressive fibroblastic reaction around the polypropylene mesh with time.
Alternative modalities have mostly been experimental and have not established their place fully in practice. Patients, who are refractory to these modalities, may resort to continent diversion with a Mitrofanoff like stoma or a simple indwelling Suprapubic catheter.The treatment of dysfunctional voiding is reversal and retraining of the toilet habits. Refractory cases may be offered ISC and some cases urinary diversion, depending on the severity and extent of the problem.
Sacral neurostimulation (Neuromodulation) has shown a promise in the management of urinary retention in women, but it appears to be a more suitable proposition in idiopathic urinary retention. Its efficacy in the management of Dysfunctional voiding and Fowler's syndrome remains to be proven. Good clinical history, thorough physical examination and complete urodynamic evaluation are the mainstay in the diagnosis.Medical therapy has a limited value in treating this condition.
Endoscopic division of stricture has a promising cure rate, but not without an incidence of recurrence.Surgical options are possible but pose a risk of damage to delicate continence mechanisms in females.
Intermittent self catheterisation may have to be instituted at least in the short term.Dysfunctional voiding and Fowler's syndrome pose special problems.

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