Vol. 21, No.

6 June 1999 20TH ANNIVERSARY

CE Refereed Peer Review

FOCAL POINT
★ Consistently effective treatment
of feline idiopathic lower urinary
tract disease (iLUTD) remains
undetermined.
KEY FACTS
■ Randomized, double-blind,
placebo-controlled clinical trials
are needed to prove the efficacy
and safety of therapies used for
symptomatic treatment of
iLUTDs, p. 497.
■ Antibiotics were reportedly of no
benefit in reducing the severity or
duration of clinical signs in cats
Feline Idiopathic
Lower Urinary Tract
Disease. Part IV.
Therapeutic Options*
Michigan State University University of Minnesota
Tina S. Kalkstein, DVM, MA Carl A. Osborne, DVM, PhD
John M. Kruger, DVM, PhD
ABSTRACT: Many therapeutic agents have been advocated for use in cats with idiopathic low-
er urinary tract disease (iLUTD); however, few have been subject to controlled clinical trials
proving their efficacy and safety. The problem is compounded by the fact that clinical signs
associated with iLUTD are frequently of short duration and self-limiting. Consequently, any
form of therapy may appear beneficial as long as it is not harmful. This article explores various
options for managing clinical signs and potential sequelae associated with iLUTD.

E
ffective treatment of male and female cats with idiopathic lower urinary
with iLUTD.
tract disease (iLUTD) remains an enigma. Because clinical signs associat-
ed with this form of the disease are frequently of short duration and self-
■ Results of one controlled
limiting, any form of therapy might appear to be beneficial if it is not harmful.
clinical trial indicated that
The self-limiting nature of clinical signs in many cats with iLUTD underscores
antiinflammatory doses of
the need for controlled, prospective, double-blind clinical studies to prove the
glucocorticoids (prednisolone)
efficacy of various forms of therapy. Therapies discussed in this article, among
were of no benefit in reducing the
others, are summarized in Table I. Selection of therapy for cats with nonobstruc-
severity or duration of clinical
tive iLUTD should be based on (1) thorough diagnostic evaluation to exclude
signs in cats with iLUTD.
other causes of lower urinary tract disease (LUTD), (2) client education empha-
sizing the lack of definitive studies demonstrating efficacy of proposed therapies,
■ Clients should be sufficiently
(3) strategies to minimize risk factors associated with urethral obstruction, (4)
educated about the biologic
strategies to prevent iatrogenically induced disease, and (5) consideration of
behavior of iLUTD and lack of
pharmacologic agents for symptomatic management of persistent or recurrent
credible evidence about treatment
clinical signs.
safety and efficacy to make
The treatment methods for nonobstructive feline iLUTD discussed in this ar-
informed decisions about
ticle have not all been substantiated by experimental and/or clinical investiga-
therapeutic options.
tions and should therefore be considered with appropriate caution. This is the
fourth article in a four-part presentation reviewing current concepts regarding
*Parts I, II, and III of this four-part presentation appeared in the January (Vol. 21, No.
1), February (Vol. 21, No. 2), and May (Vol. 21, No. 5) 1999 issues, respectively, of
Compendium.
Small Animal/Exotics 20TH ANNIVERSARY Compendium June 1999

TABLE I
Therapy of Undetermineda Efficacy for Managing Nonobstructive Idiopathic Lower Urinary Tract Disease
Therapy Properties Route Predicted Efficacy b
Acepromazine Antispasmodic PO, IV, IM, SC Unlikely
Amitriptyline Anticholinergic, PO Probable in some cases
antiinflammatory, analgesic
Ammonium chloride Acidifier PO Effective for MAP
Butorphanol Analgesic PO, IV, IM, SC Unlikely
Copper coils Unknown Intravesicular Contraindicated
Glucosamine, chondroitin Glycosaminoglycan PO Probable in some cases
sulfate, and magnesium ascorbate
Dantrolene Antispasmodic PO, IV Unlikely
Debridement Unknown Intravesicular Contraindicated
Diazepam Antispasmodic PO, IV Unlikely
Diet
Acidifying Acidifier PO Effective for MAP
Low magnesium Reduces urine magnesium PO Effective for MAP
Moist Reduces USG PO Possible
Dimethyl sulfoxide Antiinflammatory, Intravesicular Unlikely
analgesic
Feline calicivirus vaccine Immunogenic SC Unlikely
Furosemide Diuretic PO, IV, IM, SC Unlikely
Hydrodistention Analgesic Intravesicular Unlikely
Hydroxyzine Antihistamine, anticholinergic, PO Unlikely
antispasmodic, analgesic,
anxiolytic, sedative
Hyaluronidase Enzymatic SC Unlikely
Interferon α-2a Immunomodulator, PO, intravesicular Possible
antifibrotic, antiviral
Lugol’s solution Cautery Intravesicular Contraindicated
Megesterol acetate Hormone PO Unlikely
Methenamine Antiseptic PO Unlikely
Methionine Acidifier PO Effective for MAP
Methylene blue Antiseptic PO Contraindicated
Oxybutynin Antispasmodic PO May reduce pollakiuria
Pentosan polysulfate Glycosaminoglycan PO, intravesicular Probable in some cases
Phenazopyridine Analgesic PO Contraindicated
Phenol Cautery Intravesicular Contraindicated
Phenoxybenzamine Antispasmodic PO Unlikely
Piroxicam Antiinflammatory PO Unknown
Compendium June 1999 20TH ANNIVERSARY Small Animal/Exotics

TABLE I (continued)
Therapy Properties Route Predicted Efficacy b
Potassium chloride Reduces USG PO Unlikely
Prazosin Antispasmodic PO Unlikely
Propantheline Antispasmodic PO May reduce pollakiuria
Prostaglandin E1 Cytoprotective Intravesicular Unlikely
Sodium chloride Reduces USG PO Unlikely
Testosterone Hormone IM Unlikely
0.085% Tetrasodium Chelator PO Very unlikely
ethylenediamine tetraacetic
acid and 0.06% sodium
tripolyphosphate
Vitamin A Vitamin PO Unlikely
a No controlled studies comparing the degree of reduction in severity or duration of clinical signs in affected cats treated with the listed

therapeutic agents compared with placebo-treated or untreated controls have been conducted to evaluate the efficacy of these treatments.
b Our prediction of efficacy against nonobstructive idiopathic lower urinary tract disease if treatment was evaluated by a controlled

clinical trial.
IM = intramuscular; IV = intravenous; MAP = magnesium ammonium phosphate; PO = oral; SC = subcutaneous; USG = urine specif-
ic gravity.

feline iLUTD. Parts I, II, and III reviewed the clinical
features, potential causes, and diagnostic evaluation, re-
spectively, of the condition.
ANTIBACTERIAL AGENTS
Antibiotics have commonly been prescribed to em-
pirically treat iLUTD. However, bacterial urinary tract
infections (UTIs) are rare in young to middle-aged cats
with signs of LUTD.1–5 In one pilot study, antibiotic
therapy was neither beneficial nor harmful in abacteri-
uric cats with LUTD.6 If antibiotics are not harmful,
one may question why concern is warranted; however,
indiscriminate use of antibiotics is believed to play an
important role in the development of bacterial resis-
tance.
URINARY TRACT ANTISEPTICS
Urinary tract antiseptics are sometimes used as ad-
junctive agents in the treatment, control, and preven-
tion of bacterial UTIs in humans. Although their use is
frequently acknowledged in the treatment of bacterial
UTIs in dogs and occasionally mentioned for the treat-
ment of feline LUTDs, studies substantiating the effec-
tiveness of urinary tract antiseptics in these species have
not been reported.
In an acidic environment (pH below 6.0), methen-
amine hydrolyzes to form formaldehyde, an essential
component of its antimicrobial activity. Because acidic
urine is needed to form formaldehyde, methenamine is
usually given in combination with acidifiers, such as
mandelic acid (methenamine mandelate) or hippuric
acid (methenamine hippurate). Methenamine must re-
main in the urinary tract for a sufficient period to allow
the generation of effective concentrations of formalde-
hyde. Once generated in sufficient concentration,
formaldehyde is capable of killing bacteria, mycoplas-
ma, and viruses in urine at any pH. Methenamine does
not attain high intracellular concentrations and there-
fore would not be expected to eradicate intracellular
viruses. Because the efficacy of methenamine has not
been evaluated by controlled studies, we cannot recom-
mend its use.
Methylene blue (tetramethylthionine chloride) is a
weak antiseptic agent that was once commonly used in
combination with products designed to treat symptoms
of lower urinary tract disorders, especially uroliths. Its
effectiveness, however, is highly questionable. In addi-
tion, because methylene blue has the potential to cause
Heinz bodies and severe anemia, medications contain-
ing the agent are contraindicated in cats.7
URINARY TRACT ANALGESICS
Phenazopyridine, an azo dye commonly used as a
urinary tract analgesic in humans, has recently become
available as an over-the-counter preparation. The use of
phenazopyridine, alone or in combination with sulfa

URINARY TRACT INFECTION ■ METHENAMINE ■ METHYLENE BLUE

Small Animal/Exotics 20TH ANNIVERSARY
drugs, is contraindicated in cats because they are very
susceptible to dose-related methemoglobinemia and ir-
reversible oxidative changes in hemoglobin that result
in the formation of Heinz bodies and anemia.8
The use of analgesics other than phenazopyridine for
the management of lower urinary tract pain has been in-
frequently reported in humans with interstitial cystitis
(IC).9 It has been hypothesized that the analgesic proper-
ties of amitriptyline are at least partly responsible for re-
lieving bladder pain when used to treat IC in humans.10
Butorphanol has been recommended for symptomatic
management of clinical signs associated with feline
iLUTD.11 However, controlled studies evaluating the ef-
ficacy of analgesics in reducing the severity or duration
of clinical signs of iLUTD have not been reported.
URINE ACIDIFIERS
Urine acidifiers have been commonly used to treat
cats with nonobstructive and obstructive LUTDs.
Their use was apparently based on the assumption that
most, if not all, cases of feline hematuria, dysuria, and
urethral obstruction resulted from struvite crystalluria
and the formation of struvite uroliths and struvite-con-
taining urethral plugs.12–18 Although little doubt exists
that struvite uroliths and struvite-containing urethral
plugs are important causes of feline LUTD, crystalluria
per se and struvite crystalluria in particular are not sig-
nificant factors in the etiopathogenesis of all nonob-
structive feline iLUTDs. In one prospective study of 62
cats with nonobstructive iLUTD, the detection of crys-
talluria in affected cats was not different from that of
unaffected controls.19 In a more recent study, crystal-
luria was uncommonly observed in cats with nonob-
structive iLUTD.20
Acidification of urine is valuable in helping to dis-
solve or prevent sterile struvite uroliths or struvite-con-
taining urethral plugs (see Management and Prevention
of Sequelae section) but is unlikely to be of value in
treating nonobstructive iLUTD. Many commercially
manufactured diets are designed to acidify urine.
Overacidification with acidifiers resulting in metabolic
acidosis is most likely to occur in cats with concomi-
tant renal failure, cats consuming acidifying diets, and
immature cats.21 Long-term overacidification may con-
tribute to hypokalemia, renal dysfunction, demineral-
ization of bones, and calcium oxalate urolithiasis.22–25 In
addition, high doses of methionine may result in Heinz-
body anemia and methemoglobinemia.26
SKELETAL AND SMOOTH MUSCLE
ANTISPASMODICS
Pollakiuria commonly occurs in cats with LUTDs.
Inappropriate voiding of small volumes of urine that
CRYSTALLURIA ■ URINE ACIDIFICATION ■ PROPANTHELINE
Compendium June 1999
are contained in undistended urinary bladders may be
associated with sensations of pain, bladder fullness,
and urgency. Pollakiuria is presumably the result of in-
flammation-induced stimulation of urinary bladder
sacral sensory afferent nerves. Sensations of pain, full-
ness, and urgency induce a premature micturition re-
flex and subsequent inappropriate or involuntary void-
ing of small quantities of urine. Because cholinergic
parasympathetic efferents are normally responsible for
detrusor contraction, anticholinergic drugs may logi-
cally be considered a form of symptomatic treatment
of pollakiuria and urge incontinence. 27 However,
dosage and efficacy of these agents in cats with nonob-
structive iLUTD have not been established by con-
trolled clinical trials.
The anticholinergic agent propantheline minimizes
the force and frequency of uncontrolled detrusor con-
tractions28 and has been recommended for the manage-
ment of pollakiuria associated with iLUTD.6,29 In a
controlled clinical study of the efficacy of one oral dose
of propantheline (7.5 mg) for treating naturally occur-
ring hematuria and dysuria in nonobstructed male and
female cats, no difference in duration of clinical signs
was observed between treated and untreated cats. 6
Treatment of longer duration would possibly have re-
duced the severity and duration of dysuria.
Propantheline has a rapid onset of action. Care must
therefore be taken to prevent urinary retention as a re-
sult of excessive doses. Other potential adverse effects
include tachycardia, vomiting, and constipation. An
empiric dose of 0.25 to 0.5 mg/kg orally every 12 to 24
hours has been suggested. Further studies are needed to
establish appropriate doses and substantiate a beneficial
symptomatic effect of propantheline in cats with severe
pollakiuria.
Other smooth (e.g., oxybutynin, phenoxybenzamine,
acepromazine, prazosin) and skeletal (e.g., dantrolene,
diazepam) muscle antispasmodics have been recom-
mended for the symptomatic management of ure-
throspasm associated with LUTDs.29–35 Although some
of these pharmacologic agents produced significant de-
creases in intraurethral pressure in normal male cats
and cats with naturally occurring urethral obstruc-
tion,29,31–34 the role of urethral smooth or skeletal mus-
cle spasm in producing clinical signs associated with fe-
line iLUTD has not been determined. In a pilot study
of six male cats with urethral obstruction due to un-
specified causes, intraurethral pressures before adminis-
tration of antispasmodics were not significantly differ-
ent from those of normal, nonobstructed male cats.33
Similar studies in cats with idiopathic forms of nonob-
structive LUTD have not been performed. On the basis
of available data, we do not routinely recommend
Compendium June 1999 20TH ANNIVERSARY
smooth or skeletal muscle antispasmodics to treat cats
with iLUTD.
ANTIINFLAMMATORY AGENTS
Mucosal ulceration and submucosal edema, hemor-
rhage, fibrosis, and mononuclear inflammatory cell in-
filtration are common light microscopic features ob-
served in the urinary bladders of cats with iLUTD.
These abnormalities are consistent with inflammation;
however, the specific causes of inflammation in many
cats with iLUTD are unknown. The unavailability of
specific therapy for cats with iLUTD has resulted in
widespread use of antiinflammatory agents in an at-
tempt to reduce the severity of inflammation-associated
clinical signs. However, there have been few controlled
clinical trials to study the short- and long-term efficacy
of antiinflammatory agents in the symptomatic treat-
ment of dysuria and hematuria in cats. In addition, re-
call that hematuria and dysuria in cats with iLUTD are
often self-limiting.
Glucocorticoids
By virtue of their potent antiinflammatory proper-
ties, glucocorticoids are a logical therapeutic choice to
minimize dysuria and hematuria in cats with iLUTD.
However, results of a pilot double-blind, placebo-con-
trolled study of untreated male and female cats with
iLUTD indicated that antiinflammatory doses of pred-
nisolone (1 mg/kg orally every 12 hours for 10 days)
were of no benefit in reducing the severity or duration
of clinical signs in affected cats.36 Clinical signs subsid-
ed within 1 to 2 days in cats treated with prednisolone
(n = 6) and in those treated with placebo (n = 6); uri-
nalysis abnormalities of hematuria and pyuria subsided
in approximately 2 to 5 days in both groups. Because of
the inconsistency of favorable clinical responses and po-
tential adverse effects associated with glucocorticoids,
we suggest that they not be used to treat iLUTD.
Dimethyl Sulfoxide
Dimethyl sulfoxide (DMSO) is an analgesic and an-
tiinflammatory agent with weak antibacterial, antifun-
gal, and antiviral activity.37 It is apparently effective in
treating some genitourinary disorders in humans, in-
cluding IC, radiation cystitis, chronic prostatitis, and
female chronic trigonitis. 38 Results of uncontrolled
studies suggest that retrograde infusion of 50% solu-
tions of pyrogen-free DMSO into the bladder lumina
of humans with IC minimized associated clinical signs
in 50% to 90% of patients.39,40
Dimethyl sulfoxide has been used to treat feline
LUTD, presumably on the basis of its reported efficacy
in humans with IC. Dosages and frequency of adminis-
PREDNISOLONE ■ UROTHELIAL GAGs ■ PENTOSAN POLYSULFATE SODIUM
Small Animal/Exotics
tration of DMSO have been entirely empiric. Intraves-
icular instillation of 10 to 20 ml of 10% DMSO was
associated with amelioration of clinical signs in three
cats with chronic LUTD, although a causative relation-
ship was not established.29 Appropriately controlled
clinical trials designed to evaluate the effectiveness of
local instillation of DMSO into the urinary bladder of
cats with idiopathic disease apparently have not been
reported. In one controlled study of cats with induced
chemical cystitis, intravesicular administration of 45%
DMSO for 3 days was of no detectable benefit in mini-
mizing bacterial infection or inflammation.6 Adverse ef-
fects of intravesicular DMSO administration in normal
cats and cats with iLUTD have apparently not been
evaluated. Pending further studies, we do not recom-
mend DMSO to treat iLUTD.
Piroxicam
Piroxicam, a nonsteroidal antiinflammatory drug,
may be a potential therapy to reduce dysuria and pol-
lakiuria in cats with iLUTD. The empiric dosage is 0.3
mg/kg orally every 24 hours. Pending double-blind,
controlled clinical trials, it is not possible to make rec-
ommendations about the safety and efficacy of piroxi-
cam for treating cats with iLUTD.
GLYCOSAMINOGLYCANS
Transitional epithelium of the urinary bladder is cov-
ered by a thin coating of hydrated extracellular macro-
molecules called glycosaminoglycans (GAGs). Major
classes of biologically important GAGs include hy-
aluronic acid, heparan sulfate, heparin, chondroitin 4-
sulfate, chondroitin 6-sulfate, dermatan sulfate, and
keratan sulfate.41 Urothelial GAGs minimize adherence
of microorganisms and crystals to the bladder urotheli-
um and also limit movement of urine proteins and oth-
er ionic and nonionic solutes from the bladder lumen
into surrounding tissue.42 Quantitative or qualitative
defects in surface GAGs and subsequent increased
urothelial permeability have been hypothesized to be
causative factors in the pathogenesis of feline iLUTD
and human IC.42,43
Oral or intravesicular administration of GAGs is
commonly used to manage IC in humans. Pentosan
polysulfate sodium is a semisynthetic, low-molecular-
weight heparin analogue that reinforces urothelial
GAGs and reduces transitional cell injury. 44 Symp-
tomatic remission was observed in 28% to 40% of hu-
man patients with IC treated with oral or intravesicular
pentosan polysulfate sodium compared with 13% to
20% of patients treated with placebo.45–48 Prolonged
prothrombin time, epistaxis, gingival bleeding, alope-
cia, abdominal pain, diarrhea, and nausea have been
Compendium June 1999 20TH ANNIVERSARY
Answering Owner Questions
What is idiopathic lower urinary tract disease (iLUTD)?
■ Idiopathic lower urinary tract disease is a common
disorder of the urinary bladder and urethra of cats
that is characterized by nonspecific signs of bloody
urine (hematuria), difficult and painful urination
(dysuria), frequent urination (pollakiuria), and
urinating outside of the litter box (periuria).
What causes iLUTD?
■ Despite extensive study, the specific cause or
causes are unknown. However, bacteria and
crystals do not appear to be causative agents
of the disease.
How is iLUTD diagnosed?
■ Not all cats with hematuria, dysuria, and periuria
have idiopathic disease.
■ There is no one specific diagnostic test or
procedure that definitively establishes a
diagnosis of idiopathic disease.
■ Idiopathic lower urinary tract disease is an
exclusionary diagnosis; other causes of hematuria,
dysuria, and periuria must be excluded by
urinalysis, urine culture, and examination of the
urinary bladder and urethra by radiographic
studies or cystoscopy.
uncommonly observed in humans treated with pen-
tosan polysulfate sodium.49 Despite encouraging studies
in humans, the safety and efficacy of pentosan polysul-
fate sodium or other GAG preparations for treating fe-
line iLUTD have not been evaluated by controlled clin-
ical trials. Pending further safety and efficacy studies,
we urge caution in the use of GAGs to treat feline
iLUTD.
AMITRIPTYLINE
Amitriptyline has been advocated for symptomatic
therapy of feline iLUTD.11,50 Amitriptyline is a tricyclic
antidepressant and anxiolytic drug with anticholinergic,
antihistaminic, anti–α-adrenergic, antiinflammatory,
and analgesic properties. Amitriptyline is used exten-
sively for treatment of IC in humans. Despite ami-
triptyline’s popularity, its exact mechanism of action and
therapeutic value in managing patients with IC are un-
known. In an uncontrolled study of 28 human patients
DIAGNOSIS ■ PROGNOSIS ■ SYMPTOMATIC THERAPY
Small Animal/Exotics
Is effective specific treatment available?
■ Because the exact cause is unknown, specific
treatment for iLUTD is unavailable.
Is effective symptomatic treatment available?
■ Consistently effective treatments for the
symptomatic management of cats with iLUTD are
currently unavailable. However, very few well-
designed and controlled studies evaluating the
value of various therapies have been conducted.
What is the prognosis?
■ In general, the prognosis for cats with iLUTD is
good. In many untreated male and female cats,
clinical signs of hematuria, dysuria, pollakiuria,
and periuria are frequently self-limiting in
approximately 1 week. Signs may recur after
variable periods of time and again subside without
therapy. Recurrent episodes of iLUTD tend to
decrease in frequency and severity over time.75
■ Clinical signs may be frequently recurrent or
persist for weeks to months in a small percentage
of cats with iLUTD.
■ Male cats with iLUTD are at increased risk for
urethral obstruction because of the formation of
urethral plugs.
with refractory IC, remission of clinical signs occurred
in 18 (64%) patients, whereas 5 (18%) developed un-
acceptable side effects. No improvement occurred in 5
(18%) patients.51
Anecdotal reports and limited data have been inter-
preted to suggest that treatment of chronic iLUTD was
associated with amelioration of clinical signs.52 Conse-
quently, amitriptyline has gained popularity as an agent
for symptomatic therapy of feline iLUTD.50 As is the
case in humans, however, appropriately controlled clin-
ical studies designed to evaluate the effectiveness of
amitriptyline in cats with idiopathic forms of LUTD
have not been reported.
Dose, frequency, and duration of amitriptyline ther-
apy have been empiric. A dosage of 2.5 to 12.5 mg/cat
orally every 24 hours (given at night) has been suggest-
ed; the dosage may be adjusted to produce a slight
calming effect on the cat.43 Adverse reactions reported
in humans, who were treated with antidepressant doses
Small Animal/Exotics 20TH ANNIVERSARY
of amitriptyline include urinary retention, dry mucous
membranes, blurred vision, hypotension, tachycardia,
arrhythmias, sedation, weakness, lethargy, thrombocy-
topenia, agranulocytosis, elevations in liver enzyme ac-
tivities, and hypersensitivity reactions. 53 Sedation,
weight gain, unkempt haircoat, urine retention, neu-
tropenia, and thrombocytopenia54,a have been observed
in cats treated with amitriptyline. Pending further stud-
ies of the safety and efficacy of amitriptyline in cats, we
urge caution with its use.
ANTIHISTAMINES AND MAST-CELL INHIBITORS
Hydroxyzine is a heterocyclic piperazine H1-receptor
antagonist drug with antihistaminic, anticholinergic,
antispasmodic, analgesic, anxiolytic, and sedative prop-
erties. It also appears to inhibit mast-cell secretion and
neuropeptide-induced urinary bladder mast-cell activa-
tion.55–57 Results of preliminary uncontrolled studies in-
dicate that substantial improvement in symptoms oc-
curred in 40% to 55% of humans with IC treated with
hydroxyzine.58 Anecdotal observations also indicate that
some cats with chronic forms of iLUTD improved after
hydroxyzine administration.59 However, the safety and
efficacy of hydroxyzine for managing cats with iLUTD
has not been investigated. Sedation, weakness, hy-
potension, urine retention, hyperexcitability, tremors,
and seizures have been associated with hydroxyzine ad-
ministration in other species.55,60,61
UROHYDRODISTENTION
Controlled distention of the urinary bladder under
anesthesia (i.e., therapeutic urohydrodistention) is of
recognized value in alleviating signs of IC in humans.62
Approximately 30% of human IC patients experience
substantial but temporary relief of symptoms after uro-
hydrodistention.38,40 Although the exact mechanism of
action is unknown, urohydrodistention may induce (1)
increased urothelial GAG production, (2) depletion of
bladder sensory nerve neuropeptides, and/or (3) me-
chanic or ischemic degeneration of sensory nerve end-
ings within the bladder wall.38,40
Controlled distention of the urinary bladder during
cystoscopy reportedly has been associated with a reduc-
tion in the severity of clinical signs in some cats with
iLUTD. 63 As with nearly all forms of symptomatic
therapy, however, the efficacy of urohydrodistention
has not been evaluated by appropriately controlled clin-
ical trials. Establishing a diagnosis of iLUTD currently
requires retrograde contrast radiography and/or cys-
toscopy (both of which distend the urinary bladder).
Until other, more specific markers of iLUTD are iden-
a Personal communication: Murphy C, Broomfield, CO,
1997.
HYDROXYZINE ■ CYSTOTOMY ■ MACROSCOPIC DIVERTICULA
Compendium June 1999
tified, it will be difficult to differentiate the beneficial
effects of bladder distention for diagnostic purposes
versus those induced by other forms of therapy.
UROTHELIAL DEBRIDEMENT
Several decades ago, cystotomy to lavage and debride
the bladder mucosa was a popular method of treating
cats with cystitis, urethritis, and/or urethral obstruc-
tion. Although this procedure is still occasionally used,
efficacy has not been proven by controlled clinical or
experimental studies. Furthermore, reports of clinical
experiences suggest that the technique is of little bene-
fit.64 Current knowledge and understanding about the
behavior of LUTDs suggest that bladder mucosal de-
bridement may actually increase, rather than decrease,
morbidity associated with the disorder.64 In light of cur-
rent knowledge, we view this procedure as unethical.
STRESS REDUCTION
Stress has been implicated in precipitating or exacer-
bating clinical signs associated with iLUTD. 43 Al-
though it is unlikely that stress is a primary cause of
iLUTD, cat owners can attempt to reduce environmen-
tal stress by minimizing changes in the home, main-
taining a constant diet, and providing toys and hiding
places.43
OTHER AGENTS
A variety of other agents have been advocated by var-
ious authors to treat and prevent feline LUTDs, but
none have been evaluated by appropriate selection of
patients for study or controlled clinical trials. Recom-
mendations for testosterone, castor oil, garlic, megestrol
acetate, feline calicivirus/feline herpesvirus type 1 vac-
cines, Lugol’s solution, tetrasodium ethylenediamine
tetraacetic acid and sodium tripolyphosphate, vitamin
A, hyaluronidase, and various homeopathic prepara-
tions appear to be based on supposition rather than
fact. We do not recommend them.
MANAGEMENT AND PREVENTION OF SEQUELAE
Vesicourachal Diverticula
In the past, therapeutic recommendations for any fe-
line macroscopic vesicourachal diverticulum associated
with hematuria, dysuria, pollakiuria, and/or periuria
consisted of partial cystectomy and diverticulectomy.65
However, our observations suggest that macroscopic di-
verticula may develop at the bladder vertex of cats with
microscopic urachal remnants as a sequela to concur-
rent but unrelated acquired diseases of the lower uri-
nary tract (e.g., idiopathic disease, urolithiasis, bacterial
cystitis, urethral obstruction).66 Many of these macro-
scopic diverticula heal within 2 to 3 weeks after amelio-
Compendium June 1999 20TH ANNIVERSARY
ration of clinical signs of LUTD as demonstrated by re-
peated double-contrast cystography.66 Consequently,
rather than perform needless diverticulectomy, thera-
peutic efforts should be directed toward eliminating
underlying causes of LUTD. If a macroscopic divertic-
ulum persists because the underlying cause remains and
the patient has a persistent or recurrent UTI, divertic-
ulectomy is a rational therapeutic option.
Urethral Plugs
Because insoluble crystals appear to be an integral
component of many matrix–crystalline urethral plugs,
using medical protocols to prevent crystal formation in
affected patients is logical. Struvite is the primary miner-
al component of most naturally occurring urethral plugs,
although other mineral types may also be found. Suc-
cessful prevention of recurrent urethral obstruction using
diets designed to reduce urine pH and urine magnesium
and phosphorous concentration has been reported.67
Attempts to dissolve struvite crystals with urine acidi-
fiers or diets designed to promote acidic urine should
not be initiated in cats with postrenal azotemia. The
metabolic sequelae of urethral obstruction, particularly
severe metabolic acidosis, must be corrected before di-
ets designed to acidify urine are used.
Perineal urethrostomy is an effective method of mini-
mizing recurrent obstruction of the penile urethra in
patients unresponsive to medical management. Con-
trast urethrography should first be performed to con-
firm that the site(s) of urethral obstruction is (are) only
within the penile urethra. We emphasize that perineal
urethrostomies may be associated with significant
short- and long-term complications, including postop-
erative hemorrhage; wound dehiscence; urine scald der-
matitis; urethral stricture; bacterial UTI; and, rarely,
subcutaneous extravasation of urine, perineal hernia,
and urethrorectal fistula.67–74 Bacterial UTIs were iden-
tified postoperatively in 22% to 45% of patients man-
aged with perineal urethrostomy for urethral obstruc-
tion.67,73 UTI caused by urease-producing microbes
may induce struvite urolith formation.67 The prophy-
lactic benefits of minimizing recurrent urethral obstruc-
tion by urethrostomy must be weighed against a long-
term predisposition to recurrent bacterial UTI and
urolith formation. We recommend that perineal ure-
throstomies be avoided unless (1) irreversible mural or
extramural lesions exist that cause recurrent or persis-
tent obstruction of the penile urethra or (2) frequent
outflow obstruction of the distal urethra occurs despite
properly designed medical management.
CLIENT EDUCATION CONSIDERATIONS
Because of the self-limiting nature of iLUTD and the
PREVENTING CRYSTAL FORMATION ■ URINE ACIDIFIERS ■ PERINEAL URETHROSTOMY
Small Animal/Exotics
uncertainty of the efficacy of specific or symptomatic
therapy, client education assumes a prominent role in
the management of affected cats. Owners should be suf-
ficiently educated about the natural biologic behavior of
the disease and lack of credible evidence regarding the
safety and efficacy of therapeutic agents to make reason-
able decisions about therapeutic options (see Answering
Owner Questions). We also recognize that client- or
self-imposed psychologic pressure to “do something” is
occasionally overwhelming. Our desire to do something,
however, must be evaluated in light of the potential risks
and benefits of our therapeutic actions.
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About the Authors
Dr. Kalkstein is currently a resident in Small Animal Inter-
nal Medicine and Dr. Kruger is affiliated with the Depart-
ment of Small Animal Clinical Sciences at the College of
Veterinary Medicine, Michigan State University, East
Lansing, Michigan. Dr. Osborne is affiliated with the De-
partment of Small Animal Clinical Sciences, College of
Veterinary Medicine, University of Minnesota, St. Paul,
Minnesota. Drs. Kruger and Osborne are Diplomates of
the American College of Veterinary Internal Medicine.