11) Ḟew studies of FUS have included the female cat. males with increased frequency of voiding, discomfort

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1 Feline Urological Syndrome: A Study of Seasonal Incidence, Frequency of Repeat Visits and Comparison of Treatments M. A. BERNARD* I N T R O D U C T IO N The feline urological syndrome (FUS) characterized by dysuria, urethral obstruction, urolithiasis and hematuria has been previously referred to as urolithiasis, urethral obstruction, urethroadenocystitis and cystitis (14). The etiology of FUS is unknown. Factors incriminated, but not yet substantiated include castration, vitamin A deficiency, colloid-crystalloid imbalance, high ash diet, mineral ratio in diet (calcium, phosphorous, magnesium), low urinary threshold for phosphorous excretion, chemicals in the water and heredity (1, 4, 7, 9, 10, 13, 15, 18, 19, 21-23). Recently the isolation of viruses from clinical cases of FUS, experimental transmission studies and crystal formation by such viruses in tissue culture pose as yet unanswered questions in the pathogenesis of FUS (5, 15). The relationship of these viruses to the etiological agents of upper respiratory infections is also undetermined (11, 17) Ḃacterial infection is an important part of some individual cases of urinary tract disease and some cases of FUS. Whether these are a primary or secondary infection is unknown, but it is generally felt that bacteria are not a major causative factor in FUS (14, 19). Literature reviews indicate that most treatment regimes are directed at the obstructed male. The urethral obstruction is relieved by back flushing, gently milking the penis (19) or by a fine wire probe (13). The bladder is then emptied and flushed to remove residual blood clots and triple phosphate crystals. Retention catheters are used by some veterinarians to ensure urethral patency for a period of time (I 1). Subsequent therapy is directed at the uremia (if present) and establishing normal renal function. Antibacterials are used routinely despite the lack of evidence that bacteria play a major role in FUS (11, 19). Urinary acidifiers are used to lower urine ph and minimize triple phosphate crystal formation (9). These crystals form a large part of the obstruction in the penile urethra (13, 14). Long term therapy is instituted to reduce the chance of recurrence and includes the maintainance of diuresis, the reduction of triple phosphate crystal formation and diet control (10, 11) Ḟew studies of FUS have included the female cat (8, 14, 15, 19). Female cats and unobstructed males with increased frequency of voiding, discomfort when voiding, hematuria and unusual spraying are treated similarly to males after an obstruction is relieved. Cats with recurrent problems or lack of response to therapy are examined for evidence of bacterial infection, renal or cystic calculi or anatomical abnormalities. A report of long term therapy indicates a recurrence of obstruction of 15 to 20% (6). Recurrent cases of urethral obstruction not controlled medically are candidates for surgery or euthanasia. Surgical techniques include amputation of the tip of the penis, splitting the glans penis and urethra, placing permanent indwelling catheter, bladder prosthesis, ureterocolostomy, prepubic, preputial and perineal urethrostomies and cystotomies (4). There is a scarcity of data regarding the overall incidence of FUS in the feline population let alone specific data concerning seasonal incidence, percentage of repeat visits and percentage of households with multiple cases. This paper examines some of these data arising from a small animal practice in a limited geographic area (Ottawa, Ontario). This retrospective study was initiated to demonstrate a suspected seasonal incidence, to demonstrate the frequency of repeat visits and the effect of a change in therapy. MATERIALS AND METHODS Data were collected from the cats presented to the hospital for treatment between January 1, 1967 and December 31, A diagnosis of FUS was established by evidence of 1) urethral obstruction in males and 2) persistent straining, hematuria, proteinuria, crystaluria, unusual spraying, excessive licking of the external genitalia in females and unobstructed males. Occasionally FUS was diagnosed on an outpatient basis, based on history and clinical examination without a urinalysis. Some cats were treated for recurrences without an examination. The general treatment remained essentially the same in the two periods studied, January 1, 1967 to December 31, 1969 and January 1, 1970 to December 31, Female cats and unobstructed males were initially treated as outpatients. All cats with recurrent episodes of hematuria and straining were *1814 Bank Street, Ottawa, Ontario KIV 7Y Can. vet. J. 19: (October 1978)

2 hospitalized. Plain radiographs and pneumocystograms were used when cystic calculi were suspected. Urine was cultured if numerous bacteria were seen in the urine sediment or if the case did not respond and there was no evidence of calculi. Urinary acidifers (D-L methionine or ammonium chloride), antibacterials (ampicillin, chloramphenicol, furadantin, sulfasoxizole), antispasmodics (hyoscyamine hbr., aminopropazine fumarate) and maximum fluid intake were the routine treatment for all cats with FUS. Antibacterials used were selected, based on the results of sensitivity tests or on the response to treatment. Fluids in the form of broth or soup were added to the cats' regular food up to the point when food was rejected. One quarter to one half teaspoonful of salt was added to the food daily to stimulate thirst. Diet control included the elimination of dry cat foods (unless moistened) and that feeding of low ash diets.' For the latter period studied ( ) we used higher levels of D-L methionine ( mg daily) for longer periods of time (minimum one month vs two weeks in 67-69). Maintenance of a high fluid intake was preferred to continuous use of a urinary acidifier. If there were recurrent episodes of hematuria or obstruction the acidifers were continued indefinitely. These were the basic changes in the long term therapy for FUS. The only changes in initial treatment of an obstructed male would be more frequent use of catheters and more thorough flushing of the bladder in than Occasionally a long acting systemic corticosteroid2 was helpful in reducing excessive straining and hematuria. TABLE I REPEAT VISITS FOR URETHRAL OBSTRUCTIONS IN MALE CATS Percentage Initial Years Visits Repeat Visits of Repeat Visits Obstructed males were anesthetized and treated by inserting a silver abscess cannula into the urethra and flushing the urethra and bladder with normal saline. Uremic cats were not anesthetized. The bladder was emptied and flushed with ml of normal saline until the returning fluid was clear, free of clots and crystals. A sterile polyethylene catheter was inserted into the urethra and bladder and sutured to the prepuce. The catheter facilitated flushing the bladder and ensured patency of the urethra for two to three days. This time usually allowed a return of muscle tone to the bladder wall, but catheters were left in seven to ten days if the bladder wall was atonic. A restraint collar was used on some cats that would not tolerate the catheter or the sutures. To determine the incidence of repeat visits, each cat's medical record was examined to determine when the initial obstruction had occurred. Some cats may have died for other reasons or may not have been returned with a subsequent obstruction. Mortality rates were determined by tabulating known deaths from medical records. The other factors examined in this study were sex incidence, calculi, multiple cases in one household and seasonal (monthly) fluctuation in numbers of cases. RESULTS The records of six hundred and twenty-four cats with FUS were studied. One hundred and twentyone were females. During 1967 seventy-two cats were hospitalized. By the end of the study the number had increased to one hundred and sixtyfive for the year The average was 77 and for was 148. Part of this increase was due to practice growth, but the rest is unexplained. The incidence of repeat visits for urethral obstruction in male cats is presented in Table I. The results of the study of sex incidence and mortality is presented in Table II. Calculi There were thirteen cats with calculi, seven female and six male cats. Six of the females TABLE 11 FELINE UROLOGICAL SYNDROME. A Six YEAR STUDY OF SEX INCIDENCE AND MORTALITY Sex Incidence Mortality Total cases Females Percentage female Average age (range 9 mos-16 yr) yr Total cases Number deada Number of dead because of FUS' Percentage Males dead Females dead Ill 14 aby end of study. 'C/D, Hill's Division Riviana Foods, Topeka, Kansas. 2Depomedrol, Upjohn Co. of Canada, Don Mills, Ontario. 285

3 (postoperatively) were doing well, but all the males died or were euthanized shortly after calculi were diagnosed. Multiple Cases in One Household There were 20 instances of owners having had more than one cat with FUS and a total of 41 cats involved. No detailed examination of the familial relationships of the cats was obtained. It was not established whether there was actual or intimate contact. Ten cases involved male-female contact. The time interval between clinical signs in cats from one household varied from one to 36 months. Seasonal Incidence Feline urological syndrome was found to have a higher incidence in winter months. This seasonal change was more consistent in the years as opposed to The highest incidence was January to April (Figure 1). DISC USSION The dramatic increase in numbers of total initial obstructions in and the reduced incidence of revisits was a clinical impression and the stimulus for this study was to see if statistics backed up this impression. The results in Table I show the percentage of repeat visits for obstructions in affected cats to be half in what they were in The incidenc of recurrence of approximately 20% is similar to other reports for cats on continual treatment (6). Another study suggests a higher recurrence rate during maintenance therapy, but the therapy varied (21). The decreased incidence of recurrent obstructions was coincidental with changes in treatment incorporating: 1. Long term use of D-L methionine as a urine acidifier at mg daily (one 200 mg tablet given three to four times daily). 2. Addition of salt and fluids to the cat's diet to promote fluid intake for the duration of the cat's life. Acidification of the urine should decrease triple phosphate crystal formation which is an important part of the obstruction in the penile urethra. Salt and fluid intake promote diuresis and thus have a "flushing" effect to reduce urine stagnation and accumulation of crystals in the bladder (10, 16, 21). This reduction in recurrence has lessened the necessity to resort to perineal urethrostomys (2) which is the author's preferred surgical treatment if surgery is necessary N U MB 10 L n~~~~~~~~~~~~~~~~~~~~~~~~~ E R 0 F C A S E J F M A M J J A S 0 N D J F M A M J J A S 0 N D J F M A M J J A S O N D SEASONAL INCIDENCE OF FUS i... I r. J F M A M J J A S O N D J F M A M J J A S 0 N D J F M A M J J A S 0 N D FIGURE 1. Months of the Year Seasonal incidence of feline urological syndrome. 286

Feline urological syndrome in female cats has been overlooked because the females do not suffer with life threatening urethral obstructions (8, 14, 15, 19). The incidence in this study (19.

4 Feline urological syndrome in female cats has been overlooked because the females do not suffer with life threatening urethral obstructions (8, 14, 15, 19). The incidence in this study (19.4%) is similar to other studies (20%) but higher than one with 10% females with FUS (14, 19). The average age incidence in females was 6.4 years which was significantly higher than the average one of males, 3.5 years. This figure for males is from 140 randomly selected cases which is comparable to other documented age figures for males with FUS (14, 19). The age of affected females appears to be somewhat older than males in-one survey (21). The high mortality rates were a bit startling. Twenty percent of total cases studied over a six year period were dead at the end of the study period. Ninety of the 125 or 72% of the dead cats died from or were euthanized because of the condition. Thus long term studies of control will be deficient with one-fifth of the animals being destroyed in a six year period. One survey documents variable mortality rates with FUS (21). The components of cystic calculi, crystals and an organic matrix (protein) are present in the urinary tract of males and females with FUS whether obstructed or not (11, 13). Cases with calculi were recommended for cystotomy, bacterial cultures and long term therapy, whether male or female. Cultures were not done or recorded in all cases so results were not recorded. The signs of straining and hematuria associated with a cystic calculus were eliminated in female cats by surgical removal of the calculus. Male cats were still prone to urethral obstruction and this may account for most of the males being euthanized. Multiple cases in one household were low in number and may fit a hypothesis of an infectious agent such as a virus (5, 11, 12). It is not possible to discuss possible incubation periods since the periods of potential exposure are so varied. The effect of environment and diet is impossible to measure in these cases. The definite seasonal incidence and the higher number of cases seen, despite a dramatic decrease in the percentage of recurrences, all pose unanswered questions. Statements of an increased incidence in FUS related to semi-moist and dry cat foods are not substantiated (16). Assuming a contagious etiological agent (i.e. virus) then a decreased resistance of host, increased pathogenicity of the agent or increased number of carriers because of better medical control and a subsequent lower mortality, may partially account for an increased number of cases of FUS (20). The seasonal fluctuation is related to cold weather. Other local practitioners in Ontario have made clinical observations of this pattern, but there are no published data (21). How much of a factor local geographic conditions play in influencing seasonal incidence via temperature fluctuations, intensive cat-to-cat contact, and diet, should be examined by studying comparable data on a regional basis. What role cold has in causing a higher incidence is unknown. Chilling resulting in lowered resistance, urine retention, altered food and fluid intake may all be predisposing factors in initiating an attack of FUS. Cold may be the stressing factor if stress can precipitate an attack as has been suggested (3, 11, 21). Conclusions 1. The total incidence of FUS in our practice has increased in over Locally the highest incidence of FUS is in winter. 3. Long term treatment including high fluid intake and the administration of urine acidifiers has been associated with a reduction in the percentage of revisits for urethral obstructions in male cats with FUS. 4. Female cats have a significant degree of urinary tract disease and should be included in investigations of the FUS complex. 5. Multiple occurrences of FUS in one household although not numerous lend support to the hypothesis of an infectious agent. SUMMARY Over six hundred cases of feline urological syndrome were studied. A definite increase occurred in winter. The percentages of recurrence were examined before and after a change in basic therapy during a six year period. The relative occurrence in males and females is discussed. RESUME Cette etude portait sur au dela de 600 cas du syndrome urologique du chat. L'incidence de cette condition accusa une nette augmentation, au cours de l'hiver. L'auteur porta une attention speciale au pourcentage de recidives, avant et apres un changement dans la therapie de base, durant une periode de six ans. 11 commente aussi l'incidence relative de ce syndrome, chez les males et les femelles. ACKNOWLEDGMENTS The author would like to thank Dr.L.J. Rich for his encouragement and Mrs. M. Maloney for her assistance in preparing this paper. REFER ENCES 1. ANON. Urethral obstructions. In Progress in Feline Practice. pp Santa Barbara: American Veterinary Publications, Inc BLAKE, J.A. Perineal urethrostomy. J. Am. vet. med. Ass. 152: CASTON. H.T. Stress and the feline urological syndrome. Feline Practice 3: Nov.-Dec CAWLEY. A.J. and J. ARCHIBALD. Urinary surgery in cats. Can. vet. J. 8:

5 5. FABRICANT. C.G. Urolithiasis: A review with recent viral studies. Feline Practice 3: Jan.-Feb FISHLER, J.J. Urolithiasis and cystitis in male cats. Mod. vet. Pract. 48: FOSTER, s.i. Feline urolithiasis associated with age. J. small Anim. Pract. 8: GILBRIDE, A.P. Practical approach to cystitis in the cat. Norden News. pp Summer HOLZWORTH. J. Disorders of the urinary system. Cornell Vet. 53: JACKSON, O.F. Urolithiasis prevention. J. small Anim. Pract. 12: l. KOWALL, N.L. A current look at feline cystitis. Feline Practice 1: Sept.-Oct LIVINGSTON, M.L. A possible hereditary influence in feline urolithiasis. Vet. Med small Anim. Clin. 60: MEIER. F.W. Urethroadenocystitis in the male cat. J. Am vet. med. Ass. 151: OSBALDISTON, G.W. and R.A. TAUSSIG. Clinical report on 46 cases of feline urological syndrome. Vet. Med. small Anim. Clin. 65: OSBORNE. C.A., D.G. LOW and D.R. FINCO. The cystitisurethral obstruction complex in the cat. In Canine and Feline Urology. Toronto: W.B. Saunders Co PIERCE, D. Feline urolithiasis: A case study. Feline Practice 4: Nov.-Dec RICH, L.J., C.G. FABRICANT and J.H. GILLESPIE. Virus induced urolithiasis in male cats. Cornell Vet. 61: , RICH, L.J., 1. DYSART, FU-HO C. CHOW and D. HAMAR. Urethral obstruction in male cats: Experimental production by addition of magnesium and phosphate to diet. Feline Practice 4: Sept.-Oct SCHECHTER. R.D. The significance of bacteria in feline cystitis and urolithiasis. J. Am. vet. med. Ass. 156: SMITH. J.B. Comment on incidence and seasonal variation of feline urolithiasis. Mod. vet. Pract. 52: 7. Sept THE FELINE UROLOGICAL SYNDROME: Cystitis/urolithiasis/urethral obstruction. Feline Practice 3: Jan.-Feb WHITEHEAD. J.E. Diseases of the urogenital system. In Feline Medicine and Surgery. p Santa Barbara: American Veterinary Publications, Inc WHITEHEAD. J.E. Feline urolithiasis. Vet. Med. small Anim. Clin. 1: CONCOURS "SCHERING" POUR ETUDIANTS EN MEDECINE VETERINAIRE Les prix "Schering" sont offerts aux finissants de chacun des trois colkeges veterinaires du Canada. Trois prix de $100 seront disponibles pour chaque college. REGLEMENTS 1. 1:ligibilite: Le concours ne s'adresse qu'aux finissants d'un college veterinaire du Canada. 2. Les prix seront attribues aux auteurs des meilleurs rapports de cas cliniques (de prefeence: 300 'a 1,000 mots), rediges sous forme convenable pour fin de publication dans la "Revue veterinaire canadienne". Veuillez consulter les "Directives aux auteurs" et les derniers numeros de la revue pour renseignements sur la forme et la presentation. 3. Les textes peuvent etre soumis en franqais ou en anglais. 4. Un "Comite de Selection" dans chaque college sera responsable du choix des dix meilleurs rapports de cas cliniques qui seront juges par le "Comite de Redaction" de l'association canadienne des veterinaires. 5. Les prix seront remis 'a I'occasion d'une ceremonie officielle. 6. La Revue se reserve le droit de publier, selon les regles habituelles de 1'edition, les articles primes. 288

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