108 | Is it time to rethink urinary disease? Here’s how to manage your blocked cats the RIGHT way
In this episode, we’re looking at a set of diseases we see all too often - feline lower urinary tract diseases.
Now I say diseases, plural, deliberately - because thinking of FLUTD as a spectrum of diseases, rather than a standalone condition itself, is one of the most important shifts we can make in how we approach it.
I’m going to be bringing you the need-to-know information from the 2025 iCatCare consensus guidelines on the diagnosis and management of lower urinary tract diseases in cats, AND some really useful information from the 2024 AAFP intercat tension guidelines, because as you'll see, the two are far more connected than you might expect.
Over the next half an hour or so, we’ll discuss how and why FLUTD occurs, how to stabilise and support obstructed patients, how to nurse cats with lower urinary disease, and how we can do more to support these patients long-term, both in and out of the hospital.
There’s far more we can do with these patients than we might think, and by the end of this episode, you’ll feel more confident managing these patients, and able to put more of your skills to use.
Let's get into it.
So what actually ARE feline lower urinary diseases?
Before we get into all of the clinical detail, I want to spend a moment on terminology, because it’s changing, and this means that we need to change with it. The words we use with our caregivers (and with each other) will affect how we perceive this condition, and how we manage patients with it.
Most of us trained with the term FLUTD: feline lower urinary tract disease. It's been around since the 1980s, it's on every discharge sheet, every referral letter, every client factsheet, you name it.
But in reality, FLUTD isn't a diagnosis. It never was. It's a non-specific umbrella term encompassing multiple conditions presenting with the same clinical signs, and the new guidelines are very clear that we need to move away from it. They refer to ‘lower urinary tract diseases’ (plural) to encompass the multiple causes of lower urinary tract signs, or LUTS, rather than implying any single diagnosis.
And while we're talking about terminology, I also want to mention FIC (feline idiopathic cystitis). This term is also problematic, because the word ‘cystitis’ in conversation with our clients and caregivers implies a bacterial cause, just as it does in human medicine. This runs the risk of antibiotic overuse, potenitally leading to complications like resistant UTIs, and poor antimicrobial stewardship.
Where does feline idiopathic cystitis fit into FLUTD?
FIC is a complex and still somewhat poorly understood condition. Interestingly, the guidelines actually suggest we rename it ‘bladder pain syndrome’, which is a term borrowed from human medicine.
This term emphasises that the condition is so much bigger than ‘just’ the bladder - it’s seen due to complex interactions between the brain and urinary tract (and other organs such as the adrenal glands). It also highlights the need for analgesia, and distances the disease from bladder infection.
So, to summarise, the clinical signs we see (dysuria, haematuria, periuria, pollakiuria, and stranguria) are signs of LUT diseases, not diagnoses in themselves. They can be caused by lots of underlying conditions, and our job (alongside our vets) is to work out which our patient has, and care for them appropriately.
So with that small soapbox moment on terminology over, let’s look at the most common causes of FLUTD, and how they impact out patients.
In most cases - around 55-65% across studies - a specific underlying cause could not be determined. Practically, this leaves us with FIC as a diagnosis of exclusion, meaning that FIC is the most common cause of lower urinary tract signs in cats.
Following this, other causes (in order of frequency) include uroliths (usually struvite or calcium oxalate), bacterial cystitis/UTI, and then less common causes such as anatomical abnormalities and neoplasia.
Patients with recurrent lower urinary signs may not always have same underlying cause - so if a patient has previously had FIC as a younger cat, but they come back in later in life with repeat signs, it may not be FIC again. It could be something like neoplasia (eg transitional cell carcinoma/urothelial carcinoma) or bacterial cystitis, since these conditions are far more common in older cats.
Let’s take a closer look at feline idiopathic cystitis and the impact it has on our urinary disease cats.
As we’ve already mentioned, FIC involves organs other than the bladder and so should be considered a multisystemic disorder.
In cats with FIC, the central threat response system - the area of the brain that responds to threat with activation of various nervous and endocrine systems - becomes persistently activated. This activation is influenced by genetic, epigenetic, and environmental factors.
This in turn causes neurogenic inflammation within the bladder, so the lower urinary signs we see are the bladder’s response to this persistent stress system activation.
So what does that actually mean?
Basically, FIC is what happens when a susceptible cat lives in a world that their nervous system perceives as threatening. The brain's threat response system becomes chronically activated, and that dysregulation plays out, partly, in the bladder, but also in other organ systems too.
Affected cats may have overlapping health problems, referred to as ‘Pandora syndrome’ . This describes the presence of stress-associated clinical signs referable to other organ systems - things like vomiting or overgrooming- in addition to lower urinary tract signs.
What factors increase the risk of FIC?
FIC is a condition primarily affecting susceptible cats living in provocative environments, and that effective management must address the cat's environment and lifestyle, as well as their bladder pathology.
Studies have consistently identified varied risk factors for these patients, including:
Genetics
Early adverse experiences
Nervous disposition
Indoor environment
Increased threat responsiveness
Frequent diet changes
Inactive lifestyle
Obesity
Use of non-clumping litter
Multi-cat home
Household instability
Lack of elevated vantage points/poor resource management.
This is really important, because it dictates how we manage these patients long-term, and how we support and advise our caregivers.
And perhaps unsurprisingly, we as nurses and technicians are central to FIC management. We can be providing advice and support on environmental management, multi-cat household considerations, nutrition and weight management, and much much more.
Before we move on to managing the blocked cat I want to mention one final thing about FIC, and that’s this: FIC is a painful condition, and analgesia should be prioritised regardless of whether the patient is obstructed or not. Lack of obstruction does not mean these patients are comfortable - that bladder inflammation is significantly painful, and analgesia needs to be considered early.
Let’s move on to triaging and stabilising our blocked bladder cats, and where we fit into this as veterinary nurses.
Urethral obstruction (UO) is a life-threatening complication of LUT disease. FIC is the most commonly reported cause of obstruction, but urolithiasis should always be considered and excluded. Urethral plugs, which are plugs of inflammatory debris and crystals trapped within a protein matrix, are also a common cause of obstruction, particularly in male cats with FIC.
Complete obstruction results in increased pressure within the bladder, leading to bladder wall pressure necrosis, mucosal injury, and back-pressure that can eventually reduce renal blood flow and glomerular filtration rate and cause acute kidney injury. And once AKI develops, we quickly see complications including hyperkalaemia, metabolic acidosis, and hypocalcaemia. Of these, hyperkalaemia is the most common life-threatening complication, causing bradycardia and cardiac arrhythmias.
So our first job in any patient presenting with lower urinary signs is to triage and stabilise them rapidly.
All cats presenting with LUTS should be assessed to determine whether they have UO and life-threatening consequences such as shock and/or hyperkalaemia.
This should include assessment of mentation, mucous membrane colour, capillary refill time, heart rate and rhythm, pulse quality, systolic blood pressure, respiratory rate and lung sounds, and gentle abdominal palpation to assess bladder size and tension. Rectal temperature can cause stress and pain, so the guidelines suggest measuring it after analgesia and sedation, or considering axillary temperature instead.
During stabilisation, intravenous fluid therapy (even in an obstructed patient - but carefully to prevent overload), analgesia, and treatments to stabilise hyperkalaemia (such as calcium gluconate, glucose, insulin and terbutaline) should be prioritised.
And as our patient stabilises and those medications take effect, we need to prepare for catheterisation.
Because cats with UO are often unstable and require emergency management, the guidelines recommend preparing all equipment before sedation/anaesthesia to minimise anaesthetic time and therefore adverse effects.
We’ll need:
Clean sharp clippers
Sterile gloves
Surgical scrub solution (dilute chlorhexidine or povidine-iodine) and swabs
Single-use sterile lubricant
Depending on the individual patient and catheter used, one-two urinary catheters (one for unblocking and one for indwelling placement as needed)
Sterile closed urinary collection system
Sterile saline for flushing
Appropriate-sized syringes
Sterile tubes for samples
Suture material
+/- An IV extension set with three-way stopcock to aide drainage
+/- A small IV catheter (without stylet) may also be useful if unblocking is challenging
During catheterisation (which you’ll either be performing or assisting with, depending on your local legislation), it’s important to move the penis dorsally and caudally to straighten the natural S-bend in the urethra. Doing this will make it much easier to pass your catheter; if you don’t, it’ll often result in failed unblocking attempts and increased urethral trauma as a result.
Speaking of urinary catheters, bigger isn’t always better - ideally we want to use a smaller diameter catheter to minimise urethral trauma.
What about nursing these urinary cats after they’re unblocked?
There’s a LOT to think about when it comes to post-obstruction nursing - both in the hospital, and long-term - so let’s get into it, beginning with how we manage our indwelling catheters.
So how should we care for indwelling urinary catheters in our blocked bladder cats?
Firstly, closed urine collection systems should be used wherever possible.
These help to prevent ascending iatrogenic infection and allow measurement of urine output. Your collection bag must be positioned below the level of the bladder for gravitational drainage but kept off the floor. The collection system should be changed every two days to avoid the risk of nosocomial infection, and should be handled with sterile gloves if you're also handling the catheter.
The junction between catheter and prepuce should be wiped with 0.05% chlorhexidine every 6-8 hours or whenever you see contamination.
We’ll also use that collection system to monitor our patient’s urine output.
This should include emptying the collection bag every four hours and calculating urine volume in ml per kg per hour. Comparing fluid given and urine produced will ensure the IV fluid rate is adequate, and catch complications such as increasing fluid overload risk early.
Postobstructive diuresis (where urine output temporarily increases post-unblocking) is common and may persist for up to 84 hours after catheterisation. If not addressed, post-obstructive diuresis can cause significant dehydration and hypokalaemia. We monitor for and manage this by matching ins and outs, monitoring potassium, and gradually reducing IV fluid rates under veterinary direction as the diuresis resolves.
We also want to avoid antibiotics in our catheterised patients, unless there is a REAL clinical indication for them.
While we won’t be making prescribing decisions as veterinary nurses, we still need to be aware of this: prophylactic antibiotic treatment of cats with indwelling urinary catheters is not recommended.
Overprescription of antibiotics for cats with LUTS is a recognised problem, and nurses who understand when antibiotics are and aren't indicated are an important part of changing that culture. It’s also important as resistant UTIs are more likely in these patients, so the last thing we want to do is expose them to unnecessary antibiotics.
Instead, we need to monitor our patients for signs of UTI, and flag these to our vet. If UTI is suspected, wherever possible the catheter should be removed and a cystocentesis sample taken for culture before treatment decisions are made.
How long should we keep these catheters in?
The answer is it really depends. According to the guidelines catheters are typically kept in for around 24-36 hours, although azotaemic cats need a longer duration (often more than 48 hours) while on supportive therapy and IV fluids, depending on severity and response.
We need to consider, though, that the UTI risk increases significantly after 48 hours of catheterisation - so the minimum time needed by the patient is always preferable.
If the catheter was easy to place without resistance, the cat is not azotaemic, and it’s appropriate based on the individual case, an in-and-out catheter may be placed - depending, of course, on the veterinary surgeon’s preference.
We also need to consider our patient’s environment and behavioural needs, because a cat-friendly approach is not optional in our blocked cats.
Cats with lower urinary tract disease and urethral obstruction are incredibly painful and likely to be anxious, and a cat-friendly environment and nursing approach is vital to reduce stress and optimise their recovery.
That means:
Minimising the sight, sound and smell of other patients (both cats and other species)
Optimising the environment for the hospitalised cat (similar to as we discussed in episode 107, ensuring cats have sufficient and separate resources, and the ability to hide)
Replicating litter substrate and litter tray preferences in the hospital where possible
Careful, minimal and gentle restraint and handling
Elizabethan collars are necessary in catheterised cats, but they can cause real distress for some cats. Make sure that hides/beds have large enough holes to accommodate access, and if possible, provide supervised collar-free time. A fabric collar may be enough for some patients (as long as your vet is happy with this).
Other supportive treatments used under veterinary direction include anxiolytics (such as gabapentin), antiemetics, and appetite stimulants in a nauseous or inappetent patient.
And that stress management needs to continue long term too, which is where we really come in as veterinary nurses.
Right, this is the section I'm most passionate about, and I think it's where nurses and technicians are genuinely underutilised in practice. Because long-term management of FIC is not primarily pharmacological. We don’t prescribe meds and ‘fix’ the problem, or even do a perineal urethrostomy and ‘fix’ the problem - we might have stopped our patient blocking, but we haven’t done anything to prevent the underlying stressful triggers.
Management is environmental. It's behavioural. It's relational. And it requires time, client communication skills, and an understanding of feline behaviour that nurses are often better placed to provide than anyone else on the team.
The gold standard for FIC management is MEMO, AKA multimodal environmental modification. MEMO has been shown to be effective in reducing the recurrence of all disease signs in cats with FIC and is something we all need to be discussing with the families of these patients.
MEMO is the institution of changes to the cat's environment to attempt to reduce LUTS by decreasing the likelihood of activation of the central threat response system. It incorporates caregiver education and variable combinations of changes to the cat's inanimate physical environment, their diet, and their interactions with other cats, other animals, and humans.
This includes:
Litter tray management
Increasing water intake
Providing sufficient safe places and resting areas
Daily opportunities for interactive play, enrichment, and human interaction (including things like puzzle feeders, positive reinforcement training, and stimulating natural hunting behaviour)
Vitally, avoiding physical or other forms of punishment (such as yelling or squirting with water) is essential. Punishment increases fear and stress and is not a humane or effective way to change behaviour. You'd be surprised how often clients are doing this in response to periuria or inappropriate urination.
Inappropriate urination is one of the most frustrating things to deal with as a caregiver, and one of the things that most quickly damages the human-animal bond. Our goal is to support clients and maintain this bond as much as possible, while educating clients on how to manage these signs the right way at home.
And intercat tension goes hand-in-hand with house soiling and FIC.
We know that social tension between cats in multi-cat households, as well as tension involving cats outside the home, contributes to stress and can trigger or exacerbate LUT diseases.
If we think about the risk factors for FIC again, they include a multi-cat home, indoor environment, and household instability. Intercat tension is an important part of this, and an area we have a whole separate set of guidelines to help us manage.
The intercat tension guidelines remind us that tension affects between 62 and 87 percent of multi-cat households globally - and because most signs are subtle, it frequently goes unrecognised.
The most common signs of intercat tension are staring, chasing, stalking, fleeing, tail twitching, hissing, and wailing. And staring is the most frequently observed, occurring in nearly 45 percent of cases.
Things like staring at a cat trying to get to or use their tray, or blocking access to the tray, is a very quick route to LUTS.
For our FIC and LUTS patients in multi-cat homes, we need to be asking about feline social dynamics, using the five key principles for a feline-friendly environment as a guideline.
This means:
Every cat needs safe places, with one per cat plus one additional, to allow choice and prevent competition.
All key resources (safe places, food, water, litter boxes, scratching surfaces) should be distributed throughout the home, with visual barriers between resources and distance between feeding stations. Even affiliated cats should be separated during feeding to prevent competition.
Every cat needs opportunities for play including predatory play that mimics their natural behaviour as hunters
Human social interaction should be positive and predictable, and offered to all cats in the home on their terms
Their environment should respect their sense of smell.
And when it comes to introducing a returning hospitalised cat, caregivers should be advised on how to reintroduce the previously hospitalised cat to resident cats and pets to avoid frustration and redirected aggression. This can include initially confining the returning cat to one room, using a sock or glove rubbed onto the cats' faces to allow scent-swapping, encouraging positive emotions, and allowing all animals (and people) in the home to settle and calm before reintroduction.
This is important advice for us to offer when discharging these patients. A cat who has been in hospital for two days, smelling of the clinic, stressed, and returned home to a multi-cat household is at real risk of a social breakdown with the resident cats - even when they have previously cohabited happily.
This social breakdown risks conflict, which adds stress and risks recurrence of LUT signs, so it’s essential we anticipate it and advise our clients accordingly. And of course, as nurses and technicians, we’re in a great place to do that.
The importance of long-term nursing care in feline lower urinary disease
Reported survival rates to discharge for cats with urethral obstruction are excellent, from 91 to 94 percent. But recurrence rates range from 11 to 58 percent at various time points, with 21 percent of cats eventually being euthanased.
That high recurrence and euthanasia rate shows us how much work there is to do on long-term support - and as nurses we’re ideally placed to do this.
According to the guidelines, post-discharge management and caregiver communication can improve long-term outcomes.
At discharge, we need to discuss:
Ongoing analgesia
Medication administration
Litter tray management
Strategies to increase water intake
Environmental enrichment and modification
Diet
Stress reduction
In multi-cat homes, that specific reintroduction protocol
Signs of recurrence to watch for and when to come back
That is a lot of information, and clients should ideally leave with a written resource to back up everything you’ve discussed. The iCatCare guidelines actually have a caregiver guide and questionnaire you can download and I’d highly recommend you use them.
I’d also really encourage you to think about whether there's a role in your practice for nurse-led FIC management consultations. The guidelines make the point that longer consultations to discuss environment and stress factors are recommended for cats with recurrent episodes, and we’re ideally placed to do this as nurses. We could also offer this support remotely or via video consultation where the patient is stable, minimising their stress and reducing trips to the clinic.
So let me leave you with this.
FIC is a pain condition, driven by chronic threat perception in a susceptible cat living in a challenging environment. The guidelines are clear that its management must go beyond the bladder and address the whole cat, in their whole environment.
And the good news is that most of what that requires is not medication or even ‘just’ inpatient care. It's thorough, empathetic, cat-centred nursing care and client support - and it’s what we’re great at as VNs.
Of course, if our patient is obstructed we need to triage and stabilise them rapidly, prioritising analgesia, fluids, monitoring and anaesthetic support - and then careful post-procedure nursing.
But if that cat is going home, particularly after their second or third obstruction, we MUST discuss multimodal environmental management in a way that a caregiver actually understands and feels motivated to implement. Then we need to follow up on it, advocate for our patients at home, and keep providing that support - and we’re great at this, we just need the opportunity to do it.
Did you enjoy this episode? If so, I’d love to hear what you think. Take a screenshot and tag me on Instagram (@vetinternalmedicinenursing) so I can give you a shout-out and share it with a colleague who’d find it helpful!
Thanks for learning with me this week, and I’ll see you next time!
References and Further Reading
Rodan, I., Ramos, D., Carney, H., DePorter, T., Horwitz, D. F., Mills, D., & Vitale, K. (2024). 2024 AAFP intercat tension guidelines: recognition, prevention and management. Journal of feline medicine and surgery, 26(7), 1098612X241263465. https://doi.org/10.1177/1098612X241263465
Taylor, S., Boysen, S., Buffington, T., Chalhoub, S., Defauw, P., Delgado, M. M., Gunn-Moore, D., & Korman, R. (2025). 2025 iCatCare consensus guidelines on the diagnosis and management of lower urinary tract diseases in cats. Journal of feline medicine and surgery, 27(2), 1098612X241309176. https://doi.org/10.1177/1098612X241309176
