Management of feline idiopathic cystitis: nursing interventions

Environmental modification

According to Buffington et al (2006a), environmental modification should form part of FIC management. In their study many of the cats that presented with FIC signs spent their time indoors, with their clinical signs occurring during periods of inactivity, which is thought to be boredom-induced stress. Changes to the physical environment, such as the provision of scratching posts, toys, perches, video and audio stimulation and human interaction were suggested. The same study focused on the implementation of an individualized environmental enrichment plan based on individual needs, and 75% of the cats had no FIC signs during a 10 month follow-up period. In the veterinary practice the RVN should obtain information from the client about the home environment, and the questionnaire provided by the Indoor Pet Initiative (2008) was designed for this purpose and can be utilized by the RVN to provide an effective environmental modification plan. The plan should be fully explained to the client, with reassessment and support when problems arise. Buffington et al (2006a) also argued that there is a case for environmental management to be used for all indoor cats to prevent FIC occurring, although this is unsupported. By utilizing the environmental modifications recommended by Buffington et al (2006a) and the Indoor Pet Initiative (2008) in preventative healthcare clinics, the RVN may help to prevent FIC occurring in indoor cats.

Stress

Stress is thought to play an important role in FIC (Buffington et al, 2006a and 2006b). A study conducted by Westropp et al (2006) examined the effects of stress in FIC cats compared with healthy cats in a laboratory environment, to define the link between stress and occurrence of FIC. The study found that plasma catecholamine (the hormone released when the body is stressed) levels were higher in cats with FIC than in normal cats following the same stress, they also found that high levels of catecholamine resulted in FIC clinical signs. However, the process of obtaining the plasma for analysis could itself be a cause stress; making the results obtained unreliable as they could be attributed to stress suffered during sampling. Stress avoidance is highly recommended (Hostutler et al, 2005; Buffington et al, 2006a; Elliott and Grauer, 2007) because of its direct link to recurrence of FIC. When creating a nursing care plan thought should be given to keeping stress-inducing interventions to a minimum. This can be achieved through the grouping together of treatments, and by minimizing disruptions to routine, for example.

Behavioural therapy

A case study conducted by Seawright et al (2008) evaluated the effects of behavioural therapy. The therapy programme consisted of making changes to remove known stressors to the cat and to increase security within the home. The subject of the case study was a multi-cat household cat, and a major stress factor was conflict between other cats. The therapy was proven to work despite occasional lapses resulting in a return of FIC signs. However, this study was limited to one case and did not discuss the implications of such therapies for single cat households, so its effectiveness could not be fully evaluated. Despite this, the successful outcome proved the importance of behavioural modification. Elliott and Grauer (2007) discussed the importance of inter-cat conflict, and in agreement with Seawright et al (2008) they recommended that in multi-cat households individual resources, such as food and water bowls, be provided to minimize stress, along with the provision of escape routes and hiding places. The RVN could minimize stress and fear often experienced by hospitalized cats by providing hiding places within the kennel, such as a box to hide in, and by placing them out of sight of other animals (Figure 1). An analysis of the number of cats in the household should be carried out with the client, and the amount of inter-cat conflict determined. The RVN could also advise the client on solutions to reduce inter-cat conflict at home, for example advising on providing a safe hiding area for each cat. In some cases, referral to a behavioural specialist may be required.

Behaviour therapy in the treatment of IC in humans has not been studied (Rovner and Goudelocke, 2010). Despite this, recommendations for reducing stress have been made in order to reduce the severity or regularity of recurrence of IC in humans. Forest and Dell (2007) and Meijlink (2010) both discussed the use of patient counselling in the management of IC. Frustration and misunderstanding about the treatment of IC could be reduced through discussions with health professionals, leading to a reduction in stress and a greater understanding of the condition (Forrest and Dell, 2007). More importantly, patients could be empowered to provide treatments themselves. Meijlink (2010) recommended the use of support groups, websites and patient information about their condition to empower human patients. In order to avoid client frustration at repeated recurrence of FIC, the RVN could educate and support the client. Detailed information explaining the complexity of the condition along with an individualized home care plan would empower the client to carry out the necessary interventions at home. The RVN should also provide home visits and support clinics that can offer emotional support to clients.

Pheromonotherapy has been indicated to help improve negative behaviours and decrease stress in cats. The feline facial pheromone Feliway^® exerts an anxiolytic effect by decreasing the activity of the parasympathetic nervous system (Elliott and Grauer, 2007; Forrester and Roudebush, 2007). Hostutler et al (2005), Elliott and Grauer (2007), Forrester and Roudebush (2007), and Kruger and Osborne (2009) all encourage the use of Feliway^® to reduce stress, despite clinical trials failing to provide evidence of clear benefit. In the veterinary hospital the RVN can use the pheromone diffusers to reduce stress for hospitalized cats and should include the use of Feliway^® in the home care plan. Correct use of the product must be demonstrated to the client to ensure full benefit is obtained at home.

Litter trays

The litter tray of a cat with FIC needs to be examined in order to encourage regular waste elimination. The litter tray must be kept clean to encourage frequent elimination (Hostutler et al, 2005; Elliott and Grauer, 2007), and it is important that the litter tray is kept in the correct location (Hostutler et al, 2005), which should be in an area that is quiet and away from appliances that may disturb the cat. In a hospital environment, the RVN should give thought to the location of the litter tray in the kennel; a litter tray placed at the front of a kennel in view of other animals would probably discourage elimination. The RVN should instruct the owner that there should be a litter tray for each cat in the house plus one extra, and that they should be located in areas where the cat is unlikely to be suddenly disturbed. The relationship between litter tray location and elimination problems has been studied and it has been found that there is no correlation between location and inappropriate toileting (Sung and Crowell-Davis, 2006). Interestingly, the study did conclude that the type of substrate in the litter tray affected elimination; the cats that displayed inappropriate elimination did not dig or spend much time in the litter tray, suggesting a dislike of the substrate. Buffington et al (2006a) along with Elliott and Grauer (2007) stated that an unscented clumping litter should be used, but in contrast, Hostutler et al (2005) stated that non-clumping unscented litter should be used. There is no clinical evidence to support either claim, so as suggested by Elliott and Grauer (2007) the cat should be allowed to choose the type of litter substrate used. In a hospital environment the RVN could determine the preferred litter substrate of the cat by offering different substrate types over several days, and observing which type of substrate the cat was seen to dig around and eliminate frequently in. This information can then be passed to the client, to continue the use of the preferred substrate at home. The RVN's role can be extended further to educate the client on the importance of excellent litter tray hygiene, which involves frequent and thorough cleaning.

Diet and water intake

The majority of cats diagnosed with FIC are fed a dry food diet (Elliott and Grauer, 2007). These cats were also found to have a lower water intake, resulting in urine of a higher concentration than healthy cats (Hostutler et al, 2005; Buffington et al, 2006a; Elliott and Grauer, 2007; Kruger and Osborne, 2009). Dietary management is generally aimed at producing dilute urine in order to reduce the concentration of noxious substances in contact with the bladder lining, which is reported in a study by Forrester and Roudebush (2007) to be achieved by the feeding of a wet diet. Some argue that the feeding of acidifying urinary diets is not indicated as there is no evidence of benefit (Hostutler et al, 2005; Elliott and Grauer, 2007). There is no specific diet for FIC (Elliott and Grauer, 2007), so focus should be given to providing a diet that has a higher water content. The RVN should, therefore, aim to feed a hospitalized cat with a wet food diet, and advise the client to make an informed decision on the diet to feed at home.

Increased water intake through drinking is recommended in order for dilute urine to be produced (Hostutler et al, 2005; Buffington et al; 2006a; Elliott and Grauer, 2007; Kruger and Osborne, 2009). This can be achieved through the us of water fountains, flavoured water and multiple water bowls (Elliott and Grauer, 2007). Therefore the RVN must ensure that a cat with FIC in the veterinary hospital has an adequate water supply, and could also encourage drinking by the use of flavouring such as tuna juice. On discharge, the RVN should also discuss the importance of water access at home, and demonstrate a range of interventions such as water fountains.

Nutraceuticals

Nutraceuticals utilized in the management of FIC include those used to replace the glycosaminoglycan (GAG) layer in the bladder lining. This layer is designed to reduce the adherence of noxious substances to the urothelium of the bladder, and in FIC cats it is thought that this layer is defective, enabling the bladder urothelium to become irritated by substances in the urine (Forrester and Roudebush, 2007; Kruger et al, 2008). Glucosamine and pentosan polysulphate have been trialled in human and feline medicine. Wallius and Tidholm (2009) conducted a study on the effectiveness of pentosan polysulphate in cats diagnosed with FIC, and found no significant difference between the placebo and treated groups. In human medicine, similar trials conducted on IC patients revealed that pentosan polysulphate produced only a small percentage benefit (Nickel et al, 2005; Seth and Teichman, 2008). Nevertheless, both human and veterinary studies revealed that the duration of treatment rather than the dose was significant; with many patients showing improvement after several months (Nickel et al, 2005; Kruger and Osborne, 2009). In the meantime, the RVN should consider this as a treatment option particularly in cases of chronic recurrence (Elliott and Grauer, 2007; Forrester and Roudebush, 2007; Kruger and Osborne, 2009. Kruger and Osborne (2009) briefly deliberated the possibility of a synergism between chondroitin sulphate and glucosamine. This had come about from recent studies conducted into the efficacy of chondroitin sulphate in human IC cases (Nickel et al, 2010). RVNs should be aware of this development, so when further studies are conducted, the outcomes can be evaluated and used to inform clinical practice as necessary.

Conclusion

It is clear from the published work examined that the management of FIC should be multimodal and tailored to the specific needs of each cat. Environmental modification is arguably the most important intervention, as the majority of literature examined focused on this. Stress reduction, litter tray management, dietary management, and behavioural therapy are also important interventions, and changes are to be achieved through making improvements to the physical environment, resolving conflict in multi-cat households, providing the cat with its own resources, the feeding of a wet food diet and the use of pheromones and GAG layer replacements. Behavioural therapy may require referral to a behavioural specialist, especially if the RVN lacks knowledge in this area. Any home care plan must be thoroughly explained, a demonstration of products and therapies provided, and most importantly support must be provided to the client. The client should also be provided with literature, so that the important points are not forgotten and also for use as a reference guide. Nursing interventions should be provided to the hospitalized cat first, as prompt treatment not only reduces the duration of clinical signs but decreases the chance of recurrence. By providing ongoing support, and reviewing the treatment plan when problems occur, the client can make informed decisions on the most effective treatment for the FIC cat, and in doing so prevent recurrence. Even if problems do not occur, regular check ups should be encouraged so that continuous support is provided, allowing the RVN to examine the efficacy of the plan created. Colleagues in the veterinary practice should also be informed on the interventions necessary in the management of this condition, in order to provide a unified approach to clients.

Key Points