Eliminating inappropriate elimination (Proceedings)
Tragically, in North America, tens of thousands of cats are euthanized or surrendered to shelters each year for behavior problems. Of these cats, between 40% and 75% of all cats presented for behavior problems have an elimination disorder involving urination or defecation. In addition, many cats are presented with the clinical signs of lower urinary tract disease (LUTD) (pollakiuria, stranguria, and hematuria). Thus, there are three populations of cats who may urinate/defecate inappropriately: those with behavior-based problems, those with medical problems and a small group of cats experiencing both problems, concurrently.
Because cats may urinate in unacceptable locations out of discomfort or to "announce" LUTD, it is critically important to rule out a physical component of this unwelcome behaviour by performing a full, thorough physical examination as well as a complete urinalysis, before going to the in-depth behaviour consultation. If the cat is defecating inappropriately and the problem is determined to be a medical one, then appropriate steps need to be taken. Further tests may be indicated according to whether the problem is large bowel or small bowel in nature. This may running a fecal examination as well as rectal cytology (if large bowel origin) or endoscopy if small bowel in origin. A complete blood count, serum biochemistries, rectal examination, anal sac assessment, vaginal examination, fecal ova and parasite may be advisable for evaluation of inappropriate defecation that is believed to be behavioural in origin.
Several "oddities" should be recognized.1) Some cats with hyperthyroidism, defecate outside of their litter box, without showing any other, more classic signs of this disorder.
2) Abdominal alopecia caused by licking, may be due to the pain of cystitis, thus it may be wise to perform a urinalysis on cats presented for this problem.
3) Idiopathic cystitis (interstitial cystitis, neurogenic cystitis, sterile cystitis) may cause LUTD with hematuria as the only abnormality on urinalysis. If abdominal ultrasound or plain and contrast radiography are unremarkable, then medication that alleviates pain/blocks release of the chemical mediators causing the pain, such as amitriptylline, are indicated. Whether the inappropriate urination is due to the pain or due to the anxiety caused by the pain becomes a moot point, as far as the patient is concerned.
Determining who the culprit is can be confusing in a multicat household. For urination related problems, this can be elucidated by administering fluoroscein (0.3 ml at 100 mg fluoroscein/ml = 10%) subcutaneously or place six large (9 mg fluorescein / strip) fluorescein dye strips in a gelatin capsule and give orally to cat. The cat will eliminate bright yellow-green fluorescent urine for 24 hours after administration when viewed with a fluorescent black light. Untreated urine will also fluoresce, so clients must become familiar with normal fluorescence so they can appreciate the enhanced fluorescence. Be aware that the fluorescein treated urine may be visible to the naked eye on certain fabrics. Clients should be cautioned that fluoroscein stains some fabrics.
Having baseline blood work is advisable in any patient with a behaviour problem whose therapeutic plan may include the use of pharmacological agents. For any medication that is going to be used for a prolonged period of time, there is always the concern of hepatotoxicity, which might be prevented by screening for pre-existing disease. As with the diazepam adverse reactions (i.e. acute hepatotoxicity resulting in death), there is always the possibility of idiosyncratic drug reaction with any drug in any patient. For this reason, it is most pertinent to disclose this risk to clients while discussing options, as well as considering using an informed consent form.
An extremely valuable resource for the practitioner is Dr. Karen Overall's book, entitled Clinical Behavioral Medicine for Small Animals, Mosby, 1997. This text has important chapters covering behavior problems in depth, as well as extremely important basic chapters: Taking the Behavioral History and Behavioral Pharmacology. In addition, there are appendices, which include easy to follow protocols for each category of behavior disorder. These make (and are designed as) wonderful client handouts. This book is the main reference for these notes.
Once the clinician has ascertained that it is, indeed, a behavior based problem, a thorough, detailed behavior history should be taken. As success in dealing with behavioral disorders often requires recognition of subtle changes from what is normal for that individual, it is imperative to explore and learn what the norm consisted of. Using a standardized approach prevents overlooking important pieces of information. There are many sources of detailed history questionnaires.
The history should include all relevant information regarding the source and age of the cat at adoption, age at surgical altering, prior behavioral problems, daily routine, indoor/outdoor status, feeding patterns, other family pet illnesses, family and household structure, and then progress to eliciting information about the problem behavior itself, including the most recent incident, the second most recent incident and the third most recent incident. For elimination histories, the number, location, sizes, depths and types of litter boxes, litter, history of use of litter types, frequency of changing litter as well as scooping the litter and number of cats sharing the boxes is critical. Find out as much as you can about how the cat uses the box. What has the client observe? Knowing whether the culprit gets fully inside the box or not when using it, where the accidents are occurring is helpful in getting a picture of what is going on. Much of this can be done having the client fill in/check off history forms. Ask the client to draw a floor plan sketch of the home and have the client mark the location of the litter boxes, the doors and windows and where the cat is eliminating. A good time to have the client do this is while you are observing the cat interact with his/her environment and while you are reviewing the history questionnaire. Remember to observe how the cat and client interact. The history will take about 20-30 minutes to take, so hour or longer consultations are advisable. Be sure to charge accordingly.
Once the history has been taken, be sure to ask the client if there is anything else that they can think of that hasn't been covered by the questions. Throughout the questioning, give the client as much time to answer as possible. By this time, you should be noting some correlations between the cat's behaviors and the home environment (social, physical). These correlations will allow you and the client to test some theories in order to determine causality. Dr. Overall's text also includes algorithmic flow charts that are very useful once history has been obtained.
Elimination disorders can be categorized as being