August & September 2010

UrinatingOutside the Box: Medical or Behavioral Problem?

Dear Doctor:
I have a problem with my eight-year-old cat, Sammy. I have seen him urinating recently in our dining room and on our bed. He seems to be fine otherwise. How do I get him to stop doing this?

Signed,

Hans in Stevens Point

This is a relatively common problem that we see in our feline friends. We believe that cats will urinate outside of the litter box as a means of marking "territory", or as a sign of distress when they are not feeling well. As such, it is important to rule-out any medical problems before we assume that it is a behavioral issue. Because there are many points to consider for both medical and behavioral problems, the answer will be divided into two portions. This month, we will address the patient history, medical concerns and litter box management, and next month we will examine the role of stress for some cats, along with various treatment options.

We will typically start with a thorough history, asking about any changes in overall activity, appetite, or thirst for the patient. We will also determine where the cat is urinating, the amount of urine passed, if there is any vocalization or straining while urinating, or if blood is noted in the urine. A complete physical exam, along with an analysis of the urine, is the best starting point. In some patients, additional testing may include blood tests or x-rays if we suspect kidney disease, diabetes or urinary stones. The age of the cat may also dictate the type of testing performed.

If the examination and testing do not reveal a medical cause, then a behavioral issue may be present. We will typically start by discussing litter type, box location, number and type of boxes, and hygiene. Some cats do not like to try different brands of litter, so recent changes in litter type may be the problem. Most cats do not like to be disturbed in the area of the litter box; consequently, a box in a high traffic area or a noisy area (such as the laundry room) may stress the cat. If the cat is stalked or 'attacked" by another cat or dog in the house when coming out of the box, this can cause a cat to avoid using that box. Covered litter boxes may also be a problem for some cats, and boxes with tall sides can be difficult to maneuver for cats with arthritis. In terms of number of boxes, the general rule is one box per cat in the house, plus one additional box. Homes with multiple levels should have at least one box per level. Lastly, it is important to scoop the boxes a minimum of once daily. Even if your middle aged cat has not had a problem in the past several years with changing litters, box location, etc., I have seen many middle age or older cats that had their urinary habits return to normal by managing the litter boxes as discussed above. It does seem that their preferences can change as they get older.
Next month, we will continue to examine this topic, with a discussion of the role of stress for some cats, along with treatment considerations. Meanwhile, it would be ideal to take Sammy to your veterinarian for the initial evaluation.

Dear Doctor:
I have a problem with my eight-year-old cat, Sammy. I have seen him urinating recently in our dining room and on our bed. He seems to be fine otherwise. How do I get him to stop doing this? (see the first portion of the response on August 6, 2010)

Last month, we responded to this concern by discussing the medical history, basic laboratory testing, and litter box management issues. We also suggested that Sammy should visit his veterinarian to start the evaluation process.

If your veterinarian did not identify any medical problems, such as diabetes, kidney disease, bladder stones, or arthritis, and if the litter box management issues do not apply to Sammy, then we will also wonder whether anything may be causing stress for your cat. Obvious stresses include a recent move to a new home, bringing a new pet into the home (or the loss of a pet), changes in someone's work schedule, visitors, recent vacations without the pet, etc. Less obvious stresses may include relocating furniture or remodeling in the home. Sometimes an outside cat that roams the neighborhood may be stressing an indoor cat (your cat may see or smell the cat, even if you never spot the outside cat). And for some cats, a simple lack of play and social interaction can be stressful.

As such, some cats will urinate out of the box as a means to "mark territory", which is considered purely behavioral. However, some cats will have stress that actually causes physiological changes in the body. The physiologic changes will cause inflammation within the lining of the bladder, which is seriously painful for the cat. We believe that the affected cat will associate the painful urination with the litter box, so the cat starts to avoid the litter box in an effort to avoid the pain. Obviously, the pain persists anywhere the cat urinates, so it is essential to restore comfort as soon as possible.

The treatment approach may include medications, along with management of the environment. The latter includes use of cleaning agents specifically made to neutralize a cat's urine, as a cat will be more prone to return to an area that already smells like urine. We have also had good success with a natural pheromone, called Feliway. The pheromones are a natural calming agent for many cats, so the product is used in the environment as a room diffuser or a spray. I have also recently heard of a product called "Cat Attract", which is a litter additive designed to encourage cats to want to use the litter box. Although I do not have personal experience with this product yet, it has received favorable reviews by some.

In terms of medical management, there are a variety of treatments. Your veterinarian will make recommendations tailored to your cat, which may include medications to improve comfort by relieving inflammation and pain, or decreasing urinary spasms. In many cases, anti-anxiety medications will be prescribed.

Some cats respond quickly to treatments and environmental management techniques, while others may relapse periodically, and some never resume proper litter box habits. In my experience, the longer the behavior is allowed to continue, the more natural the behavior becomes for the cat. Early intervention is always best. Good luck with Sammy!