In this blog post, we have compiled the key highlights from the session titled “Lower Urinary Tract Diseases in Cats and Dogs”, presented by Dr. Erman Koral, held as part of VetSummit 2025: New Horizons in Veterinary Clinical Sciences, sponsored by the Kito Healthy Pet Nutrition Ecosystem. We would like to thank our speaker for the presentation.
Lower Urinary Tract Diseases: Accurate Diagnosis, Proper Interpretation, and Targeted Treatment
Lower urinary tract diseases are extremely common in clinical practice—so common that they can appear in one out of every five patients—yet they also represent a world where conditions easily overlap and get confused. In Transcript 11, Dr. Erman Koral presents a clear, practical roadmap that makes real-life work easier: look closely at the urine, collect it correctly, interpret the pH–sediment–ultrasound trio accurately, and then place the disease into the correct category.
1) Why Are Lower Urinary Tract Diseases Such a “Clinical Headache”?
Cystitis, crystal/stone problems, feline idiopathic cystitis (FIC) / FLUTD, and urinary incontinence in geriatric patients all originate in the same anatomical region and often arrive with very similar clinical signs.
That is why:
- they are seen very frequently,
- they are easily confused with one another,
- and they are often overlooked.
The lifetime prevalence rates shared by the speaker are striking: 14–20%. In practical terms, this means one out of every five patients visiting a clinic.
2) “Urine Is Gold”—But Only If You Collect It Correctly
Urine provides extremely valuable information. However, if the sample is collected incorrectly, we may misinterpret contamination as disease.
Two main collection methods:
Spontaneous urination / sample obtained by compression
- high risk of contamination from the urethra or vagina
- seeing bacteria does not automatically mean infection
Cystocentesis (preferably ultrasound-guided)
- minimal contamination
- the only correct method for culture and susceptibility testing
A clear statement from the speaker:
If you plan to send a culture, the sample must be collected via cystocentesis.
A crucial additional detail:
- bacteria in urine left at room temperature begin to die within one hour
- sediment begins to settle within 30 minutes
If you are not evaluating the sample immediately, send it to the lab right away.
3) The First Thing to Check on a Dipstick: pH
Normal canine and feline urine should be mildly acidic: pH 5.5–6.5 (maximum around 7).
If pH is elevated (7.5–9):
The first suspicion should be urinary tract infection, because many causative agents are urease-positive gram-negative bacteria
(E. coli, Klebsiella, Proteus, Pseudomonas, etc.)
→ they shift urine toward alkaline pH.
If pH is decreased (4.5–5.5):
Possible causes include:
- diabetes mellitus
- renal failure (loss of concentrating ability)
- very high-protein diets
- fever, prolonged fasting, intense exercise
In short: pH is the first directional signpost.
4) Protein, Glucose, Ketones: The “Three Siblings”
Protein (+)
Can originate from three sources:
- renal: glomerulonephritis, renal failure
- pre-renal: hypertension, fever, intense exercise
- post-renal: cystitis, bleeding, urine retention
Because blood and leukocytes also count as protein, false protein elevation is common in hematuria.
Glucose (+)
It is tempting to say “glucose always means diabetes,” but this is incomplete:
- diabetes is the most common cause
- leptospirosis (rarely)
- stress-induced glucosuria in cats is important
If you see glucose in a cat’s urine, never ignore stress as a possibility.
Acute pancreatitis may also increase glucose.
Ketones (+)
This is often the “next step after glucose.”
- diabetic ketoacidosis is the primary concern
- prolonged fasting
- low-carbohydrate diets
- pregnancy
If ketones are present, the case is no longer mild.
5) Knowing How to Read Sediment Is a Clinical Turbo Boost
A simple but effective protocol:
- centrifuge urine at 5000 rpm for 5 minutes
- place sediment on a slide and examine microscopically
Findings:
- RBCs: bleeding, stones, infection, trauma, neoplasia
- WBCs: suggests infection, but not proof alone
- bacteria: meaningful only if seen in cystocentesis samples
- epithelial cells:
- transitional: bladder/ureter inflammation, stones, infection
- squamous: distal urethral or vaginal contamination (increases with catheterization)
- renal epithelial: kidney-origin damage (AKI, tubular necrosis, etc.
- casts: if you see them, recognizing them is enough; the exact type often does not significantly change clinical decisions
6) Clinical Signs: Translate the Owner’s Words Correctly
- Dysuria: difficult urination
- Stranguria: painful urination (crying/meowing)
- Pollakiuria: frequent but small urinations
- Hematuria: blood in urine
- Periuria: urinating outside the litter box (very typical in cats)
- Nocturia: nighttime urination
- Pyuria: pus/inflammatory cells in urine
A key distinction:
- in diabetes, frequent urination = large volume
- in lower urinary tract disease, frequent urination = small volume repeatedly
7) Bacterial Cystitis: Common in Dogs, Less Common in Cats
Risk profile:
- more common in female dogs
- recurrent cases are more likely with diabetes, Cushing’s disease, or thyroid disorders
Key clinical tip:
If urolithiasis is present, bacteria are often present as well.
Stopping antibiotics too early while dissolving stones means giving underlying bacteria a chance to recur.
Diagnostic support:
- sediment: WBCs + bacteria + RBCs
- ultrasound:
- thickened and irregular bladder wall
- clots/sediment (“snow globe” or “rice grain” appearance)
Treatment logic:
Target gram-negative bacteria first:
- fluoroquinolones (enrofloxacin, marbofloxacin, ciprofloxacin)
Alternatives:
- amoxicillin–clavulanate
- trimethoprim–sulfonamide
- first-generation cephalosporins (cefadroxil, cefpodoxime)
- nitrofurantoin (concentrates in the bladder; an effective urinary antiseptic)
Important:
Do not combine fluoroquinolones with nitrofurantoin due to antagonism.
If recurrence occurs:
- fewer than 3 episodes/year → sporadic
- 3 or more episodes/year → recurrent/chronic
→ culture and susceptibility testing are mandatory.
8) Feline Idiopathic Cystitis / FLUTD: More Stress Than Bacteria
Feline idiopathic cystitis is:
- sterile (no bacteria)
- stress-related
- highly recurrent (~58%)
Typical clinical package:
pollakiuria + periuria + hematuria + stranguria/dysuria
Most important task: identify the stressor.
This is not “exam stress,” but micro-change stress:
- changes in feeding time, brand, bowl type
- changes in bowl location
- changes in litter box location or litter brand
- increased household traffic/noise
- a family member leaving or arriving
- renovations, new furniture, new electronics
- multi-cat households → resource competition
→ number of litter boxes and food stations should be at least the number of cats + 1
Diagnostic clue:
In FLUTD:
- urine is usually bacteria-free
- bladder wall thickening may be absent
- urine can appear completely clear
Treatment foundation:
Environmental modification (MEMO):
- quiet, safe resting areas
- feeding through puzzles/hunting-style enrichment
- scratching posts (horizontal and vertical)
- elevated observation spots
- water fountains / running water
- pheromone diffusers
If needed, medical support:
- analgesics
- anxiolytics/antidepressants (amitriptyline, fluoxetine, clomipramine)
- phenoxybenzamine if urethral spasm is present
9) Stones and Crystals: Match the Shape With pH
Struvite
- alkaline urine (pH 7.5–9)
- “coffin lid” crystals
- dissolves with urine acidification diets
- if resistant: acetohydroxamic acid
Calcium Oxalate
- acidic urine (pH 5–6)
- “envelope” or square-shaped crystals
- does not dissolve → prevention is key
- potassium citrate is very effective
- thiazides (hydrochlorothiazide) rarely used
Cystine
- hexagonal
- low-protein diet + potassium citrate
Urate / Ammonium Biurate
- yellow, “sea urchin-like” appearance
- associated with liver disease
- allopurinol + low-purine diet
Breed notes:
- Dalmatian / English Bulldog → urate and ammonium biurate may be considered “normal tendencies”
- Newfoundland / Terrier breeds / English Bulldog / Mastiff breeds → cystine more common
10) Prostate Problems: Present as Constipation, Detected Through Urinary Signs
When the prostate enlarges:
- compresses the colon → thin ribbon-like stool
- compresses the urethra → dysuria
- stiffness in hindlimb movement
- chronic cases may show preputial discharge (toothpaste-like)
On ultrasound:
- normally homogeneous and bright
- gray-black areas raise suspicion of prostatitis, cysts, or abscesses
Treatment:
Antibiotics that penetrate the prostate barrier
(clindamycin, trimethoprim–sulfonamide, chloramphenicol, third-generation cephalosporins)
For symptomatic benign prostatic hyperplasia: finasteride
11) Urinary Incontinence: Storage or Emptying Problem?
Storage disorder:
- leaking occurs while sleeping or lying down
- common in early-spayed females
- urethral sphincter mechanism incompetence (USMI) / lower motor neuron bladder
Emptying disorder:
- the patient urinates but cannot fully empty
- repeated attempts at short intervals
Quick treatment guide:
- USMI → phenylpropanolamine, estrogen
- emptying disorder → bethanechol, diazepam (sometimes acepromazine or cisapride)
- if there is a lower motor neuron hernia → surgery is necessary
12) Obstruction Is an Emergency: “Acute Kidney Injury Is Coming”
When obstruction occurs:
- the bladder fills
- back pressure travels to the kidneys
- risk of acute kidney injury and hyperkalemia rises
Practical tips:
If the catheter does not pass, attempt high-pressure flushing (20–50 ml syringe) using saline and appropriate solutions.
If unsuccessful, proceed with sedation and smooth muscle relaxation.
In hyperkalemia, glucose + insulin can rapidly reduce potassium levels.
Do not force aggressively before relieving pressure by emptying the bladder.
Final Message: Success in Lower Urinary Disease = Correct Classification
The essence of this session was clear:
- collect urine correctly
- interpret the pH–dipstick–sediment trio accurately
- complete the picture with ultrasound
- determine whether it is cystitis, FLUTD, stones, prostate disease, or incontinence
- select treatment accordingly
Lower urinary tract disease is not something solved by “just giving an antibiotic.”
If you correctly name what you are treating, half of the clinical work is already done.
We will continue sharing key takeaways from the sessions of VetSummit 2025: New Horizons in Veterinary Clinical Sciences, sponsored by the Kito Healthy Pet Nutrition Ecosystem. See you in our upcoming content that will support your clinical practice.
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