Pandora syndrome: Rethinking our approach to idiopathic cystitis in cats - Veterinary Medicine
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Pandora syndrome: Rethinking our approach to idiopathic cystitis in cats
Cats with idiopathic cystitis often have multisystemic comorbidities, so look outside the urinary tract—as well as in the cat's environment—for diagnostic and therapeutic answers.


Litter boxes

Litter boxes should be provided in several locations throughout the house, particularly in multicat households. Placing litter boxes in quiet, convenient locations that provide an escape route for a cat if necessary may help improve conditions and encourage normal elimination behaviors. Since individual preferences for litter type have been documented, if different litters are offered, it is preferable to test the cat's preference by providing them in separate boxes. For cats with a history of urinary problems, unscented clumping litter should be considered. Litter boxes should be cleaned regularly and replaced; some cats are sensitive to dirty litter boxes. Litter box size and whether it is open or covered may also be important to some cats.15


Cats interact with both physical structures and other animals, including people, in their environment. The physical environment should include opportunities for scratching (both horizontal and vertical), climbing, hiding, and resting. Many cats prefer to monitor their surroundings from elevated vantage points, so climbing frames, hammocks, platforms, raised walkways, shelves, or window seats may appeal to them. Playing a radio to habituate cats to sudden changes in sound and human voices also may be useful, and videotapes to provide visual stimulation are available.


Some cats prefer to be petted and groomed, whereas others may prefer play interactions with owners. Cats also can be easily trained to perform behaviors (tricks); owners just need to understand that cats respond better to praise than to force and are more amenable to learning when the behavior is shaped before feeding. Cats may also enjoy playing with toys, particularly those that are small, move, and mimic prey characteristics. Many cats also prefer novelty, so a variety of toys should be provided and rotated or replaced regularly to sustain their interest.

Conflict management

When a cat's perception of safety becomes threatened, it responds by attempting to restore its perception of control.16 During such responses, some cats become aggressive, withdrawn, or ill.10 In my experience, intercat conflict commonly is present when multiple cats are housed indoors together and health problems are encountered.

Signs of trouble. Signs of conflict between cats can be open or silent. Cats in open conflict may stalk each other, hiss, and turn sideways with legs straight and hair standing on end to make themselves look larger. In contrast, signs of silent conflict can be easily missed: Threatened cats may avoid other cats, decrease their activity, or both. They often spend increasingly large amounts of time away from the family, stay in areas other cats do not use, or attempt to interact with family members only when the assertive cat is elsewhere.

Signs can result from two types of conflict: offensive and defensive. In offensive conflict situations, the assertive cat moves closer to the other cats to control the interaction. In defensive conflict situations, the threatened cat attempts to increase the distance between itself and the perceived threat. Although cats engaged in either type of conflict may spray or eliminate outside the litter box, I find that threatened cats are more likely to develop elimination problems.

Causes of conflict. A common cause of conflict between indoor-housed cats is competition for resources (e.g. space, food, water, litter boxes, perches, sunny areas, safe places where the cat can watch its environment, or attention from people). Conflict may develop even if no limitation to access to these resources is apparent to the owner. The cat's perception of how much control it wants over the environment or its housemates' behaviors determines the result.

Open conflict is most likely to occur when a new cat is introduced into the house or when cats that have known each other since kittenhood reach social maturity. Conflict occurring when a new cat is introduced is easy to understand, and good directions are available for introducing a new cat to the residents.17 However, clients may be puzzled by conflict that starts when one of their cats becomes socially mature or when a socially mature cat perceives that one of its housemates is becoming socially mature. When cats become socially mature, they may start to exert control over the social groups and their activities, which may lead to open conflict between male cats, between female cats, or between male and female cats. Although the cats involved in the conflict may never be best friends, they usually can live together without showing signs of conflict or conflict-related illness. In severe cases, a behaviorist can be consulted for assistance in desensitizing and counterconditioning the cats in conflict so they can share the same spaces more comfortably.

Treatment interventions. Treatment for conflict between cats involves providing a separate set of resources for each cat, preferably in locations where the cats can use them without being seen by other cats. That lets the cats avoid each other if they choose to without being deprived of any essential resource. Cats may require more space than the average house or apartment affords them. The addition of elevated spaces such as shelves, kitty condos, cardboard boxes, beds, or crates may provide enough three-dimensional space to reduce conflict to a tolerable level.

In severe situations, some cats may benefit from behavior-modifying medications. In my experience, medication can help when combined with environmental enrichment, but cannot replace it. Conflict also can be reduced by neutering all cats and by keeping all nails trimmed as short as practical. Whenever the cats involved in the conflict cannot be directly supervised, they may need to be separated. For example, the threatened cat could be provided with a refuge away from the other cats. This space should contain all necessary resources for the cat staying in it.

Conflict with other animals, dogs, children, or adults is relatively straightforward. In addition to being solitary hunters of small prey, cats are small prey themselves for other carnivores, including dogs. Regardless of how sure clients are that their dogs will not hurt their cats, to the cat, the dog may represent a predator. To ensure a cat's safety, it must be provided with avenues of escape that can be used at any time. For owners, it usually suffices to explain that cats may not understand rough treatment as play, but may perceive it as a predatory threat.

Most cats in urban areas in the United States are housed indoors and neutered, so conflict with outside cats occurs when a new cat enters the area around the house the affected cat lives in. To cats, windows offer no protection from a threatening cat outside. If outside cats are the source of the problem, a variety of strategies to make one's garden or yard less desirable to them are available.


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