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Initial treatment factors associated with feline urethral obstruction recurrence rate: 192 cases (20042010)
Peter F . Hetrick, DVM, and Elizabeth B. Davidow, DVM, DACVECC

ObjectiveTo evaluate the association of treatment factors during initial urinary catheterization (IUC) of cats with recurrence of urethral obstruction at 24 hours and 30 days after catheter removal. DesignRetrospective case series. Animals192 male cats with urethral obstruction that were treated at an emergency and specialty center from 2004 through 2010. ProceduresData were obtained from the cats medical records. Duration of indwelling catheterization, catheterization with a 5F versus 3.5F urinary catheter, treatment with phenoxybenzamine versus prazosin, consistent administration of pain medication, and treatment with meloxicam or antimicrobials during IUC were reviewed for association with rate of recurrent urethral obstruction (rUO). ResultsOverall rUO rates were 10.94% (21/192 cats) at 24 hours and 23.57% (37/157 cats) at 30 days after IUC. At 24 hours and 30 days after IUC, rUO developed in 10 of 140 (7 .14%) and 20 of 110 (18.18%) prazosin-treated cats, respectively, compared with 10 of 46 (21.74%) and 16 of 41 (39.02%) phenoxybenzamine-treated cats, respectively. Reobstruction developed following use of a 5F or 3.5F urinary catheter in 11 of 58 (18.97%) and 7 of 105 (6.67%) cats, respectively, through 24 hours. There was no association between rUO and duration of urinary catheterization, administration of antimicrobials or meloxicam, or consistent administration of pain medication during IUC. Conclusions and Clinical RelevanceAt 24 hours and 30 days after IUC, rUO rates in prazosin-treated cats were signicantly lower than rates in phenoxybenzamine-treated cats. Reobstruction rate at 24 hours was signicantly lower when a 3.5F versus 5F urinary catheter was used. (J Am Vet Med Assoc 2013;243:512519)

eline UO is a common emergency, constituting 1.5% of all feline cases brought to 24 veterinary teaching hospitals in the United States and Canada between 1980 and 1999.1 Another study2 found that UO represented 9.0% of the annual feline emergency caseload at an emergency and referral center. At our emergency department from 2004 to 2010, cats with UO represented 4.63% of all feline cases evaluated and 8.11% of male cat cases. For cats, UO is a life-threatening but treatable emergency.2,3 The rate of survival to hospital discharge for affected cats is 93.6%.4 Treatment typically involves days of hospitalization and substantial owner investment with considerable potential for rUO following treatment.57 In a study6 reported in 1979, the combined rate of rUO and death as a result of rUO among cats was > 50%, with 74% of reobstructions developing in the rst 7 days following catheter removal. More recently, a long-term rUO rate of 36% to 43% has been reported.7 Another study8 found a 6-month rUO rate of 22%; however, that study excluded an additional 10% of cats that underwent perineal urethrostomy following
From Animal Critical Care and Emergency Services, 11536 Lake City Way NE, Seattle, WA 98125. The authors declare no conicts of interest. Address correspondence to Dr. Hetrick (phetrick@criticalcarevets. com). 512 Scientic Reports

ABBREVIATIONS
UO rUO Urethral obstruction Recurrent urethral obstruction

failed initial medical management. In a recent studya to evaluate rUO in cats, the recurrence rate was reported to be even lower (11.4%) in the 30 days following hospital discharge; however, cats that developed reobstructions during hospitalization were excluded, which may account for the lower recurrence rate observed in that study. Typical emergency treatment of cats with UO includes anesthesia, retrograde urethral ushing to relieve the obstruction, correction of uid and electrolyte disturbances, indwelling urethral catheterization with connection to a sterile closed collection system for a period of 24 to 48 hours, and administration of -adrenergic receptor antagonist medication to reduce urethral smooth muscle tone and pain medication; antimicrobials are administered when indicated.25,912 The effects of individual treatment factors such as the use of urinary catheters and treatments with antimicrobials, anti-inammatory drugs, and antispasmodic agents have been studied in healthy male cats, Beagles, and some cats with naturally occurring UO,1318 but only a study by Eisenberg et ala investigated whether duraJAVMA, Vol 243, No. 4, August 15, 2013

tion of indwelling urethral catheterization and hospitalization were associated with rUO. To our knowledge, there have been no clinical studies to examine the association of urethral catheter size or administration of opioids, NSAIDs, antimicrobials, or different -adrenergic receptor blocking medications with overall rUO rate in cats. The purpose of the study in cats reported here was to evaluate the association of treatment factors such as the size of the indwelling urinary catheter, duration of initial urinary catheterization, and medications administered during initial urinary catheterization with rUO rate during the rst 24 hours and 30 days after urinary catheter removal when, anecdotally, the risk for recurrent obstruction is highest. Materials and Methods Case selectionMedical records at the Animal Critical Care and Emergency Services were searched for feline cases given a diagnosis of urinary tract obstruction from January 2004 through December 2010. Cases selected for analysis were male cats with UO (not involving urolithiasis, neoplasia, or toxicosis) that were treated solely at Animal Critical Care and Emergency Services with an indwelling polyvinyl chloride catheter.b Records of cats for which a lateral radiographic or ultrasonographic view of the urinary bladder was not available were eliminated from further consideration. Cats in which urethral catheterization was attempted prior to referral, cats that were transferred with a urinary catheter in place, or cats that had been catheterized in the 7-day period preceding referral were removed from the study. Cats that were transferred to the care of the referring veterinarian prior to urinary catheter removal were also not included in the study. Medical records reviewRecords were retrospectively reviewed, and data collected for each cat included hospital admission date; age, body weight, rectal temperature, heparinized whole blood electrolyte and BUN concentrations at the time of admission; size of the indwelling urinary catheter; consistent treatment with opiate pain medication (dened as a minimum of 4 doses administered at least every 12 hours) during initial urinary catheterization; administration of meloxicam during initial urinary catheterizationc; treatment with prazosin or phenoxybenzamine (including dose, frequency, and duration of administration) during initial urinary catheterization; mean value of blood pressure measurements obtained at least 2 hours after administration of prazosin or phenoxybenzamine; administration of antimicrobials (including type, timing, and justication for antimicrobial use) during initial urinary catheterization; duration of urinary catheterization; and results of bacteriologic culture of a urine sample collected at the time of initial evaluation. Urinary tract infection at the time of initial evaluation was diagnosed on the basis of bacteriuria (detected via urinalysis) or positive results of bacteriologic culture of a urine sample. Samples of urine for bacteriologic culture were collected via urinary catheter or cystocentesis and plated on blood agar. After urinary catheter removal, cats were followed for 30 days to determine whether a reobstruction deJAVMA, Vol 243, No. 4, August 15, 2013

veloped. If rUO developed, the interval from catheter removal to detection of the reobstruction was recorded. The reobstruction data were based on original records and information obtained from follow-up phone calls, additional records at Animal Critical Care and Emergency Services, or records from the referring veterinarian during the 30-day period following urinary catheter removal. Additional follow-up telephone calls were made during the study to owners of cats for which complete follow-up information for the 24-hour period following urinary catheter removal was lacking. The time of catheter removal was designated as 0 hours. For purposes of analysis, the 24-hour follow-up group included cats that developed rUO and cats that did not develop rUO from 0 through 24 hours; the 30-day follow-up group included cats that developed rUO and cats that did not develop rUO from 0 hours through 30 days. Statistical analysisFor comparison of categorical data between groups of cats receiving different treatments, the 2 test for independence was used, and when indicated, the Yates correction was used.d Linear data were analyzed for normality by means of the ShapiroWilk test, and null hypothesis testing was performed by means of the Student t test for parametric data and the Wilcoxon rank-sum test for nonparametric data. Results were considered signicant at a value of P < 0.05. Statistical evaluations were performed with statistical software.e Results Five hundred fty-nine cases of feline UO were initially identied through a search of the medical record database. Three hundred sixty-seven cats were excluded on the basis of selection criteria; thus, 192 cases were available for data analysis. Reasons for case exclusion included urolithiasis (n = 57), transfer with a urinary catheter in place (54), transfer to the referring veterinarian for continued care prior to urinary catheter removal (49), catheterization within the 7-day period preceding referral (44), discharge from the hospital < 24 hours after urinary catheter removal and without follow-up (41), lack of a radiographic or ultrasonographic examination of the urinary bladder to detect calculi (26), treatment on an outpatient basis (25), euthanasia at initial evaluation (25), ability to urinate within the rst hour of administration of initial medications (7), female sex (7), cardiopulmonary arrest from the time of triage to the time of urinary catheter placement procedure (5), urinary bladder rupture (5), use of different urinary catheter type (4), UO secondary to neoplasia (4), incorrect diagnosis code (3), surgery after unsuccessful attempts to pass a urinary catheter (2), discharge from hospital without medical treatment (2), prior perineal urethrostomy (2), UO secondary to trauma (1), urethral tear (1), death prior to arrival after transfer (1), referral after undergoing cystotomy (1), and UO secondary to acetaminophen toxicosis (1). For the 192 cats that met the selection criteria, data for the 24-hour period following catheter removal were available. Thirty-day follow-up data were obtained for 157 of 192 (81.77%) cats. Cats without 30-day followup information included 26 cats for which no referring
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veterinarian records were obtained, 7 cats for which no referring veterinarian was listed, and 2 cats for which no further information was available through either Animal Critical Care and Emergency Services or from the referring veterinarian. Data for the 192 cases that met the initial selection criteria were analyzed. Cats with urethral plugs or idiopathic feline lower urinary tract disease were not differentiated. Among the 192 cats, 21 (10.94%) developed rUO in the rst 24 hours after urinary catheter removal. Overall, from the time of catheter removal through 30 days, 37 of 157 (23.57%) cats developed rUOs. Most rUOs (28/37 [75.68%] cats) developed within the rst 48 hours (day 1, 21 cats; day 2, 7 cats); by day 4, 32 of 37 (86.49%) cats had developed rUOs (day 3, 3 cats; day 4, 1 cat). An additional cat each developed rUO on days 8, 9, 11, 15, and 17. Seven of the 37 (18.92%) cats with reobstruction were euthanized. Age, rectal temperature, and body weight as well as the percentage of cats with azotemia or hyperkalemia at the time of admission to the hospital did not differ signicantly between cats that developed rUO and those that did not. During the period evaluated, there was a shift in treatment protocol that occurred in mid-2006 (Table 1). Prior to June 2006, cats with UO were treated primarily with phenoxybenzamine; after that time, prazosin was predominantly used as an antispasmodic. There was also a shift in use of other medications and catheter size. Before June 2006, meloxicam was commonly administered to cats with UO for analgesia, whereas after that time, use of buprenorphine was much more common. Two of 50 (4.00%) cats treated prior to June 2006 received both buprenorphine and meloxicam. Starting in June of 2006, 9 of 142 (6.34%) cats received both buprenorphine and meloxicam. The shift in protocol was associated with a signicant (P = 0.025) decrease in the incidence of rUO at 30 days, from 35.55% among the cats treated prior to the protocol change to 18.75% among the cats treated subsequent to the protocol change.

At 24 hours after removal of the urinary catheter, cats that began treatment with prazosin during the initial urinary catheterization had a signicantly (P = 0.006) lower rate of rUO (7.14%), compared with cats that began treatment with phenoxybenzamine (21.74%; Table 2). At 30 days after removal of the urinary catheter, cats that received prazosin during the initial urinary catheterization had a signicantly (P = 0.008) lower rate of rUO (21.74%), compared with cats that received phenoxybenzamine (39.00%; Table 3). In 6 cats, neither medication was used; data for these cats were compared separately. Oral administration of prazosin or phenoxybenzamine was typically started following recovery from initial anesthesia and continued for 1 week. The mean SD total duration of prazosin administration was 7.80 2.16 days, and that of phenoxybenzamine administration was 7.15 2.91 days. For 124 cats, the dosage of prazosin was 0.5 mg every 12 hours; for 5 cats, the dosage of prazosin was 0.5 mg every 8 hours. One 2.04-kg (4.49-lb) cat received 0.25 mg of prazosin every 12 hours, and 10 larger cats (6.12 to 10.25 kg [13.46 to 22.55 lb]) received 1 mg of prazosin every 12 hours. For 44 cats, the dosage of phenoxybenzamine was 2.5 mg every 12 hours. Another cat received 2.5 mg of phenoxybenzamine every 8 hours, and yet another cat received 4 mg of phenoxybenzamine every 12 hours. Blood pressure measurements taken at least 2 hours following the initiation of treatment with either medication were recorded. Following prazosin administration, the blood pressure variables of 66 cats were monitored, with a mean systolic arterial blood pressure of 139.65 24.80 mm Hg. In comparison, 12 cats were monitored following phenoxybenzamine administration, with a mean systolic arterial blood pressure of 138.64 29.39 mm Hg. The difference in mean values was not signicant (P = 0.900). Opioid pain medications were used consistently during hospitalization in 122 of 192 (63.54%) cats. Buprenorphine (113/122 [92.62%]) was the most commonly administered analgesic agent, followed by tram-

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Table 1Changes in treatment protocol for male cats with UO at an emergency and specialty center during the period of 2004 through 2010 (determined from medical records of 192 treated cats). Variable Urinary catheter size 3.5F 5F -Adrenergic receptor antagonist administered Prazosin Phenoxybenzamine Pain medication administered Buprenorphine Meloxicam Antimicrobials administered rUO At 24 h after catheter removal At 30 d after catheter removal Duration of catheterization (h) January 2004 through May 2006 18/43 (41.86) 25/43 (58.14) 0/50 (00.00) 45/50 (90.00) 6/50 (12.00) 18/50 (36.00) 23/50 (46.00) 9/50 (18.00) 16/45 (35.55) 30.82 10.55 June 2006 through December 2010 87/120 (72.50) 33/120 (17.50) 141/142 (99.30) 0/142 (00.00) 116/142 (81.69) 28/142 (19.72) 44/142 (30.99) 12/142 (8.45) 21/112 (18.75) 37.93 13.17

With the exception of duration of catheterization (mean SD), values represent the number of cats receiving the specied treatment/total number of cats in that time period (%). Six cats did not receive either -adrenergic receptor antagonist, and catheter size was not noted in the medical record of 29 cats. For the 2 phases, rUO rate at 30 days after catheter removal was signicantly (P = 0.025) different, but the difference at 24 hours after catheter removal was not signicant (P = 0.063). 514 Scientic Reports JAVMA, Vol 243, No. 4, August 15, 2013

Table 2Recurrence of UO at 24 hours after urinary catheter removal in male cats with UO treated at an emergency and specialty center during the period of 2004 through 2010 on the basis of whether they received treatment with antimicrobials, prazosin or phenoxybenzamine, meloxicam, or opioid pain medication during the initial urinary catheterization and placement of a 3.5F or 5F urinary catheter. Variable Antimicrobials administered Yes No -Adrenergic receptor antagonist administered Prazosin Phenoxybenzamine None Meloxicam administered Yes No Opioid pain medication administered Yes No Catheter size 3.5F 5F Total No. of cats 67 125 140 46 6 46 146 122 70 105 58 No. of cats with rUO (%) 9 (13.43) 12 (9.60) 10 (7.14) 10 (21.74) 1 (16.67) 5 (10.87) 16 (10.96) 13 (10.66) 7 (10.00) 7 (6.67) 11 (18. 97) P value* 0.417 0.006 0.045 1.000

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0.888 0.017

Data were derived from medical records for 192 cats. Urinary catheter size was not noted in the medical record of 29 cats. *For a given variable, P values are stated for the comparison between the 2 groups, unless otherwise stated. Value stated relates to the comparison between the cats that received prazosin and the cats that received phenoxybenzamine. Value stated relates to the comparison between cats that received prazosin, cats that received phenoxybenzamine, and cats that did not receive an -adrenergic receptor antagonist.

Table 3Recurrence of UO at 30 days after urinary catheter removal in male cats with UO treated at an emergency and specialty center during the period of 2004 through 2010 on the basis of whether they received treatment with antimicrobials, prazosin or phenoxybenzamine, meloxicam, or opioid pain medication during the initial urinary catheterization and placement of a 3.5F or 5F urinary catheter. Variable Antimicrobials administered Yes No -Adrenergic receptor antagonist administered Prazosin Phenoxybenzamine None Meloxicam administered Yes No Opioid pain medication administered Yes No Catheter size 3.5F 5F Total No. of cats 53 104 110 41 6 39 118 95 62 82 51 No. of cats with rUO (%) 14 (26.42) 23 (22.12) 20 (18.18) 16 (39.00) 1 (16.67) 10 (25.64) 27 (22.88) 21 (22.11) 16 (25.81) 14 (17.07) 16 (31.37) P value* 0.549 0.008 0.025 0.725

0.593 0.055

Data were derived from medical records for 157 of the 192 cats in Table 2. Urinary catheter size was not noted in the medical record of 24 cats. See Table 2 for remainder of key.

adol (4), fentanyl (2 transdermal patches and 1 continuous rate infusion), and oxymorphone (1). The mean buprenorphine dose was 0.010 0.003 mg/kg (0.005 0.001 mg/lb); 86 cats received a dose every 8 hours, and 27 cats received a dose every 12 hours. The mean duration of buprenorphine treatment was 4.20 1.57 days. There was no signicant difference in rUO rate at 24 hours or 30 days after removal of the urinary catheter between cats that received pain medication (Table 2) and those that did not (Table 3). In cats to which meloxicam was administered prior to urinary catheter removal, the rUO rate was not
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signicantly different at either follow-up time point (Tables 2 and 3). The mean initial dose of meloxicam was 0.093 0.029 mg/kg (0.042 0.013 mg/lb), with a mean of 3.64 1.99 doses daily. Antimicrobials were used during the initial urinary catheterization in 67 of 192 (34.90%) cats. Among these cats, the rate of rUO at 24 hours (Table 2) or 30 days following urinary catheter removal (Table 3) did not differ signicantly from the corresponding rate among cats that did not receive antimicrobials during the initial urinary catheterization. Treatments with antimicrobials were initiated for the following reasons: feScientic Reports 515

ver (n = 18), positive results of bacteriologic culture of a urine sample (14), presence of bacteriuria (14), suspected urinary tract infection (determined on the basis of urinalysis results; 4), initiation by a referring veterinarian (4), suspected pyelonephritis (3), microscopic detection of bacteria during a second urinalysis (2), difcult catheter placement (2), and pyuria (1); a reason was not specically stated for 5 cases. Amoxicillinclavulanic acidf was the antimicrobial most commonly administered orally (40 cats), followed by amoxicillin (18), enrooxacing (5), marbooxacinh (2), and cephalexin (1). One cat received only ampicillin-sulbactam.i Antimicrobials were administered for a range of 6 to 25 days. At initial evaluation, urinary tract infection was diagnosed in 41 of 192 (21.35%) cats on the basis of microscopic detection of bacteriuria (14/41) or positive initial results of bacteriologic culture of a urine sample (27/41). In the 24-hour period following urinary catheter removal, 4 of 41 (9.76%) cats with urinary tract infection developed rUO, compared with 17 of 151 (11.26%) cats without urinary tract infection. This difference in rUO rate was not signicant (Yates P = 1.000). For cats with 30-day follow-up information, reobstruction developed in 8 of 29 (27.59%) with evidence of initial infection versus 29 of 128 (22.66%) without evidence of initial infection (P = 0.572). For 183 of 192 (95.31%) cats, bacteriologic culture of a urine sample was performed at the time of initial catheterization; positive results were obtained for 27 (14.75%) cats. Escherichia coli was the most commonly cultured organism (13/27 cats); multiple bacteria types were obtained for 6 cats, Pasteurella spp were obtained for 3 cats, Staphylococcus sp was obtained for 1 cat, and Streptococcus sp was obtained for 1 cat. No organism identication was possible for 3 cats. Duration of indwelling urinary catheterization did not differ signicantly between cats with and without rUO. For the cats with rUO in the rst 24 hours after catheter removal, mean duration of catheterization was 36.31 14.86 hours; for those cats that were able to urinate, mean duration of catheterization was 36.05 12.69 hours. This difference in duration of catheterization was not signicant (P = 0.907). For the cats with rUO during the 30 days after catheter, mean duration of catheterization was 34.19 12.75 hours; for those cats that did not develop reobstruction, mean duration of catheterization was 35.22 12.07 hours. This difference in duration of catheterization was also not signicant (P = 0.669). The use of an indwelling 3.5F catheter was associated with a signicantly lower rate of rUO at 24 hours after urinary catheter removal, compared with ndings following use of a 5F catheter (Table 2). Through 30 days, the rate of reobstruction in cats that were treated with a 3.5F catheter was lower, albeit not signicantly (Table 3). Urinary catheter size was chosen at the clinicians discretion and was not noted in the medical records of 29 of 192 cats, including 24 of 157 cats for which follow-up information for the 30-day period after urinary catheter removal was available. Additional comparisons were made with combinations of catheter size, phenoxybenzamine adminis516 Scientic Reports

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Figure 1Percentage of cats with UO that received placement of a 3.5F urinary catheter and administration of prazosin (3.5+Pr), placement of a 3.5F urinary catheter and administration of phenoxybenzamine (3.5+Ph), placement of a 5F urinary catheter and administration of prazosin (5+Pr), or placement of a 5F urinary catheter and administration of phenoxybenzamine (5+Ph) during the initial urinary catheterization and subsequently did (dark gray bars) or did not (light gray bars) have rUO at 24 hours (A) and at 30 days (B) after urinary catheter removal. Values in each bar indicate the actual number of cats. In each panel, differences were signicant when all groups were compared (2 test of independence, Yates P = 0.029 [A] and Yates P = 0.017 [B]).

tration, and prazosin administration in cats for which these data were available (Figure 1). Not included in this analysis were cats for which catheter size was not noted in the medical record or to which neither of these medications were administered (24 hours after catheter removal, 34 cats; 30 days after catheter removal, 29 cats). The use of a 5F urinary catheter along with administration of phenoxybenzamine was associated with a signicantly higher rate of rUO than any other combination of catheter size and drug treatment. In the rst 24 hours after catheter removal, 7 of 23 (30.43%) cats that were treated with both phenoxybenzamine and a 5F catheter developed rUO, in contrast to 5 of 85 (5.88%) cats that were treated with prazosin and a 3.5F catheter (Yates P = 0.003). In the 30 days after catheter removal, 11 of 21 (52.38%) cats that were treated with both phenoxybenzamine and a 5F catheter developed rUO, whereas 11 of 64 (17.19%) cats that were treated with prazosin and a 3.5F catheter developed rUO (P = 0.001). Discussion Emergency treatment of UO has evolved since originally studied in 1979, but there is still considerable
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potential for rUO following medical management.3,7,8,a Studies6,7 have shown that rUO is most likely to occur within the rst 7 days following emergency treatment. In the present study, 32 of 37 (86.49%) rUOs in male cats developed in the rst 4 days after urinary catheter removal. The aim of this study was to evaluate initial treatment factors for association with short-term rUO rate, with the goal of identifying factors that could help reduce recurrence of UO in affected cats. The results of the study have suggested that administration of prazosin and use of a 3.5F urinary catheter were both associated with signicantly lower rates of rUO, compared with rates of rUO associated with administration of phenoxybenzamine and use of a 5F catheter. Overall, prazosin administration was associated with an rUO rate of 7.14%, whereas phenoxybenzamine administration was associated with an rUO rate of 21.74% (P = 0.006), through the rst 24 hours after urinary catheter removal. Through 30 days after urinary catheter removal, those rUO rates were 18.18% and 39.00%, respectively (P = 0.008). Treatment with these -adrenergic receptor antagonists is aimed at reducing urethral spasms, which are thought to play a major role in UO in cats,5,10,j without affecting detrusor muscle contractility.19 Phenoxybenzamine is a nonselective -adrenergic receptor antagonist that reduces urethral smooth muscle tone in healthy male cats.20 Although prazosin and phenoxybenzamine are both in the same drug class, prazosin has greater 1-adrenergic receptor afnity21; thus, it more specically decreases urethral smooth muscle contractility with fewer cardiovascular adverse effects when used in humans.1923 A few studies15,16,24,25 have looked at the effects of prazosin in small animals. In a study15 evaluating urethral pressure proles in healthy Beagles, administration of prazosin reduced urethral pressure to a greater extent than did administration of phenoxybenzamine. In a study16 of 3 cats with naturally acquired UO, treatment with prazosin (0.03 mg/kg [0.01 mg/lb], IV) and a skeletal muscle relaxant decreased urethral pressure proles; however, because of some variability among the 3 cats, this result was not signicant. Another study24 that used IV prazosin in anesthetized male cats revealed dose-dependent inhibition of experimentally induced increases in intraurethral pressure. In addition to its increased specicity for affecting the urethra, prazosin also has a more rapid onset of action, reaching peak circulating concentrations within a few hours after administration, whereas phenoxybenzamine can take several days to achieve its maximum effect.25 Prazosins more rapid onset may have been advantageous for cats in the present study for which mean urinary catheterization time was approximately 36 hours and 75.68% of rUOs developed in the rst 48 hours after urinary catheter removal. With regard to adverse effects, there was no signicant difference in blood pressure measurements between cats that received phenoxybenzamine and those that received prazosin in the present study. Additional -adrenergic receptor subtypes, such as 1A, have been identied and are thought to have even greater specicity for affecting urethral tissue.26 This has led to the development of at least 7 additional 1adrenergic receptor antagonist medications with greatJAVMA, Vol 243, No. 4, August 15, 2013

er specicity for affecting the urethra and prostate and fewer cardiovascular adverse effects.2123,2628 In studies in dogs,22,27,28 prazosin and 6 of these newer medications were all able to inhibit increases in intraurethral pressure, with variable dose-dependent cardiovascular effects. In cats, alfazosin has greater uroselectivity than does prazosin or doxazosin, although all 3 drugs appear to effectively inhibit experimentally induced increases in intraurethral pressure.24,29 Further studies are needed determine whether any of the newer medications would offer any clinical advantage for cats with UO. In the present study, size of the urinary catheter used had a signicant effect on rUO rate in the rst 24 hours following catheter removal; placement of a 5F catheter was associated with a rate of rUO that was > 2.5 times as high as that associated with placement of a 3.5F catheter (P = 0.017). In the 30-day period following urinary catheter removal, cats catheterized with a 5F catheter had 1.8 times as great a rate of reobstruction as did cats catheterized with a 3.5F catheter, although this difference was not signicant (P = 0.055). Both inammation and spasms are thought to play a major role in UO in cats,5 and urethral catheterization has been shown to incite inammation.18,30,31 A 5F catheter would have more forcible contact with the urethral mucosa, which may incite inammation and trigger more urethral spasms, thereby resulting in the higher rate of rUO associated with this larger catheter size. Cats catheterized with a 3.5F catheter had a low rUO rate independent of the -adrenergic receptor antagonist medication they received (Figure 1). All cats in the present study had polyvinyl chloride infant feeding tubes placed as urinary catheters. The feeding tubes were chosen because they are radiopaque, are exible, and have length measurements marked on them. A study30 of cats that had or had not been catheterized with similar 3.5F polyvinyl catheters or polypropylene catheters for 3 days revealed that urethral tissue from cats catheterized with polyvinyl catheters was difcult to distinguish microscopically from that of cats that had not been catheterized, whereas cats catheterized with polypropylene catheters had signicantly more urethral inammation (determined via histologic examination). Additional studies would be needed to make conclusions about red rubber or other types of urinary catheters currently in use. During the period in which the cases reviewed for the present study were seen, there was a shift away from use of 5F urinary catheters. The reason for that shift is unknown because urinary catheter size was chosen at the individual clinicians discretion. In the case series of this report, there were many variables that affected duration of urethral catheterization of the cats, including owner choice, azotemia, gross appearance of urine during catheterization, patency of the urethral catheter, and clinical appearance of patients. As a result, there was wide variability in the duration of catheterization. There was also a noticeable change toward longer catheterization times after mid2006. Despite the wide variability in duration of catheterization in the present study, there was no signicant difference in the duration of catheterization between cats with and without rUO. These results are contrary
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to those of a recent investigation,a which indicated that a shorter duration of catheterization and hospitalization was associated with a higher rate of rUO. This difference in study ndings may be in part explained by a difference in study populations, considering that the present study included cats that developed reobstruction during hospitalization and that other studyk did not. Initial factors that were not associated with signicant differences in rUO rate included evidence of bacterial cystitis at the time of admission and administration of antimicrobials, consistent use of pain medication, or administration of meloxicam during initial urinary catheterization. Despite these ndings, administration of opioid pain medication is recommended to help relieve discomfort associated with catheterization. Meloxicam was originally used to diminish pain and inammation of the urethra. However, NSAIDs cause a dose-dependent reduction in prostaglandin concentrations, which can lead to reductions in renal blood ow. In late 2010, the manufacturer changed the product labeling for meloxicam with the warning that repeated administration of that drug has been associated with acute renal failure and death in cats. In the present study, treatment with meloxicam was not associated with any change in rUO rate. Given the label warnings and the fact that a reduction in renal blood ow and ischemic injury to the kidneys may have already developed as a result of UO,32 administration of meloxicam to cats with UO is not recommended. During the present study, there was another change in the treatment protocol for cats with UO over time, namely an abrupt switch from treatment with phenoxybenzamine to treatment with prazosin in mid-2006. There were also shifts in other medications administered, length of catheterization, and urinary catheter size. During the years in which the cases included in the study were seen, there could have been changes to the cat population, the disease process, or other unidentied factors that inuenced the rate of rUO. However, the shift in protocol also highlights the inuence that changes to initial treatments can have on 30-day outcomes for cats with UO. In the present study, urolithiasis was considered ruled out on the basis of ndings of either radiographic or ultrasonographic examination of the urinary bladder. This was a potential source of error because calculi and neoplasia may not be detected via radiography or ultrasonography, which was often performed by emergency staff clinicians with variable skill levels. This type of error could have potentially increased the observed rUO rate because both calculi and cystic neoplasia would be expected to increase the risk of reobstruction. Given the retrospective nature of the present study, sources of error also include removal of cases because of incomplete follow-up information or owners who moved or decided to change their regular veterinarian. Preventative strategies that were applied by owners after their pet was discharged from the hospital were not tracked. Variability in follow-up recommendations and owner compliance may have affected rUO rate. In addition, treatments were not standardized for all cats. There was substantial variability in medications used,
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dosages, and timings of administration. For example, according to the medical records of cats included in the present study, several antimicrobials were administered, and antimicrobial treatments were started at various points during the initial urinary catheterization. Administrations of opioid pain medication also varied considerably with regard to dose, frequency, and duration of treatment. Treatments with phenoxybenzamine and prazosin were the least variable, with most cats receiving the selected drug at the same dose and frequency of administration for a mean duration of 1 week. Randomized prospective studies would be needed to fully substantiate these ndings. The aim of the present study was to evaluate the effects of initial treatment factors on the recurrence rate of UO during the rst 24 hours and 30 days after urinary catheter removal in male cats with UO. Whenever a cat develops a urethral reobstruction, there is additional potential for complications, further hospitalization is necessary, and overall prognosis for the patient is worse. Repeated catheterization increases the risk for urethral trauma and complications,18,31 and perineal urethrostomy surgery is often considered.33 In addition, data from the present study indicated that 25 of 559 (4.47%) cats with UO were euthanized at the time of the initial evaluation; cats with rUO had a higher incidence of euthanasia (7/37 [18.92%]). The ndings of this retrospective study have suggested that the use of a 5F polyvinyl urinary catheter combined with administration of phenoxybenzamine was associated with a rate of rUO at 24 hours that was 5.2 times higher and a rate at 30 days after urinary catheter removal that was 3 times higher than the rate following use of a 3.5F polyvinyl catheter combined with administration of prazosin. Thus, a few simple changes in emergency treatment protocol could have a major impact in reducing shortterm rUO in cats.
a. Eisenberg B, Allen S, Aloisio K, et al. Evaluation of factors associated with prolonged and recurrent clinical signs in cats with urethral obstruction (abstr), in Proceedings. 17th Int Vet Emerg Crit Care Symp 2011;726. Tyco Healthcare Group LP , Manseld, Mass. Metacam, Boehringer Ingelheim Vetmedica Inc, St Joseph, Mo. Calculation for the chi-square test: an interactive calculation tool for chi-square tests of goodness of t and independence, Preacher KJ, Vanderbilt University, Nashville, Tenn. Available at: www.quantpsy.org/chisq/chisq.htm. Accessed Apr 4, 2011. R, version 2.1.3.0, R Foundation for Statistical Computing, Vienna, Austria. Available at: www.r-project.org/. Accessed Apr 13, 2011. Clavamox, Pzer Inc, New York, NY. Baytril, Bayer Corp, Pittsburg, Pa. Zeniquin, Pzer Inc, New York City, NY. Unasyn, Sandoz Inc, Princeton, NJ. Cooper E. Feline urethral obstruction (abstr), in Proceedings. 17th Int Vet Emerg Crit Care Symp 2011;135138. Eisenberg B, Massachusetts Veterinary Referral Hospital, Woburn, Mass: Personal communication, 2011.

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b. c. d.

e. f. g. h. i. j. k.

References
1. 2. Lekcharoensuk C, Osborne CA, Lulich JP . Evaluation of trends in frequency of urethrostomy for treatment of urethral obstruction in cats. J Am Vet Med Assoc 2002;221:502505. Osborne CA, Kruger JM, Lulich JP , et al. Medical management of feline urethral obstruction. Vet Clin North Am Small Anim Pract 1996;26:483498. JAVMA, Vol 243, No. 4, August 15, 2013

3. 4.

5. 6. 7. 8. 9. 10. 11. 12.

13.

14. 15. 16.

17. 18.

Burrows CF , Bove KC. Characterization and treatment of acidbase and renal defects due to urethral obstruction in cats. J Am Vet Med Assoc 1978;172:801805. Lee JA, Drobatz KJ. Characterization of the clinical characteristics, electrolytes, acid-base, and renal parameters in male cats with urethral obstruction. J Vet Emerg Crit Care 2003;13:227 233. Cooper ES, Owens TJ, Chew DJ, et al. A protocol for managing urethral obstruction in male cats without urethral catheterization. J Am Vet Med Assoc 2010;237:12611266. Bove KC, Reif JS, Maguire TG, et al. Recurrence of feline urethral obstruction. J Am Vet Med Assoc 1979;174:9396. Gerber B, Eichenberger S, Reusch CE. Guarded long-term prognosis in male cats with urethral obstruction. J Feline Med Surg 2008;10:1623. Segev G, Livne H, Ranen E, et al. Urethral obstruction in cats: predisposing factors, clinical, clinicopathological characteristics and prognosis. J Feline Med Surg 2011;13:101108. Rieser TM. Urinary tract emergencies. Vet Clin North Am Small Anim Pract 2005;35:359373. Drobatz KJ. Urethral obstruction in cats. In: Bonagura JD, Twedt DC, eds. Kirks current veterinary therapy XIV: small animal practice. Toronto: WB Saunders Co, 2009;951954. Hostutler RA, Chew DJ, DiBartola SP. Recent concepts in feline lower urinary tract disease. Vet Clin North Am Small Anim Pract 2005;35:147170. Westropp JL, Bufngton CAT, Chew D. Feline lower urinary tract disease. In: Ettinger SJ, Feldman EC, eds. Textbook of veterinary internal medicine. 7th ed. St Louis: Elsevier Saunders, 2009;18281850. Marks SL, Staeter-Knowlen IM, Moore M, et al. Effects of acepromazine maleate and phenoxybenzamine on urethral pressure proles of anesthetized, healthy, sexually intact male cats. Am J Vet Res 1996;57:14971500. Barsanti JA, Shotts EB, Crowell WA, et al. Effect of therapy on susceptibility to urinary tract infection in male cats with indwelling urethral catheters. J Vet Intern Med 1992;6:6470. Fischer JR, Lane IF , Cribb AE. Urethral pressure prole and hemodynamic effects of phenoxybenzamine and prazosin in nonsedated male Beagle dogs. Can J Vet Res 2003;67:3038. Straeter-Knowlen IM, Marks SL, Rishniw M, et al. Urethral pressure response to smooth and skeletal muscle relaxants in anesthetized, adult male cats with naturally acquired urethral obstruction. Am J Vet Res 1995;56:919923. Kalkstein TS, Kruger JM, Osborne CA. Feline idiopathic lower urinary tract disease. Part IV. Therapeutic options. Compend Contin Educ Pract Vet 1999;21:497509. Smith CW, Schiller AG, Smith AR, et al. Effects of indwelling urinary catheters in male cats. J Am Anim Hosp Assoc 1981;17:427433.

19. Lepor H. The emerging role of alpha antagonists in the therapy of benign prostatic hyperplasia. J Androl 1991;12:389394. 20. Mawby DI, Meric SM, Crichlow EC, et al. Pharmacological relaxation of the urethra in male cats: a study of the effects of phenoxybenzamine, diazepam, nifedipine and xylazine. Can J Vet Res 1991;55:2832. 21. Yamaguchi T, Nagano M, Osada Y. Effects of different alpha-1 adrenoceptor blockers on proximal urethral function using in vivo isovolumetric pressure changes. J Smooth Muscle Res 2005;41:247256. 22. Brune ME, Katwala SP , Milicic I, et al. Effect of duxosin, an antagonist selective for alpha1A- and alpha1D- adrenoceptors, on intraurethral and arterial pressure responses in conscious dogs. J Pharmacol Exp Ther 2002;300:487494. 23. Lane IF , Westropp JL. Urinary incontinence and micturition disorders: pharmacologic management. In: Bonagura JD, Twedt DC, eds. Kirks current veterinary therapy XIV: small animal practice. Toronto: WB Saunders Co, 2009;955959. 24. Lefvre-Borg F , OConnor SE, Schoemaker H, et al. Alfuzosin, a selective alpha 1-adrenoceptor antagonist in the lower urinary tract. Br J Pharmacol 1993;109:12821289. 25. Plumb DC. Phenoxybenzamine. In: Plumbs veterinary drug handbook. 7th ed. Stockholm, Wis: Pharma Vet Inc, 2011;1087 1089. 26. Yoshida M, Kudoh J, Homma Y, et al. Safety and efcacy of silodosin for the treatment of benign prostatic hyperplasia. Clin Interv Aging 2011;6:161172. 27. Ohtake A, Sato S, Saitoh C, et al. Effects of tamsulosin on hypogastric nerve stimulation-induced intraurethral pressure elevation in male and female dogs under anesthesia. Eur J Pharmacol 2004;497:327334. 28. Tatemichi S, Tomiyama Y, Maruyama I, et al. Uroselectivity in male dogs of silodosin (KMD-3213), a novel drug for the obstructive component of benign prostatic hyperplasia. Neurourol Urodyn 2006;25:792799. 29. Yang ZH, Ren LM, Wu ZJ, et al. Selective effects of alfuzosin and doxazosin with intraduodenal administration on urethral pressure of cats. Zhongguo Yao Li Xue Bao 1999;20:431434. 30. Lees GE, Osborne CA, Stevens JB, et al. Adverse effects caused by polypropylene and polyvinyl feline urinary catheters. Am J Vet Res 1980;41:18361840. 31. Smarick S. Urinary catheterization. In: Silverstein DC, Hooper K, eds. Small animal critical care medicine. St Louis: Elsevier Saunders, 2008;603606. 32. Bartges JW, Finco DR, Polzin DJ, et al. Pathophysiology of urethral obstruction. Vet Clin North Am Small Anim Pract 1996;26:255264. 33. Corgozinho KB, de Souza HJM, Pereira AN, et al. Catheterinduced urethral trauma in cats with urethral obstruction. J Feline Med Surg 2007;9:481486.

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