Monday, December 19, 2011

Feline Inappropriate Urination: Acting out all over the house!

When medical issues have been ruled out, and husbandry issues have been resolved, if a cat is still eliminating outside the box, it is likely to be due to a behavioral issue.  Unfortunately, while litterbox environment and medical issues are relatively straightforward to address, behavioral issues can be complicated.

New furniture can stress your cat.
One of the most common causes of behavioral inappropriate elimination is stress. Stress can come from a variety of sources.  It can be due to a bold or aggressive animal re-establishing his territory or a timid, shy animal urinating because he is a “victim” of his social environment (being passive-aggressive). A change to the household that disrupts the cat’s schedule may also be a contributing factor to a cat choosing not to use the litterbox -- such as a new baby, visitors staying in the home, a child going off to college, a change in someone’s work schedule, a move to a new home, new furniture, a new pet, a family vacation, renovations to the home, a visit from a plumber or other repair-person, etc. In some cases, the behavior will resolve on its own after the event (such as vacations, visitors, and renovations), and in other cases, the behavior may be ongoing (new furniture, a baby, a new home). Each type of stressor may have several solutions.

For example:
If your cat eliminates inappropriately when you go on vacation, you may find that you can curb the behavior by boarding the cat while you are gone, hiring an in-home sitter versus having a neighbor stop by the house once or twice daily, or by taking your cat with you. Discussions with your veterinarian may even lead to recommendations for medicinal therapy while you are gone to alleviate anxiety.

If you are planning on getting a new pet or having a baby, preparing your cat for the new addition may head off any potential behavioral issues. Also, making sure to introduce the new pet to the resident cat on a gradual basis will help lessen the stress your cat may feel about a new addition.

When planning to move to a new home, it is often helpful to establish the cat in the new home prior to moving day, if possible, so that their first exposure to the new home is not amidst chaos. If your cat can be set up in a room with all his familiar things and you can avoid moving things into that room right away, that will also help. If your cat can’t be moved ahead of time, then moving your cats into a room that will be little-disturbed on moving day, such as a bathroom or walk-in closet may also help. Let the cat become accustomed to the moving-day room before allowing him out to explore the whole house. That way, if something about the new house is frightening, he has a safe place to retreat to.

Sometimes inappropriate elimination can become so ingrained in a cat that even once the stress has been removed, the behavior continues. If this is the case it is a good idea to seek advice from your veterinarian as to how to re-train your cat. 

Spraying posture - standing near a vertical surface, tail erect
If a cat chooses to eliminate near a door or window, it is likely that either the presence of feral/stray or wandering neighbor cats may be causing your cat stress, anxiety or frustration or stimulating your cat to mark his territory and warn off these tresspassers. It is important to determine if your cat is urinating or spraying, as these behaviors are approached differently. Spraying is generally performed in a standing position with the tail raised, and the urine is deposited on a vertical surface such as a wall or piece of furniture (though it may run down the wall and puddle on the floor). Spraying tends to deposit small amounts of urine as compared to the size of the urine clumps you find in the litterbox. The tail may appear to quiver or vibrate. When your cat is urinating, he will squat and deposit a large amount of urine on a horizontal surface.
Urinating posture - squatting

It is most commonly the male cat that sprays, but it is not unheard of for female cats to spray, also. Spaying and neutering your cats will help prevent this issue in most cats, as the lack of male and female hormones will dull the desire to mark and maintain territory, and the need to advertise sexual availability – which are the primary reasons that cats urine mark. However, about 10% of neutered males and 5% of neutered females also spray. In households with more than seven cats, the likelihood of spraying is high. 

If outside cats frustrate your cat, you may be able to address the problem by discouraging stray cats from visiting your house. A plant called Coleus canina, also known as the “scaredy cat plant” or the “pee-off plant” is a deterrent to cats, dogs and foxes. Coleus plants are those that you often see with brightly colored leaves. This species of Coleus has green foliage and small, spikes of pretty blue flowers in the summer. The plant only smells to the human nose when touched. In Michigan, Coleus plants are annuals, but can easily be propagated and cuttings can be kept in a frost-free place over winter. They prefer a dry, sandy soil and lots of sunlight and should be planted every 1-2 yards for best results.
Coleus canina flower

Cats also hate the smell of the herb rue. It has beautiful blue-tone leaves and tiny yellow flowers. Cats are also usually deterred by the smell of citrus, so placing orange or lemon peel in your yard may help deter strays. Similarly, coffee grounds, blood meal, cayenne pepper, lavender oil, lemon grass oil, citronella oil, peppermint oil and eucalyptus oil can be used near areas where outdoor cats like to hang out.

Avoid feeding birds or squirrels in your yard if your cat is bothered by stray cats.

Motion detectors that trigger sprinklers can be used to deter them from coming onto your property. Additionally, you can discourage your cat from looking outside by closing blinds or shades, or making the windowsill inaccessible. Double-sided tape, tin foil or strips of carpet runner on the sill may also deter your cat. 

Spraying can also result from territorial disputes between cats in the same household. They may need to be separated and reintroduced slowly, using food treats to reward and encourage peaceful behavior. This re-introduction can successfully develop good relations between cats in some cases, even if the spraying has been going on for a long time.

While the presence of other cats, lack of access to prey species or sexual maturity are the most common reasons that cats perform spraying behavior, other causes can be new or unfamiliar scents in the home (such as new furniture, or digging out the Christmas tree from the attic or bringing a live tree into the home) or frustration due to lack of mental stimulation. Often, spraying new items with a pheromone called Feliway can help lessen your cat’s desire to mark. This product mimics the scent of cat cheek gland secretions. Many cats will not spray on areas that have this scent. Increasing the amount of playtime for an under-stimulated cat may help ease frustration.

Behavior-related elimination issues are often addressed with anti-anxiety medications, such as Prozac (fluoxetine), BuSpar (buspirone), Elavil (amitriptyline), and Clomicalm (clomipramine). Anxitane is a neutraceutical (nutritional therapy) supplement of L-Theanine that has also been shown to aid in decreasing anxiety in cats. Medications are useful in helping to decrease behavioral inappropriate elimination, but they should always be used in conjunction with changes to the home or other environmental changes with the goal of hopefully weaning the cat off the medication, if possible.
More information about inappropriate elimination:
Lovin' the Litterbox: Husbandry Reasons Why Your Cat May Not Use the Litterbox
Kidneys and Crystals and Stones, Oh, My! Medical Reasons Why Your Cat May Not Use the Litterbox
Breaking the Cycle of Smell: How to Stop Habitual Elimination Problems

Friday, December 9, 2011

Feline Inappropriate Elimination: Kidneys and Crystals and Stones, oh my!

Struvite crystals
Struvite crystals in urine - the most common type we see
Even if your cat is currently using the litterbox and not eliminating elsewhere, he or she may be visiting the litterbox less frequently than necessary, which can lead to urination issues down the road. We strongly recommend making your cat's litterbox situation as ideal as you can to help prevent urination issues.

Why is it a bad idea to urinate infrequently? If a cat holds his urine in his bladder for a long period of time, the urine becomes more concentrated. Concentrated urine has more “stuff” in it – more cells, more protein, more body by-products, etc. and the more stuff that is in the urine, the more likely it is to stick together and form crystals and stones. Urinary crystals and stones are uncomfortable and can lead to some of the medical reasons why cats avoid the litterbox.

This is one of the reasons that, even if we suspect a medical issue, we will discuss ways in which you can make your litterboxes more pleasant for your cats. Many of the elimination problems we see are complex and may have several contributing issues that need addressing. Treating the medical condition in conjunction with making changes to the litterbox will often speed your cat's recovery, and encourage them to return to the litterbox sooner.

**NOTE: many times, a cat will not 100% stop using the litterbox - they are fastidious about their environment and instinctively want to use the box. Most cats will use the box sometimes and eliminate elsewhere other times, so just because your cat is still going in the box sometimes doesn't mean that there isn't a medical problem. Also, just because your cat has always used the litterbox before doesn't mean that there isn't something about the box they don't like. Again, cats want to use the box, so are often very tolerant about litterbox situations that they consider to be sub-par - they just go less frequently, or they tolerate the box as-is until something else in their life changes.**

There are a number of medical reasons why a cat will stop using the litterbox:

Urinary crystals look like sand
Once removed from the bladder and dried, crystals look like sand.
--Urinary crystals or stones: Crystals and stones can be found in any part of the urinary system – the kidneys, the ureters, the bladder or the urethra. In male cats, these situations can quickly become an emergency, as clumps of crystals or small stones can become lodged in the tiny tube that leads from the bladder to the outside of the body (the urethra). This blocks the passage of urine, which means that the urine has nowhere to go, except to backup towards the kidneys. This causes the kidneys to start to shut down, since they can’t pump out any more urine. We call these cats “blocked cats”. Their bladders feel hard and firm, their bellies are tender, and the bladder can be in danger of breaking, like an over-inflated balloon. These kitties may be straining in the litterbox and not producing anything, or may just dribble a few drops of urine in the box. They are painful and may not eat, or may vomit near the litterbox. Again, this is an emergency, and a cat in this situation should be seen by a veterinarian as soon as possible!

Urinary crystals tend to show up well with an ultrasound but not on x-ray. Urinary stones will often show up questionably on ultrasound but will show up better on x-ray. There are a rare few stones that will not show up on x-ray, however (we call these "non-radiodense" or "non-radio-opaque" stones). Because of this, if the presence of a stone is suspected, it may be recommended or necessary to do both an x-ray and an ultrasound to confirm its presence. Because of the size of urinary stones, it is not likely that they can be diagnosed with just a urinalysis because they will not pass out of the bladder.

X-ray of a urinary bladder with stones
A urinary bladder full of stones.
Sometimes, a cat may show no real indication of bladder stones or bladder discomfort.  One of our technicians, Jennifer, has a cat named Marley whose only indication that he had stones in his bladder was that he stopped squatting in the litterbox.She was frustrated because he was standing in the box and urinating a good stream of normal-looking urine over the edge of the box. She thought that he was having problems with hip arthritis, but when the x-rays were taken, the hips looked normal and there were 9 stones visible in the bladder! A quick urinalysis indicated that there was microscopic blood in his urine but no crystals or infection. Shortly after that, he had surgery to remove the stones from his bladder (a cystotomy) and after he recovered from surgery, he started squatting to urinate again. He must have felt so much better!

For females, the situation is less dire, but the symptoms are similar – straining in the box, you may see bloody urine, dribbling, crying in the litterbox, or inappropriate elimination.

X-ray of a cat with kidney stones
Dr. Bailey's cat, Tic Tic, has kidney stones in both kidneys.
If the stone is in the kidney, it is less treatable. In some cases, the stone may pass out of the kidney and become stuck in the tube that goes from the kidney to the bladder (the ureter). In this case, the kidney may stop working. In other cases, the stones are so big they will not pass, but surgical removal involves the risk of damaging the kidney's delicate filtration structures. In some situations, a change in diet can help dissolve the stones, or if the stones are limited to one kidney, the kidney can be removed.

These problems are one of the reasons that we recommend that cats eat 6-9 oz canned food daily. Canned food helps dilute the urine and helps prevent the formation of crystals and stones.

X-ray of a constipated cat
This x-ray is of a cat that is severely constipated.
--Constipation: Cats that cannot pass stool are uncomfortable, and may strain unproductively in the litterbox, only to defecate elsewhere later. They also may vomit near the litterbox. They may pass small amounts of diarrhea around a solid stool that they cannot pass. Some of these symptoms may be easily confused with straining to urinate, or a blocked cat, so don't feel bad if you call for an appointment for straining to urinate and discover your cat is constipated, and don't assume that your straining cat is constipated only to find out later when your cat is very ill that he was blocked.

Cats with a history of urinary crystals or stones should have a urine sample and/or x-rays checked every 6-12 months for the rest of their lives in order to prevent recurrence. They should also eat canned food only to help keep their urine dilute and the pH more neutral to help prevent recurrence. If your cat absolutely will not eat canned food and has a history of urinary crystals or stones, a prescription-grade dry diet may be necessary.

For these reasons, it is good to occasionally monitor your cat's behavior in the litterbox and become familiar with what is normal for your cat, so that if something changes and you become concerned, you can describe it accurately to the veterinarian.

--Diabetes: Cats with undiagnosed or uncontrolled diabetes drink large amounts of water and also urinate large volumes. These cats may not be able to get to the litterbox in time to urinate, or they may object to a flooded litterbox that has not yet been scooped. They may also just not feel well and choose to urinate elsewhere because they feel poorly. Cats with diabetes also tend to eat well but lose weight. Long-term, uncontrolled diabetes can lead to a life-threatening situation called Diabetic Ketoacidosis (DKA), which usually requires hospitalization and intensive care.

--Hyperthyroid disease: Cats with overactive thyroid glands also drink a lot and urinate a lot. These cats have an overactive metabolism – high heart rate, increased hunger, weight loss, and often high blood pressure. Just like diabetics, they may not be able to get to the litterbox in time to urinate, may flood the box and then not want to use it again, or may just feel poorly and choose to urinate elsewhere as a result. Sometimes, these cats also have soft stools, and may defecate outside the litterbox. They also tend to have high energy levels and may “talk” a lot, especially at night (we call this "inappropriate vocalization"!).

--Kidney Disease: Cats can lose up to 75% of their kidney function before they start to show signs of illness. Like diabetics and hyperthyroid cats, these cats will usually drink more and urinate more, but they are more likely to feel poorly and eat less. Because their kidneys are not filtering the toxins from their bodies normally, the waste products of normal life tend to build up in the blood stream and cause them to feel nauseous and lackluster. Just like diabetics, they may not be able to get to the litterbox in time to urinate, may flood the box and then not want to use it again, or may just feel poorly and choose not to urinate in the box.

Bacterial culture growing bacteria
Bacterial culture is a very good way to help I.D. bacteria in the urine.
--Urinary tract infection: Occasionally, cats will develop a bacterial infection in their bladders. This could be due to poor grooming around the rear end, often due to weight issues. Some cats are naturally susceptible to urinary tract infections, or may become more susceptible due to a medical issue, such as diabetes. Normal urine is sterile while in the bladder. It isn't until the urine passes out of the body that it picks up bacteria. Because of this, the best way to collect the sterile urine is with a needle inserted into the bladder. Any urine that passes through the urethra will have bacterial contaminant from the external genitalia and fur.

Sterile urine collected directly from the bladder will not grow bacteria on a culture plate. Urine that has an infection will grow in little dots and lines called "colonies" - usually in less than 24 hours. These colonies can then be easily classified by looking at them under the microscope and noting their patterns of growth, as well as the color and smell of the colonies. Some antibiotics work better for some types of bacteria than others, and the doctors can make better decisions about which medication will best treat the infection. In some recurrent cases where the cat is hard to medicate or has not been fully treated in the past, the culture plate may need to be sent in to a reference laboratory for more specific testing (called a "culture and sensitivity") that includes testing for antibiotic sensitivity or resistance.

It is also because of antibiotic resistance that antibiotics should be given regularly for the entire course of the prescription, and not stopped when the symptoms of the infection go away. A few individual bacteria that linger can become a whole new infection that is stronger and more resistant. Some cats that have chronic recurrent urinary tract infections may really have one infection that never gets fully treated because the course of antibiotics is not long enough, the antibiotics are stopped too soon, or a urine culture is never rechecked after treatment to show that the infection has fully resolved.

In the case of a bacterial infection, white blood cells to fill the bladder to combat the bacteria, inflammation of the lining of the bladder may lead to blood in the urine, and there is also usually a change to the pH level of the urine (changes the acidity). These changes can make it quite painful to urinate, and the cat, not knowing that it is sick, may link the litterbox to the pain and decide to go elsewhere, in search of a comforting surface to urinate on.

Because of these issues, it is important to check a urine sample, bloodwork, and/or x-rays when a cat is urinating or defecating outside the box in addition to making changes in litterbox husbandry.

More information about inappropriate elimination:
Lovin' the Litterbox: Husbandry Reasons Why Your Cat May Not Use the Litterbox
Acting Out All Over the House: Behavioral Reasons Why Your Cat May Not Use the Litterbox
Breaking the Cycle of Smell: How to Stop Habitual Elimination Problems

Monday, December 5, 2011

Case Report: Debbie - why it is recommended to spay your cat when she's young

**Note: Pictures of surgery below - Beware to the squeamish!**

Dilute patched tabby cat
Debbie, pre-surgery
Debbie is a 2 year old stray female who arrived at Elizabeth Lake Animal Rescue to look for a home. She appeared to be pregnant on November 5th. She was active, friendly and had a good appetite. Pregnancy lasts about 63 days in a cat, and cats begin to show pregnancy at about 5 weeks along, so the decision was made to wait for the kittens. On December 2, concern arose that she was not yet showing signs of delivering the kittens, so she was brought to our hospital for an exam.

Lateral radiograph with no visible anatomy
Pre-surgical radiograph
Usually, ultrasound can detect kittens after two weeks of pregnancy, and the heartbeat can be seen on ultrasound after day 24. Debbie’s X-ray showed no indication of fetal skeletons – only large fluid-filled areas that obscured normal anatomy. Ultrasound also showed no sign of kittens – just large chambers of fluid.

Normal post-surgical abdominal radiograph
Post-surgical radiograph
Feline female reproductive anatomy
Feline female reproductive anatomy
This situation can quickly become an emergency if the fluid in the uterus is contaminated with bacteria (called a pyometra), so Debbie was taken to surgery to spay her. Unlike a normal spay surgery patient, Debbie was considered to be a critical case – she had to be checked for systemic infection, changes to her kidney and liver function, or other signs of poor health. Outwardly, she seemed to feel well. Although Dr. Bailey anticipated the surgery would go well, we had to be ready for the patient to quickly change from stable to crash status due to her delicate condition. Emergency drugs were kept at the ready, but her blood pressure, heart rate and oxygen levels remained stable. Sometimes in these cases, the fluid in the uterus is just a clear fluid with no cells or infection, in which case the problem is called a “hydrometra”. In Debbie’s case, she had something called a “hydrometrocolpos” which is fluid built up in both the branching uterus and in the vaginal canal. Dr. Bailey had to remove more of her reproductive tract than usual, because her vaginal canal was swollen with fluid to the size of her bladder, and if it had been left intact, it would have filled up again and been at risk for infection, due to abnormal anatomy (probably a congenital defect).

Normally, a spay incision requires about 2-3 sutures because the uterus is very small. In Debbie’s case, her three-pound uterus was so large that her surgical incision ran the length of her belly.

Financially speaking, a spay surgery usually runs about $200 whereas the kind of intensive-care surgery that Debbie had usually runs $800-1500, depending on the length of surgery and the number of complications that arise.
Normal and abnormal feline uterine anatomy
On the left, Debbie's uterus. On the right, a normal uterus
After a normal spay surgery, a cat will generally be spry, and want to eat almost before she can stand. In Debbie’s case, she required hospitalization on IV fluids overnight, and was not interested in eating after surgery.

Fortunately, she did very well overnight and was able to be released from the hospital. She is doing well at the rescue group, Elizabeth Lake Animal Rescue, and once she has her sutures out, she will likely be ready to look for her forever home!

Thursday, December 1, 2011

Feline Inappropriate Elimination: Lovin’ the Litterbox

A longhair dilute calico half in and half out of a litterbox
There is something about this litterbox that this cat doesn't like.
 One of the most common reasons that we see cats here at Exclusively Cats is for inappropriate elimination – either urinating or defecating outside the litterbox. There are many reasons that a cat may be avoiding the litterbox, but the reasons tend to fall into 3 categories:

1)      Husbandry issues: “I don’t like something about my litterbox!”
2)      Medical issues: “I don’t like something about how I am feeling!”
3)      Behavioral issues: “I don’t like something about my environment!”

Most people assume that their cat is eliminating outside the litterbox for behavioral reasons, but more commonly, it is either an issue with the litterbox itself or a medical issue. Fortunately, husbandry and medical issues are much more easily solved than behavioral problems.

In the image above, the cat is standing half-in and half-out of the box. This indicates that there may be something about the box that the cat doesn't like. It looks like this box may be too small for the cat, or there may be something about the litter texture that she doesn't like.

What is husbandry?  Husbandry is a fancy term to describe the care and management of animals.

Many experts have discussed the issue of cats and litterboxes over and over again. Most experts agree on a few key facts about litterbox maintenance that will help keep cats happiest about their boxes.

--The number of litterboxes: x=n+1 where n = the number of cats in the home
Yes, math lovers, there is actually a mathematical formula for determining the best number of boxes in your house. The ideal number of litterboxes that you should have is 1 more litterbox than the number of cats you live with. This does mean that ideally, a single cat should have two boxes. This is for two reasons – most cats like to urinate in one box and defecate in another, and most cats prefer to have a litterbox on every level of the home. 

This can especially be true for kittens – although kittens instinctively seek to bury their urine and stool, they’re still babies and may have a hard time judging how long it is going to take them to get to the box if they have to go. If they’re up in the second floor bedroom and have to go all the way to the basement to potty, they probably are going to stop somewhere along the way to go somewhere else because they just can’t hold it anymore!

Three different colored litterboxes in a line
Although we see three boxes, cats generally see this as one box.
--The location of the boxes: Most cats prefer to have their boxes located a little out of the way but not isolated. Most people prefer to tuck the boxes away in a utility room or laundry area, away from public use rooms like the family room or kitchen. Cats like their boxes easily accessible, and away from scary machines like the furnace or the washing machine. If your timid cat is in the middle of using the box when the furnace kicks in, that may be all he needs to convince himself he is never going back there again! The same is true for less obvious scary threats –  walking past the barking dog’s crate to get to the litterbox, or when company is over, having to pass through the noisy dining room on Thanksgiving Day in order to get to the box may be just enough to make your cat decide it’s easier to use the bed or the rug in the front hallway instead of facing her fears.

Also, cats like their boxes to be easily visible. If the box is tucked away in the back corner of a basement storage room with the light off, they may have trouble locating it. Although cats can see in about 1/6th the light that we humans need, they do need some light to navigate – especially as they get older. If they can’t see the litterbox, they may not use it.

Additionally, cats don’t like strong smells, so if your litterbox is located next to a plug-in air freshener, or your child’s sweaty-smelly sporting equipment, they may avoid going near it.

When following the x=n+1 rule of litterboxes, placing three boxes next to each other may look like three litterboxes to us, but to a cat who is more interested in smell than sight (and who likely can't count), three boxes next to each other is still just one big litter area. Each litterbox should be located away from each other - across the room or even in different rooms.
Small gray kitten in small littterbox
This box is the right size for this kitten.

-- The size and shape of the litterbox: Cats generally prefer a litterbox that is 1.5 times the length of their body. This length may become longer as the cat gets older and less flexible.

Most cats also prefer an uncovered box, since the cover tends to keep in odors (much like a Port-A-Potty)  – which is exactly why most people like them. Imagine, though, if the smell we are trying to avoid were magnified by 200 times! Your cat has every reason to avoid a box that to them is oppressively stinky – especially if it smells like another cat’s stool.
A large orange tabby cat in a small corner litterbox
This litterbox is too small for this cat.

Another reason that cats prefer uncovered boxes is that despite being a carnivore species, cats are small enough that they are also a prey species to larger carnivores. They instinctively feel a need to keep an eye out while in a vulnerable position – such as using the litterbox. Many cats that will use a covered litterbox will stand in the doorway with their heads stuck out of the box – both for visibility’s sake and to get their nose out of the stinky litterbox.

An orange tabby cat in front of a converted litterbox
Sometimes a converted litterbox is best.
A third reason that cats prefer their boxes uncovered is spatial issues. Once a cover is on the box, the space a cat has to turn around and scratch at the litter becomes much smaller.

Ideally, under-the bed storage bins or 30-40 gallon tubs with an opening cut out are great litterbox solutions. Many of the litterboxes sold at pet stores are just too small for adult cats, and quite a bit more expensive than the larger tubs.

--The type of litter: Cats prefer unscented litters to scented litters. Again, because of their super-strong sense of smell, the scented litters that are pleasant to us smell overpowering to them (especially if they are used in conjunction with a covered litterbox!).

A litterbox filled with strips of paper
Paper litter may cause cats to stop using the litterbox.
The type of litter may also have a texture or taste that your cat doesn’t like. You may wonder why taste matters – most cats groom their paws after visiting the litterbox. If they come out of the box and their paws taste bad, they may not want to return.

The absorptive ability of the litter is also important. Most cats prefer the scoopable clay litters to the plain clay, the pine, corn or wheat litters. May people express a desire to change their litter due to environmental concerns, but cats just don’t see it that way. Given a choice between a “green” litter and scoop clay, they will choose the clay, and given no choice, they may decide to go to the laundry pile, a plastic bag, a rubber-backed rug, or the couch instead of the litterbox.

A litterbox in a cabinet or end table
This box doesn't really have enough space for a cat when it's closed.
--Additives in the litterbox: Less is best! Cats don’t really approve of plastic liners – their claws get caught, and the texture is adversive. Additionally, the plastic liner can get folded and inhibit scooping the box, so that more urine and stool are left behind, increasing the odor of the box.

Baking soda has a bitter flavor that may deter cats if they lick their paws after using the box, and other additives may change the texture of the litter and make it less desirable.

--Cleanliness of the box: Most cats prefer that the box be scooped daily, sometimes even twice to three times daily. Imagine going into your own bathroom and finding that someone forgot to flush the toilet and left no toilet paper on the roll…

A small kitten drowning in litter
Filling the box too full may upset your cat.
Cats also prefer about 2-3 inches of litter in the box at all times, so when scooping, make sure to replenish the litter to about that level. Sometimes more litter than 2-3 inches can make a cat feel unsteady, so more is not always better.

Try to completely change the litter every 4-6 weeks, washing the box with a mild, unscented detergent like Dawn dish soap. Avoid heavy cleaners like bleach, PineSol or Lysol because the residual chemical odors are a deterrent, and the phenols in some cleaners is toxic if inhaled or ingested by cats. 

More information about inappropriate elimination:
Kidneys and Crystals and Stones, Oh, My! Medical Reasons Why Your Cat May Not Use the Litterbox
Acting Out All Over the House: Behavioral Reasons Why Your Cat May Not Use the Litterbox
Breaking the Cycle of Smell: How to Stop Habitual Elimination Problems

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