Integrative treatment for inappropriate urination in cats

It’s not always easy to get inside the mind of a cat, but behavioral clues can help you understand your patients and get to the bottom of litterbox issues such an inappropriate urination.

Cats are the most popular pet in the US, and although we love them, litterbox issues (including inappropriate urination and housesoiling) are the most common complaint among cat parents. In fact, it is estimated that among cats with behavioral disorders, 40% to 75% involve elimination problems (Overall, 1997). Unfortunately these issues often lead to abandonment or euthanasia. Honing your diagnostic and therapeutic skills around this problem can help you save lives, and what is more rewarding than that? A stepwise holistic approach, complete with a thorough behavioral history, will help identify common patterns and lead to lasting solutions to litterbox problems.

The first step in addressing inappropriate urination is to conduct a complete physical exam, urinalysis, CBC, and metabolic panel. Common rule-outs include cystitis, FLUTD, FIC, crystalluria, calculi, metabolic disorders (such as hyperthyroidism, diabetes, renal failure) and geriatric problems (such as dementia and DJD).

Once medical problems have been ruled out, the behavioral sleuthing begins. Your job as a feline forensics specialist is to uncover what the cat is communicating via his behavior. I highly recommend Dr. Karen Overall’s Behavioral Questionnaire for Cats with Elimination Disorders (Overall, 1997). It outlines the process of taking a thorough behavior history that will allow you to make an accurate behavioral diagnosis. I have highlighted the key questions and behavioral red flags in this article, based on my 24 years in practice and my successful mitigating of hundreds of cat litterbox cases. To begin the behavioral investigation, differentiate whether the cat is urine marking or housesoiling.


Marking almost always involves stress, often caused by other cats, either within the household or outdoors. Marking can present as either vertical spraying or horizontal marking, usually in small spots around the perimeter of the room.

Treatment involves minimizing stress by meeting the cat’s behavioral needs. In a multi-cat household especially, the goal is to provide plenty of space and privacy in order to minimize conflict. Establish separate zones with food, water, litterboxes, climbing towers, wildlife viewing areas, beds, treats and toys. Prevent outdoor cats from having visual contact with indoor cats, by drawing blinds or using chemical deterrents such as Ropel®, Boundary® or mechanical deterrents like ScareCrow®, a motion activated sprinkler.

It is imperative that clients clean soiled areas very thoroughly. The product proven most effective in clinical trials is Anti-Icky Poo™, a professional carpet cleaner that utilizes live bacteria to break down urine odor (Pryor, 2001). Very soiled areas may require professional cleaning, carpet replacement, or sealing with several layers of Kilz® primer. Steam cleaning is not recommended as it may lock urine scent into the carpet. If the soiled surface is tile or concrete, a ten to one water to bleach solution may be used for cleanup.

Clients can also place food and water or toys near the soiled area, to change the significance of this area for the cat. Spots used for marking can also be sabotaged with upside down plastic carpet runners or strong essential oils (clove, cedar, citrus) near the soiled area, discouraging use.

In addition to environmental management, a number of holistic approaches can modulate stress in cats. TCVM, Western botanicals, homeopathy, flower essences, osteopathy and chiropractic can be effective. Not all of these will work for all cats; they should be used on a successive trial and error basis. Frequent communication with clients will help you decide which modalities are most helpful.


By activating the nervous system, acupuncture releases endorphins, hormones and neurotransmitters, thereby rebalancing emotions. Although it may seem counter-intuitive, cats are often good candidates for acupuncture. In my 16 years of experience using this modality, I’ve found that most cats tend to respond well to acupuncture and enjoy their treatments.

Inject GV20 with 0.1cc injectable B12. Repeat every three to four weeks as needed (Schoen, 2001). If used in conjunction with environmental management, the acupuncture may only be needed once or twice.  Some cats will need ongoing treatment.


  • Catnip (Nepeta cataria) is a fragrant herb that induces relaxation in a genetically based sub-population of cats. Fresh or dried catnip, or concentrated sprays such as KONG® Naturals Catnip Spray, can be used for those patients that find catnip calming. It can also be used as an attractant for toys or resting spots, to give alternative, relaxing and engaging activities to spatting cats.
  • Some of my patients have found relief from stressful situations with Bach Flower Remedies. One such product is Rescue Remedy®, a combination of flower essences for traumatic or stressful situations. Because these tinctures are made with alcohol, they should be diluted in spring water for use in cats (four drops Rescue Remedy per ounce of spring or filtered water). Serve four drops, four times daily on a treat. Refrigerate for up to two to three weeks.

Supplements and nutritional therapies

  • Composure™ chews are a tasty supplement formulated to promote relaxation, without inducing sedation or personality changes. The three main ingredients work synergistically: thiamine (vitamin B1), C3™ (Colostrum Calming Complex) and L-theanine (Suntheanine® brand). I have used these chews successfully over many years with my patients. The lack of sedation and lower stress levels allow for valuable learning to take place.
  • While some readers may object to a dry, commercial food as not ideal for feline patients, Royal Canin Veterinary Diet® Feline Calm dry cat food is an interesting product. It utilizes a milk protein called alpha-casozepine to induce a state of calm. This food also incorporates L-tryptophan, an amino acid required for the body to produce melatonin and serotonin, which can decrease anxiety and enhance sleep. Because it is a food product, it may also be easier to administer to fractious cats.
  • Zylkene® supplement is pure alpha-casozepine. It is water soluble and can be added to the cat’s normal diet.


Feliway® is a commercial product containing a synthetic pheromone that mimics cheek gland secretions from a cat. It is intended to produce a state of calm and induce facial marking versus urine marking behaviors. Use it daily on areas where cats have sprayed urine, or use a diffuser in areas of spraying, or where cats are most likely to interact. This product is a good option for finicky or fractious cats that may be hard to medicate.


Domestic cats descended from the Middle Eastern wildcat, Felis sylvestris, a desert dweller that roamed the wild expanse of the Fertile Crescent of Mesopotamia. It stands to reason, and has been borne out by research (Overall, 1997), that if given the choice, most cats will naturally pick clean sandy litter, lots of space, privacy, and a quiet low-stress environment. Unfortunately, many cat parents misinterpret their cats’ housesoiling activities as a demonstration of spite or anger. In fact, a housesoiling cat is simply expressing his innate preferences. Educate clients that punishing a cat is not effective in correcting soiling problems and may lead to increased stress and further problems. Although there are four main categories of litterbox problems, these conditions may overlap and defecation is sometimes involved as well.

1. Litterbox aversion

Litterbox aversion is the most common elimination problem in cats (Overall, 1997). In general, most cats do not like covered boxes, plastic liners, strong scents (malodorous or fragrant) or competition from other cats. The mere scent of another cat may cause litterbox aversion, as can feline aggression from housemates.

The key question is: will the cat use a freshly cleaned litterbox?

Behavioral red flags: Most often, the cat will urinate near the litterbox. In some cases, though, if the box is in an inconvenient, noisy or fear-inducing location, the cat may avoid the box entirely.

Action plan:

  • Use unscented clumping litter.
  • Use at least one more box than the number of cats in household.
  • Use only unscented Ivory liquid soap or similar to clean box (no bleach, Lysol, Pinesol, citrus cleaners, etc.).
  • Scoop twice daily.
  • Replace litter once a month, or when crumbs are visible.
  • Get an extra large box, especially if you have an extra large cat.
  • Place the new boxes where the cat is inappropriately eliminating. Once litterbox habits are well established, move the box 1” to 2” a day to a more appropriate location.
  • Clean soiled areas as outlined above.
  • Use scent to attract the cat, such as a small amount of organic potting or garden soil in box; or Dr. Elsey’s Cat Attract™, which contains a proprietary herb mixed with a premium scoopable litter.

2. Substrate aversion

Behavioral red flags: The cat may scratch at adjacent, preferred textures (such as smooth surfaces or carpet). He may run from the box or shake his paws after using it. I have even had patients that perch on the edge of a box to avoid touching the litter.

Action plan:

  • Follow the suggestions given for litterbox aversion.
  • Use unscented clumping litter in a second box, adjacent to the current box.
  • Provide a third box with a different substrate, such as Dr. Elsey’s Cat Attract or World’s Best Litter Original formula, made from ground corn. In my experience, most cats dislike scented litters, sawdust type litters, clay litter, recycled newspaper litter and litter crystals.
  • Depth may be an issue. Most cats prefer about 2” of litter, but you can tilt the box to create a gradient from shallow to deep so the cat can choose.
  • Add litter as needed to keep depth at 2”.

3. Surface preference

Behavioral red flags: The cat will eliminate on a preferred texture, such as carpet, bathmat, sink or bathtub, potting soil or fabric. He may scratch his preferred surface if it is adjacent to the box, or may scratch the inside of the box.

Action plan: 

  • Provide the preferred substrate within the litterbox. If a smooth surface is preferred, use an empty litter box, sprinkled with a small amount of litter. If soft surfaces are preferred, place a small square of carpet, bath mat, old T-shirt, synthetic fleece or hand towel in the empty litter box. Gradually replace it with smaller squares of fabric, while simultaneously adding increasing amounts of litter.
  • If feasible, simply restrict the cat’s access to the soiled area or preferred surface (e.g. keep bedroom door closed, keep laundry picked up, put ½” of water in bathtub, cover soil on potted plants with pinecones or foil).

4. Location preference

Behaviorial red flags: The cat may choose a quiet, low traffic or private area in which to eliminate. This can indicate a fear of people, other animals or unwanted noises, such as a furnace or washer and dryer that suddenly turn on.

Action plan:

  • Place an uncovered box in a quiet, easily accessible location. Locating it under a card table or behind a plant provides privacy and a feeling of security.

Although it is not always easy to get inside the mind of a cat, behavioral clues can help you understand your patients and get to the bottom of litterbox issues. Taking a thorough, stepwise approach can help resolve elimination problems in cats, ensuring longer, happier lives and stronger human-feline bonds.


Overall, KL. Clinical Behavioral Medicine for Small Animals, Mosby, 1997.

Pryor PA, Hart BL, Bain, MJ, Cliff KD. “Causes of urine marking in cats and effects of environmental management on frequency of marking”. JAVMA; 219 (12): 1709-1713, 2001.

Schoen, AM. Veterinary Acupuncture, Ancient Art to Modern Medicine, Mosby, 2001.


Dr. Rhea Dodd earned a Doctorate in Veterinary Medicine from Colorado State University in 1992, and a Master’s Degree in Biology from the University of Colorado at Boulder. She became certified in Veterinary Acupuncture through both CSU and IVAS in 2001, and was selected as a teaching assistant, clinical preceptor and presenter for the Course in Basic Acupuncture for Veterinarians at Colorado State University. In 2008, she became certified in Veterinary Chiropractic through the International Veterinary Chiropractic Society. She owns Gentle Vet, PC, focusing on acupuncture, chiropractic and behavior solutions. Dr. Dodd lectures, teaches and writes about pet behavior, health and pain management. She has served on the Board of Directors for Freedom Service Dogs, Inc., the Coalition for Living Safely with Dogs, and the Africa Network for Animal Welfare.