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Debunking Myths about Cats and Litter Boxes (Medical)

There is little more frustrating than a cat not using his litter box. Shelters report that litter box problems are the number one reason owners give up their pets. Improper elimination does not have to be a death sentence. This article discusses various causes and options for correcting the problem. This is not an exhaustive discussion, however, merely an overview. And it only discusses problems related to urination outside the litter box, not defecation which may need to be approached differently.

First and foremost is the all important question—“is the source of the problem medical or behavioral?” All too often a medical problem is mislabeled behavioral and so not only are the proper steps not taken to remedy the situation, but the cat continues to suffer with pain or chronic discomfort.

Most litter box issues can be traced back to a medical problem. Believe this fact, know it—and you are on your way to a solution. Medical problems that cause inappropriate elimination cannot be diagnosed through a phone consultation with your vet or simply with an office exam. For a proper diagnosis, your vet needs to collect a urine sample and run an analysis of the sample. Some medical conditions may not be uncovered with a urinalysis, but certainly, this should be the first step.


Myth #1: I know the problem isn’t medical because sometimes my cat does use the litter box.

Logically, it might seem that a cat isn’t sick if sometimes she uses the litter box and other times she does not. This must indicate a behavioral choice—right? Wrong—intermittent litter box use is actually a classic sign of an underlying medical problem. Out in the wild, burying waste is a survival technique to avoid detection by predators. Driven by instinct, it is natural for a cat to eliminate in a litter box.

A conflict occurs when the cat starts associating with the litter box with the pain or discomfort caused by a medical condition. Many medical issue cause increased pain when a cat tries to urinate. If so, she may start to avoid the litter box, thinking the box itself is the source of the discomfort. In this conflict between pain and instinct, the pain may not be strong enough to always deter litter box use—leading to intermittent use. Or maybe it is a question of timing—since the litter box is associated with pain, if she happens upon a soft place on the carpet or in the laundry basket she may simply utilize the new spot that does not have a history of causing pain.


Myth #2: It can’t be a medical problem—my cat has been eliminating outside the litter box on and off for years.

Some medical conditions do not cause constant pain. Urinary crystals, bladder stones and interstitial cystitis are some of the more common conditions that can cause flare ups of discomfort leading to improper elimination. Even the most attentive of owners may dismiss an occasional transgression outside the litter box as an accident instead of a potential medical problem. Some medical issues worsen with time, so an occasional elimination outside the box could turn into a more frequent problem. It may seem that your cat’s behavioral problem is just getting worse, but it’s more likely a medical problem that has deteriorated over time. Give your cat the benefit of the doubt—take him to the vet for a urinalysis and any necessary follow up tests.


Myth #3: My vet analyzed a urine sample and didn’t find anything, so the problem is behavioral, not medical.

Not every medical problem will manifest in a cat’s urine. Usually urinary crystals will show up in an afflicted cat’s urine, but not always. Sometimes the crystals accumulate in the bladder, never passing into the urine. In these cases, a sludge or stone forms in the bladder causing irritation and pain during urination. Ultrasound is the best diagnostic for identifying this condition, but some stones can be seen by x-ray.

Kidney disease can also lead to improper elimination. Some medical conditions causing a cat to go to the bathroom outside of his litter box are not even directly related to a problem with the urinary tract system. Diabetes, constipation, and arthritis are examples of conditions that may manifest in the early stages with improper elimination. In these situations, blood tests, x-rays or other diagnostics may be necessary to properly identify the medical cause of the unwanted behavior.


While it is true that elimination outside the litter box is likely a warning of an underlying medical condition, don’t assume that if your cat continues to faithfully use his litter box that he is healthy. There are other clues that should alert you to a potential medical problem. Frequently urinating in small amounts, going in and out of the litter box without using it, and crying out in pain when trying to urinate—these are all signs of serious medical conditions calling for immediate vet attention. Catching these problems early can be the difference between a minor problem and a chronic or even life threatening situation.




1. Too High and Too Low blood sugar are essentially the same. In both cases, the body doesn't have glucose available to it to use. Cats sometimes "present" when the level is too high/too low. "Presenting" can be anything from no energy, not eating, collapsing, or any other odd behavior. Some cats present, some cats don't.  Therefore, #2 is very important:

2. Get a blood glucose monitor and get comfortable using it. Use it before giving insulin, every time. It's nowhere near as painful as you think it is, and since diabetic cats are fixated on food (diabetes tends to make them feel hungrier), you can use food as a motivational device to get them to tolerate it. The monitor could save the cat's life one day, it will ease your anxiety about what the glucose level is, and it will avoid some of those emergency trips to the vet's. No human would ever take insulin without testing their glucose levels first because taking insulin when your glucose level is low could kill you. Even if the cat is not "presenting", knowing the glucose level can help you determine what attention they may need.

3. Get a notebook and keep a record of the time & date when you took the glucose reading and what it was. It is also helpful to make notes regarding when the cat ate or what it ate. You are establishing a pattern of behavior; some cats have a cycle of being "high" or being "low". Once you have the pattern, it can help you notice out-of-the-ordinary behavior easier.

4. Low glucose levels are relatively easy to fix: Get some Nutri-cal (in a tube, the stuff they give to kittens/puppies) or Karo Syrup (in the grocery store). If the cat tests low, a little bit of sugar will bounce them back. High glucose levels, especially when the cat is presenting, is more dangerous. That's when they need to go to the emergency room.

5. Make sure you are working with a vet who supports your active engagement in the managing of your cat's diabetes. Some vets would prefer you to just give the cat the insulin they recommend and be done with it. They resent you making decisions yourself about the insulin doses. However, most vets will admit that it's very hard to regulate a cat perfectly, so I think it's normal to test for glucose, and if it's already too low, why would you give the dose (or, at least, a full dose?)

6. MANY things contribute to the glucose level: How much was eaten (get the cat on a high-protein diet, but try to make it natural protein as "fake" protein can cause other issues), when it was eaten (there's the "dawn" affect, which shows the glucose rising over night as dawn approaches because the liver "dumps" glucose into the body for the day ahead: fix for that is to feed a little bit overnight), how active the cat is (activity can lower glucose levels), and if the cat has been exposed to cold. You won't find this last concept on the web; I discovered it with Punkin. During the winter, when we would be going back & forth to our weekend house, I would notice that about 50% of the time, Punkin's glucose level would drop as we moved him from the car to the condo. We usually arrived home around dinner time, so I would be testing his glucose right after we got in. No vet would confirm it, but my observations are that cold will decrease the glucose levels as the body is forced to use more glucose to stay warm.

7. Diabetic cats pee more. To make your life easier, get plastic, sifting liners for the litter box.

8. What is "high" and what is "low"? That depends on the cat. I saw Punkin's numbers range from 30 to 500 (lower would result in a "LO" reading on the monitor and higher would result in "HI"!) Punkin never presented. His diabetes was never a problem. However, when I cat-sat Oliver who was also diabetic, he presented at around 250 with Ketoacidosis (read about on the Wikipedia) and spent a week in the hospital. The main difference, I believe, was that Punkin had type II diabetes and Oliver had type I. Older, overweight cats tend to get type II, younger cats tend to get type I. Find out the type of diabetes the cat has, and that can also help you manage the condition.

9. Diabetes is manageable. On the plus side, it makes you spend a lot more time with the cat, and you will become much closer because of it. If Punkin hadn't died of cancer, we could've continued to manage his diabetes longer than the 4 years that we did.

Below are some links with useful information regarding diabetes in cats.

Diabetic Cats in Need






elieve this fact, know it—and you are on your way to a solution. Medical problems that caus