As a pain medicine physician one of the hardest parts of my job is to get people to buy into the idea that addressing stress or anxiety or sleep or nutrition doesn’t mean I think their pain is “all in their head” or that I am not taking their pain seriously. Or both.
Chronic pain is often a life-altering-in-a-bad-way-kind-of-thing and something that catastrophic seems like it should require an intervention of equal magnitude. Something like an MRI, or opioid medications, or surgery. Or all three.
This desire for a big sounding interventions and their illusion of immediacy reflects the way most people have been enculturated in North American to understand chronic pain and the way most doctors have sadly been educated about pain. And then there is the fact that it is easier with most health insurances, from Medicaid to the swankiest PPO, to get an affordable hysterectomy than than it is to get reasonably priced physical therapy or anxiety management. Diet and lifestyle also seem nebulous when you see something concrete like a cyst on ultrasound, even though the physical exam and symptoms mean that 3 cm ovarian cyst can’t possible be the cause of the pain. Something that we can see makes the allure of a “quick fix” that more palpable.
But lifestyle, stress and nutrition do cause real symptoms and often because of physical changes, like inflammation. Addressing these issues is the cornerstone of pain management. Just ask my cat.
A year ago we adopted Luna, a 6-month-old kitten who was found on the street at the age of 6 weeks or so. She had a serious eye infection that led to removing one eye and surgery on the other. Her one eye has a scarred cornea and she doesn’t see well. She is also tiny. About 6 lbs when we got her and at the age of 1 she was 7 lbs. She is also a love and possibly the most cuddly cat. She was raised with our lab puppy and they are fast friends.
All was great until she was about 1 year and she started peeing blood in the sink. Multiple times a day. One day I stopped counting at 50. There would be intervals where I would see her pee drops of blood 10 or 15 times in the sink in 7 or 8 minutes. That’s pretty severe urgency and frequency. She was clearly in pain when she emptied her bladder and definitely straining (cats I now know make the same face when they valsalva – as an OB/GYN I’m well-trained to spot that expression). She also started peeing in the toilet all on her own. Apparently the smell of blood in the litter box is a hard stop.
Several trips to the vet and two trials of antibiotics and several urine tests and imaging studies later it was clear she didn’t have a bladder infection and she didn’t have stones.
“She has stress cystitis,” my vet said apprehensively. I think she was bracing herself for the fact that I would want more tests and more imagining and more antibiotics and other, “bigger” things.
I laughed. “Oh the irony!”And then I explained, “My practice is chronic pain for women and you are telling me that my cat has interstitial cystitis and I treat that every day.”
The vet then started asking me how we treat it in humans and offered some urinary care food, pain medications, and Prozac.
My cat hated the food, so that didn’t work. I decided to pass on the pain killers and Prozac for the time being.
But then I started to get desperate, not only was my cat in pain and peeing blood but her non-litter box peeing stopped being confined to porcelain and she started peeing on the couch. A cat peeing blood multiple times an hour on your furniture leads one to want to do big things. Like pain medications and Prozac. Or bigger things if they were available. I briefly flirted with the idea of having someone do a cystoscopy (look inside her bladder) and then decided I needed to walk the walk and address the basics first: lifestyle and nutrition.
How do you get in a cat’s head and figure out what is stressing her out? That, my friends, is not easy.
I observed where she was peeing and while it was all over the house it was always in front of me. I wondered if given her poor vision and the sudden urge to go getting to her litter box was stressful? She is a very social cat so she is always with me and I am rarely ever next to her litter box. I got two extra litter boxes and put them in the rooms where I spent most of my time so she she could pee in my line of sight. My 7 lb cat in a 1,400 square foot house now had 3 litter boxes.
Cats apparently like to be high up. I did not know this, but let me tell you there is a wealth of information about cats on the Internet :), so I rigged up some stools and chairs so she had an elevated walkway throughout the main area of the house where I am most of the time.
I knew she desperately wanted to go outside (she tries all the time), but we have hawks and coyotes outside and she is tiny and visually impaired so she is an indoor cat. I brought the outside in and started walking her on a leash.
She also loves lettuce so my boyfriend fixed us up with an indoor lettuce garden.
I wondered if the dog was part of the issue, but she routinely jumps the gate to sleep with the dog when I am away so I figured she loves the dog (or has a bad case of Stockholm syndrome).
And then the food. She was already getting a good quality dry food, but it turns out a good quality dry food with cats can be like good quality fast food for humans. I also noticed her water bowl was very rarely touched. My friend has a cat that loves water so much he dunks his head in and drinks all the time, but Luna doesn’t. I thought about making my own super moist cat food, but after going down that particular Internet rabbit hole I decided that might trigger a sequence of events that could lead to me never having sex again. Eventually I settled on a cat food that is apparently rotted fish and assorted entrails (with broth!) that is so pure it is could be hand-packed by gluten-free virgins under a full moon.
Luna loved it. I mean, loved it (well, only the salmon and tuna thank you very much – the turkey and chicken were knocked over in displeasure). I thought she loved her dry food, but this is a new level of kitty food love
A few days after all these changes she stopped peeing on the couch and then a few days later she stopped peeing blood in the sink and then her whole behavior changed. She was always cuddly, but she seemed more robust and, well, frisky. But I guess when you are not in constant pain peeing blood 50 or more times a day you might feel a bit better. She has put on a pound and her coat is glorious.
The only bad thing is she stopped peeing in the toilet.
Diet, sleep issues, stress, immobility, anxiety, depression, obesity – these are all things that promote inflammation and other changes that perpetuate chronic pain. If you think of pain like a forest fire these things are like fuel on the fire. You can’t put a fire out while you are pouring gasoline on it.
I am not converting to a cat blog and the human experience is obviously different from the feline, but I think Luna a good example of how real, terrible, painful physical symptoms can be caused by things that may seem small to the general public, but to those of us that do chronic pain they are actually the “big” things.