Pandora Syndrome in Cats

Does your cat occasionally go to the bathroom outside the litter box, strain to pee, or have bloody urine? While you may assume that your cat is experiencing a primary urinary problem, they could be having issues because of a stress disorder called Pandora syndrome. 

Pandora syndrome is a term coined by feline health expert Dr. Tony Buffington. It was named after multiple problems that were released when Pandora opened the box in Greek mythology. It refers to a complex and challenging stress-related disease condition in cats. 

Read on to learn more about Pandora syndrome in cats, including how it’s diagnosed and treated, and how you can lower your cat’s risk.

What Is Pandora’s Syndrome in Cats?

Pandora syndrome is a blanket term that is used to describe what happens when a cat gets sick because they are chronically stressed. As a result of stress, these cats develop multiple illnesses at the same time, one of which is usually lower urinary tract inflammation. For example, a cat could have bloody urine and red, runny eyes from conjunctivitis or sneezing from an upper respiratory infection at the same time. 

Pandora syndrome can be used interchangeably with other veterinary terms that describe lower urinary tract inflammation, including feline interstitial cystitis (FIC), feline idiopathic cystitis, sterile cystitis, and feline lower urinary tract disorder (FLUTD).

What Causes Pandora Syndrome in Cats?

Historically, veterinarians believed that symptoms due to inflammation in the urinary tract were associated with a urinary tract infection or urinary crystals and stones. Now we know that most of this explanation is incorrect. In actuality, many cats have lower urinary tract inflammation due to chronic stress, and symptoms often resolve once the stress is managed.

While we don’t entirely know which cats Pandora syndrome will affect, we do know that the condition tends to be seen in: 

• Male cats
• Young to middle aged indoor-only cats who are overly nervous or anxious
• Overweight cats
• Cats who consume a diet that is more than 50 percent dry food
• Cats who live in multi-cat households

These cats also have a history of prenatal stress or early severely stressful events. Research has shown that these cats have anatomical and functional differences in their central nervous system as compared to healthy cats, including upregulated sensory neurons, increased secretion of stress hormones, increased pain sensation, and an increased startle response [1].

In addition to changes in the central nervous system, Pandora syndrome cats can also have abnormal lining of the wall of their urinary bladder. This makes their bladders more easily irritated and painful.

So what does this all mean? Pandora syndrome cats are in a continual, hyperexcitable state of fight, flight or freeze, and they feel pain more sharply than normal cats. 

Additional factors that can trigger a Pandora syndrome flare-up include:

• Cats who don’t have quiet, protected access to resources (food, water, litter box, resting areas). Instead, something bothers them (such as a child, other pet, furnace, buzzing dryer, etc.) when they try to access those resources
• Moving from one house to another
• Having visitors in your home
• Visits to the veterinary hospital or grooming
• Boarding 
• Renovating or moving furniture
• Adding or subtracting people or animals from the household
• Being bullied by another cat
• Stray cats in the neighborhood
• Dirty, crowded, or otherwise undesirable litter box
• Cats who do not have opportunities to engage in typical hunting behavior
• Lack of scratching opportunities
• Boredom

Pandora Syndrome in Cats Symptoms

One of the systems usually affected by Pandora syndrome is the lower urinary tract, causing the following symptoms that wax and wane, flaring up after stressful events: 

• Bloody urine
• Straining to urinate
• Vocalization during urination
• Spending more time in the litter box or visiting the litter box more often
• Urinating outside the litter box
• Vomiting
• Hiding
• Loss of appetite

Pandora syndrome is also known for affecting multiple body systems, causing a variety of additional fluctuating symptoms. These can include:

• Behavioral abnormalities (pica, aggression, hiding)
• Cardiovascular problems (hypertrophic cardiomyopathy, saddle thrombus)
• Endocrine issues (obesity, type 2 diabetes mellitus)
• Gastrointestinal problems (feline odontic resorptive lesions, vomiting, excessive hairballs, diarrhea, pooping outside the litter box)
• Low immunity (upper respiratory infections, infectious conjunctivitis)
• Respiratory problems (asthma)
• Skin problems (overgrooming, chin acne)

Any of these issues in combination with lower urinary tract symptoms increases the suspicion that a cat is suffering from Pandora syndrome. 

Diagnosing Pandora Syndrome in Cats

Pandora syndrome is an anxiety disorder and considered a diagnosis of exclusion — this means that it is diagnosed and treated by a veterinarian only after all other diseases have been ruled out. Pandora syndrome is diagnosed by using an oral history, physical examination, and testing. Your veterinary care team will acquire a comprehensive history from you by asking questions about:

• Your cat’s life history (stray, orphaned, bottle fed, exposure to serious trauma, etc.)
• Your cat’s health history (especially if sickness occurs frequent and in association with identifiable stressors and if your cat is fearful or anxious)
• Your cat’s home environment

The veterinarian will conduct a full physical examination and recommend testing based on what they find. Testing may include lab work (blood work and urinalysis) and imaging studies (radiographs and abdominal ultrasound). 

Treating Pandora Syndrome in Cats

Veterinary intervention usually includes pain or anti-inflammatory medication and anxiety medication to reduce inflammation and calm your cat. Veterinarians also provide support to pet parents on how to modify the home environment to reduce their cat’s stress. 

Pandora syndrome is usually a self-limiting condition and often resolves on its own. However, it is very painful and symptoms will return the next time a cat is stressed. This is why it is important to identify what is stressing your cat out and modify the environment to reduce stress triggers. 

How to Prevent Pandora Syndrome in Cats

The best way to prevent Pandora syndrome is by reducing your cat’s exposure to stressful triggers. Try seeing the world through their eyes to figure out what is stressing them out. The following recommendations can help reduce stress for most cats: 

Environmental enrichment

Ensure that each cat has access to their own resources (food and water bowls, resting areas, toys, litter box) in a quiet, low traffic area. Also, each cat needs to feel safe and secure in their home environment.

Maintain a pristine litter box —  scoop poop daily and refresh the litter every three days.

Use unscented, sandy, clumping litter. Use a regular box that is big enough for the cat to turn around in, and cover the bottom with 1 inch of litter. Avoid litter boxes with covers, liners, or anything fancy.

Have one more litter box than the number of cats in the household, and place them in different spots.

Provide ample scratching opportunities, both vertical and horizontal, in your cat’s favorite substrate. Most cats prefer the texture of sisal rope scratching posts. 

Use feline pheromones, such as Feliway, to reduce stress.

Play time

Boredom can trigger Pandora syndrome in indoor cats. You can minimize your cat’s stress (and maximize their wellbeing) by playing with your cat. Cats have short attention spans and tend to enjoy multiple short 5-10 minute play sessions per day. 

If your cat enjoys outdoor time, train them to wear a harness and take them for walks. Alternatively, invest in a catio where your cat can spend unsupervised time safely outdoors.

For more ideas, ask your veterinary care team for their thoughts on how to improve your cat’s home environment.

Feeding

Cats need to eat an appropriate amount of complete and balanced food that meets or exceeds AAFCO nutritional standards. Try to feed your cat a combination of canned and dry food, and give them opportunities to exercise their minds with feeding puzzles and no bowl feeders. Use a water fountain to encourage them to drink more water. Some pet parents may want to consider giving their cat a probiotic supplement (e.g., Purina Pro Plan Calming Care) that is designed to calm the nervous system.

While there are commercial diets that are formulated to support the health of the nervous system, it is not advised to change a cat’s diet while they are experiencing Pandora syndrome symptoms. This is because changing a cat’s diet can be stressful for some cats and make the problems worse. If you want to change to a calm cat food, wait until your cat is feeling better before switching their diet. 

Recurrence of the symptoms associated with Pandora syndrome can be common. It is important to watch for symptoms and be aware of stressful changes in your cat’s environment that may trigger a recurrence. Pandora syndrome cats can be very sensitive to these changes. Thankfully, if you are aware that your cat is anxious or sensitive, have taken steps to reduce stress in your cat’s environment, and are attentive to flare-ups, you can keep this condition under control.

Related Conditions

• Urinary tract infection
• Anxiety disorders
• Urinary struvite stones
• Urinary calcium oxalate stones
• Urinary crystals
• Overgrooming
• Inappropriate elimination
• Urethral blockage

Reference

1. Wooten, Sarah J. “Feline interstitial cystitis: Its not about the bladder.” DVM360. Nov 2017. Retrieved from https://www.dvm360.com/view/feline-interstitial-cystitis-it-s-not-about-bladder