Ketamine‐associated bladder dysfunction

Abstract

Objective:To assess the impact of ketamine abuse on genitourinary tract dysfunction. Methods: Eleven patients with urinary tract symptoms and a history of ketamine abuse in recent years were studied. Urinalysis, urine culture, renal function tests, abdominal sonography and urodynamic studies were done. Bladder biopsies were carried out in selected cases. Results: The most common complaints were lower urinary tract symptoms, including dysuria, frequency, urgency and gross hematuria. Urinalyses showed nonbacterial pyuria and were negative for tuberculosis. All biopsy specimens showed infiltrations of granulocytes (mostly eosinophils) and mast cells within the bladder tissue. Medications produced only slight clinical improvements. Intravesical instillation of hyaluronan solution was performed for some patients and a significant improvement of lower urinary tract symptoms was observed. Conclusions: Although the dosage and duration of ketamine abuse causing severe side-effects are still unclear, some patients develop irreversible histological changes in the urinary tract. Therefore, clinicians should be aware of the negative effects of ketamine abuse on genitourinary tract function.

Genitourinary toxicity of ketamine

“…1,11 These entail a thin epithelium with neutrophilic and lymphoplasma cell infiltration of the bladder mucosa, 16 and/ or a mononuclear inflammatory cell infiltrate in submucosal tissue. 18,36 A proliferation of von Brunn's nests in the bladder has also been described. 29 Some patients with serious bladder lesions show no surface epithelium, but only smooth muscle (Fig 3), collagen and adipose tissue.…”

“…11 A bladder capacity of less than 150 mL could be regarded as a clinical threshold. 18 Urinary leakage occurred even when the bladder was filled to a capacity of 30 to 50 mL. 2 The potassium sensitivity test was positive in some patients, indicating interstitial cystitis (IC).…”

“…15 Cessation of ketamine is the milestone of treatment, both for preventing deterioration of renal function and offering the possibility of symptom resolution. 6,7 After ketamine cessation, oral pentosan polysulfate 1,16,17 and intravesical instillation of hyaluronic acid solution 16,18 or lidocaine and heparin 17 appear to provide some symptomatic relief. Duloxetine (a well-known antidepressant) may be considered a therapy for depressed patients as it is also believed to counter LUTS to some extent.…”

“…12 Many patients fail to attend urodynamic testing, as they do not tolerate bladder distention or urethral catheterization during the procedure. 2,18 Patients available for urodynamic studies had detrusor overactivity 16 and poor relaxation of the external sphincter 19 or decreased bladder compliance, with or without variable vesico-ureteric reflux and decreased bladder capacity. 11 A bladder capacity of less than 150 mL could be regarded as a clinical threshold.…”

“…11,16 Cystoscopic findings classically associated with IC are detailed in the Table. 1,2,7,8,[10][11][12][13][16][17][18]20,24,[26][27][28][29][30][31][32][33][34][35] They include low bladder capacity, contracted bladder, marked inflammation consistent with in-situ carcinoma or significant infection, 8 severe bladder ulceration, 1,16 multiple erythematous swelling 12,13 with necrotic mucosa, 13 various degrees of epithelial inflammation with neovascularisation and petechial haemorrhages, 11 or cystitis glandularis confirmed by biopsies only. 2 It has been noted that after cystodilation or cystoscopy on filling the bladder, there may be erythematous bladder bleeding, 21 glomerulation (bladder haemorrhages) and mucosal bleeding diffusely into the lumen, 28 and even persistent active bleeding from a bladder ulcer 16 (Fig 2).…”