The destruction of the lower urinary tract by ketamine abuse: a new syndrome?

Abstract

OBJECTIVE To report the clinical spectrum seen in young abusers of street‐ketamine (regular recreational abusers of street‐ketamine, for its hallucinogenic effects) in Hong Kong, presenting with significant lower urinary tract symptoms (LUTS) but with no evidence of bacterial infection. PATIENTS AND METHODS We retrospectively analysed the clinical presentations, pelvic pain and urgency/frequency scores, video‐urodynamic studies, cystoscopy findings, histological features of bladder biopsies and radiological findings of 59 ketamine abusers who were referred to the urology units of Princess Margaret and Tuen Mun Hospital, Hong Kong, from March 2000 to December 2007. RESULTS Of the 59 patients, all had moderate to severe LUTS, i.e. frequency, urgency, dysuria, urge incontinence and occasionally painful haematuria. Forty‐two (71%) patients had a cystoscopy that showed various degrees of epithelial inflammation similar to that seen in chronic interstitial cystitis. All of 12 available bladder biopsies had histological features resembling those of interstitial cystitis. Urodynamically, either detrusor overactivity or decreased bladder compliance with or without vesico‐ureteric reflux was detected to some degree in all of 47 patients. Thirty patients (51%) had unilateral or bilateral hydronephrosis on renal ultrasonography, and four (7%) showed features suggestive of papillary necrosis on radiological imaging. Eight patients had a raised serum creatinine level. CONCLUSION A syndrome of cystitis and contracted bladder can be associated with street‐ketamine abuse. Secondary renal damage can occur in severe cases which might be irreversible, rendering patients dependent on dialysis. The present data do not establish the precise cause nor the incidence. Street‐ketamine abuse is not only a drug problem, but might be associated with a serious urological condition causing a significant burden to healthcare resources.

Genitourinary toxicity of ketamine

“…8,9 Urine cultures including searches for acid-fast bacilli in early-morning urine samples 2,10 were negative, though individuals subsequently develop concomitant urinary tract bacterial infections that are considered to be secondary. 11 A few patients present with sterile pyuria 8,12,13 or proteinuria. 12 Enhanced bladder wall thickness and lower-than-normal urinary bladder volume, with or without upper urinary tract disorder (thickened ureteral wall and dilatation, hydronephrosis, and renal impairment) have also been described.…”

“…6 Surgical interventions can be undertaken with the aim of maintaining renal function and/or improving severe LUTS. For symptom control, patients may be offered hydrodistension, 17 a suprapubic catheter, 25 augmentation enterocystoplasty, 11,12 or even cystoprostatectomy 21 and cystectomy with construction of an ileal neobladder. 26 In patients presenting with hydronephrosis and renal failure, early treatment with endoscopic insertion of JJ stents 11,17 or nephrostomy tubes 2,11,25,27 can preserve renal function before irreversible damage.…”

“…Patients with near-normal cystometric bladder capacities who stop (or reduce) ketamine abuse may return to normal bladder function. 11 In long-term abusers of ketamine, functional bladder capacities (determined from voiding diaries) were between 30 and 100 mL only. 2 Intravenous pyelography showed a small-capacity bladder with the upper urinary tract involved 12 (Fig 1).…”

“…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. 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). 16 Many patients declined cystoscopy for the same reason as for urodynamic studies, 9,11,16 though cystoscopy was usually performed either under local or general anaesthesia (based on symptom severity and patient choice). 11,16 Cystoscopic findings classically associated with IC are detailed in the Table.…”