Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

Keynote webinar | Spotlight on medication adherence

LIVE: Thursday 27th June 2024, 18:00-19:30 (CEST)
Join our expert panel to discover why you need to understand the drivers of non-adherence in your patients, and how you can optimize medication adherence in your clinics to drastically improve patient outcomes.
ADVANCED SEARCH
Log in
Top
Current Bladder Dysfunction Reports
Published in: Current Bladder Dysfunction Reports 3/2018

01-09-2018 | Overactive Bladder and Lower Urinary Tract Symptoms (U Lee and S Adelstein, Section Editors)

Ketamine-Associated Bladder Dysfunction—a Review of the Literature

Author: Soumya Misra

Published in: Current Bladder Dysfunction Reports | Issue 3/2018

Login to get access

Abstract

Purpose of Review

The purpose of this review is to study the epidemiology, presentation, pathogenesis and management of ketamine cystitis and its complications.

Recent Findings

Recent data suggest that the toxicity of ketamine can be due to direct cytotoxicity, independent of a NMDA receptor-mediated mechanism. Bladder barrier dysfunction, neurogenic inflammation with abnormal neurotransmission and immunological mechanisms have also been proposed, based on data from animal models and in vitro studies. Effects on the bladder are dependent on the dose and duration of ketamine use. Clinical studies have showed that the model of outreach clinics with involvement of local urology services holds most promise, with a tiered approach to management based on stage of the disease.

Summary

Chronic ketamine use is associated with significant lower urinary tract symptoms including frequency, urgency, haematuria and bladder pain. This may progress to irreversible bladder dysfunction with poor capacity and compliance and upper tract dysfunction may also occur. The key to successful treatment is ketamine cessation. The role of medications is not well established but there may be benefit from drugs used for IC/BPS and bladder Botox. Patients with end stage disease will require surgery, but there is a high complication rate.
Literature
1.
Morgan CJ, Curran HV. Independent scientific committee on drugs. Ketamine use: a review. Addiction. 2012;107(1):27–38.CrossRefPubMed
2.
Dalgarno PJ, Shewan D. Illicit use of ketamine in Scotland. J Psychoactive Drugs. 1996;28(2):191–9.CrossRefPubMed
3.
4.
Yiu-Cheung C. Acute and chronic toxicity pattern in ketamine abusers in Hong Kong. J Med Toxicol. 2012 Sep;8(3):267–70.CrossRefPubMed
5.
Meng E, Wu ST, Cha TL, Sun GH, Yu DS, Chang SY. A murderer of young bladders: ketamine-associated cystitis. Urol Sci. 2013;24:113–6.CrossRef
6.
Moore KA, Sklerov J, Levine B et al. Urine concentrations of ketamine and norketamine following illegal consumption. J Anal Toxicol 200;25(7):583–588.
7.
Shahani R, Streutker C, Dickson B, Stewart RJ. Ketamine-associated ulcerative cystitis: a new clinical entity. Urology. 2007;69:810–2.CrossRefPubMed
8.
Chu PS, Kwok SC, Lam KM, et al. ‘Street ketamine’-associated bladder dysfunction: a report of ten cases. Hong Kong Med J. 2007;13(4):311–3.PubMed
9.
Chu PS, Ma WK, Wong SC, et al. The destruction of the lower urinary tract by ketamine abuse: a new syndrome? BJU Int. 2008;102:1616–22.CrossRefPubMed
10.
Cottrell AM, Gillatt DA. Ketamine-associated urinary tract pathology: the tip of the iceberg for urologists? Br J Med Surg Urol. 2008;1:136–8.CrossRef
11.
12.
Selby NM, Anderson J, Bungay P, Chesterton LJ, Kolhe NV. Obstructive nephropathy and kidney injury associated with ketamine abuse. NDT Plus. 2008;1(5):310–2.PubMedPubMedCentral
13.
Shahzad S, Antil S, Ferrie B, Ganta S. UP-3.073: dystrophic calcification of urinary bladder associated with ketamine use. Urology. 2009;74:S317.CrossRef
14.
Chiew YW, Yang CS. Disabling frequent urination in a young adult. Ketamine-associated ulcerative cystitis. Kidney Int. 2009;76(1):123–4.CrossRefPubMed
15.
Tsai TH, Cha TL, Lin CM, Tsao CW, Tang SH, Chuang FP, et al. Ketamine-associated bladder dysfunction. Int J Urol. 2009;16:826–9.CrossRefPubMed
16.
Mason K, Cottrell AM, Corrigan AG, Gillatt DA, Mitchelmore AE. Ketamine-associated lower urinary tract destruction: a new radiological challenge. Clin Radiol. 2010;65:795–800.CrossRefPubMed
17.
Mak SK, Chan MT, Bower WF, et al. Lower urinary tract changes in young adults using ketamine. J Urol. 2011;186(2):610–4.CrossRefPubMed
18.
Wood D, Cottrell A, Baker SC, Southgate J, Harris M, Fulford S, et al. Recreational ketamine: from pleasure to pain. BJU Int. 2011;107:1881–4.CrossRefPubMed
19.
Misra S, Chetwood A, Coker C, Thomas P. Ketamine cystitis: practical considerations in management. Scand J Urol. 2014;48(5):482–8.CrossRefPubMed
20•.
Huang LK, Wang JH, Shen SH, et al. Evaluation of the extent of ketamine-induced uropathy: the role of CT urography. Postgrad Med J. 2014;90(1062):185–90. In depth discussion of role of imaging in ketamine cystitis. CrossRefPubMed
21••.
Tam YH, Ng CF, Pang KK, et al. One-stop clinic for ketamine-associated uropathy: report on service delivery model, patients' characteristics and non-invasive investigations at baseline by a cross-sectional study in a prospective cohort of 318 teenagers and young adults. BJU Int. 2014;114(5):754–60. Report on service delivery using a one stop clinic for assessment of ketamine cystitis. CrossRefPubMed
22•.
Wu P, Wang Q, Huang Z, et al. Clinical staging of ketamine-associated urinary dysfunction: a strategy for assessment and treatment. World J Urol. 2016;34(9):1329–36. Report on treatment based on stage. CrossRefPubMed
23••.
Jhang JF, Hsu YH, Kuo HC. Possible pathophysiology of ketamine-related cystitis and associated treatment strategies. Int J Urol. 2015;22(9):816–25. Review article focussing on pathophysiology. CrossRefPubMed
24.
Winstock AR, Mitcheson L, Gillatt DA, Cottrell AM. The prevalence and natural history of urinary symptoms among recreational ketamine users. BJU Int. 2012;110:1762–6.CrossRefPubMed
25.
Muetzelfeldt L, Kamboj SK, Rees H, Taylor J, Morgan CJA, Curran HV. Journey through the K-hole: phenomenological aspects of ketamine use. Drug Alcohol Depend. 2008;95(3):219–29.CrossRefPubMed
26.
Gregoire MC, MacLellan DL, Finley GA. A paediatric case of ketamine-associated cystitis. Urology. 2008;71:1232–3.CrossRefPubMed
27.
Storr TM, Quibell R. Can ketamine prescribed for pain cause damage to the urinary tract? Palliat Med. 2009;23(7):670–2.CrossRefPubMed
28.
Shahzad K, Svec A, Al-Koussayer O, et al. Analgesic ketamine use leading to cystectomy: a case report. Br J Med Surg Urol. 2012;5:188–91.CrossRef
29.
Andrade C. Ketamine for depression, 1: clinical summary of issues related to efficacy, adverse effects, and mechanism of action. J Clin Psychiatry. 2017;78(4):e415–9.CrossRefPubMed
30.
Lee CL, Jiang YH, Kuo HC. Increased apoptosis and suburothelial inflammation in patients with ketamine-related cystitis: a comparison with non-ulcerative interstitial cystitis and controls. BJU Int. 2013;112(8):1156–62.CrossRefPubMed
31.
Chung SD, Wang CC, Kuo HC. Augmentation enterocystoplasty is effective in relieving refractory ketamine-related bladder pain. Neurourol Urodyn. 2014;33(8):1207–11.CrossRefPubMed
32•.
Sihra N, Ockrim J, Wood D. The effects of recreational ketamine cystitis on urinary tract reconstruction—a surgical challenge. BJU Int. 2017 Dec 12; https://​doi.​org/​10.​1111/​bju.​14094. One of the larger series describing reconstructive surgery for ketamine cystitis
33.
Kidger E, Stahlschmidt J, Garthwaite M, Fulford S, Southgate J, Baker SC. A rare urachal cyst in a case of ketamine-induced cystitis provides mechanistic insights. Urology. 2016;90:223.e1–7.CrossRef
34.
Wai MS, Luan P, Jiang Y, Chan WM, Tsui TY, Tang HC, et al. Long term ketamine and ketamine plus alcohol toxicity—what can we learn from animal models? Mini Rev Med Chem. 2013;13(2):273–9.PubMed
35.
Baker SC, Shabir S, Georgopoulos NT, Southgate J. Ketamine-induced apoptosis in normal human urothelial cells: a direct, N-methyl-d-aspartate receptor-independent pathway characterized by mitochondrial stress. Am J Pathol. 2016;186(5):1267–77.CrossRefPubMedPubMedCentral
36.
Shie JH, Kuo HC. Higher levels of cell apoptosis and abnormal E-cadherin expression in the urothelium are associated with inflammation in patients with interstitial cystitis/painful bladder syndrome. BJU Int. 2011;108(2 Pt 2):E136–41.CrossRefPubMed
37.
Gu D, Huang J, Yin Y, Shan Z, Zheng S, Wu P. Long-term ketamine abuse induces cystitis in rats by impairing the bladder epithelial barrier. Mol Biol Rep. 2014;41(11):7313–22.CrossRefPubMed
38.
Baker SC, Stahlschmidt J, Oxley J, Hinley J, Eardley I, Marsh F, et al. Nerve hyperplasia: a unique feature of ketamine cystitis. Acta Neuropathol Commun. 2013;1:64.CrossRefPubMedPubMedCentral
39.
Meng E, Chang HY, Chang SY, Sun GH, Yu DS, Cha TL. Involvement of purinergic neurotransmission in ketamine induced bladder dysfunction. J Urol. 2011;186(3):1134–41.CrossRefPubMed
40.
Wei YB, Yang JR, Yin Z, Guo Q, Liang BL, Zhou KQ. Genitourinary toxicity of ketamine. Hong Kong Med J. 2013;19(4):341–8.PubMed
41.
Jhang JF, Hsu YH, Jiang YH, Kuo HC. Elevated serum IgE may be associated with development of ketamine cystitis. J Urol. 2014;192(4):1249–56.CrossRefPubMed
42.
Chuang SM, Liu KM, Li YL, Jang MY, Lee HH, Wu WJ, et al. Dual involvements of cyclooxygenase and nitric oxide synthase expressions in ketamine-induced ulcerative cystitis in rat bladder. Neurourol Urodyn. 2013;32(8):1137–43.CrossRefPubMed
43.
Tan S, Chan WM, Wai MS, et al. Ketamine effects on the urogenital system—changes in the urinary bladder and sperm motility. Microsc Res Tech. 2011;74(12):1192–8.CrossRefPubMed
44.
Wang J, Chen Y, Gu D, Zhang G, Chen J, Zhao J, et al. Ketamine-induced bladder fibrosis involves epithelial-to-mesenchymal transition mediated by transforming growth factor-β1. Am J Physiol Renal Physiol. 2017;313(4):F961–72.CrossRefPubMed
45.
Yeung LY, Rudd JA, Lam WP, Mak YT, Yew DT. Mice are prone to kidney pathology after prolonged ketamine addiction. Toxicol Lett. 2009;191(2–3):275–8.CrossRefPubMed
46.
Wai MS, Chan WM, Zhang AQ, Wu Y, Yew DT. Long-term ketamine and ketamine plus alcohol treatments produced damages in liver and kidney. Hum Exp Toxicol. 2012;31(9):877–86.CrossRefPubMed
47.
Lo RS, Krishnamoorthy R, Freeman JG, Austin AS. Cholestasis and biliary dilatation associated with chronic ketamine abuse: a case series. Singap Med J. 2011;52(3):e52–5.
48••.
Yee CH, Lai PT, Lee WM, et al. Clinical outcome of a prospective case series of patients with ketamine cystitis who underwent standardized treatment protocol. Urology. 2015;86(2):236–43. Outcome of treatment from the largest prospective series of ketamine cystitis. CrossRefPubMed
49.
Lai Y, Wu S, Ni L, Chen Z, Li X, Yang S, et al. Ketamine-associated urinary tract dysfunction: an underrecognized clinical entity. Urol Int. 2012;89(1):93–6.CrossRefPubMed
50.
Middela S, Pearce I. Ketamine-induced vesicopathy: a literature review. Int J Clin Pract. 2011;65(1):27–30.CrossRefPubMed
51.
52.
Oxley JD, Cottrell AM, Adams S, Gillatt D. Ketamine cystitis as a mimic of carcinoma in situ. Histopathology. 2009;55:705–8.CrossRefPubMed
53.
Ho CC, Pezhman H, Praveen S, Goh EH, Lee BC, Zulkifli MZ, et al. Ketamine-associated ulcerative cystitis: a case report and literature review. Malays J Med Sci. 2010;17(2):61–5.PubMedPubMedCentral
54.
Jalil R, Gupta S. Illicit ketamine and its bladder consequences: is it irreversible? BMJ Case Rep. 2012;2012:bcr2012007244.PubMedPubMedCentral
55.
Hopcroft SA, Cottrell AM, Mason K, Abrams P, Oxley JD. Ureteric intestinal metaplasia in association with chronic recreational ketamine abuse. J Clin Pathol. 2011;64(6):551–2.CrossRefPubMed
56.
Logan K, Gill P, Shaw C, et al. Users experience of ketamine bladder syndrome (KBS). Neurourol Urodyn. 2015;34(S3):47–8.
57.
Cheung RYK, Chan SSC, Lee JHS, Pang AW, Choy KW, Chung TK. Urinary symptoms and impaired quality of life in female ketamine users: persistence after cessation of use. Hong Kong Med J. 2011;17:267–73.PubMed
58.
Chen R, Lee AM, Chan R et al. A study on the cognitive impairment and other harmful effects from ecstasy and ketamine abuse. Narcotics Division, Security Bureau. The Government of the Hong Kong Special Administrative Region. Narcotics Division 2004.
59.
Forster JA, Harrison SC. Ketamine uropathy: rising to the challenges of a new condition. BJU Int. 2012;109(9):1277–8.CrossRefPubMed
60.
61.
Smart C, Kabir M, Pati J. Treatment of ketamine-associated cystitis with chondroitin sulphate. Br J Nurs. 2013;22(18):S4. S6, S8-9CrossRefPubMed
62.
Zeng J, Lai H, Zheng D, Zhong L, Huang Z, Wang S, et al. Effective treatment of ketamine-associated cystitis with botulinum toxin type a injection combined with bladder hydrodistention. J Int Med Res. 2017;45(2):792–7.CrossRefPubMedPubMedCentral
63.
Ng CF, Chiu PK, Li ML, et al. Clinical outcomes of augmentation cystoplasty in patients suffering from ketamine-related bladder contractures. Int Urol Nephrol. 2013;45(5):1245–51.CrossRefPubMed
64.
Jhang JF, Birder LA, Chancellor MB, Kuo HC. Patient characteristics for different therapeutic strategies in the management ketamine cystitis. Neurourol Urodyn. 2017;36(3):687–91.CrossRefPubMed
Metadata
Title
Ketamine-Associated Bladder Dysfunction—a Review of the Literature
Author
Soumya Misra
Publication date
01-09-2018
Publisher
Springer US
Published in
Current Bladder Dysfunction Reports / Issue 3/2018
Print ISSN: 1931-7212
Electronic ISSN: 1931-7220
DOI
https://doi.org/10.1007/s11884-018-0476-1

Other articles of this Issue 3/2018

Current Bladder Dysfunction Reports 3/2018 Go to the issue

Overactive Bladder and Lower Urinary Tract Symptoms (U Lee and S Adelstein, Section Editors)

Cost-Effectiveness of Third-Line Therapies for Overactive Bladder

Stress Incontinence and Prolapse (S Reynolds, Section Editor)

Apical Prolapse: Is There a Best Approach?

Neurogenic Bladder (C Powell, Section Editor)

The Role of Chemical Sphincterotomy with Urethral Botulinum Toxin Injection in Patients with Neurogenic and Non-neurogenic Failure to Empty

Overactive Bladder and Lower Urinary Tract Symptoms (U Lee and S Adelstein, Section Editors)

Managing of Lower Urinary Tract Dysfunction Following Stroke

Overactive Bladder and Lower Urinary Tract Symptoms (U Lee and S Adelstein, Section Editors)

New Concepts in Bladder Sensation and Urinary Urgency

Overactive Bladder and Lower Urinary Tract Symptoms (U Lee and S Adelstein, Section Editors)

Post-Implant Management of Sacral Neuromodulation