The veterinary anaesthetic ketamine has been used for its hallucinogenic properties by misusers. The drug is self-administered either intra-muscularly, orally or can be inhaled. It has been linked with date rape cases because of its known amnesia effect. It is also considered a recreational drug amongst young people. It can also be legitimately prescribed to patients for neuropathic pain or end of life symptom control. Frequently it’s combined on the street with ecstasy and can be known by several names such as Jet K, KitKat or Cat Valium. Because of the growing popularity of the drug, in 2006 the Misuse of Drugs Act made ketamine a class C substance. The incidence of ketamine bladder syndrome was first documented in 2007 and since then cases have been reported in North America, Asia and Europe, including the UK. It has been found that the bladder can be affected quite severely through ketamine misuse and in some cases the bladder damage has been proven to be irreversible.
Frequently those who have misused ketamine and have become patients with ketamine bladder syndrome delay reporting problems due to perhaps embarrassment but also the risk of being identified as being a user of illegal substances. Because of the dual stigma attached of the embarrassment and also the reluctance of identifying oneself as someone who uses such drugs this syndrome tends to be under-reported.
Ketamine bladder syndrome symptoms include an increased frequency in voiding, and increased urgency, increased bladder sensation, so therefore the desire to void when the bladder is not full is increased. It can also involve pelvic, urethral or bladder pain. Patients can present with haematuria, they can also be urge incontinent too. Because of the nature of the symptoms of ketamine bladder syndrome, it can be confused with other conditions such as interstitial cystitis, lower urinary tract symptoms, and ulcerative cystitis.
Those who use ketamine may or may not be aware of the side effects that often present with prolonged abuse of the drug. Prompt recognition of the syndrome is required in order to maximise effectiveness of treatment and prevent further bladder damage. Frequently the first contact a ketamine abuser will have raising awareness of their problems is with their GP or practice nurse and therefore it is important for the healthcare staff to be aware and alert to the possibility of ketamine-related problems. So therefore, if there are people under the age of 30 that are presenting with symptoms that are normally attributed to cystitis it’s important that ketamine abuse should be considered and perhaps this should be discussed with the patient if ketamine abuse is a factor of the problem and therefore this needs to be addressed and not just purely treat the patient for cystitis.
Currently there are no clinical guidelines regarding ketamine abuse and bladder symptoms, so therefore a multidisciplinary and sensitive approach needs to be employed to ensure that the patient is fully informed of their condition, is aware of what treatment is available and also changes that need to be made in their lifestyle in order to prevent serious risks later on, including irreversible bladder damage. Sometimes patients will present with urinary symptoms that have previously been treated with antibiotics and these haven’t worked; in such cases it might be worth considering they might have been abusing ketamine. Patients may need to be referred onwards to aid diagnosis. Therefore, a cystoscopy may be considered to determine whether there’s been any damage to the bladder wall. Bladder function tests and urodynamic studies may also be considered. Patients with ketamine-induced bladder damage may experience irritation and/or inflammation of the bladder wall, haemorrhages, ulcers, possibly presenting as haematuria. Patients may also present with the urge to void more frequently, as with this condition bladder capacity can be reduced by as much as 90%. If ketamine abuse is part of the problem, patient education is important at this stage to promote healthy habits and decrease or halt the intake of recreational drugs, and therefore halt the damage done to the bladder. They may need to be referred on to a drug rehabilitation service although it has been found in studies that the success rate of those stopping ketamine use is at about 30%. In extreme cases the bladder damage is irreversible; it may lead to patients requiring long-term indwelling catheters or perhaps a cystectomy. These procedures can lead to relief from abdominal, pelvic or bladder pain and the urgency associated with the condition.
Ketamine bladder syndrome is frequently not recognised because it is often not expected. It is a serious condition, however, and therefore it is vital that it is recognised as soon as possible.