Clinical Outcome of a Prospective Case Series of Patients With Ketamine Cystitis Who Underwent Standardized Treatment Protocol

Ketamine uropathy: Clinical experience in a high prevalence center

OBJECTIVES

Ketamine uropathy causes inflammatory changes to the urothelium, manifesting as significant lower urinary tract symptoms, small bladder capacity, and pelvic pain. Upper tract involvement and hydronephrosis can occur. Data from UK centers are limited, and no formal treatment guidelines exist.

PATIENTS AND METHODS

All patients with ketamine uropathy presenting to our unit over an 11-year period were identified through operative and clinic lists, emergency presentations, and a prospectively collected local database. Demographic data, biochemical findings, imaging techniques, and both medical and surgical management were recorded.

RESULTS

A total of 81 patients with ketamine uropathy were identified from 2011 to 2022; however, a large proportion presented from 2018 onwards. The average age at presentation was 26 years (interquartile range [IQR]: 27-34), 72.8% were male, and average follow-up time was 34 months (IQR: 8-46). Therapeutic interventions included anticholinergic medication, cystodistension, and intravesical sodium hyaluronate. Hydronephrosis was present in 20 (24.7%) patients and nephrostomy insertion was required in six. One patient underwent bladder augmentation surgery. Serum gamma-glutamyl transferase and length of follow-up were significantly higher in patients with hydronephrosis. Adherence to follow-up was poor.

CONCLUSIONS

We present a large cohort of patients with ketamine uropathy from a small town in the UK which is unusual. The incidence appears to be rising, in-keeping with increasing recreational ketamine use and should be of concern to urologists. Abstinence is a key aspect of management, and a multi-disciplinary approach works best particularly as many patients are lost to follow-up. The development of formal guidance would be helpful.

Ketamine-induced uropathy: A narrative systemic review of surgical outcomes of reconstructive surgery

Aims

Refractory ketamine-induced uropathy (KU) (RKU) has devastating effects on the lower urinary tract leading to ureteral obstruction and even renal failure. The only effective treatment for RKU is major surgical reconstruction or urinary diversion. Nevertheless, there is a paucity of awareness about this destructive condition; the aim of this study is to conduct a narrative systemic review of all surgical outcomes of RKU.

Methods

This is an English language literature review of surgical outcomes in KU patients who underwent reconstructive lower urinary tract surgery or urinary diversion through 5 August 2022. Two independent researchers assessed the relevance of each paper and disputes were settled by a third party. In-vitro, animal studies, letters to the editor and papers that did not evaluate surgical outcomes were excluded.

Results

Of the 50 763 identified articles, 622 were relevant based on title, 150 based on abstract, but only 23 papers were relevant by content. In all, 875 patients were documented as having KU, of whom 193 (22%) underwent reconstructive surgery. The data were disconcerting, as the apparent rapid progression from the beginning of KU to end-stage bladder was only a 1-year difference of ketamine abuse between those patients who required surgery (4.4 years) and those that did not (3.4 years).

Conclusions

The data suggest that the time interval from the beginning of ketamine-induced uropathy to the end-stage bladder may be measured in months, confounding decision making. There is a dearth of literature about KU, and more research is needed to better understand this pathology.

Current approaches for the treatment of ketamine-induced cystitis

AIMS

Ketamine is a dissociative anesthetic, historically used in a clinical setting for the induction and maintenance of anesthesia. Ketamine usage can produce undesirable psychological manifestations including hallucinations and long-term psychotomimetic effects. As a results of its fast onset and short period of action, ketamine is widely used as a recreational drug. Chronic abuse of ketamine can lead to significant urinary system complications including ketamine-induced cystitis (KIC). Common side effects of chronic ketamine abuse are urinary pain and discomfort and decreased bladder compliance and voiding pressure. Cessation of ketamine use is associated with improvement of symptoms however the exact pathophysiology of KIC remains unknown, complicating the ability of clinicians to treat this condition.

METHOD

A literature search was performed using the National Center for Biotechnology Information (NCBI) Pubmed database up to May 2021.

RESULTS

Animal models of KIC are necessary to further our understanding of KIC pathophysiology and explore potential treatment options. In all cases, cessation of ketamine use is the first line of treatment and is most effective in managing KIC. In addition to cessation, treatment plans must be tailored to the individual, based on the severity of symptoms and disease progression, and include options such as: oral anti-inflammatories, intravesical treatment and in the most severe cases, surgical intervention.

CONCLUSION

KIC is a painful condition that currently lacks standardized treatment methods. Both animal models of KIC and clinical trials to further elucidate the mechanism of KIC pathophysiology must be explored to create targeted treatment plans.

Review of Animal Models to Study Urinary Bladder Function

Simple Summary

The treatment of urinary bladder dysfunction requires the knowledge of bladder function, which involves physiology, pathology, and even psychology. Several animal models are available to study a variety of bladder disorders. These models include animals from rodents, such as mice and rats, to nonhuman primates, such as rabbits, felines, canines, pigs, and mini pigs. This review adapted animal models to study bladder function according to facility, priority, and disease.

Abstract

The urinary bladder (UB) serves as a storage and elimination organ for urine. UB dysfunction can cause multiple symptoms of failure to store urine or empty the bladder, e.g., incontinence, frequent urination, and urinary retention. Treatment of these symptoms requires knowledge on bladder function, which involves physiology, pathology, and even psychology. There is no ideal animal model for the study of UB function to understand and treat associated disorders, as the complexity in humans differs from that of other species. However, several animal models are available to study a variety of other bladder disorders. Such models include animals from rodents to nonhuman primates, such as mice, rats, rabbits, felines, canines, pigs, and mini pigs. For incontinence, vaginal distention might mimic birth trauma and can be measured based on leak point pressure. Using peripheral and central models, inflammation, bladder outlet obstruction, and genetic models facilitated the study of overactive bladder. However, the larger the animal model, the more difficult the study is, due to the associated animal ethics issues, laboratory facility, and budget. This review aims at facilitating adapted animal models to study bladder function according to facility, priority, and disease.

Comparison of bladder autoaugmentation by transurethral vesicomyotomy and hydrodistention for ketamine cystitis

Background

To illustrate the bladder autoaugmentation by transurethral vesicomyotomy (BATV) and compare the efficacy and safety of BATV to bladder hydrodistention (BH) for managing ketamine cystitis (KC).

Methods

We retrospectively analyzed clinical data for 53 patients with KC who received surgical intervention between 2014 and 2019 at our hospital. Of these, 41 (77.4%) underwent BH and 12 (22.6%) were subjected to BATV, with a minimum of 1-year follow-up. These groups were compared with reference to urodynamic parameters, subjective symptom scores as well as all complications.

Results

Both groups were matched in age, addiction time, preoperative urodynamic parameters, postvoid residual urinary volume (PVR), and symptom scores. All urodynamic parameters including maximum cystometric capacity (MCC), maximum detrusor pressure (P_{det max}), compliance, maximum urinary flow rate (Q_max) and symptom scores had improved significantly in two groups whether at 3 or 12 months. Moreover, the MCC was significantly increased after BATV than BH, at a mean [standard deviation (SD)] of 281.0 (25.7) vs. 213.5 (35.6) mL (P<0.001) at 12-month follow-up. The Q_max and the Pelvic Pain and Urgency/Frequency (PUF) symptom score were still noted better in the BATV group at 3 months after surgery. Additionally, patients in both groups had similarly low rates of complications.

Conclusions

BATV is superior to BH with increased bladder capacity and urodynamic outcomes, although showing equivalent in symptom relief and a similar rate of complications.

Comparison of intravesical instillation of hyaluronic acid with intradetrusor botulinum toxin A injection or cystoscopic hydrodistention for ketamine-associated cystitis

OBJECTIVE

This study aimed to compare the therapeutic effect of intravesical instillation hyaluronic acid with intradetrusor botulinum toxin A (BTX-A) injection or cystoscopic hydrodistention for ketamine-associated cystitis.

METHODS

Thirty-six patients were evenly randomly divided into the BTX-A group or the hydrodistention group. Patients received 200 U BTX-A detrusor injections in the BTX-A group and cystoscopic hydrodistention in the hydrodistention group. Intravesical instillation of hyaluronic acid was administrated in both groups for eight times. Patients with involuntary detrusor contraction were divided into the persistent involuntary detrusor contraction group and resolved involuntary detrusor contraction group after treatment in 6 months. The predictors of persistent involuntary detrusor contraction were analyzed.

RESULTS

Twelve months after treatment, the daytime frequency, Interstitial Cystitis Symptom Index, maximal capacity, and maximal cystometric capacity in the BTX-A group were significantly better than those in the hydrodistention group. Patients with resolution of involuntary detrusor contraction had a significantly shorter duration of ketamine, lower amount of fibrosis in pathology, and higher maximal capacity than those with persistent involuntary detrusor contraction 6 months after therapy.

CONCLUSION

Intravesical instillation of hyaluronic acid with intradetrusor BTX-A injection appears to be a preferable option for long-term effectiveness compared with cystoscopic hydrodistention.

Risk of Renal Function Decline in Patients with Ketamine-Associated Uropathy

Ketamine-associated diseases have been increasing with the rise in ketamine abuse. Ketamine-associated uropathy is one of the most common complications. We investigated the effects of ketamine-associated uropathy on renal health and determined predictors of renal function decline in chronic ketamine abusers. This retrospective cohort study analyzed 51 patients (22 with ketamine-associated hydronephrosis and 29 with ketamine cystitis) from Kaohsiung Veterans General Hospital in Taiwan. Primary renal outcome was end-stage renal disease or estimated glomerular filtration rate decline >30% from baseline. Compared with the ketamine cystitis group, the hydronephrosis group had lower initial and final estimated glomerular filtration rates and higher alkaline phosphatase and gamma-glutamyl transferase levels (p < 0.05). Elevated cholestatic liver enzyme levels correlated with renal dysfunction in ketamine-associated uropathy. The hydronephrosis group had a higher proportion of patients reaching endpoints than the ketamine cystitis group (50% and 7%, respectively, p < 0.001). After adjusting for age, sex, and initial serum creatinine level, hydronephrosis remained an independent risk factor for renal function deterioration. Ketamine-associated hydronephrosis was a poor renal outcome and strong predictor of renal function decline in chronic ketamine abusers. Elevated cholestatic liver enzyme levels correlated with the severity of ketamine-associated uropathy. Ultrasonography screening of these high-risk groups and regular renal function follow-ups are necessary.

Efficacy of cystectasia in the treatment of ketamine-induced bladder contracture

Background

The treatment of ketamine-induced bladder contractures remains poorly studied. We therefore evaluated the efficacy of cystectasia with a sodium hyaluronate balanced solution in this kind of bladder contracture.

Methods

Eighteen patients presenting with ketamine-induced bladder contracture between July 2010 and February 2018 were selected and analysed. Ketamine was discontinued in all patients, who were then treated with weekly cystectasia (0.09% sodium hyaluronate balanced solution) 3 times. The volume of the first perfusion was twice the preoperatively measured bladder capacity, and the volume of the subsequent two perfusions was increased by 100 mL each time. The Pelvic Pain and Urgency/Frequency (PUF) symptom score, O'Leary-Sant Interstitial Cystitis (IC) Symptom Index (ICSI), IC Problem Index (ICPI), Quality of Life (QOL) score, and bladder capacity were recorded before surgery and 3 and 12 months after the 3^rd expansion.

Results

No significant complications were observed during the 3 expansions. Fourteen patients completed the full follow-up schedule. Preoperatively and at the 3- and 12-month follow-up evaluations performed after the 3^rd expansion, the PUF symptom scores were 20.4±3.6, 11.5±3.1, and 13.2±3.3, respectively; the mean ICSI was 13.6±2.8, 7.7±2.3, and 8.2±2.5, respectively; the mean ICPI was 10.6±2.6, 7.3±2.1, and 7.7±2.5, respectively; and the mean QOL scores were 6.0±0, 2.1±0.5, and 2.7±0.8, respectively; and the mean bladder catheter volume was 83±27, 234±56, and 228±52 mL, respectively. There were significant differences between all preoperative and postoperative values.

Conclusions

Cystectasia with a sodium hyaluronate balanced solution is an effective treatment modality for ketamine-induced bladder contracture.

What urologists need to know about ketamine-induced uropathy: A systematic review

AIMS

Ketamine is a general anesthetic. Dissociative effects and low cost led ketamine becoming an illegal recreational drug in young adults. Ketamine-induced uropathy (KIU) is one of the complications observed in abusers. This study aimed to provide a systematic literature review on KIU clinical presentation, pathophysiology, and treatments.

METHODS

We performed the literature search in PubMed, Web of Science, Scopus, and Embase using the terms ketamine and bladder. English papers on human and animal studies were accepted.

RESULTS

A total of 75 papers were selected. Regular ketamine users complain about severe storage symptoms and pelvic pain. Hydronephrosis may develop in long-term abusers and is correlated to the contracted bladder, ureteral stenosis, or vesicoureteral reflux due to ureteral involvement and/or bladder fibrosis. Cystoscopy shows ulcerative cystitis. Ketamine in urine might exert direct toxicity to the urothelium, disrupting its barrier function and enhancing cell apoptosis. The presence of ketamine/ions in the bladder wall result in neurogenic/IgE-mediated inflammation, stimulation of the inducible nitric oxide synthase-cytokines-cyclooxygenase pathway with persistent inflammation and fibrosis. Abstinence is the first therapeutic step. Anti-inflammatory drugs, analgesics and anticholinergics, intravesical instillation of hyaluronic acid, hydrodistension and intravesical injection of botulin toxin-A were helpful in patients with early-stage KIU. In patients with end-stage disease, the control of intractable symptoms and the increase of bladder capacity were the main recommendations to perform augmentation enterocystoplasty.

CONCLUSIONS

KIU is becoming a worldwide health concern, which should be taken into account in the differential diagnosis of ulcerative cystitis.

ls clinical practice aligned with the latest scientific evidence on GAG therapy?

The role of glycosaminoglycans (GAGs) as key components of the protective bladder barrier is well accepted. Replenishment of the GAG layer could restore the normal protective barrier function of the damaged bladder urothelium and re-establish normal permeability. A number of bladder diseases, including interstitial cystitis/bladder pain syndrome, recurrent urinary tract infections, radiation cystitis, and other forms of cystitis may benefit from GAG therapy.

The Risk of Upper Urinary Tract Involvement in Patients With Ketamine-Associated Uropathy

Purpose

The aims of this study were to investigate the prevalence of upper tract involvement in ketamine-associated uropathy, and to determine the predictors of hydronephrosis in patients with a history of ketamine abuse.

Methods

This was a cross-sectional study of a prospective cohort of patients with ketamine-associated uropathy. Data including demographics, pattern of ketamine abuse, pelvic pain and urgency or frequency (PUF) symptom score, uroflowmetry (UFM) parameters, serum renal function, and liver function tests were collected. Upon consultation, ultrasonography was performed to assess the function of the urinary system.

Results

From December 2011 to October 2015, we treated 572 patients with ketamine-associated uropathy. Of these patients, 207 (36.2%) had managed to achieve abstinence at the time of their first consultation. Ninety-six patients (16.8%) in the cohort were found to have hydronephrosis on ultrasonography. Univariate analysis identified age, duration of ketamine abuse, PUF symptom score, voided volume on UFM, serum creatinine levels >100 μmol/L, and an abnormal serum liver enzyme profile as factors associated with hydronephrosis. Logistic regression revealed the following parameters to be statistically related to hydronephrosis: age (adjusted odds ratio [OR], 1.090; 95% confidence interval [CI], 1.020–1.166; P=0.012), functional bladder capacity (adjusted OR, 0.997; 95% CI, 0.995–0.999; P=0.029), serum creatinine >100 μmol/L (adjusted OR, 3.107; 95% CI, 1.238–7.794; P=0.016, and an abnormal serum liver enzyme profile (adjusted OR, 1.967; 95% CI, 1.213–3.187; P=0.006).

Conclusions

Ketamine-associated uropathy can involve the upper urinary tract. Patient demographics as well as investigations of UFM, renal function tests, and liver function tests may allow us to identify at-risk patients.

Erectile Dysfunction among People Who Use Ketamine and Poly-Drugs

Despite the rise in recreational use of ketamine in Malaysia, there have been no studies of users or of the health-related consequences they face. This study was initiated to examine ketamine use and its health consequences. A structured questionnaire was used to elicit information. A final sample of 127 males was divided into persons who used only ketamine and those who were poly-drug users. Each group was further divided into long-period and short-period users. Urine toxicology screening for ketamine and other illicit drugs commonly used in Malaysia was also done. Our findings corroborate those of earlier studies that link ketamine use to urological problems such as frequent urination, dysuria, incontinence, painful bladder, nocturia, and urinary urgency. A new finding in this study is the significant association between ketamine use and erectile dysfunction, such that higher odds of reporting erectile dysfunction were linked to long-period users. Our findings strengthen the case for early intervention, as ketamine users are drawn from young and unmarried male participants. The association of ketamine use with erectile dysfunction, if substantiated, will help physicians in their diagnosis of erectile dysfunction, particularly among youths.