Ketamine Bladder

1
Ketamine Bladder

• Carmel Ramage
• 19th October 2012

2
Case Presentation

• 24 year old woman
• Complaining of
• Urinary frequency
• Urgency
• Pain
• Dysuria - shooting and leads to poor flow
  because tenses up
• post micturation pain
• Symptoms of recurrent UTI but one proven UTI
• Jelly like urethral discharge
• Deep dyspareunia

3
History

• P 14
• No significant medical history
• Smoker
• Social alcohol intake
• NKDA
• 10 stone lost weight but normal appetite
• LFT only raised gamma GT

4
Examination

• Pelvic examination normal
• Urethra no discharge
• Attempted cystoscopy in OPD very tender and in
  severe discomfort
• Cystoscopy under GA

5
Cystoscopy

• Severe haematuria
• Unable to visualise any anatomy
• No response to saline washout
• Indwelling catheter left in situ
• USS organised

6
Further investigations

• USS fluid in POD, catheter in bladder
• Discussed with Urologists
• CT recommended
• Free fluid confirmed in pelvis and abdomen
• Bladder abnormally thick walled and small
• Plan
• Catheter in for 2 weeks
• Cystogram

7
Diagnosis

• Re-interviewed following initial USS and CT
• Admitted to Ketamine use for 4 years
• Several times a week for a year
• Stopped during pregnancy (2008)
• Now once / twice monthly
• Previous hospital admission (November 2010) with
  severe abdominal pain following sniffing ketamine
  
• Managed conservatively
• Treated for UTI
• Readmission 4 months later with upper abdominal
  pain
• Gastroscopy )
• Abdominal USS ) NAD
• Renal USS )

8
Cystogram

• Small volume bladder (20mls) and patient unable
  to tolerate
• CT
• No further fluid in pelvis and abdomen
• contrast in uterus and vagina suspicion of
  vesico-uterine fistula
• Repeat cystogram 3 weeks later
• Severe pain on distending bladder
• No extravasation seen

9
Ongoing Management

• Continued with indwelling catheter
• Started on Solifenacin
• Cystistat bladder installations
• Aware that symptoms may not settle due to
  irreversible bladder fibrosis
• May need Augmentation cystoplasty

10
Current Update

• Cystistat bladder instillations for 8 months
• Symptoms
• Daytime frequency 3 hourly
• Nightime 6 hourly
• Full bladder without urgency
• No bladder pain
• No Haematuria
• No UTI
• No need for reconstructive bladder surgery

11
Ketamine

• Fastest growing "party drug" among 16-24 year
  olds
• Also known as
• Special K
• Kit-Kat
• Ket
• Cat valium
• Vitamin K
• Estimated 125,000 users in the UK
• More users than crack and heroin combined in UK
  and Wales

12
History

• Developed by Parke-Davis in 1962
• First given to American soldiers during the
  Vietnam War
• Battlefield / emergency anaesthetic
• Short duration of action
• Dissociative anaesthesia
• Muscle paralysis
• Increase in illicit use in USA during 1990s
• Class C drug (January 2006)
• Possession - 2 years
• Supply - 14 years
• Unlimited fine

13
Ketamine effects

• Floating feeling
• may feel completely detached from body and
  surroundings
• Dissociative paralysis entering the K-hole
• Change in perception
• Hallucinations
• Trip for up to an hour
• After effects may take several hours to wear off
• Confusion
• Panic attacks
• Depression
• Exacerbation of any pre-existing mental health
  problems

14
(No Transcript)
15
Ketamine Use

• Sold in either powdered or liquid form
• Inhaled as snuff
• Injected
• Orally
• Bitter taste
• Slower onset of action
• Ecstasy Tablets known as "Strawberry and
  "Sitting Duck" contained Ketamine
• gt80 ketamine seized in the US is of Mexican
  origin

16
Ketamine Detection

• Urine
• Blood/ plasma
• Norketamine
• Pharmacologically-active metabolite
• Plasma levels
• Therapeutic - 0.5-5.0 mg/L
• Arrested for impaired driving
• 12 mg/L
• Acute fatal overdose - 320 mg/L

17
Ketamine and Urinary system

• Bristol bladder
• described in 20081
• frequency, haematuria, incontinence and dysuria
  associated with ketamine use
• Scarred thickened shrunken bladder
• Erythema with contact bleeding
• Severe ulcerative cystitis
• Can ascend to ureters and kidneys
• Symptomatic relief
• Cessation of Ketamine use2
• Pentosan Polysulphate
• 1Cottrell et al 2008. BMJ 336 973
• 2Shahani et al 2007 Urology 69 (5)

18
Presentation

• K cramps
• Severe long lasting abdominal pain
• Cause unknown
• Usually limited to users of gt1 g / day
• Hepatic damage
• Urinary tract
• Overactive bladder syndrome
• Painful bladder symptoms
• Incontinence
• Upper tract obstruction
• Renal papillary necrosis
• Patients erroneously treated for recurrent UTIs/
  painful bladder syndrome

19
Ketamine and Bladder damage

• Causal link
• Precise mechanism unclear
• Direct toxicity of Ketamine or its metabolites
  (supported by animal models)
• Microvascular damage
• Autoimmune reaction triggered by circulating or
  urinary ketamine
• Unrecognised bacteruria
• Toxicity receptor mediated
• No NDMA receptors in bladder

20
Diagnosis of Ketamine Bladder

• Cystoscopy
• Denuded urothelium
• Can slough off as intact sheets of cells
• Histology
• Absence of urothelium
• Eosinophilia in blood vessels
• Lymphocytic infiltration
• mast cells
• Cell Markers
• P53 (assoc. with cell death) high
• Ki07 (assoc. with cell growth) - very low
• CK20 (assoc with Ca in situ) absent
• Wood et al 2011 BJUI 1071881-1884

21
How to make the Diagnosis

• Good history of recreational drug abuse
• MSU for CS
• Cystoscopy and biopsy
• Renal function tests
• CT urogram for extent of disease

22
Treatment

• Stop ketamine
• Involve
• drug support agencies
• GP
• National Club Drug Clinic London (Chelsea and
  Westminister)
• Liaise with chronic pain team
• Medication
• Bupenorphine patches
• Co-codamol
• Amytriptylline at night (Bristol)
• Anticholinergics
• Intra-vesical installations
• Bladder augmentation / urinary diversion /-
  cystectomy

23
Future

• Awareness and Education of Clinical Staff
• Education and Support for ketamine users
• Effects on the urinary tract
• Where to seek help
• Liaison with pain services, psychiatry, social
  services

24
Summary

• Increasing Ketamine use
• May cause significant urinary tract damage
• Be aware of potential diagnosis in young patients
  with severe painful bladders