1. Mo Belal Consultant Urological Surgeon University Hospitals Birmingham
Ketamine Bladder
Mo Belal
Consultant Urological Surgeon
University Hospitals Birmingham

2. Physiological impact of ketamine on the bladder
Surgical Options
Pre-assessment implications
Post-operative management

3. Ketamine
Ketamine hydrochloride is an N-methyl-D-aspartic acid receptor antagonist
Used as an anesthetic agent in human and veterinary procedures
Use in severe depression, nasal and IV early trial promising

4. Ketamine Hallucinogenic properties
Taken orally, inhaled or injected into muscle.
Cheap and easy to obtain it is often mixed with ecstasy. It has several street names, such as
“Cat Valium”, “Jet K”, “Kit Kat”, and “Special K Super K
High and “k-hole” (outer body experience) it can give.
In 2006, the Misuse of Drugs Act made ketamine a class C substance (Cottrell and Gillatt, 2008)

5. Volpe, M. A. , Shah, S. , Cooper, K. , & Kaplan, S. A
Volpe, M. A., Shah, S., Cooper, K., & Kaplan, S. A. 2003, "Illicit ketamine abuse (special K) causing eosinophilic cystitis", J.Urol., vol. 169, no. 4 (supplement 1), p. 9

6. Presenting Symptoms Increased day time frequency Urgency
Urge urinary incontinence 
Increased bladder sensation 
Pelvic, bladder and or urethral pain 
Haematuria 

7. Investigations Rigid Cystoscopy and biopsy Video Urodynamics
CT Abdomen/Pelvis

8. Cystoscopic findings
BJU International Volume 102, Issue 11, pages , 1 AUG 2008 DOI: /j X x

9. Histology
Ketamine‐associated cystitis shows a variable degree of inflammation (A,B). The infiltrates comprised predominantly lymphocytes and a variable number of eosinophils (C). Ultrastructural examination shows querciphylloid muscle cells (D).
IF THIS IMAGE HAS BEEN PROVIDED BY OR IS OWNED BY A THIRD PARTY, AS INDICATED IN THE CAPTION LINE, THEN FURTHER PERMISSION MAY BE NEEDED BEFORE ANY FURTHER USE. PLEASE CONTACT WILEY'S PERMISSIONS DEPARTMENT ON OR USE THE RIGHTSLINK SERVICE BY CLICKING ON THE 'REQUEST PERMISSIONS' LINK ACCOMPANYING THIS ARTICLE. WILEY OR AUTHOR OWNED IMAGES MAY BE USED FOR NON-COMMERCIAL PURPOSES, SUBJECT TO PROPER CITATION OF THE ARTICLE, AUTHOR, AND PUBLISHER.
BJU International Volume 102, Issue 11, pages , 1 AUG 2008 DOI: /j X x

10. Video Urodynamic findings
Cystometric plot showing severely decreased bladder compliance with detrusor overactivity and leakage when only 22 mL of 0.9% normal saline was instilled to the bladder.
IF THIS IMAGE HAS BEEN PROVIDED BY OR IS OWNED BY A THIRD PARTY, AS INDICATED IN THE CAPTION LINE, THEN FURTHER PERMISSION MAY BE NEEDED BEFORE ANY FURTHER USE. PLEASE CONTACT WILEY'S PERMISSIONS DEPARTMENT ON OR USE THE RIGHTSLINK SERVICE BY CLICKING ON THE 'REQUEST PERMISSIONS' LINK ACCOMPANYING THIS ARTICLE. WILEY OR AUTHOR OWNED IMAGES MAY BE USED FOR NON-COMMERCIAL PURPOSES, SUBJECT TO PROPER CITATION OF THE ARTICLE, AUTHOR, AND PUBLISHER.
BJU International Volume 102, Issue 11, pages , 1 AUG 2008 DOI: /j X x

11. Video urodynamic findings
Cystometric bladder capacities in 47 patients who had a video‐urodynamic study, showing that most of them had capacities of <150 mL.
IF THIS IMAGE HAS BEEN PROVIDED BY OR IS OWNED BY A THIRD PARTY, AS INDICATED IN THE CAPTION LINE, THEN FURTHER PERMISSION MAY BE NEEDED BEFORE ANY FURTHER USE. PLEASE CONTACT WILEY'S PERMISSIONS DEPARTMENT ON OR USE THE RIGHTSLINK SERVICE BY CLICKING ON THE 'REQUEST PERMISSIONS' LINK ACCOMPANYING THIS ARTICLE. WILEY OR AUTHOR OWNED IMAGES MAY BE USED FOR NON-COMMERCIAL PURPOSES, SUBJECT TO PROPER CITATION OF THE ARTICLE, AUTHOR, AND PUBLISHER.
BJU International Volume 102, Issue 11, pages , 1 AUG 2008 DOI: /j X x

12. Video urodynamics
VCMG finding of the same patient in Fig. 1A: the cystometric bladder capacity was 30 mL only, with detrusor overactivity and leakage (A), and bilateral VUR during detrusor overactivity (B).
IF THIS IMAGE HAS BEEN PROVIDED BY OR IS OWNED BY A THIRD PARTY, AS INDICATED IN THE CAPTION LINE, THEN FURTHER PERMISSION MAY BE NEEDED BEFORE ANY FURTHER USE. PLEASE CONTACT WILEY'S PERMISSIONS DEPARTMENT ON OR USE THE RIGHTSLINK SERVICE BY CLICKING ON THE 'REQUEST PERMISSIONS' LINK ACCOMPANYING THIS ARTICLE. WILEY OR AUTHOR OWNED IMAGES MAY BE USED FOR NON-COMMERCIAL PURPOSES, SUBJECT TO PROPER CITATION OF THE ARTICLE, AUTHOR, AND PUBLISHER.
BJU International Volume 102, Issue 11, pages , 1 AUG 2008 DOI: /j X x

13. Not just the bladder
Upper and lower tract issues

14. Anterograde stenting and upper tract destruction
Bilateral antegrade pyelogram of a patient who had used ketamine for 10 years and presenting with acute renal failure 3 months after augmentation enterocystoplasty. He required bilateral PCNs. Nephrostograms subsequently showed bilateral ureteric strictures involving the (A) right upper ureter and (B) left upper ureter.
IF THIS IMAGE HAS BEEN PROVIDED BY OR IS OWNED BY A THIRD PARTY, AS INDICATED IN THE CAPTION LINE, THEN FURTHER PERMISSION MAY BE NEEDED BEFORE ANY FURTHER USE. PLEASE CONTACT WILEY'S PERMISSIONS DEPARTMENT ON OR USE THE RIGHTSLINK SERVICE BY CLICKING ON THE 'REQUEST PERMISSIONS' LINK ACCOMPANYING THIS ARTICLE. WILEY OR AUTHOR OWNED IMAGES MAY BE USED FOR NON-COMMERCIAL PURPOSES, SUBJECT TO PROPER CITATION OF THE ARTICLE, AUTHOR, AND PUBLISHER.
BJU International Volume 102, Issue 11, pages , 1 AUG 2008 DOI: /j X x

15. Pre operative considerations
Absolute requirement for a patient to stop ketamine use
Unreliable attendees at both outpatient and investigation appointments
Multi disciplinary team working
Chronic pain team
Drug support
Analgesic strategy buprenorphine patches with cocodamol and amytriptiline.
. This may sound straightforward, but in a context where patients feel their only way of controlling the pain is with ketamine, it has proven to be difficult. It is not universally true, but many of

16. Treatment options Lifestyle Management Oral medication
Stop ketamine, bladder retraining
Oral medication
Analgesics, anticholinergics, beta 3 agonists, amitrip
Intravesical agents
Hyacyst, cystistat, heparin/lidacaine
Minimal invasive therapies
SPC, hydrodistension, Intradetrusor botox injections

17. Operative Treatment strategies
Clam ileocystoplasty
Cystectomy and Substitution cystoplasty
Ileal interposition for ureters
Ileal condiut

18. Comparison Type Reservoir Continent method Conduit Ileal conduit N/A
Ileum
Clam cystoplasty
Ileum/bladder
Rhabdosphincter
Urethra
Continent Diversion
Caecum/ileum
Ileocaecal valve
Ureterosigmoidostomy
Sigmoid
Anal sphincter
Anorectal

19. What can you use Reservoir Continent mechanism Conduit Bladder
Rhabdosphincter urethral
Urethra
Stomach
Mitrofanoff
Appendix
Ileum
Kock
Caecum
Ileocaecal
Ileum (tubed)
Colon
Anal Sphincter
Ureter
Rectum
Artificial Sphincter
Skin tube

20. Mitrofanoff

21. Monti

22. Augmentation cystoplasty

23. Augmentation Cystoplasty
Use ileum
Preoperative counselling
bowel disturbance
metabolic acidosis
mucus production
UTI and urinary retention
Small risk of malignancy
Provide life-long follow-up

24. Summary
Ketamine is a veterinary anaesthetic that has hallucinogenic properties and impairs memory
Bladder symptoms associated with ketamine abuse are consistent with those of interstitial cystitis, ulcerative cystitis and lower urinary tract symptoms
Ketamine abusers are often aware of these side effects but reluctant to seek help
Prompt recognition of the syndrome and referral to urologists could prevent further damage to the bladder and make treatment more effective
A multi-disciplinary approach is needed to manage patients with urinary tract pathology associated with ketamine use