Ketamine bladder
Download
Report
Transcript Ketamine bladder
Carmel Ramage
19th October 2012
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
History
P 1+4
No significant medical history
Smoker
Social alcohol intake
NKDA
10 stone – lost weight but normal appetite
LFT – only raised gamma GT
Examination
Pelvic examination – normal
Urethra –no discharge
Attempted cystoscopy in OPD – very tender and in
severe discomfort
Cystoscopy under GA
Cystoscopy
Severe haematuria
Unable to visualise any
anatomy
No response to saline washout
Indwelling catheter left in situ
USS organised
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
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
Renal USS )
)
)
NAD
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
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
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
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
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 1990’s
Class C drug (January 2006)
Possession - 2 years
Supply - 14 years
Unlimited fine
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
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
>80% ketamine seized in the US is of
Mexican origin
Ketamine Detection
Urine
Blood/ plasma
Norketamine
Pharmacologically-active
metabolite
Plasma levels:
Therapeutic - 0.5-5.0 mg/L
Arrested for impaired driving –
1–2 mg/L
Acute fatal overdose - 3–20 mg/L
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)
Presentation
“K cramps”
Severe long lasting abdominal pain
Cause unknown
Usually limited to users of >1 g / day
Hepatic damage
Urinary tract
Overactive bladder syndrome
Painful bladder symptoms
Incontinence
Upper tract obstruction
Renal papillary necrosis
Patients erroneously treated for recurrent UTI’s/ painful
bladder syndrome
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
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 107:1881-1884
How to make the Diagnosis
Good history of recreational drug abuse
MSU for C&S
Cystoscopy and biopsy
Renal function tests
CT urogram for extent of disease
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
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
Summary
Increasing Ketamine use
May cause significant
urinary tract damage
Be aware of potential
diagnosis in young
patients with severe
painful bladders