Ketamine is widely used in healthcare as both a general anaesthetic agent and for procedural sedation, however It has gained popularity as a recreational drug due its psychoactive properties. Regular use can lead to ketamine uropathy causing inflammatory changes to the urothelium, manifesting as significant lower urinary tract symptoms, small bladder capacity and pelvic pain. Upper tract involvement can also occur causing hydronephrosis and ureteric strictures. Ketamine uropathy is a relatively new clinical entity with much of the early work coming from Eastern-Asia. Data from UK centres is limited, and no formal treatment guidelines exist. Usage remains widespread with annual usage in 16- to 24-year-olds increasing to 3.2% in 2020, its highest figure to date. We aim to share our initial experience in managing this condition.

All patients with ketamine uropathy presenting to our unit over the past 10 years were identified. This was achieved via screening of theatre listings for patients undergoing cystodistension, clinic lists, emergency presentations and a prospectively collected local database. Inclusion criteria required documented established recreational ketamine use in the presence of typical lower urinary tract symptoms as diagnosed by a urologist.  Demographic data, imaging and biochemical findings and management strategies were recorded.

A total of 81 patients with ketamine uropathy were identified from 2011 to 2022 however a large proportion presented from 2018 onwards (Fig. 1). Average age at presentation was 26 (18-39), 72.8% were male and average follow-up time was 34 (0-128) months. Therapeutic interventions included anticholinergic medication, cystodistension, intravesical sodium hyaluronate and botox. Hydronephrosis was present in 20 (24.7%) patients and nephrostomy insertion was required in six. One patient underwent bladder augmentation surgery. Over the study period the mortality rate directly rated to complications of ketamine uropathy was 2.5%). Serum GGT and length of follow-up were significantly higher in patients with hydronephrosis (p=0.012 and p=0.003 respectively, Table 1). Overall, adherence to follow-up was poor.

We present a large cohort of young patients with ketamine uropathy from a small town in the UK which is unusual. The incidence appears to be rising and should be of concern to urologists nationally. Abstinence is a key aspect of management in limiting the progression of urothelial damage, and a multi-disciplinary approach works best particularly as many patients are lost to follow-up and rates of relapse are high. Surgical interventions in patients with on-going active use are higher risk and we recommend biochemical confirmation of abstinence beforehand.

Ketamine uropathy presents a mix of storage lower urinary tract symptoms, pelvic pain an upper tract disease. It frequently presents management challenges due to the severe nature of symptoms and the difficulty in maintaining abstinence. The development of formal guidance would be helpful.