Ketamine bladder

💊 Ketamine bladder, also called ketamine-induced cystitis or ketamine uropathy, is urinary tract damage caused by regular or prolonged ketamine use. It can cause severe bladder pain, urinary frequency, urgency, incontinence and haematuria.

🧠 Why It Happens

• Ketamine and its metabolites irritate and damage the bladder lining.
• This can cause chronic inflammation, ulceration and fibrosis of the bladder wall.
• Over time, the bladder may become small, stiff and painful.
• Severe disease can affect the ureters and kidneys, causing hydronephrosis or renal impairment.

🚩 Symptoms

• Frequency: passing urine very often, sometimes every few minutes.
• Urgency: sudden need to pass urine.
• Nocturia: waking repeatedly at night to urinate.
• Dysuria: burning or pain when passing urine.
• Suprapubic pain: bladder pain, often severe.
• Haematuria: visible or microscopic blood in the urine.
• Incontinence: leakage due to urgency or poor bladder capacity.
• Loin pain: may suggest upper urinary tract involvement.

⚠️ Important Clinical Clues

• Symptoms may mimic recurrent UTI, overactive bladder or bladder pain syndrome.
• Urine cultures may be negative despite severe symptoms.
• Young adults with severe urinary frequency, urgency or bladder pain should be asked sensitively about ketamine use.
• Patients may continue ketamine because it temporarily dulls pain, creating a harmful cycle.

🔍 Assessment

• Take a sensitive drug history: frequency, amount, duration and route of ketamine use.
• Ask about urinary frequency, urgency, nocturia, pain, haematuria and incontinence.
• Check for red flags: fever, flank pain, urinary retention, visible haematuria, weight loss or renal impairment.
• Urine dipstick and culture to exclude infection.
• Blood tests may include U&Es/eGFR, FBC and inflammatory markers if clinically indicated.
• Consider renal tract ultrasound if severe symptoms, loin pain, recurrent haematuria or suspected upper tract involvement.
• Refer to urology if symptoms are severe, persistent, complicated or associated with haematuria or renal tract obstruction.

💊 Management

• Stop ketamine: cessation is the most important intervention.
• Substance misuse support: offer referral to local drug and alcohol services.
• Pain relief: use a stepwise approach; avoid long-term opioids where possible.
• Treat confirmed UTI: only use antibiotics if infection is supported clinically or microbiologically.
• Hydration: encourage regular fluid intake, but avoid excessive drinking that worsens frequency.
• Bladder irritants: consider reducing caffeine, alcohol and acidic drinks if they worsen symptoms.
• Specialist care: urology may consider cystoscopy, bladder instillations, intravesical treatments or reconstructive surgery in severe cases.

🚑 When to Escalate Urgently

• Severe uncontrolled pain.
• Visible haematuria or blood clots.
• Fever, rigors or suspected sepsis.
• Loin pain or suspected upper tract obstruction.
• Reduced urine output or acute kidney injury.
• Severe urinary retention.
• Suicidal thoughts, severe addiction or safeguarding concerns.

🧩 Differential Diagnosis

• Urinary tract infection
• Sexually transmitted infection
• Bladder pain syndrome / interstitial cystitis
• Overactive bladder
• Renal or ureteric stones
• Malignancy, especially with persistent visible haematuria
• Endometriosis or pelvic pain syndromes

🧠 Clinical Pearl

Ketamine bladder should be considered in young patients with severe urinary frequency, urgency, suprapubic pain or haematuria, especially when urine cultures are repeatedly negative. The key treatment is ketamine cessation; analgesia alone will not prevent progression. Early recognition matters because established bladder fibrosis and upper tract damage may be difficult to reverse.

📚 Exam Pearl

🚩 Young adult + severe urinary frequency + bladder pain + negative urine cultures = ask about ketamine use.