Tasty Morsels of EM 057 – Ketamine induced uropathy

17 Aug

As always, this is from the ever expanding google doc on bits and bobs I read and learn from and transfer here for all our learning pleasure.

Wei YB, Yang JR, Yin Z, Guo Q, Liang BL, Zhou KQ. Genitourinary toxicity of ketamine. Hong Kong Med J. 2013;19:(4)341-8. [pubmed] Free PDF

I suspect most of us are aware that chronic ketamine abuse can cause this but I also suspect that we miss this fairly commonly by simply not asking and diagnosing young men with UTI or urethritis and sending them off into the night (and inevitably their cultures are negative)

I’ve seen/suspected this twice in the last few years and no doubt missed it in lots of others.

The paper is a nice summary of theories and potential treatments. There is a lovely free case report in WestJEM of bilateral hydro associated with this (presumably related to ureteric obstruction from bladder thickening) so yet one more excuse to channel your inner sono. 

  • young people
  • chronic ketamine use is a huge issue in south east asia
  • typically chronic abusers (they suggest more than 3 times in a week)
  • mechanisms:
    • unclear (what a surprise)
    • possible toxic effects of metabolites
    • possible damage to microvasculature
    • change in neuromuscular control due to the ketamine
  • typical manifestations are lower urinary tract symptoms including severe dysuria, painful haematuria, urinary urgency, urge incontinence and frequency
  • on imaging you might see an irregular thick walled bladder with small volumes. Hydro is quite common (up to 50%)
  • stopping the ketamine is the most important thing however there are significant numbers for whom this won’t work. the paper suggests resolution in only a third.
  • various treatments suggested
    • oral anti cholinergics
    • intra vesical hyaluronic acid or even botulinum
    • surgery is an option with all kinds of complicated procedures I don’t understand
  • there is genuine bad outcomes here – renal function decline from chronic hydro and irreversible LUTS and quality of life issues. This isn’t a STEMI by any means but it’s important we think of this and refere

Take home message – that young lad with “UTI” for no apparent reason probably doesn’t have a UTI…

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