Tam et al.  in this month’s BJUI publish the largest prospective cohort to date on ketamine uropathy (KU). KU is a growing international problem since initial reports in 2007 from Canada and Hong Kong, where ketamine is second only to heroin in popularity amongst drug takers [2, 3]. Prevalence of KU may be higher than previously thought with up to a quarter of people misusing ketamine reporting urinary symptoms .
Importantly, the Tam et al.  paper demonstrates the benefit of stopping ketamine amongst those presenting with KU. Dose, frequency and dependency upon ketamine have been reported as risk factors for developing KU [1, 4]. Achieving cessation is not always straightforward following identification, assessment and urology input. Consistent with the Winstock et al.  recommendations a multi-disciplinary approach is required to assess symptoms and risk profile. The recommendation of Tam et al. of a one-stop clinic is thus appealing.
The key to diagnosing KU, is a focused history including specific drug use, performing non-invasive uroflowmetry investigations and upper tract imaging. Urologists need to be aware of motivational interviewing strategies, and incorporate them in their assessment. Presenting symptoms include dysuria, frequency, urgency and pain that may be consequent on the small contracted bladder that develops in KU. The diagnosis should exclude other bladder diseases and cystoscopy and biopsy is advised . If left late, pain and bladder contraction can be so severe that bladder augmentation, cystectomy and neobladder or ileal conduit may be required . It is strongly advised that ketamine use is stopped before, as ketamine metabolites will be readily absorbed through bowel and potentially lead to a fatal overdose.
In the Tam et al.  paper, renal ultrasonography (US, performed on a second visit) showed hydronephrosis in 8%. However, their client uptake for renal US was only 50%. Having a one-stop KU clinic with integrated US is more patient-friendly and consistent with our unit’s one-stop clinic approach . Management of hydronephrosis and reversal of renal impairment is crucial and more definitive surgical management may be warranted. Renal failure secondary to KU may rise as the numbers of ketamine users continues to climb.
What makes KU interesting and difficult to manage is the stigmatising nature of illicit drug use that makes patients uncomfortable in disclosing ketamine use. Patients may not recognise the causal link between ketamine use and their discomfort. Instead symptoms may be attributed to other pathologies such as UTIs, sexually transmitted infections (common in high-risk drug use behaviour), excessive alcohol or caffeine consumption or be mistaken for ‘K cramps’, which may be a direct result of ketamine itself . Pain team input may be required. The Bristol unit report managing KU pain with buprenorphine patches, co-codamol (combination of codeine phosphate and paracetamol) and amitriptyline , whereas the Tam et al.  unit prefer a combination of diclofenac, anti-cholinergics and opioids.
Promoting early treatment seeking will help reduce the time between symptom onset and assessment. However, due to the nature of ketamine patients, their history may be unreliable, follow-up intermittent and compliance poor. These issues may lead to a delay in presentation and referral.
Ultimately, what is required is a raised awareness among users of the potential for ketamine to cause irreversible bladder and upper tract harm. While abstinence may be the most attractive option for clinicians this remains an unrealistic and unhelpful approach for many users including those most at risk. Consideration needs to be given to support users to reduce harm and to maintain abstinence once achieved. Stopping ketamine may require psychological, addiction and even psychiatric support.
Importantly, clinicians should accept that ketamine users are interested in their own health and wellbeing. They may appreciate learning strategies to minimise their harm risk. Harm reduction strategies as outlined in the Global Drug Survey Highway Code (stay well hydrated, have breaks between use periods, and avoid alcohol use) not only encourage safer use but can raise awareness of symptoms suggestive of KU .
Given the complexity of ketamine patients and the fact that users share information, provision of high-quality care from a dedicated understanding team has obvious advantages. An age-appropriate unit including a urologist, psychiatrist, pain management consultant and a sexual health expert provides a comprehensive approach. A one-stop clinic, as described by Tam et al., may expedite initial assessment but withdrawal from ketamine requires long-term investment to achieve overall improvements in KU outcomes.
The key message to get out to the ketamine-using community is that as a rule, marked improvement in function follows cessation of ketamine use. There is an increasing role for the urologist to be a source of credible information to ketamine users and healthcare professionals. Finally, dedicated management centres offering a holistic approach to the management of these patients seems ideal. This will concentrate exposure and understanding of KU, which we hope will help continue to improve management of this difficult condition.
Claire F. Taylor, Adam R. Winstock* and Jonathon Olsburgh
Young Onset Urology Clinic, Urology/Renal Unit, Guy’s and St Thomas’ Hospital, and *South London and Maudsley NHS Trust, London, UK
1 Tam YH, Ng CF, Pang KK et al. One-stop clinic for ketamine-associated uropathy: report on service delivery model, patients’ characteristics and non-invasive investigations at baseline by cross-sectional study in a prospective cohort of 318 teenagers and young adults. BJU Int 2014; 114: 754–60
2 Chu PS, Kwok SC, Lam KM et al. ‘Street ketamine’-associated bladder dysfunction: a report of ten cases. Hong Kong Med J 2007; 13: 311–3
3 Shahani R, Streutker C, Dickson B, Stewart RJ. Ketamine-associated ulcerative cystitis: a new clinical entity. Urology 2007; 69: 810–2
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5 Wood D, Cottrell A, Baker SC et al. Recreational ketamine: from pleasure to pain. BJU Int 2011; 107: 1881–4
6 NgCF,ChiuPK,LiMLetal.Clinical outcomes of augmentation cystoplasty in patients suﬀering from ketamine-related bladder contractures. Int Urol Nephrol 2013; 45: 1245–51
7 Coull N, Rottenberg G, Rankin S et al. Assessing the feasibility of a one-stop approach to diagnosis for urological patients. AnnRCollSurg Engl 2009; 91: 305–9
8 Winstock AR, Mitcheson L. New recreational drugs in the primary care approach to patients who use them. BMJ 2012; 344: e288
9 Global Drug Survey Ltd. Global Drug Survey Highway Code. Available at: https://www.globaldrugsurvey.com/wp-content/uploads/2014/04/The -High-Way-Code_Ketamine.pdf. Accessed September 2014