International Emergency Nursing (2009) 17, 69–71
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Case study
Ketamine associated cystitis – A case report Rebecca Hoskins MA, BSc (Hons) RGN, RN (Child) (Consultant Nurse and Senior Lecturer) * Emergency Department, University Hospitals Bristol NHS Foundation Trust, School of Health and Social Care, University of the West of England, Bristol BS2 8HW, UK Received 12 August 2008; accepted 8 September 2008
Introduction Staff working within emergency care are familiar with managing patients who attend the emergency department (ED) as a direct or indirect consequence of having taken illegal drugs (Binks et al., 2005; Hoskins et al., 2005). However, this is an area where staff cannot afford to become complacent in their knowledge and skills. This case report examines the physical consequences of illegal drug use and highlights the importance of emergency nurses being aware of emerging trends in illegal drug use.
Case presentation A 20 year old man attended the ED with an 18 month history of urinary frequency, nocturia, urgency, episodes of frank haematuria and suprapubic pain. He had to keep a milk carton by his bed at night because of the severity of the nocturia and urinary urgency. He also complained of a very poor sleep pattern and the inability to leave the * Tel.: +44 117 9445956; fax: +44 117 9282713. E-mail address:
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house due to urinary frequency and urgency. He had been a DJ at a club but had to give this up because of the severity of his symptoms. He had used ketamine for the past five years. He was currently using 6 g a day. A friend had encouraged him to seek help for his symptoms which were preventing him from leaving the house. His past medical history was unremarkable and he was taking no prescribed medication. His sexual history did not suggest the possibility that his symptoms were due to a sexually transmitted disease. He lived in a shared house. He had sought help once in the past for his symptoms, but had unfortunately lost the prescription for antibiotics from his GP. Examination showed no remarkable findings apart from suprapubic tenderness, there was no renal angle tenderness. Differential diagnoses included urinary tract infection, interstitial cystitis, urethritis and diabetes. Routine urine analysis showed the presence of blood and protein only. Routine bloods showed no abnormalities and indicated there was no evidence of renal failure. He was referred to the drug specialist nurse team at the time of presentation who gave him information about detoxification programmes and explained the correlation of his symptoms with ketamine use. He was referred to the urology nurse specialist for urgent outpatient review and was discharged
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70 home with a prescription for ciprofloxacin 500 mg twice daily for five days in view of his ongoing symptoms and co-codamal 30/500 for pain relief. A flexible cystoscopy was attempted two weeks later at an outpatient appointment, but was unable to be completed because of the pain the patient experienced during the procedure. Preliminary findings showed that the bladder and urethra were very inflamed and the bladder capacity was considerably reduced. Unfortunately the patient had not been able to reduce his ketamine use. The patient was listed for a further investigation under general anaesthetic. Before this could be carried out the patient represented to the ED a week later with increasing pain and was admitted under the urology team who were considering carrying out a cystectomy depending on the outcome of further investigations.
Discussion Ketamine is a short acting general anaesthetic used most often in paediatric anaesthesia, conscious sedation and in veterinary practice (Dillon et al., 2003). It has become increasingly popular as an illegal recreational drug (Shanhani et al., 2007). Jansen (2000) reported that as early as 1967 ketamine was being used as a recreational drug. Ketamine was known as ‘vitamin K’ in the 1980s and resurfaced as ‘special K’ in the 1990s especially at raves. Interestingly Ahmed and Petchkovsky (1980) reported on the non medical, unauthorised experimentation with ketamine, they believed it was largely confined to medical circles because of the ease of access to it. Street ketamine is usually found in the form of a white powder which is inhaled or smoked. Tablets containing ketamine and ephedrine are also ingested. It is important to note that ketamine is often taken with other drugs such as ecstasy, (Dillon et al., 2003). Ketamine has been found to cause a variety of effects which are thought to be physiologically rather than physically addictive. Users report altered sensations, out of body experiences and a euphoric rush, as well as auditory and visual hallucinations, enhanced colour vision and weightlessness (Dillon et al., 2003). There are also unpleasant side effects from taking the drug such as tachycardia, hypertension, nausea and vomiting, convulsions and temporary paralysis (Shanhani et al., 2007). The most concerning side effect that users report is the ‘K-hole’ experience where users describe a near death experience, including buzzing, ringing and whistling sounds, a sense of travel-
R. Hoskins ling through a dark tunnel into a light at high speed and intense visions, and the conviction that they are dead (Jansen, 2000). Interestingly there have been very few deaths associated with ketamine use (Gill and Stajic, 2000). There seem to be a small but growing number of case reports in the literature discussing the side effects of chronic cystitis and reduced bladder capacity associated with ketamine use (Colebunders and Van Erps, 2008; Shanhani et al., 2007). Interestingly Dillon et al. (2003) interviewed 100 ketamine users and this symptom was not reported in their study, although 91% of the people interviewed reported that deteriorating general health was likely or extremely likely to deter future ketamine use. While this phenomenon appears to be a recent one, Shanhani et al. (2007) highlight that personal reports from ketamine users have revealed that this is a well recognised complication of chronic ketamine use amongst active ketamine users. This is further supported from anecdotal evidence from the drug specialist nurses in the trust and the urology team. The mechanism by which ketamine causes cystitis and inflammatory changes as well as reduced bladder capacity is not clear. Shanhani et al. (2007) suggest the effects may result from the formation of an active metabolite of ketamine and that the accumulation of ketamine and its active metabolite in the urine may induce significant bladder irritation. No known treatment has yet been found to cure the symptoms of inflammation and reduced bladder capacity in this population of patients. Colebunders and Van Erps (2008) found in their case review of 10 patients that eight out of ten patients found their symptoms benefited from cessation of ketamine. It is not clear whether the remaining patients were unable to stop taking the drug or derived no benefits from cessation.
Conclusion While ketamine associated cystitis appears to be a relatively new clinical phenomenon, it would seem that this side effect has been recognised for some time in the drug taking population. However, it is only recently that patients have been presenting to emergency care with these symptoms related to ketamine use. It is important that cases such as these are published in the literature and that reports of these symptoms are coordinated and analysed in order that evidence based treatment guidelines can be devised. There appears to be an increasing prevalence of ketamine associated cystitis and as ketamine use rises presentations to emergency departments look set to increase. This
Ketamine associated cystitis – A case report case report also demonstrates the importance of interdisciplinary and specialty involvement in managing potentially complex clinical management problems.
Conflict of interest statement None.
Funding None.
References Ahmed, S.N., Petchkovsky, L., 1980. Abuse of ketamine (letter). British Journal of Psychiatry 137, 303.
71 Binks, S., Hoskins, R., Salmon, D., Benger, J.R., 2005. Prevalence and healthcare burden of illegal drug use amongst emergency department patients. Emergency Medicine Journal 22, 872–873. Colebunders, B., Van Erps, P., 2008. Cystitis due to the use of ketamine as a recreational drug: A case report. Journal of Medical Case Reports 26 (2), 219. Dillon, D., Copeland, J., Jansen, K., 2003. Patterns of use and harms associated with non medical ketamine use. Drug and Alcohol Dependence 69, 23–28. Gill, J.R., Stajic, M., 2000. Ketamine in non-hospital and hospital deaths in New York city. Journal of Forensic Science 45, 655–658. Hoskins, R., Binks, S., Salmon, D., Moody, H., Benger, J.R., 2005. A study exploring drug use and management of patients presenting to an inner city emergency department. Accident and Emergency Nursing Journal 13, 147–153. Jansen, K.L.R. 2000. Ketamine dreams and realities. Multidisciplinary Association for Psychedelic Studies, Florida. Shanhani, R., Streuker, C., Dickson, B., Stewart, R.J., 2007. Ketamine-associated ulcerative cystitis: a new clinical entity. Urology 69 (5), 810–812.
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