Case Report #41: Ketamine Bladder Pain by Dr Matthew Cole and Dr Sunil Dasari

Cessation of ketamine is strongly recommended for all KIC patients.  In most cases of early KIC simply discontinuing ketamine use is sufficient and research shows that in 51% of cases the symptoms will reverse and bladder function will improve².  Discontinuation of ketamine is safe and usually does not lead to physical symptoms, although some patients may experience cravings and psychological dependence.  Some occasional withdrawal symptoms include mood swings, sweating and heart palpitations. 

Tapering the ketamine dose over several days is one way to manage psychological withdrawal symptoms and can be used if a patient’s cystitis is mild.  Psychological and social support should be provided during and after ketamine cessation and has been shown to improve the success rate of cessation.  However, even when the patient understands the benefits of coming off the drug, cessation is not always easy.  Often the greatest problem is bladder pain, this can be so extensive that the patient resorts to taking ketamine to alleviate the pain but ultimately this will only make the symptoms worse.  This cycle can lead to delayed medical attention which correlates with chronic or more advanced stages of bladder damage and the need for more active interventions against KIC.

Currently there is no agreed pharmacological management plan for KIC and a number of strategies have been described³. First line treatments for KIC include simple analgesics such as paracetamol and NSAIDs.  Other medications to control symptoms of KIC such as anticholinergics e.g. solifenacin to control urinary urgency/frequency have been suggested. 

Second line pharmacological therapies involve assessing for any neuropathic component and starting amitriptyline, pregabalin or gabapentin.  The use of opiates in ketamine uropathy has been described including a strategy involving buprenorphine patches with co-codamol and amitriptyline at night which was reported to give patients reasonable symptom control and allowed for the cessation of ketamine⁴.   Zhou et al describe the use of opioids and pregabalin as a second line treatment for pain in KIC reporting a 67.7% improvement in patient symptoms ¹.  Pentosan polysulfate (PPS) can also be tried to reduce pain. It acts to supplement the glycosaminoglycan layer of the bladder and protect the tissue from irritating substances in the urine. PPS is the only FDA approved medicine for the treatment of bladder pain and discomfort in interstitial cystitis and has also been effective in KIC ¹.

In patients whose symptoms remain uncontrolled despite oral medications intravesical instillation of treatments such as Parson’s cocktail (typically containing combinations of heparin, lignocaine, sodium bicarbonate and hydrocortisone), chondroitin sulphate or sodium hyaluronate can be used.  In general, these regimens are weekly installations for 4 to 6 weeks or monthly instillations for 4 to 6 months.  If these measures fail, a trial of botulinum toxin A injection into the bladder under GA should be considered as it has been shown to reduce urinary symptoms and increase bladder capacity ⁵.

Surgical interventions have been used as a last line treatment in patients with stage 3 disease who do not respond to other treatment options.  Surgical options include hydrodistension, augmentation cystoplasty and cystectomy.  Patients with hydrodistension often experience a short period of pain relief followed by recurrence of symptoms post treatment.  Patients receiving augmentation cystoplasty often have initial improvement in symptoms, but relapse with continued ketamine use postoperatively.