Does ketamine (anesthetic) cause cystitis?

Ketamine and Cystitis: A Serious Urological Complication

Yes, ketamine can cause cystitis, particularly with chronic recreational use, leading to a condition known as ketamine-induced cystitis (KIC) that can significantly impact morbidity, mortality, and quality of life. 1

Pathophysiology and Clinical Presentation

Ketamine-induced cystitis is characterized by:

• Severe lower urinary tract symptoms including:

  • Dysuria (painful urination)
  • Urinary frequency and urgency
  • Gross hematuria
  • Suprapubic pain 1, 2

• Pathological changes in the bladder:

  • Ulcerative cystitis with easily bleeding mucosa
  • Bladder wall thickening
  • Contracted bladder with reduced capacity
  • Epithelial denudation and inflammation with eosinophilic infiltrate 1, 3

• Potential progression to:

  • Ureter stenosis
  • Kidney failure in severe cases 2

Risk Factors and Dose-Response Relationship

• Regular ketamine consumption increases the risk of cystitis symptoms by 3-4 fold 2
• Higher doses (≥5 g/day) and longer duration of use (≥3 years) are associated with significantly lower maximum anesthetic bladder capacity, indicating more severe disease 4
• Daily recreational use appears to be the primary risk factor in the development of this condition 1

Diagnostic Findings

When evaluating patients with suspected ketamine-induced cystitis:

• Urine cultures are typically sterile 1
• CT imaging reveals:
  • Marked thickening of the bladder wall
  • Small bladder capacity
  • Perivesicular stranding consistent with inflammation 1
• Cystoscopy shows severe ulcerative cystitis 1
• Biopsies demonstrate:
  • Epithelial denudation
  • Inflammation with mild eosinophilic infiltrate 1, 3
• Urodynamic studies show reduced maximum cystometric capacity (average 115 mL) 4

Treatment Approaches

The cornerstone of treatment is:

1. Complete cessation of ketamine use - this is essential and associated with symptom improvement 2

2. Additional therapies may include:

   • Pentosan polysulfate for symptomatic relief 1
   • Chondroitin sulfate 0.2% (Gepan) 5
   • Intravesical installation of hyaluronic acid in selected cases 3
   • Intravesical injection of botulinum toxin type A for symptom relief in selected patients 3
   • Augmentation enterocystoplasty for patients with irreversible contracted bladder 3

Clinical Implications for Medical Use

While the evidence primarily focuses on recreational ketamine use, clinicians should be aware that:

• Ketamine is commonly used as an anesthetic and analgesic in medical settings 2
• The documented cases of ketamine-induced cystitis are predominantly associated with chronic recreational use rather than medical administration 1, 2
• For medical use, ketamine is typically administered at controlled doses for limited periods, which likely explains the rarity of cystitis in medical contexts

Monitoring and Prevention

For patients requiring medical ketamine:

• Use the minimum effective dose and carefully titrate, especially in elderly patients or those with underlying conditions 6
• Be vigilant for early signs of urinary symptoms in patients receiving repeated ketamine administration
• Consider alternative agents when appropriate, especially for patients with pre-existing urological conditions

For patients with recreational ketamine use:

• Provide education about the risk of cystitis and other complications
• Recommend cessation of use at the first sign of urinary symptoms
• Offer appropriate psychological and social support for those attempting to stop use 2