What is the treatment for ketamine-induced cystitis?

Treatment for Ketamine-Induced Cystitis

The first-line treatment for ketamine-induced cystitis (KIC) is complete cessation of ketamine use, which should be supplemented with motivational interviews and psychological and social support. 1

Pathophysiology and Clinical Presentation

• Ketamine-induced cystitis is characterized by urinary frequency, bladder pain, and contracted bladder with wall thickening 2
• Common cystoscopic findings include ulcerative cystitis with easily bleeding mucosa 2
• Microscopically, the urothelium is denuded and infiltrated by inflammatory cells, including mast cells and eosinophils 2
• The pathophysiology involves direct toxic effects, bladder barrier dysfunction, neurogenic inflammation, and immunoglobulin-E-mediated inflammation 2

Treatment Algorithm

Step 1: Ketamine Cessation

• Complete cessation of ketamine use is mandatory and strongly recommended for all KIC patients 1, 2
• Cessation alone is associated with improvement of symptoms in many cases 3
• Provide psychological and social support to help maintain abstinence 1

Step 2: Medical Management for Early KIC

• For patients with early KIC who have ceased ketamine use:
  • Oral anti-inflammatory medications can help manage symptoms 3
  • Muscarinic receptor blockers (anticholinergics) may be tried, though they often provide limited relief 4

Step 3: Intravesical Treatments for Moderate KIC

• For patients with persistent symptoms despite ketamine cessation and oral medications:
  • Intravesical installation of hyaluronic acid has shown effectiveness for symptom relief in selected patients 2
  • Botulinum toxin type A injection combined with bladder hydrodistention has demonstrated marked symptom relief, reduced nocturia, increased bladder capacity, and improved urinary flow rates 4

Step 4: Surgical Intervention for Severe KIC

• For patients with contracted bladder (maximal bladder capacity <100 ml) and/or upper urinary tract damage:
  • Augmentation enterocystoplasty may be the only solution to increase bladder capacity and relieve intractable bladder pain 2, 5
  • Patients who undergo augmentation enterocystoplasty typically report better outcomes than those who continue with conservative management 5

Monitoring and Follow-up

• Regular urodynamic testing to evaluate bladder capacity and function 4
• Assessment using validated symptom scores such as the O'Leary-Sant interstitial cystitis symptom index (ICSI) and problem index (ICPI) 4
• Monitoring for upper urinary tract complications, including hydronephrosis and renal dysfunction 5

Important Considerations

• Treatment plans must be tailored based on the severity of symptoms and disease progression 3
• Patients with extremely small bladder capacity (<300 ml) with irreversible urinary tract changes may require earlier surgical intervention 5
• The vicious cycle of patients attempting to manage their urinary pain with increased ketamine use must be addressed through appropriate pain management and psychological support 1

Prognosis

• Regular ketamine consumption increases the risk of cystitis symptoms by 3-4 fold 1
• Early intervention with complete cessation of ketamine provides the best chance for symptom improvement 3
• Patients with advanced disease and contracted bladders may have permanent urological damage requiring lifelong management 5