Can ketamine therapy be used to treat pelvic floor hypertonicity in a patient with deep perineal pressure, reduced genital sensation, mild bladder irritation, normal continence, who is already receiving pelvic‑floor physical therapy and taking daily quercetin?

Ketamine Therapy for Pelvic Floor Hypertonicity

Ketamine therapy is not recommended for treating pelvic floor hypertonicity and may actually worsen urinary symptoms; instead, continue with supervised pelvic floor physical therapy as first-line treatment and consider adding botulinum toxin A injections if symptoms remain refractory. 1, 2

Why Ketamine is Contraindicated

Ketamine causes direct bladder toxicity and should be avoided in patients with pelvic floor dysfunction:

• Ketamine induces cystitis through direct urothelial toxicity when present in urine, causing bladder epithelial barrier damage, inflammatory signaling, and persistent inflammation that leads to fibrosis 3, 4
• Regular ketamine use increases the risk of cystitis symptoms by 3- to 4-fold, causing urinary pain, reduced bladder storage capacity, and increased bladder pressure—symptoms that overlap with and would exacerbate your existing mild bladder irritation 3
• Ketamine-induced uropathy presents with severe storage symptoms and pelvic pain, the exact symptoms you are trying to treat 4
• The drug creates a vicious cycle where patients attempt to manage urinary pain with increased ketamine use, worsening the underlying bladder pathology 3

Recommended Treatment Algorithm

First-Line: Optimize Current Pelvic Floor Physical Therapy

Continue supervised pelvic floor physical therapy for at least 3 months as this is the evidence-based first-line treatment for pelvic floor hypertonicity 5, 1, 2:

• Ensure you are working with a specialist physiotherapist trained in pelvic floor dysfunction, as proper supervision is essential for optimal outcomes 5
• Therapy should focus on manual trigger point release techniques rather than strengthening (Kegel) exercises, since strengthening can worsen hypertonicity and pain 1
• Treatment should include biofeedback to teach muscle relaxation during straining and restore normal pelvic floor coordination 6, 1
• Success rates with comprehensive pelvic floor physical therapy approaches reach 90-100% when properly implemented 1

Second-Line: Add Topical Anesthetics

Apply topical lidocaine to areas of persistent perineal pain and reduced sensation 6, 1:

• Lidocaine application before activities that provoke symptoms can improve dyspareunia and deep perineal pressure 6
• This is particularly effective for persistent introital pain and can be used as an adjunct to physical therapy 1

Third-Line: Consider Botulinum Toxin A Injections

If symptoms remain refractory after 3-6 months of optimized physical therapy, botulinum toxin A injection into hypertonic pelvic floor muscles is the next appropriate step 7, 8:

• BoNT-A aids relaxation of hypertonic pelvic floor musculature including the obturator internus, levator ani, and coccygeus muscles 7
• Injections can be performed safely under conscious sedation with local anesthesia 7
• Side effects are rare and self-limiting, though reinjection may be necessary due to the reversible nature of BoNT-A 7
• This represents a promising treatment option for chronic pelvic pain with pelvic floor hypertonicity in women 7

Evidence Quality Considerations

The recommendation against ketamine is based on strong evidence showing direct bladder toxicity 3, 4, while the recommendation for pelvic floor physical therapy is supported by multiple guidelines from the American Urological Association, American College of Oncology, and systematic reviews showing efficacy across all outcome measures including pain, sexual function, and quality of life 1, 2. The evidence for BoNT-A is emerging but promising for refractory cases 7.

Critical Pitfall to Avoid

Do not perform pelvic floor strengthening (Kegel) exercises if you have pelvic floor tenderness or hypertonicity, as this will worsen your symptoms 1. Your physical therapy should focus exclusively on relaxation and trigger point release techniques, not muscle strengthening.