Role of Urologists in the

management of Drug Abusemanagement of Drug Abuse

Dr Chan Kwok Keung Sammy

Specialist in Urology

Outline

• Ketamine induced cystitis

– Diagnosis

– Management

• Team approach for management of drug • Team approach for management of drug

abuse

• Experience of co-operation with NGOs

• Future development

Ketamine cystitis - History

• Ketamine associated ulcerative cystitis

• 1st reported in Medical Literature in 2007

• Chu SK et al

‘Street ketamine’–associated bladder dysfunction: a report of ten casesreport of ten cases

• Hong Kong Med J 2007;13:311-3

• Shahani R, Streutker C, Dickson B, Stewart RJ. Ketamine associated ulcerative cystitis: A new clinical entity.

• Urology 2007; 69: 810–812.

• 9 patients in Toronto

Epidemiology

• Prevalence of cystitis in ketamine abuser

– No official figure

– Very common

– Risks factors– Risks factors

• Duration of abuse

• Dosage

• ?Age

• ?Sex

• ?effect of multiple drug abuse

• ?Genetic predisposition

Classical symptoms

– Bladder pain/perineal pain/dyspareunia

– Dysuria

– Urinary frequency and urgency

– Small volume voids– Small volume voids

– Nocturia

– Urge Urinary incontinence

– Blood in urine

– Mucus in urine

History

– Exposure to ketamine

– Symptoms worsen when ketamine increases

– Symptoms improved after stopping or reducing ketamineketamine

– Rebound after stopping ketamine

– Previously treated as bacterial cystitis

– Reluctant to admit history of ketamine exposure

– Doctor shopping

– Received medicine for ‘cystitis’ in dispensaries

Investigations

• Aim

– To confirm diagnosis and exclude other pathology

• TB cystitis

• Interstitial cystitis

• Acute Bacterial cystitis• Acute Bacterial cystitis

• Carcinoma-in-situ of bladder

• Overactive bladder

• Prostatitis

– To look for complications

– To look for associated medical problems

Complications of ketamine cystitis

• Secondary bacterial cystitis

• Contracted bladder

• Vesicoureteric reflux

• Ureteric strictures• Ureteric strictures

• Papillary necrosis

• Renal failure

Common medical problems in

ketamine abuser

• ENT: nasal bleeding, perforation of nasal

septum

• GI: impairment of liver function, hepatic

fibrosis, dilated common bile duct, gastritisfibrosis, dilated common bile duct, gastritis

• Gynae: pelvic pain, dyspareunia

• Neurology:epilepsy

• Psychiatric: mood disorders, depression,

psychosis

Investigations

• Urine tests

– Routine/microscopy/culture

• Blood tests

– RFT/LFT– RFT/LFT

• USG kidneys

– Look out for hydronephrosis

• Specific tests depending on signs and

symptoms and history

USG kidneys

Hydronephrosis

Papillary necrosis

Other imaging modalities

IVUCT Scan

normal bladder bladder of ketamine abuser

Cystoscopy

• Ketamine-associated cystitis shows a variable degree of inflammation (A,B). The

infiltrates comprised predominantly lymphocytes and a variable number of

eosinophils (C). Ultrastructural examination shows querciphylloid muscle cells (D).

Uroflow Study

Urodynamic Study

Urodynamic study showing small bladder with poor

compliance, detrusor overactivity and urinary leakage at

22ml

Video-urodynamic study

Video-urodynamic study showing small bladder with

bilateral vesicoureteric reflux during detrusor

overactivity

Cystogram

Normal bladder “ketamine bladder”

Assessment of symptomsPUF score OABSS

Management of ketamine cystitis

• “Total abstinence is the only way to achieve

long term control or improvement of

symptoms and to avoid complications”

• Other treatments may help to improve • Other treatments may help to improve

symptoms if patient started to quit or

reducing dose

• Management of complication

Symptom control

• Most effective when patient start to quit or

reduce in dosage

• For patient fail to quit – doubtful effect

• There is no single effective method of • There is no single effective method of

symptom control

• Variable results obtained from treatment

adopted from interstitial cystitis

Possible drugs of use

• NSAIDs

• Anticholinergics

• Urine antiseptics

• Antibiotics• Antibiotics

• Amitriptyline

• Sodium pentosan polysulfate (Elmiron)

• Opioid analgesics

Intravesical Therapy

• Intravesical Instillation

– Dimethyl sulfoxide (DMSO)

– Heparin

– Local anaesthetics– Local anaesthetics

– Hyaluronic acid (Cystistat)

– Pentosan polysulfate

• Intravesical Injection

– Botox

Management of complications:

Ureteric strictures

• Temporary drainage – PCN

• Reconstructive surgery

– Reimplantation

– Ureteroureterostomy

– Ileal interposition

Bilateral ureteric strictures and hydronephrosis presented

with acute renal failure managed by bilateral percutaneous

nephrostomy

Patient with bilateral percutaneous nephrostomies

Management of complications :

contracted bladders

• Augmentation cystoplasty

• Subtotal cystectomy

• Total cystectomy with urinary diversion or bladder

substitutionsubstitution

• Urinary tract complications deemed to recur if total

abstinence cannot be achieved

• Changes similar to ketamine cystitis has been observed in

substituted intestinal segment after removal of bladder

• “Failure of abstinence is the absolute contra-indication

for radical surgery”

Augmentation cystoplasty

Urology Clinic in

Co-operation with Counselling

Centre for Psychotropic Substance Centre for Psychotropic Substance

Abusers

August 2010 – August 2013

Criteria of referral

• Significant urinary tract symptoms while on ketamine

• Persistent urinary tract symptoms despite quitting

• Other urological conditions not related with ketamine

Total no. of cases Triage by Nurse Referred to Urology(%)

774 270 98 (12.7)

• Other urological conditions not related with ketamine

• Prevention of rebound of symptoms after stopping ketamine

• Health screening and education

• Conditions requiring follow up after initial care in UROK clinic

• Preparation for admission to detox centre

Information provided by Cheer Lutheran Centre

Degree of urgency and aims of referral

Degree of

urgency

PUF

score

>=14

Abnormal

urine test

Dose

reduction/

quit

Aim

Urgent + + + Prevent symptom rebound

Semi-urgent + + - •Let patient aware of their

health condition and to make health condition and to make

contract or set short term goal

before seeing urologist

•To motivate patients by

providing subsidized urology

care to patients with financial

difficulties

Information provided by Cheer Lutheran Centre

Criteria for subsequent visits

Scenario Aim

High bothersome score but improving

symptoms and urine tests

•Make treatment plan with social

worker

•Make short term targets

High dose ketamine with emotional

problems

•Refer to psychiatrists til stable then

discuss drug problemproblems discuss drug problem

•Refer to urologist if ready for action or

for further motivation to quit

Low dose ketamine •See urologist for medications and

psychological support then set

treatment plan or targets

Information provided by Cheer Lutheran Centre

Patient demographics

Total no. of patients 96

Male(%) 57.3

Female(%) 42.7

7 patients had no history of ketamine abuse and consulted for other urological

problems

Mean(Range)

Age(yr) 26(17-43)

Duration of abuse(yr) 8.38(1-20)

Dosage of ketamine before

consultation (g/day)

5.31(1-35)

Median 3.5

% of patient with polysubstance

abuse

67.7(65/96)

% Chronic smoker 93.2(83/89)

problems

Pre-existing medical problems

No. of problems

Psychiatric disorder 21

Impaired LFT 4

Gastritis/peptic ulcer 10

Perforated nasal septum 2

Alcoholism 4

Others 21

Nil 35

Symptoms of patientsNo. of patients % of patients

Dysuria/bladder pain 72/96 75

Urinary frequency

<30m 47/84 56.0

30m – 1hr 18/84 21.4

1-2hrs 11/84 13.1

>2hrs 8/84 9.5

Voided volume

Mean no. of

Nocturia

4.1(0-20)

Mean PUF

symptom

13.5(4-23)

Voided volume

<50ml 20/64 31.3

50-100ml 27/64 42.1

100-200ml 10/64 15.6

>200ml 7/64 11.0

Incontinence

No need to use pads 23/96 24.0

Use regular pads/napkins 5/96 5.2

Haematuria 24/95 25.3

symptom

score

Mean PUF

bothersome

score

8.4(2-12)

Results of Investigations

No. of patients %

USG showing

hydronephrosis (1or both

sides)

10/92 10.9

Pyuria 41/84 48.8

Microscopic haematuria 39/85 45.9Microscopic haematuria 39/85 45.9

Positive urine culture 9/84 10.7

Impaired renal function 2/74 2.7

Impaired liver function 23/66 34.8

Abnormal CBC 34/64 53.1

Abnormal ECG 10/58 17.2

Abnormal KUB 3/57 5.3

Treatment outcomes during follow up

Treatment method % patient with

Improvement in symptoms

% patient with static or

increased symptoms

Dose reduction only 18.2 (10/55) 1.8 (1/55)

Dose reduction + medicine 38.2 (21/55) 5.5 (3/55)Dose reduction + medicine 38.2 (21/55) 5.5 (3/55)

No dose reduction 0 (0/55) 14.5 (8/55)

No dose reduction +

medicine

3.6 (2/55) 18.2 (10/55)

Team approach for management

of substance abuseof substance abuse

Mental and

Physical Health

Doctors

NursesLegislation &

Law

Enforcement

Patient

Social

Support

Psychological

Support

Social

Worker

? Clinical

Psychologist

Co-operation with NGOs

• Aims

– Provide specific care to patient according to their needs

– Detect urgent medical problems and act accordingly

– Increase patient’s motivation to quit

– Streamline referral to other health care services– Streamline referral to other health care services

– Promote a more positive approach to their health problems

– Improve patient’s understanding of their own body

– Provide opportunity to patient to ask questions concerning their

health

– Provide psychological support

– Health screening

“Hopefully, to improve the overall success for the patient to quit”

• Advantages

– Better patient motivation to quit drugs

– Provide better specialty service to patient after triage by nurse

– Provide better information concerning the psychological and social aspect of the patient in a combined setting with nurse and/or social worker

– Provide feedback on patient’s progress and needs

– To deepen the understanding of medical and health knowledge of our partners

Context of a visit to urology clinicBefore the visit

• Triage by Nurse

• Booking of appointment

• Preparation of patient’s summary including history, PUF score, basic investigation findings

• Consent form• Consent form

During the visit

• Patient arrived at clinic, accompanied by social worker and/or nurse

• Short discussion with nurse/social worker before seeing patient if necessary

• History taking focusing on duration of abuse, dosage of drugs, previous attempts of quitting, reasons of failure, reasons for seeking help from NGOs, symptoms present, psychological and social impact, past health, alcohol and smoking habit

During the visit (cont.)

• Focused physical examination including bedside USG of bladder and kidneys

• Explained to patient the effect of drug abuse on their body

• Emphasized the importance of quitting as the only way for betterment

• Explain the possible body response after quitting (rebound)(rebound)

• Explain what doctors can and cannot do for them and role of medical treatment

• Initiate medical treatment/further investigations/referral to other health care workers

After the visit

• Screen all investigation results and feedback to nurse for further action

Estimated consultation time 15-30mins

Future improvements

• Better co-operation with HA hospitals and

clinics

• Better co-operation with other specialists and

family doctorsfamily doctors

• More feedback concerning the outcome of

patients

• More exchange of ideas concerning ways to

improve the service

The physical characteristics, PUF score, cystometric bladder

capacity and RUS findings of the 59 patients

• Male : female ratio 38:21

• Age, years 24.3 (18–35)

• Duration of ketamine abuse, years 3.5 (0.5–10)

• PUF score : 24.7 (4–35)• PUF score : 24.7 (4–35)

• Cystometric bladder capacity, mL : 154.5 (14–600)

• Patients with VUR : 6 (13%)

• Patients with unilateral/bilateral hydronephrosis 30 (51%)

• Patients with renal impairment (serum creatinine >120μmol/L) 8 (14%)

The destruction of the lower urinary tract by ketamine abuse: a new

syndrome? Dr Chu SK et al, 2008 BJUI, 102, 1616-1622

Commonly asked questions

• Why somebody have bladder symptoms while

others not?

– ?dose related

– ?duration of exposure– ?duration of exposure

– ?Immunity response

– Need epidimiological study

Commonly asked questions

• Can I get better after I quit?

– Quitting is the only way to ‘cure’ the problem or to

control the symptoms

– It is not sure whether the bladder can return to – It is not sure whether the bladder can return to

normal or not after quitting

• Bladder volume may be one of the predictors

Commonly asked questions

• Why sometimes I get worse even though I try

to take less?

– 2/11 patients complained of increase symptoms

after reducing ketamineafter reducing ketamine

– Need to rule out other diagnosis

– Analgesic effect of ketamine

Commonly asked questions

• Is drinking plenty of water useful?

– Theoretically adequate hydration should reduce

toxic chemical effect on bladder

– Overdrinking itself will give rise to increase urinary – Overdrinking itself will give rise to increase urinary

frequency

– Beware of water intoxication

Commonly asked questions

• I can’t quit but can I get better?

– Probably NOT

– No benefit of any form of medications or intravesical therapy according to local paper (?HA patients with more severe cystitis)patients with more severe cystitis)

– Variable response after medical therapy in other small series and peel review

– There is definite evidence on continue damage to urinary tract even after bladder is removed if patient can’t quit