Ketamine uropathy

Introduction

Urinary symptoms are unusual in healthy young adults, especially in men. This is changing as a result of increased recreational use of ketamine and its effects on the urinary system. This article highlights the clinical features of ketamine-induced uropathy and outlines treatments.
 

Case history

(Please note a pseudonym has been used and details changed to protect patient confidentiality)

What is ketamine?

Ketamine was developed in 1962 and is used as an anaesthetic, a sedative, an antidepressant and for the management of complex chronic pain (Hottat and Hantson, 2023).

When it is given as an anaesthetic it causes a dissociative state with profound analgesia and amnesia. Airway reflexes are preserved, respiration is unaffected and it does not affect cardiovascular stability. These properties make it useful in less-developed countries and in emergency medicine (Peltoniemi et al, 2016).

 

Ketamine abuse

Ketamine is now also thought of as a ‘party drug’ and began to be used in clubs and at raves in the UK in the early 1990s. It may be referred to as ‘green, K, ket, special K, super K, vitamin K or donkey dust’ and comes as a crystalline powder, tablets or liquid. Ketamine can be smoked, snorted, dissolved in drinks or injected, although it is usually snorted. Ketamine users can develop a tolerance to the drug, meaning that they require ever higher doses to have the same effect. Heavy use of the drug can lead to dependence (Drugwise, 2024; Stonehouse, 2024). It is most commonly used in people aged 16–24 years, its use has doubled since 2016 and has more than tripled in those under 25 years old (Office for National Statistics, 2024).
 

Effects of ketamine

Ketamine users experience a dissociative effect, which has been described as an out-of-body experience. When large doses are used there is complete detachment from reality and altered perception of time and space. This is sometimes called ‘entering the K-hole’.

Short-term effects of ketamine include confusion, disorientation, hallucinations, loss of motor coordination, and cardiovascular effects, including hypertension and tachycardia. Higher doses may cause agitation, aggression and paranoia (Orhurhu et al, 2023). Long-term abuse may result in memory defects and schizophrenia-like symptoms that persist or recur regularly despite discontinuing use of the drug (Niesters et al, 2014).
 

How ketamine affects the body

Ketamine is metabolised into norketamine which can be detected in the urine of ketamine users. As well as its effects on the upper and lower urinary tract, discussed below, ketamine affects the gastrointestinal tract, the hepatobiliary system and the central nervous system, and can cause sexual dysfunction. These effects are summarised in Table 1.
 

Table 1. How ketamine use can affect different body systems
Urinary system	Storage symptoms
	Haematuria
	Dysuria
	Bladder pain
Renal system	Hydronephrosis
	Renal dysfuction
Hepatobiliary system	Dilated bile ducts
	Liver fibrosis
Gastrointestinal system	Gastritis
	Peptic ulceration
	Gastroduodenal erosions
Central nervous system	Impaired verbal fluency
	Structural brain damage
	Decreased cognitive processing speed
Based on Belal et al (2024)

How ketamine affects the urinary system

Ketamine abuse can lead to ketamine-induced uropathy. The metabolite of ketamine, norketamine, causes suburothelial inflammation and urothelial cell death (Lin et al, 2022). This leads to ketamine-induced cystitis and ketamine-induced uropathy, first described by Shahani et al in 2007. The superficial urothelial cells are also called umbrella cells and protect the deeper layers of the bladder from damage. Norketamine damages the superficial urothelial cells which causes the lamina propia, which contains nerve cells, to be exposed to urine (Duan et al, 2017). This causes inflammation and damage to the urothelial cells, leading to vascular changes and bladder fibrosis (Jhang et al, 2023).
Urinary symptoms are common and affect 26–30% of ketamine users (Winstock et al, 2012; Misra, 2018). Around half of those who have urinary symptoms delay seeking medical attention (Li et al, 2019).

Uropathy is related to usage – using ketamine three or more times a week for 2 years is known to result in ketamine-induced uropathy (Misra, 2018). It is difficult to determine what level of use results in uropathy as the strength of ketamine varies and people who use it are not always honest about this with clinicians. Severity of symptoms is linked to dose of ketamine taken and frequency of use (Jhang et al, 2015). Some people appear to develop symptoms quickly within a few weeks or months of ketamine use, while others have a history of long-term use and increasing dosage before developing symptoms (Misra, 2018).
 

Clinical features of ketamine-induced uropathy

People presenting with ketamine-induced uropathy are usually young. Most ketamine users are aged 16–25 years old and present with bladder problems, which are unusual in healthy young people.
Table 2 illustrates how ketamine use can affect the urinary tract.
 

Table 2. How ketamine use can affect the urinary tract
Bladder	Frequency
	Haematuria
	Dysuria
	Urge incontinence
	Small painful bladder
	Severe suprapubic cramps
Ureters	Vesico-ureteric reflux
Kidneys	Obstruction
	Papillary necrosis
	Acute renal failure

 
When a person presents for the first time this is usually a result of bladder symptoms rather than symptoms affecting the ureters or kidneys. The most common presentation is severe suprapubic pain. This may require strong analgesics, and the patient may take further ketamine pain to stop the pain (Lindsay and Wood, 2020). Clinical features generally relate to the lower urinary tract and include frequency, urgency, urge incontinence, dysuria and haematuria. The person may also have hydronephrosis, ureteral stricture, vesicoureteral reflux, and renal failure. These upper urinary tract symptoms may not be clinically apparent or may develop at a later stage with continued use of ketamine (Jhang et al, 2023).
 

Diagnostic difficulty

Ketamine-induced uropathy is difficult to diagnose and treat (Belal et al, 2024). Symptoms such as frequency, urgency, dysuria and urge incontinence may be misdiagnosed as a urinary tract infection (UTI). The National Institute for Health and Care Excellence (NICE, 2018) defines lower UTI as:
 
'an infection of the bladder usually caused by bacteria from the gastrointestinal tract entering the urethra and travelling up to the bladder'.
 
The European Association of Urology (2025) categorises UTIs based on clinical presentation and the anatomical level of the UTI (Table 3).
 

Table 3. Localised and systematic signs and symptoms of urinary tract infection (UTI)
Localised UTI	Dysuria (pain, burning, stinging)
	Urgency
	Frequency
	Incontinence
	Urethral purulence
	Pressure or cramping in the lower abdomen
Systemic UTI	Fever or hypothermia
	Rigors, shaking chills
	Delirium
	Hypotension
	Tachycardia
	Costovertebral angle pain or tenderness
Based on European Association of Urology (2025)

 Women may initially present to a local pharmacist as they can now obtain prescriptions for antibiotics to treat suspected UTI from pharmacies (Clinical Pathways, 2025).
 

NICE (2018) guidance recommends urine culture and sensitivity testing in men and pregnant women. The decision to check culture and sensitivity in non-pregnant women under the age of 65 years who present for the first time with a suspected UTI is a matter of clinical judgment.
 
Antibiotics are not effective in treating ketamine-induced uropathy and the person may re-present in primary care or seek treatment in urgent care or emergency departments. Ketamine-induced uropathy is a rare diagnosis and it is important to eliminate other possible causes of lower urinary tract symptoms. In sexually active adults it is important to consider the possibility of sexually transmitted infections such as chlamydia and gonorrhoea. The clinician should also check for urethritis. The symptoms of urethritis are a more frequent urge to urinate, pain and burning on urination, and irritation in the urethral area. The primary cause is gonococcal infection but there are many other causes including trichomonas infection and non-infective causes. It is also important to check if women of childbearing age could be pregnant as this will affect management (Hoffman et al, 2025).
 
Investigations that can be carried out in primary care include keeping a bladder diary. This provides information on the frequency of micturition, any episodes of incontinence, and details of fluid input and output. Urine should also be tested for any underlying infection. Blood tests to determine renal and liver function, check white cell count and measure levels of inflammatory markers such as C-reactive protein can help to determine the diagnosis. Pre- and post-void bladder ultrasound scans are very helpful. Ketamine use leads to a contracted bladder with thickening of the bladder wall. Pre-void scanning will usually show a very small amount of urine in a bladder that feels full to the patient. Post-void scanning enables the nurse to check for urinary retention, this is not likely but it is important to check (Zeng et al, 2017; Misra, 2018). If ketamine-induced uropathy is suspected, it is important to ask if the person is taking ketamine. It can be difficult to ask about this, and people may not wish to admit to taking ketamine as its use is illegal. It is important for the nurse to stress that if the person is not honest it makes diagnosis and treatment more difficult.
In certain clinical settings such as accident and emergency departments and psychiatric units drug screening may be carried out using a urine test. Routine urine screens do not usually include ketamine – ketamine screening requires a separate targeted test (Attolife, 2025).

Figure 1 illustrates the diagnostic process.

 

Figure 1. Determining the differential diagnosis

If ketamine-induced uropathy is suspected or if the person is unresponsive to treatment, they should be referred to urology. The urgency of referral will be based on clinical symptoms.

Classification and treatment of ketamine-induced uropathy

The British Association of Urological Surgeons (Belal et al, 2024) have adapted the clinical staging system developed by Wu and colleagues (2016) (Figure 2).
 

Figure 2. Classification of ketamine-induced uropathy.
Based on Belal et al (2024).

Urologists will perform investigations to enable them to determine the extent of ketamine-induced uropathy, including history, physical examination, bladder scans, ultrasound of the urinary tract and cystoscopy. Bladder biopsy and further investigations may be required (Belal et al, 2024).

Treatment is based on the stage of ketamine-induced uropathy and clinical symptoms (Figure 3).

Figure 3. Treatment of ketamine-induced uropathy.
Based on Belal et al (2024).

The most important action is to support the person to stop using ketamine – 51% of people experience an improvement of symptoms when they stop using ketamine (Castellani et al, 2020).
 
Overactive bladder symptoms of urgency, urge incontinence and reduced bladder capacity are treated with anticholinergic medicines such as darifenacin, fesoterodine, imidafenacin, oxybutynin, solifenacin, tolterodine or trospium. If these are not successful beta 3 adrenergic agonists, e.g. mirabegron, may be used, alone or in combination with anticholinergics.
 
Bladder pain can be excruciating and is often managed by the pain team. Treatment options include non-steroidal anti-inflammatory drugs, opioids, or medicines to treat nerve pain, such as amitriptyline. gabapentin or pregabalin (Hong et al, 2018).
 
Fluids may be instilled into the bladder in an effort to relieve symptoms (Ou et al, 2018; Belal et al, 2024). Botulinum toxin A injections into the bladder may be used alone or in combination with instillations (Zeng et al, 2017).
 

Reconstructive surgery

A review by Vizgan et al (2023) indicates that 22% of those diagnosed with ketamine-induced uropathy require reconstructive surgery. The British Association of Urological Surgeons recommend that the person must have ceased ketamine use for at least 6 months before reconstructive surgery is considered. Urine testing is used to confirm this (Belal et al, 2024). If the ureters are involved, this may require a range of procedures including reimplantation and ileal substitution depending on the severity. Surgical treatments include:
 

Augmentation enterocystoplasty

This is a surgical procedure in which the bladder is enlarged using a segment of the intestine. The most commonly used intestinal segments are the ileum and the ileocaecal segment, although sometimes a segment of colon may be used (Jeong and Oh, 2020).

Augmentation enterocystoplasty is the main reconstructive option and aims to increase bladder capacity and reduce pressure.

Ng and colleagues (2013) reported that augmentation enterocystoplasty increased bladder capacity in four patients from 25–50ml to 400–500ml. Complication rates are high and the option of providing a simple ileal conduit instead should be discussed before surgery.
 

Supratrigonal cystectomy combined with augmentation cystoplasty

This involves partial cystectomy, preserving the bladder trigone, ureters and urethra, and then a segment of bowel is sutured to the bladder trigone (Grilo et al, 2021).
 

Benign cystectomy

Removal of a non-cancerous bladder can be combined with an ileal conduit or orthotopic neobladder formation (Belal et al, 2024). An ileal conduit, also known as a urostomy, involves attaching the ureters to a piece of small bowel and creating a stoma to enable urine to drain into a bag (Cancer Research UK, 2025). Orthotopic neobladder formation involves creating a new bladder using a piece of small intestine and putting it in the same part of the body as the original bladder. Orthotopic refers to things being in their usual place in the body. Generally, this is a treatment of last resort (Vetterlein et al, 2022).
 

Discussion

People who abuse ketamine are at risk of devastating life-altering urinary dysfunction. Many people who take ketamine and develop bladder symptoms delay seeking medical attention (Li et al, 2019). Bladder symptoms can ironically lead to the escalation of ketamine use and worsening bladder problems (Lindsay and Wood, 2020; Cole and Dasari, 2024). Ketamine-induced uropathy can progress very rapidly from stage 1 (potentially reversible changes) to stage 3 (potentially life-changing damage). Vizgan et al (2023) found a 1-year difference in time abusing ketamine between requiring surgery (4.4 years) and not needing this (3.4 years).
 

Implications for practice

Ketamine-induced uropathy is rare, but the use of ketamine is increasing, especially in people aged under 25 years. Bladder problems are unusual in young healthy adults so when a young adult presents with bladder symptoms the nurse should be alert to possible causes. Bladder pain is not a common symptom in young adults and may indicate ketamine-induced uropathy. This can progress very rapidly from stage 1 (potentially reversible changes) to stage 3 (potentially life-changing damage). When the cause of bladder pain is not immediately apparent the nurse should enquire sensitively about ketamine use. Early diagnosis and appropriate support and treatment can prevent a lifetime of urinary dysfunction.
 

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