Urologists Reckon With Ketamine’s Toll on the Bladder

 Heavy use of ketamine can damage the urinary tract, sometimes irreversibly.

Pharmaceutical and surgical treatments can help, but the most important step is to stop taking the drug, according to physicians who treat patients with ketamine cystitis or uropathy.

Quitting the anesthetic is not easy, partly because the drug creates a vicious cycle.

“Ketamine cystitis is painful, and ketamine is a very powerful painkiller,” Laetitia M.O. de Kort, MD, PhD, with University Medical Center Utrecht in Utrecht, Netherlands, said in a presentation at the European Association of Urology (EAU) 2026 Annual Meeting.

de Kort and her team run a ketamine cystitis clinic where an addiction specialist works with patients to stop use of the drug while clinicians may also prescribe medications for pain and symptoms of overactive bladder.

Shiv Sarna, MBBS, a surgical trainee at Norfolk and Norwich University Hospital, Norwich, England, treats patients at his hospital’s ketamine bladder clinic, which opened in 2021.

At the EAU meeting, he also emphasized the importance of ketamine cessation.

“The best treatment isn’t a scalpel; it’s abstinence. Once we treat the addiction, the bladder usually follows,” Sarna said.

Pathophysiology

Ketamine and its metabolites appear in high concentrations in urine. They can irritate the bladder wall and lead to ulcers, de Kort explained. Patients with ketamine cystitis typically have severe urgency, frequency, pain, and gross hematuria.

When the condition is still reversible, histologic changes in the bladder include inflammation, urothelial erosion, microvascular injury, and apoptosis. At a later, irreversible state, fibrosis of the bladder wall occurs.

Medically, ketamine is used in anesthesiology and more recently for severe depression with a therapeutic dose of up to 200 mg a week, de Kort said. But the drug is also popular among recreational users, who snort or smoke it for its sedating, dissociative, and hallucinogenic effects. People who use ketamine recreationally might take 150 mg/d, and those with addiction might use several grams per week, she said.

Research has shown a quarter of people who regularly use ketamine recreationally may have urinary symptoms and using 1 g/d or more heightens the risk.

‘New Pandemic’

In a session at the EAU meeting, Benoit Peyronnet, MD, PhD, with University of Rennes in Rennes, France, called ketamine cystitis “the new pandemic” in urology in Europe. 

Ketamine cystitis was a focus at a urology conference in France, and experts there have published guidelines on the management of the condition.

The International Consultation on Incontinence Research Society has outlined treatment strategies, proposing initial treatment with oral medications. After quitting ketamine, patients may receive intravesical therapy for initial bladder fibrosis. For irreversible damage, patients may undergo reconstructive surgery.

At an addiction treatment center in England, adults with ketamine addiction have been fitted with urine bags, the BBC reported in March.

One surgeon there told the news agency he has seen an uptick in patients with ketamine-induced bladder problems.

In the US, the potential complication was raised when The New York Times reported last May that Elon Musk had told people he had experienced bladder issues from taking ketamine. Musk responded on social media by denying taking drugs. (“I tried *prescription* ketamine a few years ago and said so on X, so this not even news,” he wrote. “It helps for getting out of dark mental holes, but haven’t taken it since then.”)

Patient Outcomes

de Kort presented data from a cohort of nearly 180 patients at the Dutch ketamine cystitis clinic. Patients typically were male, in their late 20s, and taking an average ketamine dose of 22 g/wk. Patients generally had severe daytime and nighttime urinary frequency, hematuria, and high pain scores.

The team found patients who stopped ketamine improved more with oral medications than those who continued using the drug.

Second-line treatment may consist of therapies used in other chronic bladder pain syndromes, such as instillations, hydrodistension, botulinum toxin injections, or laser coagulation.

Most of the 54 patients who received laser coagulation improved or were symptom-free and were satisfied after treatment, according to de Kort.

In refractory cases, major surgery is the next step.

“Of course, we want to avoid this in this very young patient group,” she said. Earlier treatment with intravesical therapy may be warranted to try to avoid major surgery, de Kort added.

In 18% of the cohort, the condition also involved the upper urinary tract, which may be caused by vesicoureteral reflux.

In addition to the bladder problems, sexual function may be impaired. Erectile dysfunction is common in men with ketamine cystitis, and research shows sexual dysfunction may be common in women with the condition as well.

A Multidisciplinary Approach

At Sarna’s ketamine bladder clinic, urology, substance misuse specialists, pain specialists, and community addiction services are part of the treatment approach.

Of 229 patients managed in the clinic, 112 remained in active treatment, 110 were discharged, and seven died from renal or hepatic failure or overdose. Of those discharged, about 42% had stopped using ketamine and experienced improvements in their lower urinary tract symptoms. About a quarter of the current patients were discharged previously but were re-referred to the clinic.

Approximately 56% were male, and the mean age was 28 years, with a range of 16-59 years. Patients were exposed to ketamine for almost a decade on average and reported taking an average dose of 8.4 g/d.

“The resulting damage is severe,” Sarna said. “Our patients had a mean bladder capacity of only 179 mL. But this goes far beyond just the bladder: 13% of our cohort had hydronephrosis on referral; 26% had cholangitis.”

Still, patients can improve, Sarna said. “For those who engage and achieve abstinence, the results are clear: Over half of our cohort have reported a significant symptomatic improvement.” 

Peyronnet disclosed having ties to AbbVie, Intuitive, Medtronic, Boston Scientific, Contura, Pierre Fabre, Ipsen, IBSA, Lilial, and Schwa Medico. de Kort and Sarna had no disclosures.

https://www.medscape.com/viewarticle/urologists-reckon-ketamines-toll-bladder-2026a1000blo