Study Type – Symptom prevalence (prospective cohort) Level of Evidence 1b What's known on the subject? and What does the study add? Case series have described lower urinary tract symptoms associated with ketamine use including severe pain, frequency, haematuria and dysuria. Little is known regarding the frequency of symptoms, relationship of symptoms with dose and frequency of use and natural history of symptoms once the ketamine user has stopped. This study describes the prevalence of ketamine use in a population of recreational drug users in a dance music setting. It shows a dose–frequency relationship with ketamine use. It shows that urinary symptoms associated with recreational ketamine use may lead to a considerable demand on health resources in the primary‐, secondary‐ and emergency‐care settings. It shows that symptoms may improve once ketamine use is decreased. OBJECTIVE To investigate the prevalence and natural history of urinary symptoms in a cohort of recreational ketamine users. PATIENTS AND METHODS A purposeful sampling technique was used. Between November 2009 and January 2010 participants were invited to undertake an on‐line questionnaire promoted by a national dance music magazine and website. Data regarding demographics and illicit drug‐use were collected. Among respondents reporting recent ketamine use, additional information detailing their ketamine use, experience of urinary symptoms and use of related healthcare services was obtained. RESULTS In all, 3806 surveys were completed, of which 1285 (33.8%) participants reported ketamine use within the last year. Of the ketamine users, 17% were found to be dependent on the drug; 26.6% (340) of recent ketamine users reported experiencing urinary symptoms. Urinary symptoms were significantly related to both dose of ketamine used and frequency of ketamine use. Of 251 users reporting their experience of symptoms over time in relationship to their use of ketamine, 51% reported improvement in urinary symptoms upon cessation of use with only eight (3.8%) reporting deterioration after stopping use. CONCLUSIONS Urinary tract symptoms are reported in over a quarter of regular ketamine users. A dose and frequency response relationship has been shown between ketamine use and urinary symptoms. Both users and primary‐care providers need to be educated about urinary symptoms that may arise in ketamine users. A multi‐disciplinary approach promoting harm reduction, cessation and early referral is needed to manage individuals with ketamine‐associated urinary tract symptoms to avoid progression to severe and irreversible urological pathologies.

What's known on the subject? and What does the study add? There is a very limited literature on the syndrome described in this review. The largest series comes from Hong Kong and includes 59 patients – this was largely a description of the presenting problems and established the link between these symptoms and ketamine. Prior to this much smaller case series (including one from the same group) were all that exists. An increasing number of UK urologists are reporting seeing these patients and we have formed a collaboration interested in understanding the pathology and establishing an effective treatment pathway for these patients. This paper aims to consolidate this knowledge. Ketamine has become increasingly recognized as a drug of recreational use. Individuals using significant amounts have developed symptoms including a small painful bladder, ureteric obstruction, papillary necrosis and hepatic dysfunction. The present paper examines the current literature on the relationship between ketamine use and these symptoms. Our own clinical experience and the data available clarify the causal relationship, and further data help to elucidate the mechanism of damage. On the basis of continued work and development with patients who are ketamine users we suggest an assessment and treatment regime that includes cessation of ketamine use and adequate analgesia to overcome symptoms. In conclusion, it is important for medical practitioners who encounter patients with these symptoms to ask about recreational drug use. Ketamine remains a safe and effective drug to use under appropriate medical supervision. Patients identified as suffering from this syndrome will need to be referred to a urological unit with an interest in the treatment of the condition.

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Ketamine can lead to reactive urothelial changes that can mimic carcinoma in situ, but the long-term cancer risk remains unknown.

Chronic pelvic pain (CPP) is chronic or persistent pain perceived in structures related to the pelvis of men and women. These individuals may suffer significant distress and detriment to their daily living and quality of life. Neuromodulation may provide an effective treatment option in patients with CPP refractory to standard treatment, reducing pain and improving quality of life with an acceptable rate of complications. However, study quality is insufficient for a more certain conclusion, and therefore larger-scale, well-designed, and powered randomized controlled trials with long-term outcomes are needed.