Ketamine cystitis: Its urological impact and management

AbstractKetamine, an n-methyl-d-aspartic acid receptor complex antagonist, has been used as an anesthetic and/or analgesic. However, in the past decade, ketamine has been illegally available as a recreational drug in Asian countries and Taiwan. Due to the characteristic of being short-acting, youngsters widely assume that ketamine is not as harmful as other drugs, such as heroin. Consequently, many young patients used this drug for a longer duration before they presented with severe urinary frequency and urgency symptoms. Subsequently, other cases have been reported in Taiwan, Hong Kong, Singapore, Malaysia, and Europe. Ketamine abuse is increasing, with rates of 0.30% in 2006 to 0.40% in 2007 among those in the 16–59 year age group. In general, affected patients tend to be young with a peak age range of 16–35 years. The incidence of lower urinary tract symptoms in ketamine abuse patients is around 30%. The actual underlying pathomechanism of ketamine cystitis (KC) and associated pelvic pain remains unclear. It is speculated that chronic contact and stimulation to the bladder or ureteral mucosa due to metabolites of ketamine will result in submucosal edema, vascular ectasia, fibrosis, detrusor muscle inflammation, and fibrosis. Presentations of KC include remarkable dysuria, urinary frequency/urgency, urge incontinence, and bladder pain. Urine culture usually fails to yield any microbiology in KC with bladder pain alone. The majority of patients can enjoy clinical improvement after cessation of ketamine and urological treatment similar to interstitial cystitis/bladder pain syndrome (IC/BPS). However, patients who are still abusing ketamine and/or who have a longer duration of ketamine abuse might suffer from severe bladder pain, which does not respond to empirical oral or intravesical treatments such as hyaluronic acid. Among these patients, most have a remarkably impaired quality of life and are at risk of developing upper urinary tract damage, including hydronephrosis and kidney injury. To reduce bladder pain, improve quality of life, and avoid further deterioration of renal function, surgical intervention might be indicated

Malakoplakia of Ipsilateral Kidney, Ureter and Bladder

AbstractMalakoplakia is a rare chronic inflammatory disease of the urinary tract, usually caused by Escherichia coli infection. We report a 75-year-old woman who presented with hydronephrosis and pyuria associated with E. coli infection. Abdominal computed tomography revealed several renal stones and severe hydronephrosis of the right kidney. Biopsies of the urinary bladder and ureter revealed erosion and acute inflammation. According to a culture sensitivity test, antimicrobial treatment was prescribed with cephradine 500 mg every 6 hours and amoxicillin-clavulanic acid 100 mg twice daily for 1 month. Because of the advanced hydronephrosis with impaired renal function, a right nephroureterectomy was performed. Malakoplakia of the right kidney, ureter and urinary bladder was confirmed by pathology with Michaelis-Gutmann bodies present in the surgical specimen. The patient tolerated the operation well. She regained a good health status and was regularly followed-up in the urologic department

Renal endometriosis mimicking an angiomyolipoma

AbstractA 42-year-old woman, with a history of dysmenorrhea associated with low-back soreness, presented with sudden onset of right flank pain, a palpable tender mass in the right upper quadrant of the abdomen, and hematuria. A contrast-enhanced computed tomography revealed a huge encapsulated right renal tumor with a minimal fat component, which was initially diagnosed as a renal angiomyolipoma (AML) on the basis of her history and imaging findings. She underwent a right nephrectomy after initially receiving conservative treatment. Results of a pathologic examination of the resected specimen, however, revealed renal endometriosis. After the operation, she received hormone therapy with danazol. During the 10 months after the operation, no untoward events developed. Herein, we report a rare case of renal endometriosis that initially mimicked an AML

Practical points in the medical treatment of overactive bladder and nocturia in the elderly

AbstractThe prevalence of overactive bladder (OAB) increases with age. Degeneration of the central nervous system in the elderly has been proposed as one of the pathogenic factors of OAB. Antimuscarinic therapy is effective in the treatment of OAB; however, intolerable systemic adverse events and cognitive dysfunction during treatment with nonselective antimuscarinic agents is of growing concern in elderly patients. The newly developed beta-3 adrenoceptor agonist mirabegron does not adversely affect flow rate and detrusor pressure, and its therapeutic efficacy and tolerability are similar in patients aged > 65 years and > 75 years, suggesting it might be the therapeutic choice in older patients with OAB. Nocturia can cause sleep deprivation at night and increase daytime sleepiness and loss of energy in the elderly. Desmopressin add-on therapy is effective in improving nocturia and storage symptoms. However, elderly patients with a baseline serum sodium level below the normal range are at high risk of developing significant hyponatremia

The Overactive Bladder Symptom Score, International Prostate Symptom Score–Storage Subscore, and Urgency Severity Score in Patients With Overactive Bladder and Hypersensitive Bladder: Which Scoring System is Best?

Purpose To evaluate the correlations among the Overactive Bladder Symptom Score (OABSS), International Prostate Symptom Score–Storage Subscore (IPSS-S), and the modified Urgency Severity Scale (USS) in patients with overactive bladder (OAB) and hypersensitive bladder (HSB) and to identify the most useful diagnostic tool for classifying the severity of OAB. Methods We retrospectively reviewed the charts of consecutive patients with OAB who visited our urologic clinics for treatment. All patients underwent a detailed history, physical examination, urinalysis, uroflowmetry, and postvoid residual volume measurement, and completed a 3-day voiding diary. All patients answered the Chinese versions of the IPSS, OABSS, and USS, according to which they were classified as having wet or dry OAB based on whether their chief complaint was urgency urinary incontinence or urgency without incontinence. HSB was defined as a functional bladder capacity OABSS>IPSS-S. The simplest survey, the USS, with a single item scored from 0 to 4, had the strongest correlation with the OAB severity subgroups

Prevalence of Lower Urinary Tract Symptoms in Male Aborigines and Non-aborigines in Eastern Taiwan

Lower urinary tract symptoms (LUTS) are highly prevalent in men. The relationship of LUTS with socioeconomic level has not been investigated in Asian people. This study investigated the prevalence of LUTS in men and between aborigines and non-aborigines in eastern Taiwan, and their association with demographic, socioeconomic and behavioral characteristics. Methods: A survey of LUTS in adult male community residents of Hualien district was conducted in 2006. LUTS were assessed using questionnaires for the International Prostate Symptom Score (IPSS) and Quality of Life Index (QoL-I). The prevalence of each bothersome LUTS, moderate LUTS (IPSS > 8) and impaired QoL (QoL-I > 4) were compared between aborigines and non-aborigines. The association between the prevalence of LUTS and socioeconomic status was also compared between the two groups. Results: There were 196 aborigines (32%) and 419 non-aborigines (68%) who completed the questionnaires. Nocturia was the most common LUTS in aboriginal and non-aboriginal men. The prevalence of moderate LUTS increased with age (p < 0.001) in men overall. Significantly higher prevalence rates of frequency (11.7% vs. 7.2%, p = 0.044) and nocturia (31.1% vs. 19.8%, p = 0.002) were found in aborigines than non-aborigines. However, there was no significant difference in the prevalence of moderate LUTS (12.8% vs. 8.8%, p = 0.220) or impaired QoL (24.3% vs. 19.9%, p = 0.088) between aborigines and non-aborigines. The higher prevalence of frequency and nocturia in aborigines was associated with significantly lower educational and economic levels, which were also associated with a higher prevalence of alcohol drinking, betel quid chewing and cigarette smoking. Conclusion: Nocturia was the most common LUTS in community dwelling aboriginal and non-aboriginal adult males. A low socioeconomic level was associated with a higher prevalence rate of moderate LUTS and impaired QoL, especially in aborigines