Role of Urologists in the management of ketaminec4e.hkcss.org.hk/user/Role_of_Urologists.pdfRole of...
Transcript of Role of Urologists in the management of ketaminec4e.hkcss.org.hk/user/Role_of_Urologists.pdfRole of...
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