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Ketamine Bladder Syndrome — MRCPsych Paper B MCQ

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HardSubstance MisuseKetamine Bladder SyndromeMRCPsych Paper B

A 22-year-old man reports an 18-month history of escalating, near-daily recreational ketamine use. He now passes urine every 20 minutes and has severe urgency, suprapubic pain, dysuria and intermittent visible haematuria. Repeated midstream urine cultures show no bacterial growth despite pyuria, and nucleic acid amplification tests for chlamydia and gonorrhoea are negative. Ultrasonography shows a thick-walled, small-capacity bladder with bilateral hydroureteronephrosis. Which diagnosis best accounts for this presentation?

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Correct answer: B — Ketamine-induced uropathy with ulcerative cystitis and bladder fibrosis

The diagnosis is **ketamine-induced uropathy**, including ketamine-associated ulcerative cystitis. The discriminating features are sustained heavy ketamine exposure, severe storage symptoms and bladder pain, sterile pyuria, haematuria, reduced bladder capacity and upper-tract dilatation. Ketamine and its urinary metabolites damage the urothelium, promoting inflammation and progressive fibrosis; advanced disease can produce a contracted bladder, ureteric involvement and hydronephrosis. Recurrent bacterial cystitis and sexually transmitted urethritis are undermined by repeatedly negative microbiology and do not adequately explain bladder contracture. Chronic prostatitis would usually involve pelvic or prostatic features rather than this characteristic fibrotic uropathy. Primary bladder pain syndrome can cause pain and frequency but is less likely given the specific exposure and upper-tract complications. Ketamine cessation is essential, alongside urgent urological and substance-misuse assessment.

Reference: Advisory Council on the Misuse of Drugs. Ketamine: an updated review of use and harms, sections 4.4, 4.9–4.10 and 8.6–8.8. 2026. https://www.gov.uk/government/publications/ketamine-an-updated-review-of-use-and-harms/ketamine-an-updated-review-of-use-and-harms-accessible