Poppy came to see me, suffering from yet another bout of cystitis (an inflamed bladder). The likeliest culprit was a urinary tract infection (UTI), which would respond to antibiotics. Men rarely get UTIs but the tube – the urethra – draining the female bladder is very short, rendering it susceptible to invasion by bacteria. This was Poppy’s fourth presentation over the course of the summer, so it was starting to look as if she would be one of the group with recurrent problems.
A student in her early twenties, Poppy has a cheerful approach to life and seemed to view these episodes as no more than mildly irritating interruptions to her general mission to party, travel and attend as many festivals as possible. Although her symptoms were typical – frequent and urgent calls to the loo, with a nasty, burning, cramping pain when she passed urine – I was starting to wonder whether a UTI was the correct diagnosis. I sent urine samples to the lab on two occasions and neither of them yielded a positive bacterial growth.
I made some tactful inquiries about any link to sex. “Honeymoon cystitis” is a term belonging firmly to another era, yet it’s still widely used as a euphemism for the association between intercourse and cystitis-like symptoms, which probably arise as a result of frictional microtrauma to the urethral opening. Although Poppy said she was intermittently sexually active, there was no clear relationship to any of her episodes of symptoms.
Another possibility was chlamydia, one of the commonest sexually transmitted infections. Many people carry it without symptoms but one of the ways it can present in a woman is with recurring bouts of what seem to be UTIs, yet return negative laboratory cultures. Poppy proved to be clear. An ultrasound scan excluded a bladder stone.
I’d investigated all the causes I could think of and had drawn a blank, so I left her with advice to ensure a good daily water intake, avoid drinking too much coffee and not to use bubble baths or other potentially irritant chemicals. Time passed and she receded in my mind, the absence of any new presentation suggesting that these simple lifestyle measures may have been all that had been required.
A couple of months later, I attended an educational event convened by our local drugs team. It was arranged because over the past few years our locality had become a national hot spot for the illicit use of ketamine. While the dangers associated with common street drugs such as heroin are well described, ketamine use is a relatively new phenomenon and some serious problems were starting to come to light.
In the UK, ketamine serves as a veterinary anaesthetic. Taken in smallish doses by human beings, it produces a hallucinatory trip (“going in the K-hole”). It seems that ketamine also provokes an intense inflammation of the bladder and, sometimes, the bowel. The latter causes abdominal pains (“K-cramps”), while the former causes symptoms indistinguishable from a UTI. With regular use, this chemical cystitis results in scarring and intractable irritability in the bladder. There is a small but growing cohort of young people facing a life blighted by incurable urinary symptoms, the only remedy being the surgical removal of the damaged bladder and the diversion of urine drainage through a stoma.
The drugs team urged us to consider ketamine use in any young person presenting with recurrent cystitis without proven infection. Poppy immediately came to mind. Before I had a chance to contact her, however, she’d made an appointment with another bout of symptoms. Now I knew the question to ask. Sure enough, it transpired that she had been dabbling with ketamine and we were able to link each of her cystitis episodes to an instance of drug use. She was shocked by the connection and sufficiently alarmed by the prospect of permanent bladder damage to forswear any future trips through the K-hole.
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