54 / Urology

� A dose and frequency response relationship has been shown betweenketamine 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-disciplinaryapproach promoting harm reduction, cessation and early referral is neededto manage individuals with ketamine-associated urinary tract symptoms toavoid progression to severe and irreversible urological pathologies.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 ofsymptoms with dose and frequency of use and natural history of symptomsonce 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 doseefrequency relationship with ketamine use. It shows that urinary symptomsassociated with recreational ketamine use may lead to a considerable de-mand on health resources in the primary-, secondary- and emergency-care settings. It shows that symptoms may improve once ketamine use isdecreased.Study Type.dSymptom prevalence (prospective cohort).Level of Evidence.d1b.

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Recreational use of ketamine is apparently commonplace in certain Asian

countries, and its use appears to be increasing in the United Kingdom as well.

The use of ketamine has been associated with the development of lower urinary

tract symptoms such as frequency, urgency, dysuria, and hematuria. The symp-

toms can progress to end-stage bladder dysfunction with hydronephrosis and

renal failure. The pathophysiology of ketamine-induced bladder dysfunction is

not clear at this time. This survey of 1285 ketamine users in the United Kingdom

indicates that approximately 25% of users will experience urinary symptoms and

that the presence of these symptoms is dose related. Fortunately, the symptoms

appear to resolve in most users after cessation of ketamine use. Recreational ket-

amine use in the United States appears to be low at this time, although it almost

certainly does exist. In younger individuals with idiopathic lower urinary tract

symptoms, it seems prudent to inquire about ketamine use.

J. Quentin Clemens, MD

Experience with Glycerin for Antegrade Continence Enema in Patientswith Neurogenic BowelChu DI, Balsara ZR, Routh JC, et al (Duke Univ Med Ctr, Durham, NC)

J Urol 189:690-693, 2013

Purpose.dMalone antegrade continence enemas are used in the manage-ment of neurogenic bowel to attain fecal continence. Several different irriga-tion solutions have been described but glycerin, an osmotic laxative that

Chapter 11eVoiding Dysfunction/Enuresis / 55

promotes peristalsis, has rarely beenmentioned or studied.We assessed clin-ical outcomes in our patients with a Malone antegrade continence enemausing glycerin based irrigation.

Materials and Methods.dWe retrospectively reviewed patients withneurogenic bowel who underwent a Malone antegrade continence enemaprocedure between 1997 and 2011. Glycerin diluted with tap water fol-lowed by a tap water flush is our preferred irrigation protocol. Bowelregimen outcomes examined included fecal continence, emptying time,leakage from stoma, enema volume, frequency and independence.

Results.dOf the 23 patients with followup greater than 6 months 19used glycerin based irrigation. Average age at surgery was 8.8 years. Patientsusing glycerin instilled a median of 30 ml (mean 29) glycerin and 50 ml(131) tap water. Fecal continence rate was 95% and stoma leakage ratewas 16%, and only 16% of patients required daily irrigation.

Conclusions.dGlycerin is a viable and effective alternative irrigant forantegrade enemas of neurogenic bowel, with an excellent fecal continencerate. The volume of irrigant needed is typically less than 90 ml, which ismuch less than in published reports using tap water alone.

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Management of chronic constipation and fecal incontinence in patients with

neurogenic bowel dysfunction can be challenging. A small percentage of patients

have continence with stool softeners and timed defecation. Retrograde enemas

are typically ineffective unless used with a cone or plug that occludes the anus

to prevent efflux until the entire volume is instilled. Even if a retrograde enema

is efficacious, self-administration is difficult in patients with poor mobility. Ante-

grade enema via a catheterizable colonic stoma or button was first described by

Malone in 1990. Saline, tap water, polyethylene glycol, and mineral oil have

been used as irrigants. Continence with this technique is excellent. However, in

patients with a very redundant colon, the irrigation volumes are often very large

(1 L), and the evacuation time often exceeds an hour.

The authors describe the addition of glycerin to the irrigant. Glycerin has been

well studied in suppositories and retrograde enemas and is safe with minimal

cramping as a side effect. This acts as an osmotic laxative that promotes peri-

stalsis. The patients were able to decrease the instilled volumes without a change

in bowel continence when compared with tap water alone. However, the mean

evacuation time after enema was still 45 minutes. This is a small sample size,

and there is no direct comparison with other irrigants. This approach warrants

further evaluation.

D. E. Coplen, MD