Initial imaging was non-specific.
Ultrasound showed an underfilled urinary bladder, while MRI pelvis and CT urinary tract demonstrated diffuse thickening of the urethra and a thick walled, collapsed urinary bladder (Figure 1).
Intravesical Botox injections offered initial relief however she eventually underwent cystectomy and neobladder formation with confirmation of diagnosis on histopathology.
Histology demonstrated extensively ulcerated bladder mucosa with granulation tissue and mixed inflammatory cell infiltrate typical of ketamine related chronic ulcerative cystitis.
She continued to have recurrent urinary tract infections and chronic bilateral flank pain.
In the 3rd postoperative year, contrast enhanced CT abdomen demonstrated bilateral moderate hydronephrosis with urothelial thickening and hyperenhancement (Figure 2).
A nuclear medicine renogram was performed to investigate further and diagnosed an asymmetrically enlarged left kidney contributing 80% of renal function.
The left kidney demonstrated a rising renogram curve which plateaued, indicating renal obstruction (Figure 3).
This was thought to be likely to ureteric stricture and was managed with left antegrade ureteric stent insertion. 6 months later she developed contralateral abdominal pain and nuclear medicine renogram confirmed an obstructed renogram curve of the right kidney.
The left kidney showed normal excretion, with resolution of obstruction following previous stent insertion (Figure 4).
Right nephrostomy and ureteric stenting were subsequently performed (Figure 5).