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What's known on the subject? and What does the study add?There is a very limited literature on the syndrome described in this review. The largest series comes from Hong Kong and includes 59 patients – this was largely a description of the presenting problems and established the link between these symptoms and ketamine. Prior to this much smaller case series (including one from the same group) were all that exists.An increasing number of UK urologists are reporting seeing these patients and we have formed a collaboration interested in understanding the pathology and establishing an effective treatment pathway for these patients. This paper aims to consolidate this knowledge.Ketamine has become increasingly recognized as a drug of recreational use. Individuals using significant amounts have developed symptoms including a small painful bladder, ureteric obstruction, papillary necrosis and hepatic dysfunction. The present paper examines the current literature on the relationship between ketamine use and these symptoms. Our own clinical experience and the data available clarify the causal relationship, and further data help to elucidate the mechanism of damage. On the basis of continued work and development with patients who are ketamine users we suggest an assessment and treatment regime that includes cessation of ketamine use and adequate analgesia to overcome symptoms. In conclusion, it is important for medical practitioners who encounter patients with these symptoms to ask about recreational drug use. Ketamine remains a safe and effective drug to use under appropriate medical supervision. Patients identified as suffering from this syndrome will need to be referred to a urological unit with an interest in the treatment of the condition.