What is the next step in evaluating a 55-year-old diabetic woman with new onset pneumaturia (air in the urine)?

From the Guidelines

The next step in evaluating a 55-year-old diabetic woman with new onset pneumaturia is to obtain a pelvic CT scan, as it is the most effective imaging study to identify the likely cause, which is most commonly an enterovesical fistula between the bladder and either the colon or small intestine. This recommendation is based on the need to promptly identify and manage potential complications associated with pneumaturia in diabetic patients, such as emphysematous cystitis, which requires urgent antibiotic treatment 1.

The patient's diabetic status increases the risk for complicated infections and delayed wound healing, contributing to fistula formation 1. A pelvic CT scan can detect the presence of air in the bladder, localize the fistula, and identify underlying conditions such as diverticulitis, colorectal cancer, or Crohn's disease.

Some key points to consider in the evaluation and management of this patient include:

• The importance of promptly identifying and managing potential complications associated with pneumaturia in diabetic patients
• The need to rule out emphysematous cystitis, which can present with pneumaturia and requires urgent antibiotic treatment
• The use of a pelvic CT scan as the initial imaging study to identify the likely cause of pneumaturia
• The potential need for follow-up procedures, such as cystoscopy, to directly visualize the fistula opening in the bladder
• The importance of counseling the patient on the potential risks and complications associated with pneumaturia in the setting of diabetes, including the increased risk for complicated infections and delayed wound healing 1.

Given the potential for serious complications, it is essential to prioritize the patient's morbidity, mortality, and quality of life in the evaluation and management of pneumaturia. The most recent and highest-quality study supports the use of a pelvic CT scan as the initial imaging study in this patient population 1.

From the Research

Evaluation of Pneumaturia

The presence of air in the urine, known as pneumaturia, can be a symptom of various conditions, including infections, trauma, and fistulas. Given the patient's new onset pneumaturia, the next step in evaluation should focus on identifying the underlying cause.

Possible Causes and Diagnostic Approaches

• Infection: Urinary tract infections (UTIs) are a common cause of pneumaturia, especially in diabetic patients 2, 3. A urine culture is essential in diagnosing UTIs and guiding antibiotic treatment.
• Trauma: Although the patient's history does not mention trauma, it is crucial to consider this possibility, especially if there are other symptoms or signs of injury.
• Fistula: A colovesicular fistula is a possible cause of pneumaturia, but the patient's history and initial evaluation may help rule out this condition 4, 5.

Diagnostic Steps

• Urine culture: This is a critical initial step in evaluating pneumaturia, as it can help diagnose UTIs and guide treatment 2, 3.
• Imaging studies: While a pelvic CT scan may be useful in some cases, it is not the first-line diagnostic step for pneumaturia. A cystogram or other imaging studies may be considered if a fistula or other structural abnormality is suspected 6.

Next Step

Based on the available evidence, the next step in evaluating the 55-year-old diabetic woman with new onset pneumaturia would be to perform a:

• Urine culture (C) to diagnose or rule out a UTI, which is a common cause of pneumaturia in diabetic patients 2, 3.