What is the management of emphysematous cystitis?

Management of Emphysematous Cystitis

Emphysematous cystitis requires prompt treatment with broad-spectrum antibiotics, urinary drainage, and management of underlying risk factors to prevent progression to severe complications including bladder necrosis, emphysematous pyelonephritis, urosepsis, and death. 1

Initial Assessment and Diagnosis

• Emphysematous cystitis is a rare, severe urinary tract infection characterized by gas pockets in and around the bladder wall caused by gas-forming organisms 2

• Presentation ranges from asymptomatic to severe urosepsis 3

• Common symptoms include:

  • Lower urinary tract symptoms
  • Abdominal/suprapubic pain
  • Hematuria
  • Pneumaturia (air in urine)
  • Dysuria
  • In severe cases: signs of sepsis

• Diagnosis is confirmed by imaging (CT scan or plain radiography) showing air within the bladder wall and lumen 3

Risk Factors to Identify

• Diabetes mellitus (most common)
• Chronic urinary tract infections
• Urinary tract obstruction
• Neurogenic bladder
• Immunocompromised status
• Long-term catheterization 2, 3

Treatment Algorithm

1. Immediate Management

• Establish prompt urinary drainage:

  • Insert urinary catheter to ensure continuous bladder drainage 2, 1
  • Monitor urine output and characteristics

• Start broad-spectrum antibiotic therapy immediately:

  • Initial empiric therapy should cover both aerobic and anaerobic organisms 4
  • Recommended regimens (based on complicated UTI guidelines) 4:
    • Amoxicillin plus an aminoglycoside
    • Second-generation cephalosporin plus an aminoglycoside
    • Intravenous third-generation cephalosporin
    • Ceftazidime-avibactam 2.5g IV q8h for cases with suspected carbapenem-resistant Enterobacterales (CRE) 4
    • Meropenem-vaborbactam 4g IV q8h or imipenem-cilastatin-relebactam 1.25g IV q6h as alternatives for CRE 4

• Obtain cultures before starting antibiotics:

  • Blood cultures
  • Urine culture with susceptibility testing 4

2. Targeted Therapy (After Culture Results)

• Adjust antibiotics based on culture and susceptibility results

• Common causative organisms:

  • Escherichia coli (most common)
  • Klebsiella pneumoniae
  • Other gas-forming bacteria 1

• Duration of therapy:

  • 7-14 days of antibiotics (14 days for men when prostatitis cannot be excluded) 4
  • Continue until patient is afebrile for at least 48 hours 4

3. Management of Underlying Conditions

• Glycemic control for diabetic patients
• Correction of urinary tract obstruction if present
• Address immunosuppression if applicable
• Remove or replace long-term catheters if present 2, 3

4. Monitoring and Follow-up

• Daily assessment of:

  • Vital signs
  • Pain levels
  • Laboratory markers (WBC, CRP)
  • Urine output and characteristics

• Repeat imaging to assess resolution of gas in bladder wall

Indications for Surgical Intervention

Surgery is rarely needed but should be considered in cases of:

• Bladder necrosis
• Bladder perforation
• Failed response to conservative management
• Progressive clinical deterioration despite appropriate antibiotics and drainage 1

Prognosis and Complications

• Overall mortality rate: approximately 7% 1
• Potential complications if not properly treated:
  • Bladder necrosis
  • Emphysematous pyelonephritis
  • Urosepsis
  • Septic shock 5, 1

Important Considerations

• Even asymptomatic cases warrant prompt treatment to prevent severe complications 2
• Conservative management with antibiotics and bladder drainage is often sufficient, avoiding the need for surgical intervention in most cases 6
• Each case must be assessed individually for severity and progression, with close monitoring for clinical deterioration 6

Remember that emphysematous cystitis is a urologic emergency that requires immediate diagnosis and treatment to prevent potentially fatal complications 5, 1.