What is emphysematous cystitis?

Emphysematous Cystitis

Emphysematous cystitis is a rare but potentially life-threatening urinary tract infection characterized by the presence of gas in and around the bladder wall, caused by gas-forming organisms, primarily affecting elderly patients with diabetes mellitus and requiring prompt antibiotic therapy and bladder drainage. 1, 2

Definition and Pathophysiology

• Emphysematous cystitis (EC) is defined as a severe urinary tract infection characterized by pockets of gas formed in and around the urinary bladder wall by gas-producing pathogens 3
• The condition is caused primarily by gas-forming organisms, most commonly Escherichia coli and Klebsiella species 1, 2
• Gas formation occurs through fermentation of glucose or albumin by these pathogens, leading to accumulation within bladder tissues 2

Epidemiology and Risk Factors

• EC predominantly affects elderly women with diabetes mellitus 2
• Major predisposing factors include: 3, 4
  • Diabetes mellitus (most common risk factor)
  • Chronic urinary tract infections
  • Neurogenic bladder
  • Immunosuppression
  • Advanced age
• The condition can occasionally present in patients without traditional risk factors 5

Clinical Presentation

• The clinical presentation varies widely from asymptomatic to severe sepsis 2
• Common symptoms include: 5, 2
  • Lower abdominal pain
  • Hematuria
  • Dysuria
  • Frequency and urgency
  • Pneumaturia (passage of gas mixed with urine)
• In severe cases, patients may develop: 6
  • Sepsis
  • Bladder rupture or necrosis
  • Renal dysfunction
  • Acute abdomen

Diagnosis

• Imaging is crucial for definitive diagnosis of emphysematous cystitis 2
• Diagnostic modalities include: 1, 2
  • Plain abdominal radiography - may show air in the bladder wall or lumen
  • CT scan - most sensitive method, clearly demonstrates gas within and around the bladder wall
• Laboratory findings typically include: 5, 2
  • Pyuria
  • Bacteriuria
  • Elevated inflammatory markers
  • Hyperglycemia in diabetic patients

Treatment

• Early appropriate antibiotics targeting common pathogens like Escherichia coli and Klebsiella species is the cornerstone of treatment 1
• Treatment approach includes: 1, 4, 2
  • Broad-spectrum antibiotics (initial empiric therapy)
  • Urinary bladder drainage (catheterization)
  • Glycemic control in diabetic patients
  • Correction of underlying predisposing factors
• Most cases respond to medical therapy, but severe instances may require surgical intervention 1
• Treatment duration of 7 to 14 days (adjusted per clinical response) is generally recommended 1

Prognosis and Complications

• EC is potentially life-threatening with a reported mortality rate of approximately 7% 2
• Complications can include: 5, 6
  • Bladder necrosis requiring cystectomy
  • Bladder perforation
  • Septic shock
  • Renal dysfunction
• Early detection and prompt treatment significantly improve outcomes and may prevent the need for surgical intervention 4, 2

Clinical Pearls and Pitfalls

• The severity of illness ranges from asymptomatic to life-threatening, making early recognition crucial 4
• EC may be an incidental finding on imaging performed for unrelated symptoms 3
• Failure to recognize and treat promptly can lead to severe complications including bladder necrosis requiring cystectomy 4
• Patients with diabetes should have strict glycemic control as part of management 2
• Follow-up imaging may be necessary to ensure resolution of gas within the bladder wall 2