How do you manage suspected emphysematous cystitis after Transurethral Resection of Bladder Tumor (TURBT)?

Management of Suspected Emphysematous Cystitis Post-TURBT

Emphysematous cystitis after TURBT requires immediate broad-spectrum intravenous antibiotics, continuous bladder drainage via urethral catheter, and urgent CT imaging to confirm diagnosis and assess for complications—this is a urologic emergency that can progress to bladder necrosis, rupture, or septic shock if not promptly treated. 1, 2

Distinguishing Pneumaturia from Emphysematous Cystitis

The critical distinction is that simple pneumaturia (gas in urine) post-TURBT is typically benign and self-limited, while emphysematous cystitis involves gas within the bladder wall itself and represents a severe infection requiring aggressive intervention. 2

• Benign post-TURBT pneumaturia occurs from instrumentation introducing air into the bladder and resolves spontaneously within 24-48 hours without treatment 2
• Emphysematous cystitis presents with gas pockets in the bladder wall and lumen caused by gas-forming organisms (typically E. coli or Klebsiella), associated with systemic symptoms 1, 3, 4

Immediate Diagnostic Approach

Obtain CT imaging of the abdomen/pelvis immediately if the patient has any of the following: 1, 2, 4

• Fever, leukocytosis, or elevated inflammatory markers
• Severe suprapubic pain beyond expected post-operative discomfort
• Hematuria with dysuria persisting beyond 48 hours post-TURBT
• Signs of sepsis or hemodynamic instability
• Diabetes mellitus or immunosuppression (high-risk patients)

CT findings diagnostic of emphysematous cystitis include: 1, 2, 4

• Gas within the bladder wall (not just lumen)
• Bladder wall thickening
• Perivesical fat stranding
• Extension of gas into surrounding tissues

Immediate Management Protocol

Once emphysematous cystitis is confirmed, initiate the following simultaneously: 1, 5, 2

1. Antibiotic Therapy

• Start broad-spectrum IV antibiotics immediately covering gram-negative organisms (E. coli and Klebsiella are most common) 3, 4
• Consider piperacillin-tazobactam or carbapenem as empiric therapy, especially if extended-spectrum beta-lactamase (ESBL) producers are suspected 3
• Adjust based on urine culture and sensitivity results 2, 4

2. Bladder Drainage

• Insert or maintain urethral catheter for continuous drainage 5, 2, 4
• Adequate drainage is essential to remove infected urine and gas 2
• Consider suprapubic catheter if urethral catheterization is contraindicated or inadequate 2

3. Glycemic Control

• Achieve strict blood glucose control in diabetic patients, as hyperglycemia facilitates gas-forming bacterial growth 3, 4
• Target glucose <180 mg/dL during acute phase 4

4. Serial Monitoring

• Admit for inpatient monitoring with serial abdominal examinations 1, 5
• Monitor for signs of clinical deterioration (worsening sepsis, peritoneal signs, bladder rupture) 1, 2
• Repeat imaging if clinical deterioration occurs 2

Surgical Intervention Criteria

Surgical debridement or partial/complete cystectomy is required if: 2

• Bladder necrosis develops on imaging or clinical examination
• Bladder perforation occurs
• Patient fails to improve with 48-72 hours of medical management
• Severe necrotizing cystitis progresses despite antibiotics and drainage

The threshold for surgical intervention should be low, as delayed surgery in necrotizing cases significantly increases mortality. 2

Duration of Treatment

• Continue IV antibiotics for minimum 7-10 days, transitioning to oral therapy based on clinical response 5, 2
• Maintain bladder catheter drainage until clinical and radiographic resolution (typically 7-14 days) 1, 4
• Repeat imaging before catheter removal to confirm resolution of gas and inflammation 4

Critical Pitfalls to Avoid

Do not dismiss pneumaturia as benign post-operative air if: 1, 2

• Symptoms persist beyond 48 hours post-TURBT
• Patient develops fever or systemic symptoms
• Patient has diabetes, neurogenic bladder, or immunosuppression

Do not delay imaging in high-risk patients—emphysematous cystitis can present asymptomatically initially but progress rapidly to life-threatening complications. 5, 2

Do not attempt intravesical chemotherapy instillation if emphysematous cystitis is suspected, as bladder wall integrity is compromised and perforation risk is elevated. 6

Post-TURBT Context Considerations

The recent TURBT creates additional risk because: 6

• Bladder wall disruption from resection provides entry for gas-forming organisms
• Post-operative catheterization may introduce bacteria
• Immediate post-operative chemotherapy instillation should be avoided if perforation is suspected 6

Antimicrobial prophylaxis at time of TURBT does not reliably prevent emphysematous cystitis in high-risk patients (diabetics, immunosuppressed), though routine prophylaxis for TURBT remains controversial. 6