Treatment of Emphysematous Cystitis
Emphysematous cystitis requires immediate hospitalization with broad-spectrum intravenous antibiotics, urinary bladder drainage via Foley catheter, and strict glycemic control in diabetic patients for 7-14 days. 1
Initial Management
Hospitalization and IV Antibiotic Therapy
- Hospitalize all patients and initiate IV antibiotics immediately targeting Escherichia coli and Klebsiella species, the most common causative organisms 1
- For stable patients without severe sepsis, start with an IV fluoroquinolone as empiric therapy 1
- For severe presentations or suspected sepsis, use combination therapy with one of the following regimens 1:
- Extended-spectrum cephalosporin (third-generation) with or without an aminoglycoside
- Aminoglycoside with or without ampicillin
- Carbapenem monotherapy
- Avoid oral monotherapy in all cases and do not use ampicillin or amoxicillin empirically due to high worldwide resistance rates 1
Bladder Drainage
- Insert a Foley catheter immediately for continuous bladder drainage, which is essential alongside antibiotic therapy 1, 2, 3
- Adequate urinary drainage prevents complications such as bladder rupture and necrosis 4
Diagnostic Testing
- Obtain urine culture and susceptibility testing in all cases before starting antibiotics to guide definitive therapy 1
- Tailor antibiotic selection based on culture results and local resistance patterns 1
Treatment Duration and Monitoring
- Continue antibiotics for 7-14 days, adjusting duration based on clinical response 1
- Longer treatment courses may be necessary for complicated cases or those with delayed clinical improvement 1
- Serial imaging (CT scan or plain radiography) can document resolution of gas within the bladder wall 3
Special Considerations
Glycemic Control
- Achieve strict blood glucose control in diabetic patients, as diabetes mellitus is the most common predisposing factor 1, 5, 3
- Poor glycemic control significantly increases morbidity and mortality 5
Risk of Progression
- Monitor closely for progression to emphysematous pyelonephritis, which carries higher mortality 1
- Watch for signs of sepsis, bladder perforation, or necrosis requiring surgical intervention 4, 6
Common Pitfalls to Avoid
- Do not delay treatment even in asymptomatic or incidentally discovered cases, as this lethal disease can rapidly deteriorate 2
- Do not underestimate severity in patients without traditional risk factors (elderly, diabetic, immunosuppressed), as emphysematous cystitis can occur in otherwise healthy individuals 4
- Do not use inadequate antibiotic coverage—this infection requires broad-spectrum IV therapy, not oral agents 1
- Ensure adequate bladder drainage is maintained throughout treatment, as antibiotics alone are insufficient 1, 2