Pyocystitis: Treatment Approach
Pyocystitis requires immediate bladder drainage via catheterization combined with prolonged antibiotic therapy, followed by intermittent bladder irrigation to prevent recurrence. 1, 2
Understanding Pyocystitis
Pyocystitis (also called empyema cystis or vesical empyema) is a severe lower urinary tract infection characterized by a purulent-filled bladder that develops in patients with defunctionalized bladders. 2 This condition most commonly occurs in:
- Patients with end-stage renal disease and anuria 1, 2
- Patients after supravesical urinary diversion without cystectomy 2
- Patients on chronic dialysis with non-functioning bladders 1
Clinical Presentation and Diagnosis
The diagnosis is often missed initially because symptoms can mimic other intra-abdominal conditions like diverticulitis. 1 Key diagnostic features include:
- Suprapubic pain and malodorous discharge (local symptoms) 2
- Fever and signs of systemic infection 2
- Risk of bacterial dissemination leading to sepsis and mortality 2
- CT scan of the abdomen can suggest the diagnosis 1
- Bladder catheterization confirms the diagnosis by draining purulent material 1
Treatment Protocol
Immediate Management
Bladder drainage via catheterization is the cornerstone of initial treatment. 1 This provides both diagnostic confirmation and therapeutic source control.
Antibiotic Therapy
Prolonged antibiotic therapy is essential, not just a short course. 1 The most frequent causative organism in upper and lower urinary tract infections remains E. coli, though complicated infections may involve other organisms. 3
For empiric therapy in community-acquired infections with gram-negative organisms:
- Trimethoprim/sulfamethoxazole or fluoroquinolone for outpatient therapy (if no nausea) 3
- If the patient is septic, hospitalization with parenteral antibiotics is mandatory 3
- Ceftriaxone or gentamicin once-daily dosing for cost-effective parenteral therapy 3
If gram-positive organisms are suspected (enterococcus):
- Beta-lactam penicillin (piperacillin) or third-generation cephalosporin (ceftriaxone) 3
- Vancomycin if penicillin allergy exists 3
Ongoing Management
Intermittent saline washing of the bladder following initial treatment prevents recurrence. 1 This maintenance strategy is critical in patients with persistent bladder dysfunction.
Special Consideration: Gallstone History
If the patient has a history of gallstones, vigilance for biliary complications is essential, but this does not change pyocystitis management. The gallstone history becomes relevant if the patient develops:
- Persistent severe right upper quadrant pain lasting several hours 4
- Fever with jaundice suggesting cholangitis 4, 5
- Signs requiring emergency care (fever, rigors, jaundice) 4
Early cholecystectomy within 7-10 days is the standard for acute cholecystitis if it develops, but this is a separate issue from pyocystitis treatment. 5, 6
Critical Pitfalls to Avoid
- Do not mistake pyocystitis for diverticulitis or other intra-abdominal infections - this delays appropriate bladder drainage 1
- Do not use short-course antibiotics - prolonged therapy is required for defunctionalized bladders 1
- Do not omit maintenance bladder irrigation - this leads to recurrence 1
- Do not delay hospitalization if septic - bacterial dissemination can be life-threatening 2