What is the diagnosis and treatment for pyocystitis, a complication of a urinary tract infection?

Pyocystitis: Diagnosis and Treatment

Pyocystitis is a purulent bladder infection occurring in a non-functioning or anuric bladder, requiring bladder drainage via catheterization combined with prolonged antimicrobial therapy and intermittent saline irrigation. 1

Clinical Recognition and Diagnosis

Pyocystitis represents a distinct clinical entity that is frequently misdiagnosed, particularly in patients on chronic dialysis with anuric bladders. 1

Key Diagnostic Features:

• Patient population: Most commonly occurs in patients on chronic hemodialysis who are anuric with non-functioning bladders 1
• Clinical presentation: May mimic other intra-abdominal pathology (such as diverticulitis), making diagnosis challenging 1
• Imaging: CT scan of the abdomen/pelvis is crucial for establishing the diagnosis when clinical suspicion exists 1
• Confirmation: Bladder catheterization confirms the diagnosis by demonstrating purulent material 1

Diagnostic Pitfall:

The primary challenge is that pyocystitis is often initially misdiagnosed as other abdominal conditions because clinicians may not consider bladder infection in anuric patients. 1 Maintain high clinical suspicion in any dialysis patient with anuric bladder presenting with lower abdominal or pelvic symptoms.

Treatment Approach

Immediate Management:

1. Bladder drainage: Insert urinary catheter for continuous drainage 1
2. Obtain urine culture: Always perform culture and antimicrobial susceptibility testing, as this represents a complicated UTI due to the anatomical abnormality 2
3. Empirical antimicrobial therapy: Initiate broad-spectrum antibiotics pending culture results 1

Antimicrobial Selection:

For hospitalized patients requiring parenteral therapy, use regimens appropriate for complicated UTI: 3

• Fluoroquinolones: Ciprofloxacin 400 mg IV twice daily or Levofloxacin 750 mg IV daily 3
• Extended-spectrum cephalosporins: Ceftriaxone 1-2 g IV daily or Cefepime 1-2 g IV twice daily 3
• Beta-lactam/beta-lactamase inhibitor combinations: Piperacillin/tazobactam 2.5-4.5 g IV three times daily 3
• Aminoglycosides: Gentamicin 5 mg/kg IV daily or Amikacin 15 mg/kg IV daily (with or without ampicillin) 3

Duration: Prolonged antibiotic course is required (typically 14 days or longer based on clinical response), as this is a complicated UTI with tissue involvement. 1, 4

Adjunctive Therapy:

• Intermittent saline bladder irrigation: Following initial treatment, perform regular saline washing of the bladder to prevent recurrence 1
• Maintain catheter drainage: Continue until infection resolves and consider long-term management strategy for the non-functioning bladder 1

Classification as Complicated UTI

Pyocystitis must be managed as a complicated UTI because: 2

• The non-functioning bladder represents a significant anatomical abnormality 2
• Urine stasis in anuric bladders creates ideal conditions for bacterial proliferation 1
• Standard short-course therapy appropriate for uncomplicated cystitis is inadequate 3, 4

Key Management Principles:

Tailor antimicrobial therapy based on culture results and local resistance patterns, as empirical regimens should be adjusted once susceptibility data are available. 3 Carbapenems and novel broad-spectrum agents should be reserved for multidrug-resistant organisms identified on culture. 3