A 46-year-old man with a medical history of type 2 diabetes mellitus, hypertension, and chronic kidney disease on hemodialysis presented to the emergency department with a history of right flank pain of 2 days' duration and air in urine of 3 weeks' duration. He was seen by a urologist 3 weeks before presentation for urinary retention, and a Foley catheter was placed to relieve obstruction. He had hematuria since that time, and it had gotten worse. He presented to the emergency department complaining of severe right flank pain and lower abdominal pain for the previous 2 days. The pain was constant and nonradiating. He also had dysuria, fever, chills, urgency incontinence of urine, and terminal hematuria. His medications included insulin, atorvastatin, lisinopril, metoprolol, PhosLo, lansoprazole, and epoietin alfa.
On examination, his temperature was 97.8°F, pulse rate was 75/min, and respiratory rate was 20/min. His blood pressure was 153/84 mm Hg. His head, ears, eyes, nose, and throat examination was normal. His neck was supple, and chest was clear. He had right flank and suprapubic tenderness with guarding but no rebound. Bowel sounds were present.
His initial laboratory studies were as follows: white blood cell count, 12.1; hemoglobin level, 12.6; hematocrit level, 37.1; and platelet count, 300,000. His serum chemistry results were the following: sodium, 139; potassium, 3.7; serum urea nitrogen, 57; and creatinine level, 4.7. His serum glucose was 236 and his glycosylated hemoglobin (HBA1C) was 7.4%. Urinalysis showed 3+ proteinuria (500 mg/dL), 1000 mg/dL glucose, white blood cell count of 6 to 10 per high-power field, and red blood cell count of 26 to 50 per high-power field; urine nitrite was negative, but it was loaded with bacteria. We obtained urine specimen for culture.
He had a computed tomography of the abdomen and pelvis that showed air fluid level in the bladder with air within the bladder wall. There was also the possibility of air bubbles outside the bladder lumen (Fig. 1).
The patient was started on intravenous ciprofloxacin and continued on the Foley catheter with gravity drainage. The urine culture grew Escherichia coli greater than 100,000 colony-forming unit. It was resistant to ciprofloxacin but sensitive to cefepime and amoxicillin. Therapy was changed to cefepime. The catheter was discontinued on day 5 because he was feeling better. The patient did not have any more episodes of pneumaturia. His therapy was switched to oral amoxicillin on discharge. On follow-up 2 weeks later, he had recovered completely and had no pneumaturia.
Emphysematous cystitis is thought to be a rare medical condition, although there are several reports in the literature. It is characterized by infection of the lower urinary tract by gas-forming organisms resulting in the formation of pockets of gas in and around the bladder.1,2 The first reports in the literature appeared in the 1800s as autopsy findings in humans and animals, but the first case in a living human was reported in 1932.2
Gas in the genitourinary tract is most often associated with enterovesical fistulas resulting from diverticulosis, Crohn disease, rectosigmoid colonic carcinoma, or recent instrumentation.3 Primary formation of gas within the urinary system is less common and is usually due to instrumentation or infection. There is no distinction between intraluminal gas or intramural gas formation because they are probably different stages of the same disease process with a common etiology.1
Factors known to be associated with emphysematous cystitis include diabetes mellitus, female sex, urinary stasis, immunocompromised state, chronic urinary tract infections, neurogenic bladder, and transplant recipients.1,2,4 Gas-forming aerobic bacteria such as E. coli, Enterobacter aerogenes, Proteus mirabilis, Klebsiella pneumoniae, streptococci, and Staphylococcus aureus are most commonly implicated in the causation of this entity. 1,2 Other organisms include Nocardia, Clostridium, and Candida.5,6 The mechanism of gas formation is thought to be due to bacterial fermentation of glucose or albumin with formation of carbon dioxide.1
The symptoms of emphysematous cystitis are similar to those of uncomplicated cystitis, consisting of frequency, urgency, and dysuria.3 Patients may be asymptomatic or have nonspecific complaints.2 Pneumaturia is an infrequent presentation.1 Therefore, a high index of suspicion is required for diagnosis especially in patients with risk factors.
Diagnosis of emphysematous cystitis is best achieved by radiological means. Plain radiographs of the abdomen reveal radiolucency within the lumen of the bladder as a ring of radiolucency outlining the bladder wall. Computed tomography of the abdomen is superior to plain radiographs as a diagnostic tool because it clarifies the extent and location of the gas collection.7
Emphysematous cystitis has been variously described as a serious condition requiring aggressive treatment to avert undesirable outcomes4 or as a benign disease.7 However, delayed diagnosis may lead to extension to the ureters and renal parenchyma, bladder rupture, and death.4 Management consists of adequate urinary drainage, appropriate antibiotic treatment, and better blood glucose control. The gas is reabsorbed once the infection is eliminated. Surgical debridement or cystectomy may rarely be needed.2
In the patient presented, although his diabetes was fairly well controlled as evidenced by his HBA1C of 7.4%, it was poorly controlled at the time of presentation. He had heavy proteinuria, glycosuria, and obstructive uropathy that put him at risk for emphysematous cystitis.
1. Bailey H. Cystitis emphysematosa: 19 cases with intraluminal and interstitial collections of gas. AJR Am J Roentgenol
2. Quint HJ, Drach GW, Rappaport WD, et al. Emphysematous cystitis: a review of the spectrum of disease. J Urol
3. Ankel F, Wolfson AB, Stapczynski JS. Emphysematous cystitis: a complication of urinary tract infection occurring predominantly in diabetic women. Ann Emerg Med
4. Bobba RK, Arsura EL, Sarna PS, et al. Emphysematous cystitis: an unusual disease of the genitor-urinary system suspected on imaging. Ann Clin Microbiol Antimicrob
5. West TE, Holley HP, Lauer AD. Emphysematous cystitis due to Clostridium perfringens
6. Bartkowski DP, Lanesky JR. Emphysematous prostatitis and cystitis secondary to Candida albicans
. J Urol
7. Weddle J, Brunton B, Rittenhouse DR. An unusual presentation of emphysematous cystitis. Am J Emerg Med