Gas Within the Bladder

An 83-year-old woman with a medical history of hypertension, chronic renal failure, and diabetes mellitus came to the emergency department of our clinic after 2 days of fever, asthenia, adynamia, and hypogastric abdominal pain associated with dysuria, polyuria, and bladder tenesmus. Her family reported that she had been increasingly fatigued in the several days before presentation, and she had been experiencing hematuria as well. On physical examination she was in a regular general state, dehydrated, hypotensive, sleepy, and febrile, with tenderness to palpation over her lower hemi-abdomen, predominating in hypogastrium but without signs of peritoneal irritation. Significant laboratory results included hyperglycemia of 578 mg/dL, mild leukocytosis (11,700 cells/mL) with a left-sided deviation, and creatinine level of 3.2 mg/dL, associated with abnormal results on urinalysis (pyuria, hematuria, and bacteriuria) and a urine culture in which Klebsiella pneumoniae extended-spectrum β-lactamase was isolated.

A hyperosmolar state was diagnosed, and aggressive rehydration was started, in addition to empiric antibiotic treatment with ertapenem according to local guidelines. A urethral catheter was placed, and the nurses noted pneumaturia; then suspecting a colo-vesical fistulae, a computed tomography scan of the abdomen was performed, which showed images of gas within the bladder (Figure).

Emphysematous cystitis (EC) is a rare urinary tract infection caused by gas-producing bacteria colonizing the urinary bladder. It is characterized by the presence of air within the urinary bladder wall and/or the presence of intraluminal air within the bladder.1 Typical symptoms are similar to those of uncomplicated urinary tract infections, including dysuria, hematuria, urinary frequency, fever, and possible suprapubic pain. Pneumaturia, although more specific, is a much less common presenting symptom. Some patients might be completely asymptomatic at the time of incidental diagnosis.2 Although the overall incidence of EC is unknown, it has a female predominance of 2:1. Other predisposing risk factors include being elderly or debilitated, bladder outlet obstruction, chronic urinary tract infections, neurogenic bladder, chronic indwelling bladder catheters, and immune deficiency. The management of EC has remained unchanged over the past 30 years, with broad-cover intravenous antibiotics being used until urinary pathogen sensitivities are known. Concurrently the bladder should be drained, and blood glucose levels should be controlled. Between 10% and 20% of documented patients with EC have undergone surgical debridement.3