Clinical images - a quarterly column: emphysematous cystitis

Accurate and timely diagnosis coupled with appropriate treatment typically leads to a favorable prognosis. 1, 3 HISTORY An 81-year-old female patient with medical history of stage II non-;small cell lung cancer on chemotherapy, poorly controlled diabetes mellitus (in the setting of recent steroid administration), and chronic UTIs presented to the emergency department (ED) with acute onset of suprapubic pain following several days of episodic dysuria and hematuria. Other predisposing risk factors include being elderly or debilitated, bladder outlet obstruction, chronic UTIs, neurogenic bladder, chronic indwelling bladder catheters, and immune deficiency. 1, 2, 5 The majority of emphysematous cystitis cases (>60%-70%) are caused by E coli, as in our case. 1, 2 Other common bacterial pathogens include Enterobacter species, Klebsiella pneumoniae, Staphylococcus aureus, Proteus mirabilis, Pseudomonas aeruginosa, and Streptococcus species. Conventional radiography and ultrasound may at times be useful in aiding with diagnosis, although CT examination is the preferred imaging technique for establishing the presence of intramural and/or intraluminal gas, thus confirming the diagnosis of emphysematous cystitis. 2 Isolated air within the urinary bladder lumen is not diagnostic on its own, as this finding may be seen in the setting of recent catheterization/instrumentation, surgery, trauma, colovesical fistula, or vesicovaginal fistula. 8 Other key radiographic findings include diffuse urinary bladder wall thickening and possible pericystic inflammatory change that are best appreciated on CT. 7, 8 Clinical presentations of emphysematous cystitis can vary greatly, ranging from patients in severe sepsis to asymptomatic patients who are incidentally diagnosed at the time of unrelated abdominal imaging. 1 Treatment typically includes broad-spectrum antibiotic coverage until the organism and antibiotic sensitivity are established from the urine culture.