Emphysematous cystitis in a non-diabetic elderly woman with severe cardiac comorbidities: A case report

Abstract

Emphysematous cystitis (EC) is a rare gas-forming bladder infection that can also affect non-diabetic elderly patients. We report a 93-year-old woman with severe cardiac comorbidities who presented with abdominal pain, elevated inflammatory markers, and acute kidney injury. CT imaging revealed intraluminal and intramural gas with bilateral hydronephrosis. Urine cultures grew E. coli and E. faecalis, prompting targeted antibiotics and bladder drainage. Despite appropriate management, her condition worsened and she died from cardiac complications. This case highlights the need for early recognition, careful clinical assessment, and comorbidity-driven treatment strategies.

Introduction

Emphysematous cystitis (EC) is a rare, gas-forming infection of the bladder characterized by the presence of gas within the bladder wall and/or lumen, most commonly caused by organisms such as Escherichia coli and Klebsiella pneumoniae. It is traditionally associated with risk factors such as diabetes mellitus (DM), urinary stasis, neurogenic bladder, immunosuppression, and older age. However, EC in non-diabetic patients remains uncommon [1,2].

Computed tomography (CT) is the imaging modality of choice, not only to confirm the presence and distribution of intraluminal or intramural gas but also to exclude fistulisation or other coexisting pathology [3].

We report the case of a 93-year-old non-diabetic woman with multiple comorbidities, including severe aortic valve stenosis and heart failure, who presented with abdominal pain and was diagnosed with emphysematous cystitis. This case highlights the importance of considering this diagnosis in non-diabetic elderly patients and the challenges in managing such infections in the context of complex medical conditions and limited therapeutic options.

Case presentation

A 93-year-old woman was admitted to the geriatrics department with complaints of abdominal pain. The patient denied nausea or vomiting and reported no fever at admission. Physical examination revealed pain on abdominal palpation without signs of an acute abdomen. Bowel sounds were preserved.

Her past medical history was significant for cholecystectomy, reflux esophagitis, recurrent iron-deficiency anaemia requiring multiple transfusions and intravenous iron supplementation, and a history of multiple unremarkable gastro- and colonoscopies. She also had COPD, heart failure, and a very severe aortic valve stenosis, for which no further intervention (eg, TAVI) was pursued due to age and comorbidities. Her code status was DNR-2. Additionally, she had right-sided internal carotid artery stenosis. Notably, the patient did not have diabetes mellitus, which is a common predisposing factor for emphysematous cystitis. She was no longer on antiplatelet or anticoagulant therapy. There were no known drug allergies.

Her home medications included antihypertensive agents, but no anticoagulants.

The initial laboratory workup performed in the emergency department demonstrated a markedly elevated C-reactive protein of 181 mg/L (reference range: <5 mg/L). The white blood cell count was elevated at 15.39 × 10⁹/L (reference range: 4.0-11.0 × 10⁹/L) with a predominance of neutrophils, consistent with neutrophilia. Serum creatinine was raised at 1.55 mg/dL (reference range: 0.6-1.1 mg/dL for females), suggesting acute kidney injury. Serum electrolytes were within normal limits. Haemoglobin was measured at 11.4 g/dL (reference range: 12.0-16.0 g/dL for females). Ferritin was significantly elevated at 782 ng/mL (reference range: 20-200 ng/mL for females).

An abdominal ultrasound showed hydronephrosis of the right kidney (HUN) (Fig. 1).

Fig. 1.

Abdominal ultrasound of the right kidney showing hydronephrosis.

A CT scan of the abdomen and pelvis revealed intraluminal and intramural gas within the urinary bladder wall, suggestive of emphysematous cystitis, along with bilateral hydronephrosis and a distended bladder. Importantly, there was no evidence of fistulisation or abnormal communication between the bladder and adjacent gastrointestinal structures (Figs. 2 and 3).

Fig. 2.

Axial CT image of the pelvis showing intraluminal and intramural gas within the bladder wall (white arrow), consistent with emphysematous cystitis. The bladder is distended, and no signs of free intraperitoneal air are noted.

Fig. 3.

Coronal CT reconstruction demonstrating the distended urinary bladder with gas in the bladder wall (white arrow). Importantly, there is no evidence of fistulization between the bladder and adjacent bowel or other structures.

A consultation with urology was requested. A 16-French transurethral catheter was inserted, draining a large volume of haematuric urine containing purulent material, consistent with significant pyuria. Empiric broad-spectrum intravenous antibiotics were initiated.

Urine cultures returned positive for significant bacteriuria, with growth of Escherichia coli at >100,000 CFU/mL. The E. coli isolate was susceptible to cefuroxime, levofloxacin, ciprofloxacin, nitrofurantoin, and fosfomycin, showed intermediate susceptibility to co-trimoxazole, and was resistant to amoxicillin and amoxicillin–clavulanic acid. In addition, Enterococcus faecalis was isolated at >100,000 CFU/mL, and this organism was susceptible to amoxicillin, ciprofloxacin, and nitrofurantoin. Based on culture sensitivities, ciprofloxacin was selected for targeted antimicrobial therapy.

During hospitalization, the patient experienced progressive worsening of her acute kidney injury, likely of prerenal origin due to reduced oral intake. The transurethral catheter remained patent with continuous drainage, and the urine gradually became less hematuric. Ultrasound examination showed no clots within the bladder. Despite targeted antibiotic therapy and adequate urinary drainage, inflammatory markers increased further, indicating ongoing infection or systemic inflammatory response. The patient remained clinically frail and expressed a clear wish not to pursue further invasive or life-prolonging interventions. In agreement with the patient and her family, palliative care was initiated. She ultimately died during hospitalization due to cardiac complications related to her advanced valvular heart disease and heart failure.

Discussion

The case reported here is notable because the patient was non-diabetic, had multiple comorbidities, and despite appropriate diagnosis and treatment, died due to cardiac complications. Further escalation of treatment was withheld in accordance with a documented DNR-2 order. This case underscores several important clinical and prognostic points.

In a retrospective analysis of 136 cases of emphysematous cystitis, it was demonstrated that EC is a rare condition that predominantly affects elderly patients with diabetes mellitus. The mean age of patients was 67.9 years, with diabetes present in 63.2% of cases. Females were overrepresented, accounting for approximately 61% of patients. The most commonly isolated pathogens were Escherichia coli (54.4%) and Klebsiella pneumoniae (11.8%), which has important implications for empirical antibiotic treatment. Despite its potentially serious presentation, the overall mortality was relatively low at 7.4%, and only 8.1% of patients required surgical intervention. These findings emphasize the importance of early recognition and imaging in at-risk patients to enable prompt conservative management, with antibiotic therapy and bladder drainage [4].

While diabetes is a well-recognized risk factor for EC, studies show that EC can occur in non-diabetic, immunocompetent patients, particularly in the elderly. For instance, in a review of literature, of 53 cases of EC described in immunocompetent hosts, around 22.6% had neither diabetes nor immunosuppressive comorbidities. The case described here aligns with those findings: the patient was elderly, female, non-diabetic, with cardiovascular disease but no known immunosuppression nor other classic risk factors such as neurogenic bladder or obstructive uropathy [5].

EC often presents with vague signs and symptoms: lower abdominal pain, haematuria, dysuria, sometimes pneumaturia, and in more severe cases, sepsis. In non-diabetic elderly patients, symptoms may be masked or attributed to other comorbidities, potentially delaying diagnosis. In this case, the patient presented with abdominal pain and haematuria (via catheter drainage), but no acute abdomen, no vomiting or nausea, and preserved bowel function, which may have delayed suspicion [4,5].

CT imaging is the gold standard for diagnosis of EC: it identifies intraluminal and intramural gas, defines the extent, rules out fistulas or communication with the GI tract, and can detect complications such as hydronephrosis or extension to the upper tracts [5]. In this patient’s CT scan, there was gas in the bladder wall and lumen, bilateral hydronephrosis (likely secondary to urinary retention), bladder distention, but no evidence of fistulization, which is important in excluding secondary causes of gas (eg, enterovesical fistula). The absence of fistula likely lowered the complexity of surgical decision-making, though her age and comorbid status still limited treatment options.

Although CT is the gold standard for diagnosing emphysematous cystitis, plain abdominal radiography and ultrasonography can provide important initial diagnostic information. Radiographs may reveal characteristic gas lucencies outlining the bladder wall or within the bladder lumen, and when interpreted in the context of clinical suspicion, up to 80% of cases can be detected. Ultrasound may also show suggestive findings, such as bladder wall thickening. The widespread availability and lower cost of these modalities make them practical first-line imaging tools in many clinical settings. Nevertheless, in high-risk patients, particularly those with predisposing factors such as diabetes mellitus, any suspicious findings on radiography or ultrasound should prompt confirmatory evaluation with CT, which provides superior sensitivity and precise delineation of disease extent [6,7].

Management of emphysematous cystitis primarily involves prompt bladder drainage through catheterization and the administration of appropriate antibiotics based on urine culture and sensitivity. Empiric broad-spectrum antibiotics are often initiated, then tailored once pathogen sensitivities are known [8]. In some cases, surgical intervention may be necessary, especially if there is bladder necrosis or abscess formation, but most patients respond well to conservative management [9]. Additionally, addressing underlying risk factors such as urinary obstruction or immunosuppression is crucial for recovery. In elderly or frail patients with multiple comorbidities, treatment must be individualized, balancing the risks and benefits of aggressive therapy.

Although emphysematous cystitis generally has a favourable prognosis with appropriate management, mortality rates can increase in patients with advanced age, severe comorbidities, or delayed diagnosis. Studies report overall mortality rates ranging from 7% to 20%, with poorer outcomes linked to sepsis and multiorgan failure. Early recognition and treatment are associated with improved survival, but in patients with significant cardiovascular or renal disease, the systemic stress of infection may precipitate fatal complications. Hence, a multidisciplinary approach involving urologists, radiologists, infectious disease specialists, and intensivists is often necessary for optimal patient care [10].

Conclusion

Emphysematous cystitis can occur in non-diabetic elderly patients and should be considered in the differential diagnosis when urinary symptoms or haematuria are present, especially if imaging reveals gas in the bladder wall. Early CT imaging is crucial for accurate diagnosis, evaluation of disease extent, and exclusion of complications such as fistulisation. Prompt bladder drainage and targeted antibiotic therapy are essential for management, but the overall prognosis largely depends on the patient’s comorbid conditions. In frail patients with severe comorbidities, including cardiovascular disease, treatment decisions may also involve palliative considerations. Further research is needed to better understand outcomes in non-diabetic EC patients and to optimize management strategies in this vulnerable population.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Patient consent

Informed consent for publication of this case report and any accompanying images was obtained from the patient or the patient’s legally authorized representative.