Severe emphysematous cystitis: Images in urology

A 78-year-old female with perinuclear anti-neutro-phil cytoplasmic antibodies (p-ANCA) vasculitis on chronic steroids, insulin-dependent diabetes mellitus (HbA1c 6.8), and a history of extended-spectrum beta-lactamase urinary tract infections presented to the emergency room after a ground-level fall. Pelvic computed tomography (CT) scan revealed severe emphysematous cystitis (Fig. 1) with extension into the space of Retzius and through a ventral hernia into subcutaneous fat. She denied dysuria, hematuria, or urinary frequency.

Fig. 1.

Representative CT scan images demonstrated diffuse air within the bladder wall extension into the space of Retzius and subcutaneous fat.

The patient endorsed gradual onset of lower abdominal fullness that has worsened in the days prior to admission. She was initially treated with Foley catheter drainage and meropenem. Urine culture revealed cefuroxime-sensitive Klebsiella pneumonia. She completed a 14-day course of cefuroxime. Repeat CT scan after seven weeks of Foley decompression showed complete resolution (Fig. 2).

Fig. 2.

Repeat CT scan images showing interval resolution of emphysematous cystitis after two weeks of antibiotics and foley catheter drainage.

Emphysematous cystitis is a rare, but severe infection of the bladder characterized by gas formation within the bladder wall. It frequently appears dramatic on imaging, but is usually successfully managed with drainage and appropriate antibiotics.¹ Only 10% of cases require surgery, with an estimated mortality rate of 7%.²