Figure 1
Radiography
Plain film of the abdomen shows a curvilinear area of radiolucency delineating the bladder wall.
Emphysematous cystitis
SectionUroradiology & genital male imaging
Case TypeClinical Cases
AuthorsGagliano M, Marangoni L, Sartoni M, Bighi S.
Connected authors
74 years, male
Clinical History
We describe the case of a patient presented with abdominal pain and haematuria.
Imaging examinations indicated the diagnosis of emphysematous cystitis.
Imaging examinations indicated the diagnosis of emphysematous cystitis.
Imaging Findings
A 74 year-old man was admitted to our hospital with the chief complaint of abdominal pain. The abdomen was distended and aching during palpation, with tympanic percussion sounds.
Laboratory evaluation on admission showed inflammation with increased white blood cell count (26000 mm3), creatinine of 10 mg/dl, and glicemia of 140 mg/dl. Urine analysis showed hematuria containing pus.
Abdominal radiography was performed and it showed a curvilinear area of radiolucency delineating the bladder wall with intraluminal gas as an air-fluid level and associated enterocolic distention with air-fluid levels.
Then patient underwent CT scan with cistography in supine and lateral position (prone position was not possible). We chose this diagnostic method because patient presented with kidney failure and also because the administration of contrast medium through retrograde filling of the bladder has allowed to obtain an increased intraluminal pressure to exclude more accurately any spreading of contrast medium.
CT demonstrated bladder wall thickening, gas vescicles of varying size in wall and gas accumulation within the lumen with air-fluid level. No contrast medium spreading and no fistulas were demonstrated. These findings suggested emphysematous cystitis.
After antibiotic therapy, a follow up plain film of the abdomen showed no evidence of residual curvilinear areas of radiolucency in the region of the urinary bladder.
Laboratory evaluation on admission showed inflammation with increased white blood cell count (26000 mm3), creatinine of 10 mg/dl, and glicemia of 140 mg/dl. Urine analysis showed hematuria containing pus.
Abdominal radiography was performed and it showed a curvilinear area of radiolucency delineating the bladder wall with intraluminal gas as an air-fluid level and associated enterocolic distention with air-fluid levels.
Then patient underwent CT scan with cistography in supine and lateral position (prone position was not possible). We chose this diagnostic method because patient presented with kidney failure and also because the administration of contrast medium through retrograde filling of the bladder has allowed to obtain an increased intraluminal pressure to exclude more accurately any spreading of contrast medium.
CT demonstrated bladder wall thickening, gas vescicles of varying size in wall and gas accumulation within the lumen with air-fluid level. No contrast medium spreading and no fistulas were demonstrated. These findings suggested emphysematous cystitis.
After antibiotic therapy, a follow up plain film of the abdomen showed no evidence of residual curvilinear areas of radiolucency in the region of the urinary bladder.
Discussion
Air within the urinary tract can occur due to 1) use of instruments in the genitourinary tract, 2) fistula between bladder and bowel, vagina or skin, 3) infections, 4) trauma, 5) gas gangrene of the uterus and vaginitis emphysematosa (may also overlie the pelvis, and further anatomic localization may be required).
Emphysematous cystitis represents a rare form of acute inflammation of the bladder mucosa and underlying musculature. Clinical symptoms of dysuria, increased urinary frequency, and hematuria are common. The patient can also be asymptomatic or present with an acute abdomen. Underlying diabetes mellitus is present in over half of reported cases, with women being affected twice as often as men. Other predisposing conditions include chronic urinary tract infections, urinary stasis secondary to bladder outlet obstruction, and a neurogenic bladder.
Frequently, isolated gas-producing bacteria include the coliform bacteria E. coli and Enterobacter aerogens, although Clostridia and fungal species (Candida albicans) are occasionally identified.
Emphysematous urinary tract infections such as emphysematous cystitis are often rapidly progressive and occasionally fatal. The mortality rate was reported to be 7% in emphysematous cystitis.
Conventional radiography of emphysematous cystitis characteristically shows curvilinear or mottled areas of increased radiolucency in the region of the urinary bladder separate from more posterior rectal gas. Intraluminal gas will be seen as an air-fluid level that changes with patient position, and, when adjacent to the nondependent mucosal surface, may have a cobblestone or “beaded neck-lace” appearance. This finding reflects the irregular thickening produced by submucosal blebs as seen at direct cystoscopy.
US will commonly demonstrate diffuse bladder wall thickening and increased echogenicity. Focal regions of high-amplitude echoes with posterior dirty acoustic shadowing into the lumen may be seen in extensive cases. CT is a highly sensitive examination that allows early detection of intraluminal or intramural gas. It is also useful in evaluating other causes of intraluminal gas such as enteric fistula formation from adjacent bowel carcinoma or inflammatory disease.
CT cystography has been shown to compare favorably with barium enema examination or cystoscopy in identifying a vesicocolic fistula. This procedure is easily performed by filling the urinary bladder to capacity in a retrograde manner via a Foley catheter with diluted water-soluble iodinated contrast material (2–3% weight by volume).
CT can more accurately define the extent and severity of disease. CT detects cases of emphysematous cystitis that are not apparent on plain abdominal films. CT can also differentiate vesicocolic fistula, intra-abdominal abscess, adjacent neoplastic disease or the presence of emphysematous pyelonephritis.
Treatment for emphysematous cystitis generally consists of broad-spectrum antimicrobial therapy, hyperglycemic control, and adequate urine drainage with correction of possible bladder outlet obstruction when present.
Patients not responding to medical management or those with severe necrotizing infections might require partial cystectomy, cystectomy or surgical debridement.
Emphysematous cystitis represents a rare form of acute inflammation of the bladder mucosa and underlying musculature. Clinical symptoms of dysuria, increased urinary frequency, and hematuria are common. The patient can also be asymptomatic or present with an acute abdomen. Underlying diabetes mellitus is present in over half of reported cases, with women being affected twice as often as men. Other predisposing conditions include chronic urinary tract infections, urinary stasis secondary to bladder outlet obstruction, and a neurogenic bladder.
Frequently, isolated gas-producing bacteria include the coliform bacteria E. coli and Enterobacter aerogens, although Clostridia and fungal species (Candida albicans) are occasionally identified.
Emphysematous urinary tract infections such as emphysematous cystitis are often rapidly progressive and occasionally fatal. The mortality rate was reported to be 7% in emphysematous cystitis.
Conventional radiography of emphysematous cystitis characteristically shows curvilinear or mottled areas of increased radiolucency in the region of the urinary bladder separate from more posterior rectal gas. Intraluminal gas will be seen as an air-fluid level that changes with patient position, and, when adjacent to the nondependent mucosal surface, may have a cobblestone or “beaded neck-lace” appearance. This finding reflects the irregular thickening produced by submucosal blebs as seen at direct cystoscopy.
US will commonly demonstrate diffuse bladder wall thickening and increased echogenicity. Focal regions of high-amplitude echoes with posterior dirty acoustic shadowing into the lumen may be seen in extensive cases. CT is a highly sensitive examination that allows early detection of intraluminal or intramural gas. It is also useful in evaluating other causes of intraluminal gas such as enteric fistula formation from adjacent bowel carcinoma or inflammatory disease.
CT cystography has been shown to compare favorably with barium enema examination or cystoscopy in identifying a vesicocolic fistula. This procedure is easily performed by filling the urinary bladder to capacity in a retrograde manner via a Foley catheter with diluted water-soluble iodinated contrast material (2–3% weight by volume).
CT can more accurately define the extent and severity of disease. CT detects cases of emphysematous cystitis that are not apparent on plain abdominal films. CT can also differentiate vesicocolic fistula, intra-abdominal abscess, adjacent neoplastic disease or the presence of emphysematous pyelonephritis.
Treatment for emphysematous cystitis generally consists of broad-spectrum antimicrobial therapy, hyperglycemic control, and adequate urine drainage with correction of possible bladder outlet obstruction when present.
Patients not responding to medical management or those with severe necrotizing infections might require partial cystectomy, cystectomy or surgical debridement.
Differential Diagnosis List
Emphysematous cystitis
Final Diagnosis
Emphysematous cystitis
References
[1] Thomas AA, Lane BR, Thomas AZ, Remer EM, Campbell SC, Shoskes DA. Emphysematous cystitis: a review of 135 cases. BJU Int. 2007 Jul;100(1):17-20. (PMID: 17506870)
[2] Reese AC, Stoller ML. Emphysematous Cystitis. Urology. 2009 Oct 23. (PMID: 19854475)
[3] Grayson DE, Abbott RM, Levy AD, Sherman PM. Emphysematous infections of the abdomen and pelvis: a pictorial review. Radiographics. 2002 May-Jun;22(3):543-61. (PMID: 12006686)
[4] Takeshita T, Shima H, Oishi S, Machida N, Uchiyama K. Emphysematous cystitis. Intern Med. 2004 Aug;43(8):761-2. (PMID: 15468984)
[5] Hung SF, Liu KL, Yu HJ, Huang KH. Emphysematous cystitis. Int J Infect Dis. 2009 Aug 6. (PMID: 19665410)
Case information
| URL: | https://www.eurorad.org/case/8175 |
| DOI: | 10.1594/EURORAD/CASE.8175 |
| ISSN: | 1563-4086 |
Figure 2
Radiography
Lateral view shows curvilinear areas of increased radiolucency in the region of the urinary bladder
Figure 3
CT
CT without contrast medium demonstrates bladder wall thickening with vescicles of varying size and air-fluid level inside bladder.
Figure 4
CT
CT cistography demonstrates air-fluid level, wall thickening and no presence of contast medium in tissues around bladder.
Figure 5
CT
Lateral CT scan confirm air-fluid level and no contrast medium spreading.
Radiography
Plain film of the abdomen shows a curvilinear area of radiolucency delineating the bladder wall.
Radiography
Lateral view shows curvilinear areas of increased radiolucency in the region of the urinary bladder
CT
CT without contrast medium demonstrates bladder wall thickening with vescicles of varying size and air-fluid level inside bladder.
CT
CT cistography demonstrates air-fluid level, wall thickening and no presence of contast medium in tissues around bladder.
CT
Lateral CT scan confirm air-fluid level and no contrast medium spreading.