Emphysematous cystitis
Updates to Article Attributes
Emphysematous cystitis (EC(EC) refers to a gas-forming infection of the bladder wall.
Epidemiology
The condition is rare and usually confined to certain patient subgroups. Median age affected is 66 years. More common in women, 2:1 F:M 9.
Risk factors
Risk factors include:
-
diabetes mellitus
- considered the commonest predisposing factor 6
- may be present in ~50% of cases 2
female sex: reported M:F ratio 1:2- immunocompromised state
- neurogenic bladder
- transplant recipients
- bladder outlet obstruction 9
- prolonged catheterisation 9
Clinical presentation
Symptoms and signs are similar to those of non-emphysematous cystitis, and maybe very non-specific, e.g. fever, abdominal ache and diarrhoea. More specific urinary symptoms, such as dysuria and haematuriamay be non-specific as they can be with non-emphysematous cystitispresent. A history of pneumaturia may be presentseen but is not common.
Most often the diagnosis is made incidentally during an imaging examination.
Complications
Potential complications include:
- ureteric and renal parenchymal extension
-
bladder rupture with
septicaemiasepsis and peritonitis
Pathology
Emphysematous cystitis may be caused by bacterial or fungal infection. The most common causative organism is E. coli, with other organisms including Enterobacter aerogenes, Klebsiella pneumonia, Proteus mirabilis, Staphylococcus aureus, streptococci, Clostridium perfringens and Candida albicans.
The constituent gases responsible are mainly carbon dioxide, nitrogen, hydrogen and methane 9.
Radiographic features
Plain radiograph
Conventional radiography 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 a gas-fluid level that changes with patient position, and, when adjacent to the non-dependent mucosal surface, may have a cobblestone or “beaded necklace” appearance. This is thought to reflect the irregular thickening produced by submucosal blebs as seen at direct cystoscopy.
CT
CT is a highly sensitive examination that allows early detection of intraluminal or intramural gas. CT is also useful in evaluating other causes of intraluminal gas such as enteric fistula formation from adjacent bowel carcinoma or inflammatory disease.
Ultrasound
Can demonstrate echogenic gas within the bladder wall with dirty shadowing artefact. Ultrasound will also commonly demonstrate diffuse bladder wall thickening and increased echogenicity.
Differential diagnosis
Gas within the bladder wall is virtually always due to emphysematous cystitis. Intraluminal gas within the bladder has a more broad differential.See article: gas in the urinary bladder.
-<p><strong>Emphysematous cystitis (EC)</strong> refers to a gas-forming infection of the bladder wall.</p><h4>Epidemiology</h4><p>The condition is rare and usually confined to certain patient subgroups.</p><h5>Risk factors</h5><p>Risk factors include:</p><ul>- +<p><strong>Emphysematous cystitis </strong>(<strong>EC</strong>) refers to a gas-forming infection of the bladder wall.</p><h4>Epidemiology</h4><p>The condition is rare and usually confined to certain patient subgroups. Median age affected is 66 years. More common in women, 2:1 F:M <sup>9</sup>.</p><h5>Risk factors</h5><p>Risk factors include:</p><ul>
-<li>female sex: reported M:F ratio 1:2</li>-<li>transplant recipients </li>-</ul><h4>Clinical presentation</h4><p>Symptoms and signs may be non-specific as they can be with non-emphysematous cystitis. A history of pneumaturia may be present. Most often the diagnosis is made incidentally during imaging examination.</p><h5>Complications</h5><p>Potential complications include:</p><ul>- +<li>transplant recipients</li>
- +<li>bladder outlet obstruction <sup>9</sup>
- +</li>
- +<li>prolonged catheterisation <sup>9</sup>
- +</li>
- +</ul><h4>Clinical presentation</h4><p>Symptoms and signs are similar to those of <a title="Cystitis" href="/articles/cystitis">non-emphysematous cystitis</a>, and maybe very non-specific, e.g. <a title="Fever" href="/articles/pyrexia">fever</a>, <a title="Acute abdominal pain" href="/articles/acute-abdominal-pain">abdominal ache</a> and diarrhoea. More specific urinary symptoms, such as <a title="dysuria" href="/articles/dysuria">dysuria</a> and <a title="Haematuria (adult)" href="/articles/haematuria-adult">haematuria</a> may be present. A history of <a title="pneumaturia" href="/articles/pneumaturia">pneumaturia</a> may be seen but is not common.</p><p>Most often the diagnosis is made incidentally during an imaging examination.</p><h5>Complications</h5><p>Potential complications include:</p><ul>
-<li>bladder rupture with septicaemia and peritonitis</li>-</ul><h4>Pathology</h4><p>Emphysematous cystitis may be caused by bacterial or fungal infection. The most common causative organism is <em>E. coli</em>, with other organisms including <em>Enterobacter aerogenes</em>, <em>Klebsiella pneumonia</em>, <em>Proteus mirabilis</em>, <em>Staphylococcus aureus</em>, <em>streptococci</em>, <em>Clostridium perfringens</em> and <em>Candida albicans</em>.</p><h4>Radiographic features</h4><h5>Plain radiograph</h5><p>Conventional radiography 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 a gas-fluid level that changes with patient position, and, when adjacent to the non-dependent mucosal surface, may have a cobblestone or “beaded necklace” appearance. This is thought to reflect the irregular thickening produced by submucosal blebs as seen at direct cystoscopy.</p><h5>CT</h5><p>CT is a highly sensitive examination that allows early detection of intraluminal or intramural gas. CT is also useful in evaluating other causes of intraluminal gas such as enteric fistula formation from adjacent bowel carcinoma or inflammatory disease.</p><h5>Ultrasound</h5><p>Can demonstrate echogenic gas within the bladder wall with dirty shadowing artefact. Ultrasound will also commonly demonstrate diffuse bladder wall thickening and increased echogenicity.</p><h4>Differential diagnosis</h4><p>Gas within the bladder wall is virtually always due to emphysematous cystitis. Intraluminal gas within the bladder has a more broad differential. See article: <a href="/articles/gas-in-the-urinary-bladder">gas in the urinary bladder</a>.</p>- +<li>
- +<a title="Urinary bladder rupture" href="/articles/urinary-bladder-rupture">bladder rupture</a> with <a title="Sepsis" href="/articles/sepsis">sepsis</a> and <a title="peritonitis" href="/articles/peritonitis">peritonitis</a>
- +</li>
- +</ul><h4>Pathology</h4><p>Emphysematous cystitis may be caused by bacterial or fungal infection. The most common causative organism is <em>E. coli</em>, with other organisms including <em>Enterobacter aerogenes</em>, <em>Klebsiella pneumonia</em>, <em>Proteus mirabilis</em>, <em>Staphylococcus aureus</em>, <em>streptococci</em>, <em>Clostridium perfringens</em> and <em>Candida albicans</em>.</p><p>The constituent gases responsible are mainly carbon dioxide, <a title="Nitrogen" href="/articles/nitrogen">nitrogen</a>, hydrogen and methane <sup>9</sup>.</p><h4>Radiographic features</h4><h5>Plain radiograph</h5><p>Conventional radiography 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 a gas-fluid level that changes with patient position, and, when adjacent to the non-dependent mucosal surface, may have a cobblestone or “beaded necklace” appearance. This is thought to reflect the irregular thickening produced by submucosal blebs as seen at direct cystoscopy.</p><h5>CT</h5><p>CT is a highly sensitive examination that allows early detection of intraluminal or intramural gas. CT is also useful in evaluating other causes of intraluminal gas such as enteric fistula formation from adjacent bowel carcinoma or inflammatory disease.</p><h5>Ultrasound</h5><p>Can demonstrate echogenic gas within the bladder wall with dirty shadowing artefact. Ultrasound will also commonly demonstrate diffuse bladder wall thickening and increased echogenicity.</p><h4>Differential diagnosis</h4><p>Gas within the bladder wall is virtually always due to emphysematous cystitis. Intraluminal gas within the bladder has a more broad differential.<br>See article: <a href="/articles/gas-in-the-urinary-bladder">gas in the urinary bladder</a>.</p>
References changed:
- 9. Sharma R, Mitra SK, Choudhary A, Majee P. Emphysematous cystitis-gas in bladder: a rare urological emergency. (2015) BMJ case reports. <a href="https://doi.org/10.1136/bcr-2015-210836">doi:10.1136/bcr-2015-210836</a> - <a href="https://www.ncbi.nlm.nih.gov/pubmed/26206783">Pubmed</a> <span class="ref_v4"></span>
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