Emphysematous Cystitis Secondary to Proteus mirabilis 12/18/2018

Becky presented a case of a middle age man with NIDDM2, HTN, and history of phimosis s/p slit procedure 4 years prior, who presents with 3 months of dysuria, hematuria, urgency, frequency, and suprapubic pain. He was seen in the ED 2 months prior and his symptoms initially improved, but they gradually recurred until the pain was unbearable. Pt also started noticing bubbles in his urine, suspicious for pneumaturia. Given the amount of pain he was in, a CT AP was performed, which revealed a diagnosis of emphysematous cystitis!

Emphysematous UTI


  • Rare, a few hundred case reports, one of the largest publication on current experience with this only has a sample size of 48.
  • Prior to 2006, 135 cases reported in the English literature

Risk Factors

  • Diabetes (main risk factor, median A1c > 9.9)
  • Elderly (Age > 60-70), women (2-6:1)
  • Immunocompromised
  • Neurogenic bladder
  • Obstructive uropathy (2nd most common risk factor)
  • Recurrent UTI


Presentation of Emphysematous Cystitis

  • Highly non-specific, presents similar to uncomplicated cystitis (dysuria, hematuria, abdominal pain, urgency/frequency. Pneumaturia, however, is unique to emphysematous cystitis.
  • Can progress rapidly, fatal if not recognized early on


  • Abd/Pelvic imaging showing presence of gas in the bladder wall and/or lumen. CT has higher sensitivity.


  • Infection
    • 2/3 cases = E.coli
    • ¼ Klebsiella
    • Rare = others, i.e. candida, clostridium, enterococci, staphylococcus, proteus
  • Vaginal fistula
  • Colovesical fistula (fecaluria might be seen)
  • Crohn’s disease
  • Malignancy of the colon or cancer
  • Instrumentation, obstruction, or trauma


  • Early recognition and initiation of IV antibiotics, at least 10-14 days
  • Catheter drainage, bladder rest
  • Surgical debridement or cystectomy may be required for patients with poor response
  • 10% of patients required combined medical and surgical therapy.


  • Mortality up to 7-10% especially if not recognized early.
  • Early medical therapy decreases need for surgical intervention.


Presentation of Emphysematous Pyelonephritis

    • Critically ill, similar to complicated and severe pyelonephritis.
    • May be abrupt or develop over 2-3 weeks
    • 54% have concurrent bacteremia
  • Diagnosis/Prognosis: Based on CT scan findings
    • Class 1: Gas in the collecting system only
    • Class 2: Gas in the renal parenchyma without extension to the extrarenal space
    • Class 3A: Extension of gas or abscess to the perinephric space (between renal capsule and renal fascia)
    • Class 3B: Extension of gas or abscess to the pararenal space (between renal fascia and adjacent tissues)
    • Class 4: Bilateral involvement or one functional kidney with emphysematous pyelo
  • Management
    • IV antibiotics
    • Percutaneous Catheter drainage, bladder rest
    • Surgical debridement, nephrectomy
  • Prognosis
    • Mortality up to 25%, mainly in class 3 & 4 where incidence of thrombocytopenia, acute renal failure, encephalopathy, and septic shock.

This rare condition has been featured on NEJM Images in Clinical Medicine

Check out this article for more information on this condition.

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