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

Epidemiology

  • 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

Diagnosis

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

Etiology

  • 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

Management

  • 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.

Prognosis

  • 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.

Small cell bladder cancer and hematuria- 10/17/18

Thanks to Naina for presenting the case of an elderly man presenting with acute onset of n/v, and abdominal pain, found to have anemia and AKI, with work up revealing small cell cancer of the bladder causing ureteral obstruction with mets to the lymph nodes, liver, lung, and bone, hospitalization complicated by TLS prior to onset of chemo and contrast induced nephropathy.


Clinical Pearls

  • Bladder cancer is the most common malignancy of the urinary system and urothelial (transitional cell) carcinoma is the culprit >90% of the time.  Less common subtypes include squamous, adeno, small cell (our patient), and sarcoma.
  • Unexplained hematuria in anyone >40 years is bladder cancer until proven otherwise!
  • CT urography is the diagnostic imaging of choice in the work up of hematuria.
  • Diagnosis of bladder cancer is often delayed due to similarity of symptoms with other benign disorders.  However, majority of cases are still caught in stage 0-1 (muscle non-invasive disease) with overall good prognosis.

Bladder cancers:

  • Epidemiology
    • Most common malignancy of the urinary system, 3-4 x more common in men but women are usually diagnosed with more advanced disease and have a higher mortality rate.
    • Median age at diagnosis is ~70
    • Incidence has increased by more than 50% during the past 20-30 years.
  • Types:
    • Urothelial (transitional cell) carcinoma is the predominant histologic subtype in the US and Europe (>90% of all bladder cancers) and can arise in renal pelvis, ureter, or urethra
    • Other: squamous, adeno, small cell, sarcoma
  • Degree of invasion:
    • Superficial (non-muscle-invasive)
    • Muscle-invasive
    • Metastatic
  • Clinical presentation
    • Painless hematuria
    • Irritative voiding symptoms (frequency, urgency, dysuria) – only in 30% of patients
    • Sometimes metastases cause the initial symptoms that lead to diagnosis (as in our patient)
    • Most cancers eventually become symptomatic
  • Diagnosis: often delayed due to similarity of symptoms to other benign d/o
    • Urine cytology >98% specific, 12-64% sensitive based on grade of tumor
    • Imaging
      • CT favored over IVP
    • TURBT done for diagnosis and staging
    • DDx
      • Hematuria from enlarged prostate
      • Pregnancy
      • Cystitis
      • Prostatitis
      • Passage of renal calculi

Staging bladder cancer

Source: Nature Outlook.

 

  • Management
    • Over 50% of people diagnosed with non-invasive disease develop recurrence
    • Assess performance status with Karnofsky or Eastern Cooperative Oncology Group scales for older patients before deciding on chemotherapy
    • Chemo regimens are often cisplatin-based which carry the side effects of nephrotoxicity, ototoxicity, and neuropathy

treatmetn of bladder cancer

Source: Nature Outlook

Hematuria

Refer to this thorough algorithm on UpToDate.

  • Incidence of malignancy in microscopic hematuria is ~2-5%
  • Incidence of malignancy in macroscopic hematuria is ~20%

Extra pearls on onset of hematuria during voiding:

  • Occurs at the beginning? Urethral source
  • Discharge noted between voidings or stain on undergarment? Urethral meatus or anterior urethra
  • Terminal hematuria? Bladder neck or prostatic urethra
  • Throughout voiding? Anywhere in the GU tract