A 2014 review discusses the treatment of emphysematous cystitis. Most cases are generally initiated with an initial IV antibiotic, tailored accordingly to the results of the culture. The duration of treatment is not specified, but usually continues until clinical improvement is observed. From there, treatment can continue or patients may switch to oral therapy. There is no discussion regarding repeat imaging beyond the diagnostic period. [1]
According to a 2007 review of 135 cases, the treatment course with antibiotics generally depends on the sensitivity of the urinary pathogen. While not directly stated, the author’s discussion suggests that antibiotics should continue until patients show improvement and response. Imaging, with plain films or computed tomography, are the standard means for diagnosis. But the benefits of repeat imaging to confirm treatment is not discussed. While conservative management is advocated for limiting cases, it remains poorly defined, suggesting an individualized approach per patient. [2]
Several case reports (See Tables 1-4) described experience in treating emphysematous cystitis, although with limited information specific to length of treatment. A 2023 case report detailed the successful conservative management of emphysematous cystitis with pneumoperitoneum in a 90-year-old woman. The patient, initially hospitalized for a hemorrhagic gastric ulcer, developed acute lower abdominal pain and hematuria six days into admission. Contrast-enhanced CT imaging revealed gas within the bladder wall, diagnostic of emphysematous cystitis, alongside pneumoperitoneum. Despite the presence of free air in the abdomen, no definitive signs of bladder or gastrointestinal perforation were evident on imaging. Given the patient's advanced age and frailty, conservative management was prioritized over surgical exploration. A urethral catheter was placed, and empirical intravenous meropenem was initiated for approximately 6 days, later de-escalated to ceftriaxone for an additional two weeks upon identification of Klebsiella pneumoniae in the urine culture. The patient demonstrated clinical improvement, and repeat imaging on day 18 confirmed the resolution of emphysematous changes and pneumoperitoneum, leading to hospital discharge on day 40. The findings suggest that patients can be managed through conservative treatment. [3]
Additionally, a 2013 case report detailed the successful management of a rare emphysematous cyst infection in a 62-year-old female patient with a 15-year history of autosomal dominant polycystic kidney disease (ADPKD). The patient presented with intermittent fever, nausea, and left flank discomfort, and imaging via CT, which demonstrated an 8.1 cm gas-forming, infected renal cyst in the left kidney. Escherichia coli was identified as the causative organism through cyst fluid culture. Despite initial management with intravenous ciprofloxacin for one week at an outside facility, the patient showed no significant improvement in symptoms or clinical parameters, prompting her referral for further intervention. Laboratory findings on presentation included elevated white blood cell counts (12,850/mcL) and C-reactive protein (6.79 mg/dL), alongside notable abnormalities in urinalysis. The treatment involved a combination of intravenous ciprofloxacin at 400 mg daily and percutaneous cystostomy drainage with intracystic ciprofloxacin irrigation. The intracystic therapy consisted of 100 mg of ciprofloxacin diluted in 450 mL of normal saline, delivered over six days. This novel approach led to significant clinical improvement, with resolution of generalized weakness, nausea, and flank discomfort, accompanied by normalization of inflammatory markers. Follow-up CT imaging revealed a reduction in the size of the infected cyst from 8.1 cm to 4.7 cm with decreased internal air attenuation. The patient was discharged on oral ciprofloxacin for six additional weeks, and no surgical intervention, such as nephrectomy, was required. This report highlights the potential efficacy of combining systemic and localized antibiotic therapies for treating emphysematous cyst infections in ADPKD patients, particularly those contraindicated for surgery. [4]
A 2009 case report detailed an 89-year-old woman diagnosed with emphysematous cystitis despite lacking typical predisposing factors such as diabetes or immunosuppression. The patient presented following a mechanical fall but exhibited mild abdominal discomfort and suprapubic tenderness. Laboratory findings revealed leukocytosis with a white blood cell count of 19.5 × 10⁹/L, pyuria, and bacteriuria, but urine cultures taken post-antibiotic initiation were negative. Imaging studies, including a plain abdominal X-ray and computed tomography (CT), identified gas within the bladder wall, confirming the diagnosis. Initial intravenous (IV) ciprofloxacin therapy was discontinued due to delirium, and the patient was switched to aztreonam, completing a 7-day course. She demonstrated clinical improvement, marked by resolution of symptoms and a subsequent decrease in leukocytosis. A follow-up abdominal X-ray one-month post-discharge confirmed the resolution of emphysematous cystitis. A literature review in the same publication analyzed 15 previously reported cases of emphysematous cystitis in immunocompetent, nondiabetic patients from 1970 to 2009, identifying advanced age as a common characteristic. The majority of cases involved females, with abdominal pain being the most frequently reported symptom. Escherichia coli was the predominant pathogen, isolated in 70% of cases where culture data was available. Imaging studies were crucial for diagnosis, as clinical manifestations varied, and only half of the reported cases exhibited classic urinary symptoms. Treatment primarily involved antimicrobial therapy (e.g., gentamicin and piperacillin/tazobactam then cefuroxime; liposomal amphotericin B and 5-flucytosin; piperacillin then ceftazidime; cefotiam; cefazolin, gentamicin, and metronidazole then oral ofloxacin and metronidazole) often in conjunction with bladder catheterization, with a standard duration of 7–10 days. Although the prognosis was generally favorable, one patient succumbed to the infection. The findings underscored the necessity for heightened clinical suspicion and prompt imaging in elderly patients presenting with atypical urinary symptoms, even in the absence of traditional risk factors. [5]
Finally, another 2024 case report details the presentation and management of a 70-year-old woman diagnosed with severe emphysematous cystitis. The patient, with a history of diabetes and active chemotherapy for breast cancer, exhibited profound asthenia and pain in the right lower extremity without fever or urinary symptoms. Cross-sectional imaging through CT identified extensive gas accumulation within the bladder wall, confirming the presence of emphysematous cystitis. Given the patient’s immunocompromised status, an empiric antimicrobial regimen was initiated alongside bladder catheterization, aiming to resolve the infection while preventing complications. Serial imaging demonstrated a marked reduction in intramural gas, suggesting clinical improvement with conservative treatment. A therapeutic course of IV piperacillin-tazobactam was administered via bladder catheterization for 7 days, yielding a favorable response characterized by symptom resolution and radiologic improvement. Microbiological assessment identified Escherichia coli and Klebsiella species as the causative pathogens, consistent with prior epidemiologic findings in emphysematous cystitis. The report underscores the utility of early CT imaging in non-specific presentations and reinforces that prompt administration of antimicrobial therapy, coupled with supportive measures such as bladder decompression, remains effective in immunosuppressed populations. [6]