Acute urinary retension as a manifestation of emphysematous cystitis Yueh-Feng Wu, Chung-Cheng Kao, Yi-Wei Tsuei, Jiunn-Bin Hung PII: DOI: Reference:
S0735-6757(14)00697-4 doi: 10.1016/j.ajem.2014.09.042 YAJEM 54540
To appear in:
American Journal of Emergency Medicine
Received date: Accepted date:
15 September 2014 21 September 2014
Please cite this article as: Wu Yueh-Feng, Kao Chung-Cheng, Tsuei Yi-Wei, Hung JiunnBin, Acute urinary retension as a manifestation of emphysematous cystitis, American Journal of Emergency Medicine (2014), doi: 10.1016/j.ajem.2014.09.042
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Acute urinary retension as a manifestation of emphysematous cystitis
RI P
T
Yueh-Feng Wu, Chung-Cheng Kao*, Yi-Wei Tsuei, Jiunn-Bin Hung
SC
Department of Emergency Medicine, Taoyuan Armed Forces General Hospital
MA NU
Taoyuan, Taiwan
* Corresponding author: Chung-Cheng Kao
Address: Department of Emergency Medicine, Taoyuan Armed Forces General
ED
Hospital, No.168, Zhongxing Rd., Longtan Township, Taoyuan County 32551, Taiwan, Republic of China.
PT
Tel: 886-2-03-4799595
CE
E-mail address: [email protected]
AC
Disclaimers: The authors declare no conflict of interests. Key words: acute urinary retension, emphysematous cystitis Short title: Emphysematous cystitis presents with acute urinary retension
ACCEPTED MANUSCRIPT Abstract
T
Emphysematous cystitis is a uncommon condition in which gas collection within the
RI P
bladder wall and lumen by gas-forming pathogens. There is limited information on
SC
this entity, and the clinical picture is poorly outlined, the severity ranges from an asymptomatic condition to potentially life-threatening cystitis. Clinical presentation
MA NU
varies and diagnostic clues often arise from the unanticipated imaging findings. We report a case of 81-year-old male who presented with acute urinary retension and low abdominal pain, after procedure of uretheral catheterization, lots of air bubbles are
AC
CE
PT
ED
drained out from bladder after urine, who was found to have emphysematous cystitis.
ACCEPTED MANUSCRIPT Case report
T
A 81-year-old male with underlying atrial fibrillation, benign prostate hypertrophy
RI P
and hypertension. He was was brought to the emergency department due to acute
SC
urinary retension and low abdominal pain. He complained of frequency and urgency and lower abdominal pain in recent days. At ER his vital signs were: blood pressure
MA NU
155/80 mmHg, pulse rate 115/minute, respiratory rate 18/minute, and body temperature 36.7°C. Cardiovascular examinations were unremarkable. Breathing sounds were bilateral clear in both lung fields. The abdomen was soft. But mild
ED
tenderness and ovoid mass lesion at lower abdomen was noted. The acute urinary
PT
retention was impressed. On examination, no knocking pain over bilateral flank area.
CE
Uretheral catheter was indwelled and about 300 ml turbid, foul smelling urine with air
AC
bubbles was drained out. Laboratory data showed white blood cell (WBC) count of 17,800/mm3 with 87.0% neutrophils (3% band forms), hemoglobin of 10.8 g/dl, hematocrit of 31.3%, platelet count of 178,000/mm3, serum glucose of 155 mg/dl, serum sodium of 136 meq/L, serum potassium of 4.5 meq/L, BUN of 23 mg/dl, creatinine of 0.88 mg/dl. Urinalysis revealed numerous red blood cells, and 30-40 white cell. KUB revealed a curvilinear area of radiolucency delineating the bladder wall (Fig. 1). Abdominal computerized tomography scan obtained subsequently revealed a hydroaeric level and a pneumo bladder with air bubbles around the urinary
ACCEPTED MANUSCRIPT bladder. (Fig. 2). Therefore, he was admitted under the impressions of
T
emphysematous cystitis.
RI P
After admission, empirical antibiotics (Ceftriaxone 2 gm/QD) was initially
SC
administrated for suspision of severe infection. In addition to urethral catheterization for urinary drainage, two percutaneous pig tail tubes were placed for drainage of
MA NU
discharge. Urine culture subsequently grew more than 105 colony-forming units/ mm3 of Klesiella pneumoniae with sensitivity to our empirical antibiotics. Blood cultures were negative. KUB on the sixth day showed no evidance of gas distribution in the
ED
bladder wall. He underwent cystoscopy with Toomy irrigation on the seventh day
PT
which bladder mucosa showed diffuse swelling, inflammatory change, and multiple
CE
blood clots in the bladder were noted. The pathologic result of the bladder biopsy
AC
revealed hemorrhagic cystitis with inflammation. He was discharged under relative stable condition after 10 days of hospitalization.
ACCEPTED MANUSCRIPT Discussion
T
Emphysematous cystitis is a rare but potentially life-threatening condition
RI P
characterized by the presence of gas in the wall and within the bladder produced by
SC
gas fermenting bacterial and fungal pathogens. The clinical picture of emphysematous cystitis is usually with fever and urinary symptoms, although sometimes it may be
MA NU
asymptomatic or with mild abdominal discomfort. In a review by Grupper et al, The symptom most commonly seen was abdominal pain, but the classic presentation of UTI were reported in only about 50% of the cases.1 Because the clinical presentation
ED
may be atypical and may contrary to the severity of inflammation, the disease is
PT
typically defined and diagnosed incidentally on abdominal plain film for other
CE
diseases, with the increased use of abdomino-pelvic imaging and a high index of
AC
suspicion of such disease, the incidence of reported cases is increasing . Plain radiograph of the abdomen often provided the first and only diagnostic clue, which was the most common imaging method (84%) used in reported cases, but CT of abdomen and pelvis can define the extent and severity of disease more accurately and even it can detect emphysematous cystitis are not apparent on plain abdominal films.2-4 Besides emphysematous cystitis, CT can also differentiate other causes such as colovesical fistula, intra-abdominal abscess, adjacent neoplastic disease, or emphysematous pyelonephritis.
ACCEPTED MANUSCRIPT E. coli is the most prevalent organism isolated in urinary culture . Other organisms
T
reported included K. pneumoniae(21%), P.aeruginosa, Proteus mirabilis, Candida faecalis,
RI P
albicans and C.tropicalis, Group D Streptococcus, Enterococcus
SC
Enterobacter aerogenes.5 The exact pathophysiology of these gas-forming infections is still not well fully explained and the combination of the presence of gas-forming
MA NU
organisms, elevated tissue glucose levels and vascular compromise all are thought to be involved in development of emphysematous cystitis. Because nondiabetic patients may also develop gas-forming infections of the urinary tract, lactose of urine or tissue
ED
proteins may serve as substrates for gas formation had been proposed. In addition,
PT
local inflammation or obstructive uropathy increasing the local pressure and impairing
CE
the circulation impair transportation of the formed gas, or vascular compromise such
AC
as diabetes. The elevated local pressure and may resulted in infarction of the adjacent tissues. The infarcted tissue might provide as a good culture medium for gas-forming organisms, interfere with gas transportation and thus creating a vicious spiral.6 Emphysematous cystitis requires aggressive treatment with parenteral antibiotics and bladder drainage.7 The clinical course may be severe evolving to overwhelming infection, ascending to ureters and renal parenchyma, bladder rupture and death if delayed diagnosis. Furthermore patients not responding to medical management or those with severe necrotizing infections might require partial cystectomy, cystectomy,
ACCEPTED MANUSCRIPT or surgical debridement(10%).5 Our patient is unique in that the patient had no
T
evidence of diabetes or recent instrumentation but urinary tract infection and
RI P
obstructive uropathy lead to severe necrotizing infection needed prompt aggressive
SC
management. Because compare with acute urinary retension, emphysematous cystitis is rarely encountered in our daily practice and it may be associated with significant
MA NU
mortality, emergency physicians should keep high index of suspicion of this entity and the variable presentations, Bladder drainage and an individualised antibiotic are
AC
CE
PT
ED
treatment plan and might be done immediately for high risk patients.
ACCEPTED MANUSCRIPT Figure Legends Fig. 1: A plain radiograph shows a curvilinear area of radiolucency delineating the bladder wall (arrow)
T
Fig. 2: CT reveals a hydroaeric level and a pneumo bladder with air bubbles around the urinary
AC
CE
PT
ED
MA NU
SC
RI P
bladder.
ACCEPTED MANUSCRIPT Conflict of interest statement
T
The authors have no commercial associations or sourced of support that might pose a
AC
CE
PT
ED
MA NU
SC
RI P
conflict of interest
ACCEPTED MANUSCRIPT References
MA NU
SC
RI P
T
1. Grupper M, Kravtsov A, Potasman I. Emphysematous cystitis: illustrative case report and review of the literature. Medicine (Baltimore). 2007;86(1):47-53. 2. Grayson DE, Abbott RM, Levy AD, Sherman PM. Emphysematous infections of the abdomen and pelvis: a pictorial review. Radiographics 2002;22:543-61 3. Ahmad M, Dakshinamurty KV. Emphysematous renal tract disease due to Aspergillus fumigatus J Assoc Physicians India 2004;52:495-7. 4. Kupeli S, Beduk Y, Yaman S, Safak M. Emphysematous pyelonephritis with pneumocystitis. Urol Int 1988;43:318-20.
AC
CE
PT
ED
5. Thomas AA, Lane BR, Thomas AZ, Remer EM,Campbell SC, Shoskes DA. Emphysematous cystitis: a review of 135 cases. BJU Int. 2007;100(1):17-20. 6. Yang WH, Shen NC. Gas-forming infection of the urinary tract: an investigation of fermentation as a mechanism. J Urol 1990;143:960-4. 7. Yasumoto R, Asakawa M, Nishisaka N. Emphysematous cystitis. Br J Urol 1989;63(6):644.
MA NU
SC
RI P
T
ACCEPTED MANUSCRIPT
AC
CE
PT
ED
Figures 1 and 2
ACCEPTED MANUSCRIPT Highlights
T
Emphysematous cystitis is a rare clinically entity but has a highly variable
RI P
presentation and clinical course, with a considerable potential for complications, and acute urinary retension is a more rare presentation of it.
SC
Mechanism proposes that mixed acid fermentation of glucose by pathogens does not explain the development of emphysematous cystitis in patients who are nondiabetic.
MA NU
No guidelines to obtain imaging to assess for emphysematous cystitis, routine imaging in patients with urinalysis findings consistent with cystitis cannot be warranted. However, keep this diagnosis in mind in high-risk patients will avoid unfavorable
AC
CE
PT
ED
outcomes
S0735-6757(14)00697-4 doi: 10.1016/j.ajem.2014.09.042 YAJEM 54540
To appear in:
American Journal of Emergency Medicine
Received date: Accepted date:
15 September 2014 21 September 2014
Please cite this article as: Wu Yueh-Feng, Kao Chung-Cheng, Tsuei Yi-Wei, Hung JiunnBin, Acute urinary retension as a manifestation of emphysematous cystitis, American Journal of Emergency Medicine (2014), doi: 10.1016/j.ajem.2014.09.042
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT Acute urinary retension as a manifestation of emphysematous cystitis
RI P
T
Yueh-Feng Wu, Chung-Cheng Kao*, Yi-Wei Tsuei, Jiunn-Bin Hung
SC
Department of Emergency Medicine, Taoyuan Armed Forces General Hospital
MA NU
Taoyuan, Taiwan
* Corresponding author: Chung-Cheng Kao
Address: Department of Emergency Medicine, Taoyuan Armed Forces General
ED
Hospital, No.168, Zhongxing Rd., Longtan Township, Taoyuan County 32551, Taiwan, Republic of China.
PT
Tel: 886-2-03-4799595
CE
E-mail address: [email protected]
AC
Disclaimers: The authors declare no conflict of interests. Key words: acute urinary retension, emphysematous cystitis Short title: Emphysematous cystitis presents with acute urinary retension
ACCEPTED MANUSCRIPT Abstract
T
Emphysematous cystitis is a uncommon condition in which gas collection within the
RI P
bladder wall and lumen by gas-forming pathogens. There is limited information on
SC
this entity, and the clinical picture is poorly outlined, the severity ranges from an asymptomatic condition to potentially life-threatening cystitis. Clinical presentation
MA NU
varies and diagnostic clues often arise from the unanticipated imaging findings. We report a case of 81-year-old male who presented with acute urinary retension and low abdominal pain, after procedure of uretheral catheterization, lots of air bubbles are
AC
CE
PT
ED
drained out from bladder after urine, who was found to have emphysematous cystitis.
ACCEPTED MANUSCRIPT Case report
T
A 81-year-old male with underlying atrial fibrillation, benign prostate hypertrophy
RI P
and hypertension. He was was brought to the emergency department due to acute
SC
urinary retension and low abdominal pain. He complained of frequency and urgency and lower abdominal pain in recent days. At ER his vital signs were: blood pressure
MA NU
155/80 mmHg, pulse rate 115/minute, respiratory rate 18/minute, and body temperature 36.7°C. Cardiovascular examinations were unremarkable. Breathing sounds were bilateral clear in both lung fields. The abdomen was soft. But mild
ED
tenderness and ovoid mass lesion at lower abdomen was noted. The acute urinary
PT
retention was impressed. On examination, no knocking pain over bilateral flank area.
CE
Uretheral catheter was indwelled and about 300 ml turbid, foul smelling urine with air
AC
bubbles was drained out. Laboratory data showed white blood cell (WBC) count of 17,800/mm3 with 87.0% neutrophils (3% band forms), hemoglobin of 10.8 g/dl, hematocrit of 31.3%, platelet count of 178,000/mm3, serum glucose of 155 mg/dl, serum sodium of 136 meq/L, serum potassium of 4.5 meq/L, BUN of 23 mg/dl, creatinine of 0.88 mg/dl. Urinalysis revealed numerous red blood cells, and 30-40 white cell. KUB revealed a curvilinear area of radiolucency delineating the bladder wall (Fig. 1). Abdominal computerized tomography scan obtained subsequently revealed a hydroaeric level and a pneumo bladder with air bubbles around the urinary
ACCEPTED MANUSCRIPT bladder. (Fig. 2). Therefore, he was admitted under the impressions of
T
emphysematous cystitis.
RI P
After admission, empirical antibiotics (Ceftriaxone 2 gm/QD) was initially
SC
administrated for suspision of severe infection. In addition to urethral catheterization for urinary drainage, two percutaneous pig tail tubes were placed for drainage of
MA NU
discharge. Urine culture subsequently grew more than 105 colony-forming units/ mm3 of Klesiella pneumoniae with sensitivity to our empirical antibiotics. Blood cultures were negative. KUB on the sixth day showed no evidance of gas distribution in the
ED
bladder wall. He underwent cystoscopy with Toomy irrigation on the seventh day
PT
which bladder mucosa showed diffuse swelling, inflammatory change, and multiple
CE
blood clots in the bladder were noted. The pathologic result of the bladder biopsy
AC
revealed hemorrhagic cystitis with inflammation. He was discharged under relative stable condition after 10 days of hospitalization.
ACCEPTED MANUSCRIPT Discussion
T
Emphysematous cystitis is a rare but potentially life-threatening condition
RI P
characterized by the presence of gas in the wall and within the bladder produced by
SC
gas fermenting bacterial and fungal pathogens. The clinical picture of emphysematous cystitis is usually with fever and urinary symptoms, although sometimes it may be
MA NU
asymptomatic or with mild abdominal discomfort. In a review by Grupper et al, The symptom most commonly seen was abdominal pain, but the classic presentation of UTI were reported in only about 50% of the cases.1 Because the clinical presentation
ED
may be atypical and may contrary to the severity of inflammation, the disease is
PT
typically defined and diagnosed incidentally on abdominal plain film for other
CE
diseases, with the increased use of abdomino-pelvic imaging and a high index of
AC
suspicion of such disease, the incidence of reported cases is increasing . Plain radiograph of the abdomen often provided the first and only diagnostic clue, which was the most common imaging method (84%) used in reported cases, but CT of abdomen and pelvis can define the extent and severity of disease more accurately and even it can detect emphysematous cystitis are not apparent on plain abdominal films.2-4 Besides emphysematous cystitis, CT can also differentiate other causes such as colovesical fistula, intra-abdominal abscess, adjacent neoplastic disease, or emphysematous pyelonephritis.
ACCEPTED MANUSCRIPT E. coli is the most prevalent organism isolated in urinary culture . Other organisms
T
reported included K. pneumoniae(21%), P.aeruginosa, Proteus mirabilis, Candida faecalis,
RI P
albicans and C.tropicalis, Group D Streptococcus, Enterococcus
SC
Enterobacter aerogenes.5 The exact pathophysiology of these gas-forming infections is still not well fully explained and the combination of the presence of gas-forming
MA NU
organisms, elevated tissue glucose levels and vascular compromise all are thought to be involved in development of emphysematous cystitis. Because nondiabetic patients may also develop gas-forming infections of the urinary tract, lactose of urine or tissue
ED
proteins may serve as substrates for gas formation had been proposed. In addition,
PT
local inflammation or obstructive uropathy increasing the local pressure and impairing
CE
the circulation impair transportation of the formed gas, or vascular compromise such
AC
as diabetes. The elevated local pressure and may resulted in infarction of the adjacent tissues. The infarcted tissue might provide as a good culture medium for gas-forming organisms, interfere with gas transportation and thus creating a vicious spiral.6 Emphysematous cystitis requires aggressive treatment with parenteral antibiotics and bladder drainage.7 The clinical course may be severe evolving to overwhelming infection, ascending to ureters and renal parenchyma, bladder rupture and death if delayed diagnosis. Furthermore patients not responding to medical management or those with severe necrotizing infections might require partial cystectomy, cystectomy,
ACCEPTED MANUSCRIPT or surgical debridement(10%).5 Our patient is unique in that the patient had no
T
evidence of diabetes or recent instrumentation but urinary tract infection and
RI P
obstructive uropathy lead to severe necrotizing infection needed prompt aggressive
SC
management. Because compare with acute urinary retension, emphysematous cystitis is rarely encountered in our daily practice and it may be associated with significant
MA NU
mortality, emergency physicians should keep high index of suspicion of this entity and the variable presentations, Bladder drainage and an individualised antibiotic are
AC
CE
PT
ED
treatment plan and might be done immediately for high risk patients.
ACCEPTED MANUSCRIPT Figure Legends Fig. 1: A plain radiograph shows a curvilinear area of radiolucency delineating the bladder wall (arrow)
T
Fig. 2: CT reveals a hydroaeric level and a pneumo bladder with air bubbles around the urinary
AC
CE
PT
ED
MA NU
SC
RI P
bladder.
ACCEPTED MANUSCRIPT Conflict of interest statement
T
The authors have no commercial associations or sourced of support that might pose a
AC
CE
PT
ED
MA NU
SC
RI P
conflict of interest
ACCEPTED MANUSCRIPT References
MA NU
SC
RI P
T
1. Grupper M, Kravtsov A, Potasman I. Emphysematous cystitis: illustrative case report and review of the literature. Medicine (Baltimore). 2007;86(1):47-53. 2. Grayson DE, Abbott RM, Levy AD, Sherman PM. Emphysematous infections of the abdomen and pelvis: a pictorial review. Radiographics 2002;22:543-61 3. Ahmad M, Dakshinamurty KV. Emphysematous renal tract disease due to Aspergillus fumigatus J Assoc Physicians India 2004;52:495-7. 4. Kupeli S, Beduk Y, Yaman S, Safak M. Emphysematous pyelonephritis with pneumocystitis. Urol Int 1988;43:318-20.
AC
CE
PT
ED
5. Thomas AA, Lane BR, Thomas AZ, Remer EM,Campbell SC, Shoskes DA. Emphysematous cystitis: a review of 135 cases. BJU Int. 2007;100(1):17-20. 6. Yang WH, Shen NC. Gas-forming infection of the urinary tract: an investigation of fermentation as a mechanism. J Urol 1990;143:960-4. 7. Yasumoto R, Asakawa M, Nishisaka N. Emphysematous cystitis. Br J Urol 1989;63(6):644.
MA NU
SC
RI P
T
ACCEPTED MANUSCRIPT
AC
CE
PT
ED
Figures 1 and 2
ACCEPTED MANUSCRIPT Highlights
T
Emphysematous cystitis is a rare clinically entity but has a highly variable
RI P
presentation and clinical course, with a considerable potential for complications, and acute urinary retension is a more rare presentation of it.
SC
Mechanism proposes that mixed acid fermentation of glucose by pathogens does not explain the development of emphysematous cystitis in patients who are nondiabetic.
MA NU
No guidelines to obtain imaging to assess for emphysematous cystitis, routine imaging in patients with urinalysis findings consistent with cystitis cannot be warranted. However, keep this diagnosis in mind in high-risk patients will avoid unfavorable
AC
CE
PT
ED
outcomes
