"Pneumaturia" in a Diabetic Patient: What to do About Air in the Urine
CASE STUDY
Synopsis: Emphysematous pyelonephritis is an unusual though important manifestation of urinary tract infection, most commonly seen in women and diabetics, presenting dramatically in some patients with pneumatoria, hernaturia, or no symptoms. Radiological findings in this case show air in the lumen or in the wall of the urinary bladder.
A 73-year-old male was admitted to the hospital with complaints of passing air in the urine (pneumaturia) and vague abdominal discomfort for two weeks. He denied fever, chills, or disturbances in bowel habits. His past medical history was significant for insulin-requiring diabetes mellitus with retinopathy and peripheral neuropathy and an episode of bacteremic urinary tract infection due to Escherichia coli, a year earlier, without any evidence of obstructive uropathy.
Physical examination revealed a non-toxic afebrile elderly male with vague discomfort on abdominal palpation but normal bowel sounds on examination. A digital rectal examination was significant for a smooth, enlarged, nontender prostate and the stool guaiac was negative.
Laboratory data included a WBC count of 5500/m3, a random serum glucose of 309 mg/dL, and a turbid urine with many RBCs and WBCs and bacteria. Abdominal and pelvic CT scans done with and without contrast showed the presence of air-fluid level in the urinary bladder. A hypodense area in the left renal cortex was suggestive of pyelonephritis. A retrograde pyelogram again showed air-fluid level in the lumen of the urinary without reflux or fistulous tracts. Blood cultures were negative. Urine culture grew greater than 105 colonies/mL of E. coli. A diagnosis of emphysematous cystitis and pyelonephritis was made. He was treated with a flouroquinolone for two weeks. Resolution of symptoms and radiological findings occurred promptly. A month later, he was retreated because of abnormal urinary sediment, but the cultures remained negative. Urological workup including cystoscopy revealed benign enlargement of the prostate. He has remained well and asymptomatic on the therapeutic regimen that includes an alpha blocker.
COMMENT BY RAJALAKSHMI NANDAKUMAR, MD, MARK ZIMERING, MD, AND JYOTI SHAH, MD
The symptoms of pneumaturia can be alarming to the patient and to the treating physician, raising, in the absence of trauma or surgery, the possibility of vesicocolic or vesicovaginal fistulas from Crohn’s disease, diverticular disease, or cancer. However, it can be a helpful clue to a more benign condition called emphysematous cystitis (cystitis emphysematosa), an infrequent complication of urinary tract infection, occurring particularly in diabetic patients.
Although the symptoms of pneumaturia and the presence of air in the bladder autopsy were described in the early part of the century,1 it was Bailey in 1961 who summarized the epidemiology, clinical bacteriological findings, and two different radiological presentations of the same entity.2 Of the 19 patients described, more than 75% had diabetes mellitus and 65% were female. Urinary stasis and diabetic neuropathy were frequently noted. The radiological findings included either air in the lumen of the bladder, the presence of tiny air bubbles in the wall of the urinary bladder, or both. Fistulous tracts, trauma, and iatrogenic introduction of air have to be excluded. Although pneumaturia, when present, is helpful, not all patients give this history. Hematuria may be a more frequent presentation. Though the majority of infections are caused by E. coli, other etiologic organisms such as Klebsiella, Proteus, Staphylococci, Streptococci, Candida albicans, Candida tropicalis,3 and Clostridium perfringens4 have been described. The intramural and intraluminal gas is predominantly carbon dioxide and hydrogen, thought to be the result of glucose fermentation. In the case of clostridial infection, a positive blood culture for the organism is helpful, although anaerobic culture of the urine is not routinely performed. The course is mostly benign with good response to appropriate antimicrobial therapy and measures to prevent urinary stasis. It can recur if these issues are not addressed appropriately.5 Occasionally, complications could occur such as perivesical abcess, peritonitis, and bladder rupture leading to cystectomy.6 It can also be a part of emphysematous pyelonephritis7 that has a more serious outcome.
In summary, emphysematous pyelonephritis is an unusual, though important, manifestation of urinary tract infection, predominantly seen in women and diabetics, presenting dramatically in some patients with pneumatoria, hernaturia, or no symptoms. Radiological findings like our case can be striking, showing air in the lumen or in the wall of the urinary bladder. Treatment includes effective antibiotics and prevention of urinary stasis. (Dr. Nandakumar is Clinical Associate Professor of Medicine, UMDNJ-Robert Wood Johnson Medical School, and Staff Infectious Disease Physician, VA New Jersey Health Care System, Lyons, NJ. Dr. Zimering is Associate Professor, Department of Medicine, UMDNJ-Robert Wood Johnson Medical School, and Staff Endocrinologist, VA New Jersey Health Care, Lyons, NJ. Dr. Shah is Staff Radiologist, VA New Jersey Health Care System, Lyons, NJ.)
References
1. Davidson J, Pollack CV Jr. Emphysematous cystitis presenting as painless gross hernaturia. J Emer Med 1995;13:317-320.
2. Bailey H. Cystitis emphysematosa: 19 cases with intraluminal and interstitial collections of gas. Am J Roentgenol 1961;86:850-862.
3. Comiter CV, et al. Fungal bezoar and bladder rupture secondary to Candida tropicalis. Urology 1996;47:439-441.
4. Katz DS, et al. Clostridium perfringens emphysematous cystitis. Urology 1993;41:458-460.
5. Angulo JC, et al. Neurogenic bladder and recurrent emphysematous cystitis. (English abstract). Archivos Espanoles de Urologia 1993;46:227-229.
6. Quint HJ, et al. Emphysematous cystitis: A review of the spectrum of disease JUrol 1992;147:134-137.
7. Joseph RC, et al. Genitourinary tract gas: Imaging evaluation. Radiographics 1996;16:295-308.
Which of the following is correct?
a. Pneumaturia in a diabetic is strong presumptive evidence of pelvic gas gangrene.
b. The presence of an air fluid level in the bladder in an uninstrumented diabetic is an indication of emergency radical cystectomy.
c. Most cases of urinary tract infection associated with pneumaturia are due to E. coli.
d. Most cases of urinary tract infection associated with pneumaturia are due to Bacteroides fragilis.
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