Endgames Spot Diagnosis

Urinary frequency and dysuria in an older woman

BMJ 2016; 354 doi: https://doi.org/10.1136/bmj.i4587 (Published 13 September 2016) Cite this as: BMJ 2016;354:i4587
  1. Joseph Dalby Sinnott, core surgical trainee1,
  2. David C Howlett, consultant radiologist2
  1. 1Department of Surgery, East Sussex Hospitals NHS Trust, Eastbourne, UK
  2. 2Department of Radiology, East Sussex Hospitals NHS Trust
  1. Correspondence to: J D Sinnott j.d.sinnott{at}gmail.com

A 66 year old woman with diabetes was admitted to the medical assessment unit with lower abdominal pain and dysuria. The patient was pyrexial (38.8°C) and had a white cell count of 17.1×109/L. A urine dipstick test was positive for leucocytes, nitrites, and blood. Computed tomography (fig 1) was performed because of the severity of the lower abdominal pain. What is the diagnosis?


Emphysematous cystitis.


Computed tomography (CT) shows a moderately distended bladder with an air/fluid level (A) and extensive air within the bladder wall (B) (figs 2 and 3).


Fig 2 Axial CT scan of abdomen showing air/fluid level (A) and air within the bladder wall (B)


Fig 3 Longitudinal CT scan of abdomen showing air/fluid level (A) and air within the bladder wall (B)

Emphysematous cystitis is commonly caused by organisms such as Escherichia coli or Klebsiella pneumonae. Fungal causes such as candida are much less common. It usually affects middle aged or elderly diabetic women.1 Other risk factors include neurogenic bladder and urinary stasis from bladder outlet obstruction.2 Patients may experience symptoms such as pneumounia, dysuria, and abdominal pain. CT scanning is the imaging modality of choice to confirm the diagnosis. One sign of emphysematous cystitis is air within the bladder lumen. This sign is never normal although the most common cause would be recent catheterisation. A second sign is air within the bladder wall. Other causes for this sign include trauma or fistulas from diverticular disease or Crohn’s disease. Treatment of emphysematous cystitis includes adequate urinary drainage, intravenous antibiotics, and glycaemic control. When promptly implemented, treatment has good results. A repeat computed tomography scan can be used to show resolution of the gas within the bladder wall.


  • Competing interests: We have read and understood the BMJ policy on declaration of interests and declare the following: none.

  • Provenance and peer review: Not commissioned; externally peer reviewed.

  • Patient consent: Obtained.


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