Near-complete circumferential intramural bladder gas in emphysematous cystitis: a case report

Abstract Background Emphysematous cystitis is a gas-forming infection of the urinary bladder characterized by intramural and occasionally intraluminal gas. Although diabetes mellitus is a common predisposing condition, the disease may also develop in association with urinary stasis or structural urinary tract abnormalities. Computed tomography is central to diagnosis and assessment of the extent of bladder-wall involvement. Case presentation A 65-year-old man receiving edoxaban presented to the emergency department with acute-onset gross hematuria accompanied by weakness and headache. He was afebrile and hemodynamically stable but had leukocytosis, markedly elevated C-reactive protein, bacteriuria, and mildly elevated venous lactate. He had no previous diagnosis of diabetes mellitus; admission serum glucose was 146.1 mg/dL, urinalysis showed no glucosuria, and an HbA1c level obtained during hospitalization was 7.23%, strongly suggesting previously unrecognized diabetes mellitus, although a definitive diagnosis was not established without confirmatory testing. Non-contrast abdominopelvic computed tomography demonstrated near-complete circumferential intramural bladder gas. A three-way urethral catheter was inserted, bladder irrigation was performed, and intravenous meropenem at 1 g three times daily was initiated. The initial urine culture yielded Escherichia coli ; following infectious diseases reassessment, intravenous meropenem was continued and completed as a 12-day course, and the repeat urine culture showed no growth. Because gross hematuria persisted despite antimicrobial therapy and bladder irrigation, cystoscopy was performed on 3 February 2026 to exclude an underlying urothelial malignancy. Cystoscopy demonstrated diffuse hemorrhagic and friable changes involving the bladder mucosa. A transurethral biopsy was obtained from a hyperemic area at the bladder base, and bleeding areas were fulgurated. Histopathological examination of the sampled bladder tissue showed severe hemorrhagic cystitis, with no malignancy identified. The patient was discharged in stable condition after a 13-day hospitalization, and no recurrence was observed during 6 weeks of follow-up. Conclusion Near-complete circumferential intramural bladder gas may occur despite preserved hemodynamic stability and limited systemic symptoms. In older anticoagulated patients presenting with gross hematuria, emphysematous cystitis should be considered alongside medication-related bleeding and urothelial malignancy. Previously unrecognized glycemic abnormality may also be identified during evaluation. Computed tomography, appropriate antimicrobial therapy, bladder drainage, and selective urologic assessment are central to management.