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Clinical Outcomes and Risk Factor Analysis of Patients Presenting with Emphysematous Cystitis: a 15-Year Retrospective Multicenter Study

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Clinical Outcomes and Risk Factor Analysis of Patients Presenting with Emphysematous Cystitis: a 15-Year Retrospective Multicenter Study medicina Article Clinical Outcomes and Risk Factor Analysis of Patients Presenting with Emphysematous Cystitis: A 15-Year Retrospective Multicenter Study Jeonghyouk Choi 1, Seung-Kwon Choi 2, Sang-Hyub Lee 1 and Koo-Han Yoo 1,* 1 Department of Urology, College of Medicine, Kyung Hee University, Seoul 02447, Korea; [email protected] (J.C.); [email protected] (S.-H.L.) 2 Department of Urology, Seoul Medical Center, Seoul 02053, Korea; [email protected] * Correspondence: [email protected] Abstract: Background and objectives: To investigate the risk factors for emphysematous cystitis (EC) compared to those of acute cystitis (AC) to increase clinicians awareness of the possibility for the aggravation of patient status. Materials and methods: We retrospectively reviewed a total of 54 patients who were hospitalized with a diagnosis of EC by abdominal computed tomography (CT) scan from 2006 to 2020. The control group included 92 patients who were hospitalized for the treatment of AC in the same period. We sought to identify the clinical features and predisposing diseases, such as age, sex, diabetes mellitus (DM), hypertension (HTN), cerebrovascular accident (CVA), chronic kidney disease (CKD), neurogenic bladder (NB), history of urinary tract infection (UTI), and emphysematous pyelonephritis (EPN), that were associated with the development of EC. Results: The median (interquartile range (IQR)) age of the patients with EC was older than that of the patients with AC (78.5 (15.3) years (range: 52–100) vs. 70.0 (26.5) years (range: 28–97 years)). Sepsis and Citation: Choi, J.; Choi, S.-K.; Lee, mortality occurred only in the EC group (48.1% and 11.1%, respectively). The univariate analysis of S.-H.; Yoo, K.-H. Clinical Outcomes predisposing factors revealed that age, DM, HTN, CVA, CKD, and NB were significantly associated and Risk Factor Analysis of Patients Presenting with Emphysematous with EC. In the multivariate analysis, DM (OR, 6.251; 95% CI, 2.254–17.250; p < 0.001), CKD (OR, Cystitis: A 15-Year Retrospective 18.439; 95% CI, 3.421–99.404; p = 0.001), NB (OR, 7.374; 95% CI, 1.993–27.285; p = 0.003) were associated Multicenter Study. Medicina 2021, 57, with EC. Conclusions: The results of this study revealed that DM, CKD, and NB were significant 531. https://doi.org/10.3390/ risk factors for EC. The tendency toward sepsis and high mortality underscore the need for careful medicina57060531 observation while treating patients with EC with the risk noted above. Academic Editor: Giuseppe Lucarelli Keywords: cystitis; emphysema; risk factors; sepsis; mortality Received: 19 May 2021 Accepted: 23 May 2021 Published: 26 May 2021 1. Introduction Emphysematous urinary tract infection (UTI), including emphysematous pyelonephri- Publisher’s Note: MDPI stays neutral tis (EPN) and emphysematous cystitis (EC), is characterized by gas-forming infections with regard to jurisdictional claims in published maps and institutional affil- in related organs. While most sources of the gas are bacteria, several cases of EC were iations. reportedly induced by chemicals [1]. Among gas-forming infections, EPN easily develops to severe necrosis of the kidney and perirenal tissues with a high mortality rate of 21%. Meanwhile, EC shows infection of the bladder wall and lumen with presentations varying from nonspecific clinical symptoms of cystitis to systemic response, including fever and myalgia up to urosepsis (mortality rate, 7%) [2–4]. Copyright: © 2021 by the authors. The first case of pneumaturia, which was most likely a symptom of EC, was reported Licensee MDPI, Basel, Switzerland. in 1671 [5]. The incidence of EC is unknown [6]. Eisenlohr first identified emphysema This article is an open access article distributed under the terms and in the bladder by autopsy in the late 1800s. In 1961, Bailey reported the relationship conditions of the Creative Commons between pneumaturia and EC, and defined EC [7]. Despite the high mortality rates of EC, Attribution (CC BY) license (https:// recent studies on EC are sparse due to its rarity. The risk factors for EC are older women, creativecommons.org/licenses/by/ diabetes mellitus, neurogenic bladder, urinary tract outlet obstruction, recurrent UTI, and 4.0/). urethral catheter placement [8–10]. EC is diagnosed based on the presence of air in the Medicina 2021, 57, 531. https://doi.org/10.3390/medicina57060531 https://www.mdpi.com/journal/medicina Medicina 2021, 57, x FOR PEER REVIEW 2 of 7 Medicina 2021, 57, 531 2 of 7 catheter placement [8–10]. EC is diagnosed based on the presence of air in the bladder wall or lumen on radiologic examinations, including abdominal radiography or com- bladderputed tomography wall or lumen (CT) on [6]. radiologic Most patients examinations, are treated including successfully abdominal with antibiotics, radiography ure- or computedthral catheterization tomography and (CT) hydration. [6]. Most However, patients surgical are treated treatment successfully, such as with cystectomy antibiotics,, is urethralrequired catheterization in 10% of patients and with hydration. EC [7]. However, surgical treatment, such as cystectomy, is requiredWhile in acute 10% of cystitis patients (AC) with is a EC common [7]. disease, EC is very rare and can be fatal. There- fore, Whileclinicians acute must cystitis discriminate (AC) is aAC common from EC. disease, However, EC iswhen very a rareclinician and encounters can be fatal. a Therefore,patient with clinicians AC in an must outpatient discriminate clinic, ACit may from be EC. difficult However, to determine when a clinicianwhether encountersto perform aimaging patient tests with such AC as in CT an or outpatient to start aggressive clinic, itmay treatment be difficult for EC. to determine whether to perform imaging tests such as CT or to start aggressive treatment for EC. 2. Material and Methods 2. Material and Methods 2.1. Study Aim The aim of our studystudy waswas toto investigateinvestigate thethe riskrisk factorsfactors forfor ECEC comparedcompared toto thosethose ofof ACAC and to help clinicians to prepare for the possibility of the aggravation of patient status. 2.2. Study Design We retrospectivelyretrospectively reviewed reviewed patients patients who who were were hospitalized hospitalized diagnosed diagnosed with ECwith based EC onbased abdominal on abdominal CT findings CT findings at Kyung at HeeKyung University Hee University Hospital Hospital at Gangdong, at Gangdong, Seoul Medical Seoul CenterMedical and Center Kyung and Hee Kyung University Hee University Medical CenterMedical between Center 2006between and 2020.2006 and The 2020. inclusion The criteriainclusion for criteria the EC groupfor the were EC group patients were over patients 20 years over of age 20 whoyears were of age admitted who were with admitted dysuria, hematuria,with dysuri anda, hematuria, pyuria in and whom pyuria urine in whom examination urine examination was performed was andperformed gas formation and gas aroundformation the around bladder the was bladder confirmed was confirmed by CT (Figure by CT1 (Figure). Patients 1). Patients with bladder with bladder gas with gas urethralwith urethral catheter catheter insertion, insertion, after cystoscopy after cystoscopy procedure, procedure or patients, or patients with gas with due gas to bladder due to damage,bladder damage were excluded., were excluded. Acute cystitis Acute iscystitis diagnosed is diagnosed when there when is suddenthere is lowersudden urinary lower tracturinary symptoms tract symptoms due to adue urinary to a urinary tract infection tract infection of the bladder.of the bladder. No special No special radiological radio- examinationlogical examination is required is required for diagnosis. for diagnosis. As control As group,control the group, AC group the AC comprised group comprised patients whopatients were who hospitalized were hospitalized for treatment for treatment of AC with of AC severe with symptoms severe symptoms including including intolerable in- abdominaltolerable abdominal pain or gross pain hematuria or gross inhematuria same period. in same Abdominal period. CT Abdominal scan wasperformed CT scan was for allperformed patients for in ACall patients group to in differentiate AC group to from differentiate other disease from related other disease to these related symptoms. to thes Ine bothsymptoms. the EC In and both control the EC (AC) and groups, control patients(AC) groups, <20 years patients of age, <20 oryears who of were age, hospitalizedor who were forhospitalized the treatment for the of othertreatment diseases, of other were diseases excluded., were The excluded. institutional The reviewinstitutional board review of our instituteboard of approvedour institute our approved study and our confirmed study and the confirmed informed the consent. informed consent. FigureFigure 1. AxialAxial computed computed tomography tomography (CT) (CT) image image through through the lower the lower pelvis pelvis of patients of patients with acute with cystitis acute cystitis(A) and( emphy-A) and emphysematoussematous cystitis cystitis (B), with (B), diffuse with diffuse bladder bladder wall thickening wall thickening shown shown in the in bladder the bladder of the of patient the patient with with acute acute cystitis cystitis and and gas gascollection collection within within the thebladder bladder wall wall and and lumen lumen in the in thepatient patient with with emphysematous emphysematous cystitis. cystitis. 2.3. Risk Factors Analysis We sought to identify the clinical features and predisposing
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