emphysematous urinary tract infections ( utis ) are potentially life threatening . although mortality rates of approximately 24% have been reported for emphysematous pyelonephritis ( ep ) , information on emphysematous cystitis ( ec ) , which is less common , is sparse . the first case of pneumaturia , which was most likely a symptom of ec , was reported in curiosities of nature by raciborsky in 1671 . here , we report one new case of severe ec and 136 cases of ec that occurred between 2007 and 2016 , and review information about the characteristics , diagnosis , treatment and mortality of these patients , and the pathogens found in these patients . a 45-year old patient was admitted to our hospital with new diagnosed hepatic lesions of unknown dignity . contrast - enhanced computed tomography ( ct ) of the abdomen revealed an advanced emphysematous cystitis involving the perirectal space ( figure 1a ) , and accompanying non - emphysematous , absceding prostatitis ( figure 1b ) . he had no fever , tachycardia or tachypnea , white blood cell count ( wbc ) was 13.9/nl , c - reactive protein ( crp ) was 30.0 he had a history of traumatic spinal cord injury l3 with intermittent selfcatheterization , and arterial hypertension . he did not show up in our hospital for a short - term follow - up appointment . searching medline for emphysematous cystitis and cystitis emphysematosa we found 140 articles ; among the search results , 106 articles reported a total of 136 cases of ec . as a reference : patient age , sex , and diabetes status ; concurrent emphysematous infections involving other organs ; urinary pathogens ; white blood cell count ( wbc ) ; c - reactive protein ( crp ) levels ; treatment ; imaging modality ; and outcome . the mean age of the 136 patients was 67.914.2 years ( ranging from 11 to 96 ; the mean age for men was 65.7 years ; the mean age for women was 69.3 years ) . a total of 83 patients were female ( 61.0% ) and 46 were male ( 33.8% ; the sex was not available for 7 patients ) . a total of 86 patients had diabetes ( 63.2% ) ; there were 58 diabetic women ( 69.9% ) and 26 diabetic men ( 56.5% ) . in 37 cases , plain radiography was used as the diagnostic tool ( 27.2% ) ; ct ( computed tomography ) was used in 98 cases ( 72.0% ) , ultrasound was used in 9 cases ( 0.7% ) , and cystoscopy was used in 5 cases ( 0.4% ) . the mean wbc was 13.610.7 10/l ( n=78 ) and the mean crp level was 48.077.6 mg / dl ( n=32 ) on admission . concurrent emphysematous infections of other organs were found in 21 patients ( 15.4% ) , with emphysematous pyelonephritis being the most common of these infections . the primary pathogen identified from urinary cultures was escherichia coli ( 54.4% ; table 1 ) . patients were mainly treated by conservative management that included antibiotics ( n=105 ; 77.2% ) and bladder drainage , with additional glycemic control in diabetic patients . surgical treatment was reported to be necessary in 11 patients ( 8.1% ) , and included cystectomy and nephrectomy in concurrent ep . ten of the 136 patients with ec died , yielding a mortality rate of 7.4% . ec is most often found in diabetic women who are in their 6 or 7 decade of life . consistent with the female predominance of ec , we found a female - to - male ratio of 2.2:1 among the reported ec patients with diabetes ; diabetic women showed an incidence rate of 91.5 per 1000 person - years for utis in general , whereas the rate was 28 in men . although most cases of ec are successfully treated by medical management that is built on an appropriate antibiotic regimen , more advanced cases of ec require surgical treatment . with a mortality rate of 7.4% , ec is markedly less life threatening than is ep . although the pathogenesis of emphysematous utis , including ec , is not yet fully understood , gas - producing bacterial fermentation is required . immunological host defense impairments , such as neurogenic bladder , immunosuppression , and diabetes , favor bacterial colonization of the urinary tract . additionally , the increased availability of fermentation substrate in diabetic urine makes diabetic patients especially prone to emphysematous utis . despite the relatively low mortality rate of ec compared with that of ep , a high degree of suspicion must be maintained to facilitate successful and conservative management .
although high mortality rates have been reported for emphysematous pyelonephritis ( ep ) , information on emphysematous cystitis ( ec ) , which is less common , is sparse.here , we report one new case of severe ec and 136 cases of ec that occurred between 2007 and 2016 , and review information about the characteristics , diagnosis , treatment and mortality of these patients , and the pathogens found in these patients.the mean age of the 136 patients was 67.914.2 years . 
 concurrent emphysematous infections of other organs were found in 21 patients ( 15.4% ) , with emphysematous pyelonephritis being the most common of these infections . 
 the primary pathogen identified was escherichia coli ( 54.4% ) . 
 patients were mainly treated by conservative management that included antibiotics ( n=105 ; 77.2% ) . 
 ten of the 136 patients with ec died , yielding a mortality rate of 7.4% . despite the relatively low mortality rate of ec compared with that of ep , a high degree of suspicion 
 must be maintained to facilitate successful and conservative management .