Emphysematous cystitis: imaging patterns and diagnostic approach on CT

Emphysematous cystitis, also known as 'cystitis emphysematosa,' is a rare complicated urinary tract infection characterized by gas within the bladder wall. Most cases are mild and detected incidentally; however, delayed management can lead to significant morbidity and mortality, particularly when infection extends to the upper urinary tract. With increasing use of cross-sectional imaging, radiologists are encountering this condition more frequently. This pictorial review presents 20 cases of emphysematous cystitis from our institution, illustrating the range of CT imaging patterns and clinical features from representative cases. We identified three distinct patterns of gas distribution: loculated or curvilinear focal collections (40% of cases), single layer of cobblestone/beaded necklace pattern (30% of cases), and circumferential dissection of the bladder wall with multilayered gas (30% of cases). Diabetes is the most common predisposing factor. Other risk factors included neurogenic bladder, long-term urinary catheters, immunosuppression, chemotherapy, recurrent urinary stones, and frequent urologic procedures. The clinical presentation ranges from incidental detection on imaging to symptomatic patients presenting with acute abdomen and dysuria in the emergency department (ED). Treatment primarily consists of antibiotic therapy, with surgical intervention required only in select severe cases. Understanding these CT patterns along with the associated clinical features and risk factors allows radiologists to accurately diagnose emphysematous cystitis and guide timely clinical management.