洗腎患者的血尿-在癌症之外? 一個產氣性膀胱炎患者的病例報告

張家郡、葉進仲

中國醫藥大學附設醫院泌尿部

Hematuria Beyond Malignancy in Hemodialysis Patient. A case report of emphysematous cystitis

Jia- Jyun Jhang, Ching-Chung Yeh 

Department of Urology, China Medical University Hospital, Taichung, Taiwan

Introduction: Hematuria in a patient with end-stage renal disease (ESRD) often raises concerns for urologists, with malignancy being most crucial consideration. However, it is essential to explore alternative differentials beyond malignancy, such as radiation cystitis, ruptured renal cysts, urolithiasis, or infection. Among these causes, infection can sometimes be overlooked, leading to potentially devastating complications. In this case report, we present a patient who initially presented with hematuria and lower abdominal discomfort. Plain radiograph showed mottled gas distribution around the bladder area, and he was later diagnosed as emphysematous cystitis.

Case presentation: This 79-year-old male has been undergoing hemodialysis for several years and has experienced anuria since the onset of end-stage renal disease (ESRD). He visited a local clinic due to a 3- day history of continuous, non-radiating lower abdominal pain, accompanied by hematuria, abdominal fullness, and difficulty in voiding. The initial concern was the possibility of malignancy, prompting his referral to our medical center. Plain radiograph showed mottled gas distribution around the bladder area, which raised suspicion of emphysematous cystitis, leading to an immediate referral to the emergency department. CT confirmed the diagnosis by revealing diffused free air in the bladder and bladder wall. A Foley catheter was inserted for drainage, with immediate passage of dark reddish to brown urine with bubbles. The patient was subsequently admitted to our ward for antibiotics treatment. After weeks of antibiotic treatment, he was discharged under relative stable condition.

Conclusion: Emphysematous cystitis is a potential life-threatening infection, with complications that can include bladder rupture, sepsis, and peritonitis when not promptly diagnosed. Antibiotics for infection control and Foley catheter insertion to ensure proper urine drainage is therefore essential for this disease. It is important to note that the fragile bladder wall in ESRD patients increases the risk of bladder rupture, leading to severe and potentially disastrous complications. While malignancy is indeed a significant concern for urologists when addressing hematuria in ESRD patients, our case serves as a reminder to consider other possible diagnoses, particularly infections.