Gangrenous cystitis presenting as an abdominal wall collection in an old frail patient: a case report

Introduction and Importance: Gangrenous cystitis (GC) is an extremely rare yet life threatening condition. It commonly presents as urosepsis. We report an unusual case of GC in a frail patient that initially manifested as an abdominal wall collection. Case Presentation: We report a 70-year-old female, frail bedridden patient undergoing urinary catheterization with history of secondary recurrent urinary tract infection, presenting with an abdominal wall reddish and necrotized lesion. CT scan revealed a 14×8×5 cm collection involving the left anterolateral abdominal wall with a thickening of the bladder wall and the sigmoid. An exploratory laparotomy was performed revealing a gangrenous cystitis confined to the bladder’s dome. Excision of the gangrenous tissue with primary closure of the bladder was performed. Postoperative course was fatal within 24 hours due to septic shock. Postmortem urine culture isolated an extended-spectrum beta-lactamase-producing Escherichia coli resistant to most β-lactams except for susceptibility for carbapenems and piperacillin–tazobactam. Discussion: In our patient, two etiological factors were identified: indirect – bladder overdistension secondary due to insufficient intermittent catheterization – and direct: urinary tract infection. Surgery remains the only lifesaving treatment in CG. In cases of unaffected trigone, it ranges from simple excision with adequate urinary drainage, to subtotal cystectomy. In more extensive disease involving the trigone, a radical total cystoprostectomy with bilateral ureterostomy is necessary. Conclusion: Via this misleading presentation of GC, we emphasize the importance of recognition of subtle symptoms in establishing early diagnosis in frail patients. Adherence to catheterization protocols and surveillance is paramount in patients undergoing intermittent or long-term indwelling urinary catheterization to prevent severe urinary complications.