CASE REPORT

Encrusted cystitis causing postrenal failure

Takaki Tanaka • Shinichi Yamashita • Koji Mitsuzuka •

Shigeyuki Yamada • Yasuhiro Kaiho • Haruo Nakagawa •

Yoichi Arai

Received: 17 January 2013 / Accepted: 9 April 2013 / Published online: 21 April 2013

� Japanese Society of Chemotherapy and The Japanese Association for Infectious Diseases 2013

Abstract Encrusted cystitis is characterized by chronic

inflammation of the bladder with encrustation of the

mucosa, induced by urea-splitting bacterial infection.

However, encrusted cystitis in itself is not well known. We

report a case of encrusted cystitis causing postrenal failure.

An 81-year-old man with pneumonia complained of

pollakisuria, micturition pain, and gross hematuria. Bladder

calculi were found, and transurethral lithotripsy was per-

formed. However, because his symptoms did not improve,

he was referred to our hospital. His urine pH was 8.5, and

urine culture grew Corynebacterium and Proteus. Com-

puterized tomography and cystoscopy revealed bladder

‘‘encrustation,’’ caused by bladder wall calcification, and

bilateral hydronephrosis. Hence, he was diagnosed with

postrenal failure resulting from encrusted cystitis. Imme-

diate bilateral nephrostomy was constructed, with contin-

uous bladder perfusion with an acid solution for

acidification of his urine, followed by intravenous admin-

istration of ceftriaxone. After 2 weeks of treatment, the

calcification disappeared and his bladder mucosa was

normalized. The postrenal failure also improved and thus

the nephrostomy tubes were removed. Encrusted cystitis is

curable by prompt treatment with acidification of urine.

Therefore, precise diagnosis and therapy are critical.

Keywords Encrusted cystitis � Postrenal failure �Corynebacterium � Alkaline urine

Introduction

Encrusted cystitis was first described by Francois [1], who

reported an ulcerated inflammatory bladder with calcium

deposits on its wall, causing intolerable functional conse-

quences for the patient. Encrusted cystitis produces severe

chronic inflammation, resulting in edematous mucosa and

encrustation of calcified plaques on the bladder wall [2].

The clinical presentation is unique. However, encrusted

cystitis in itself is not well known, being even more rarely

reported from Japan [3, 4]. This is a report of encrusted

cystitis causing postrenal failure, which was successfully

managed with ceftriaxone and continuous bladder irriga-

tion with an acid solution.

Case report

An 81-year-old man with pneumonia was referred to the

department of urology of another hospital, complaining of

pollakisuria and micturition pain. He was diagnosed with

bladder calculi. The bladder calculi was treated with

transurethral lithotripsy and disappeared. However, he was

referred to our hospital because of persistence of his uri-

nary symptoms, together with gross hematuria and urinary

incontinence.

Hematological examination revealed evidence of

inflammation, including a white blood cell count of 27,100/

ll and C-reactive protein of 11.2 mg/dl, with worsening of

renal function, as evidenced by a serum creatinine level of

5.3 mg/dl. The urine was severely alkaline (pH 8.5) with

hematopyuria. Urine culture grew Corynebacterium sp.,

Proteus mirabilis, and methicillin-resistant Staphylococcus

aureus (MRSA). Abdominal ultrasonography and comput-

erized tomography (CT) showed bilateral hydronephrosis

T. Tanaka � S. Yamashita (&) � K. Mitsuzuka � S. Yamada �Y. Kaiho � H. Nakagawa � Y. Arai

Department of Urology, Tohoku University Graduate School of

Medicine, 1-1 Seiryo-machi Aoba-ku, Sendai,

Miyagi 980-8574, Japan

e-mail: yamashita@uro.med.tohoku.ac.jp

123

J Infect Chemother (2013) 19:1193–1195

DOI 10.1007/s10156-013-0603-z

and intravesical calcification encrusting the bladder wall

(Fig. 1). Cystoscopy revealed a pale and ischemic urethral

mucosa, and the mucosa of urinary bladder was wholly

edematous, necrotizing, and surrounded by calcification

(Fig. 2). Further, chest CT showed lobar pneumonia and

lung emphysema. Hence, he was admitted with a diagnosis

of pneumonia, renal failure, and encrusted cystitis.

After admission, he developed anuria with worsening of

his renal function. First, we performed bilateral nephros-

tomy for the preservation of his renal function. Bilaterally,

his renal pelvic urine was acidic without pyuria. Antegrade

pyelography showed no narrowing of the ureters

bilaterally, except for the intramural part. Next, we con-

structed a continuous bladder perfusion (1–1.5 l/day) with

an acid solution (SOLITA T4; Ajinomoto Pharmaceuti-

cals), which contains sodium chloride 0.585 g and sodium

lactate 0.56 g in 500 ml (pH 3.5–6.5), for acidification of

the urine. We also administrated ceftriaxone (1 g/day)

intravenously for 14 days. A few days after the initiation of

treatment, his renal function improved and outflow from

the transurethral catheter increased. After 2 weeks, when

the pneumonia improved and he was fit enough for lumbar

anesthesia, he underwent transurethral resection of the

calcified bladder encrustations. Subsequently, as the

mucosa of the lower urinary tract improved and the bladder

calculi almost disappeared (Fig. 3), the nephrostomy tubes

were removed. He was discharged without deterioration of

his renal function, bacteriuria, and bladder calculi.

Discussion

Encrusted cystitis is characterized by chronic inflammation

of the bladder with encrustation of the mucosa, induced by

urea-splitting bacterial infection belonging to Corynebac-

terium sp., these being characteristic of encrusted cystitis.

Encrusted cystitis occurs in immunocompromised patients,

especially renal transplant recipients. Further, most patients

with encrusted cystitis have a history of previous urological

procedures [2, 5].

Our patient had the typical predisposing conditions and

clinical features of encrusted cystitis as have been previ-

ously reported, including old age, serious pneumonia, a

past history of transurethral lithotripsy, and positive urine

Fig. 1 Nonenhanced abdominal computed tomography (CT) at the

patient’s initial visit showed intravesical calcification encrusting the

wall of the bladder (arrow) and bilateral hydroureter (triangles)

Fig. 2 Cystoscopic findings before treatment. The bladder mucosa

was wholly edematous and necrotic and was encrusted with

calcification

Fig. 3 Cystoscopic findings after bladder perfusion with an acid

solution. Compared with Fig. 2, the mucosa of the lower urinary tract

was obviously improved and the calcification had disappeared

1194 J Infect Chemother (2013) 19:1193–1195

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culture for Corynebacterium sp. Cystoscopic examination

revealed encrusted calcification of the bladder mucosa,

leading to the diagnosis of encrusted cystitis. However,

recognition of encrusted cystitis, even by urologists, is

considered uncommon, and there are only a few reported

cases in Japan [3, 4].

This disease should be considered in patients with a poor

general condition, alkaline urine, and calcification of the

bladder. Urinalysis, urine culture, imaging findings such as

CT and ultrasonography, and cystoscopy are useful for its

diagnosis. Corynebacterium sp. is frequently detected as

the causative bacteria of encrusted cystitis [6, 7]. Three of

four previously reported Japanese cases had Corynebacte-

rium sp. infection of the urinary tract [3, 4]. Corynebac-

terium sp. is included in gram-positive bacilli with a strong

urease activity, which causes urine alkalinization; this

promotes calcification and inflammation of the urinary tract

mucosa [8]. Proteus sp. also causes urine alkalinization and

encrustation of the bladder [2, 8]. In our case, both Cory-

nebacterium sp. and Proteus sp. were cultured from the

urine, explaining alkalinization of the urine and the marked

calcification and necrotizing lesions in the bladder.

Therapy for encrusted cystitis consists of bladder per-

fusion with an acid solution, surgical resection of the cal-

cified encrustations, and antimicrobial chemotherapy [2].

These treatments have been previously successfully used in

Japanese patients with encrusted cystitis [3, 4]. Some acid

solutions such as Solution G and Thomas C24 solution

have been proposed for the treatment of encrusted cystitis

[2, 4]. The acid solutions dissolve the calculi by prevention

of oversaturation of calcium salts in alkaline urine. In our

patient as well, continuous bladder perfusion with an acid

solution was effective, with notable improvement of the

mucous membrane of the lower urinary tract within

2 weeks.

Corynebacterium sp. may also infect the upper urinary

tract, inducing calcification of the renal pelvis, known as

encrusted pyelitis [2, 9, 10]. Our case was distinct from

encrusted pyelitis because the pelvic urine was acidic and

culture negative, with no calcification of the upper urinary

tract. As our patient’s postrenal failure improved with

continuous bladder perfusion with an acid solution, the

cause of postrenal failure was considered obstruction of

both the ureteral orifices by the encrusted cystitis. Fur-

thermore, bladder perfusion with the acid solution was

continued until amelioration of the patient’s severe pneu-

monia, at which time he was considered fit for anesthesia.

At the time of surgery, the mucosa of the lower urinary

tract was significantly improved and bladder calculi were

almost eliminated. Thus, bladder perfusion with acidic

solutions may play a critical role in the treatment of

encrusted cystitis. In conclusion, it is necessary to recog-

nize that precise diagnosis and treatment, including bladder

perfusion with an acidic solution, is effective therapy in

patients with calcification encrusting the bladder mucosa.

Conflict of interest None.

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