Spontaneous pneumaturia with report of a case.

Abstract

Spontaneous pneumaturia is a term applied to the spontaneous appearance of gas in the bladder. We are all familiar with the appearance of an air-filled bladder because we inject air as a contrast medium. Its use alone or in combination with other contrast media is too well known to require discussion in this paper. The spontaneous appearance of air in the bladder, however, is rare. About 30 cases have been recorded in the literature, most of these in autopsy reports. Only 5 cases have appeared in the American literature. In a review of the last 200 intravenous pyelograms done at the Oil City and Franklin Hospitals, we were unable to find a single instance of air in the bladder. Pneumaturia may occur in several different ways: first, as a result of injection of air for diagnostic purposes, as mentioned above, or by its accidental injection during cystoscopy; second, by introduction of air through a puncture wound of the bladder or an operative procedure; third, as a result of a vesica-vaginal or vesica-intestinal fistula, which may be due to an anomaly, infection, or neoplasm; fourth, by manufacture of gas in the bladder itself. There are apparently several different ways in which gas can be produced in the bladder. It may occur in the mucosa in small blebs, ranging in size from that of a pinhead to a pea. These may cover a part or all of the bladder and, when rupturing, release gas. On cystoscopy, the bladder wall presents a silvery appearance, and one can actually observe the rupture of these vesicles. Microscopically, these air cysts are either lined with endothelial cells and multinuclear giant cells derived from the endothelium or they have no cellular lining at all and are surrounded by several layers of homogeneous fibers. The first type of cyst probably represents lymphatic distention; the other type is merely an enlarged tissue space. There are on record cases in which gas was produced in a diverticulum of the bladder. One author described gas coming from a ureteral opening and disappearing after nephrotomy. Gas, whether formed in blebs in the mucosa or in the urine itself, is probably due to the presence of gas-forming bacteria. Bacteria have been found in the mucosa in all cases examined postmortem with a single exception, but the type of organism is not constant. The most common is the colon bacillus; others are Bacillus lactis aerogenes, Bacillus aerogenes capsulaius, and yeast. Certain strains of bacteria are able to form gas from sugar, and a high percentage of the recorded cases of pneumaturia have been in diabetics. Taussig reported a case in which colon bacilli were found that were able to produce gas in the presence of sugar, but after several generations apparently lost this power. On analysis, the gas has always been found to be carbon dioxide. In cases without glycosuria, it is possible that the urine contains some type of albuminose protein capable of forming gas when the strain of bacteria in the bladder has gas-producing powers.