Computed tomography findings of irregular, gas-containing bladder nodules may help physicians identify bladder fungal balls, a rare cause of urinary obstruction, according to a case report.
Researchers described a 66-year-old patient with poorly controlled diabetes and hypertension who presented with urinary frequency, urgency, hematuria, and passage of particulate matter. The patient also passed soft, friable masses per urethra, which were later evaluated pathologically. Noncontrast computed tomography (CT) showed multiple irregular, mixed-attenuation nodules within the bladder lumen, with intraluminal gas and findings consistent with emphysematous cystitis. The largest nodule measured approximately 2.5 cm.
Pathologic evaluation of expelled material demonstrated fungal hyphae, and urine culture confirmed Candida tropicalis. The nodules had a mean attenuation of −170 Hounsfield units, suggesting a high gas component compared with a prior report.
Following 10 days of intravenous fluconazole and improved glycemic control, repeat CT showed resolution of intramural gas but enlargement and coalescence of the nodules, resulting in near-complete filling of the bladder lumen and bladder outlet obstruction. This progression indicated that antifungal therapy alone was insufficient to resolve the obstructing masses.
The imaging appearance may overlap with other conditions, including enterovesical fistula or blood clots. However, the absence of a fistulous tract, lack of extraluminal inflammation, and clinical absence of fecaluria may help distinguish fungal balls from enterovesical fistula in patients with diabetes.
Management typically involves antifungal therapy combined with procedural removal, such as cystoscopic evacuation or irrigation. In this case, procedural intervention was recommended but declined by the patient despite worsening obstruction.
The report is limited by its single-patient design, lack of long-term follow-up, and absence of definitive intervention, which limits assessment of treatment effectiveness and generalizability.
“The CT finding of multiple irregular bladder nodules with associated emphysematous cystitis should raise strong suspicion for bladder fungal balls,” wrote lead researcher Lan Zhang, MMEd, of The Fourth Affiliated Hospital Zhejiang University School of Medicine, and colleagues.
The researchers reported no conflicts of interest.
Source: Medicine