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Urology/pneumaturia,recurrent Klebsella bladder infection


Dr, I am wondering why I am having such a hard time getting my Dr.s to treat my recurrent bladder infections...BECAUSE they think I have a fistula, although all tests so far do not show one, but do show air is present in my bladder.  For 1 1/2 years I have had recurrent bladder infections and at first I would get antibiotics only when I was symptomatic (ie MISERIBLE), but 5 months ago, I started passing large amounts of air (FARTS) thru my urethra leaving no doubt now as to why I've reported "bubbles" leaking out of me for at least 1 1/2 years.  I just didn't know for sure where they were coming from till it got undeniable.Now the Dr's have told me that they prefer I do not take antibiotics until absolutely necessary, which they say is high fever and chills.  I am a medically retired RN with cardiomyopathy, CFIDS, Fibromyagia.  I was just diagnosed with DM and started on Metformin. I take 5mg of prednisone QD as well as cardiac medications.  I keep telling each doctor or surgeon exactly how the infections start.  Again and again.  Everyone just keeps running me thru all the Abdominal testing looking for the fistula.  They can't find it.  In meantime, when I get very sick I go in and get urine culture and when it gets outrageously high, they finally put me on antibiotics.  Within 4-6 urine changes smell, and as days go on gets cloudy, foul with stuff all throughout it from mucous to blood to clots, to bright red jelly rasberry sized things, occasionally things that look like lentils covered in hard mucous and when dry look mottled and biological, but not crystalized. Now I have speckled urine.  Cloudy orange urine with firm looking red dots...10 or more in a urination into a hat, not into the toliet.  I feel like I am having to get sicker and sicker before I go in and get the cultures cause lord knows they won't start me on antibiotics until the culture comes back...which sometimes takes 5-6 days before I get a call back telling me of the RX.  

I don't want surgery if not necessary and don't want to take antibiotics if I don't need them, but I have a constant dull ache in my R flank that just doesn't seem to be an issue when I mention it.  The surgeon said the GI doctor would need to determine if I have Crohns (@57 years old??) and treat it first.  But after the GI doctors checked the colon, they said no other followup was needed other than pathology for a polyp.  They felt it was unlikely I needed a Crohns workup since I was already diagnosised with IBS years ago and Small Bowel Overgrowth and treated for that 2 years ago. one knows where the infection is coming from. There is not any air within the tissues of the urinary tract.

Can you help me understand what causes the firm round red dots in my urine.  I know about blood clots and mucus and stones ...but for the life of me I can't figure out what causes my polka dot urine.

Tanya, as you might imagine, for this type of problem it is not possible for me to make an exact diagnosis or give recommendations over the internet because of the inability to take a more complete history and do a physical examination.  However, I shall try to help you.

If an individual gets air in the urinary bladder, they will often note the passage of same during urination (pneumaturia).  Not uncommonly, there are also symptoms of a urinary tract infection such as frequency and burning with urination.  The initial evaluation of this problem should be by a urologist.  He will determine if an infection is present and institute appropriate treatment.  In addition, a cystoscopic examination is generally necessary to determine the etiology of the disorder.

There are a few scenarios where air can be present in the urinary bladder.  The most common is where a communication (called a fistula) develops between the bowel and urinary bladder.  As a result, air as well as bacteria & fecal matter, can pass from the bowel into the bladder.  This type of fistula generally occurs from inflammatory types of bowel disease such as diverticulitis, ulcerative colitis or Crohn's disease.  A gastroenterologist or colorectal surgeon is the specialist who evaluates and recommends treatment options for these.  Usually surgical repair is necessary but small fistulae due to inflammatory bowel diseases can occasionally respond to medication.  The surgery is typically performed by a colorectal surgeon and urologist working together.  However, first the site of the fistula needs to located by cystoscopy, colonoscopy and specialized radiologic techniques before a definitive management plan can be recommended.  Less commonly, a fistula between the uterus and/or vagina and the bladder can produce pneumaturia.  However, with your recurrent UTIs, my money is on a bowel fistula.  

Another cause of air in the bladder is infection with gas producing bacteria.  Diabetics are more prone to the more serious types of this  condition and in them, air may also be present in the wall of the bladder.  In the latter case, they are usually quite ill with sepsis and require hospitalization, intensive care & intravenous antibiotic therapy.

Air can also be introduced into the bladder during catheterization or bladder irrigations but this does not obviously pertain in your case.  This type of air resolves or passes on its own, is quite benign and does not require treatment.

As far as the firm red dots in your urine are concerned, I would suggest you collect them in a strainer and have your urologist analyze  them.   It may be fecal debris, stone fragments or necrotic tissue sloughed from the urinary tract.  

In summary, you need to finish your evaluation to find the etiology of your problem.  You were not specific as to what studies were done but I suspect you had a colonoscopy.  If not, in addition to this, a small bowel study, evaluation of your upper urinary tract (CT or MRI), cystoscopy and cystogram and if all are negative, a gynecologic consult should be considered.  

Again, most likely is a small bowel fistula.  If present, they occasionally respond to medical measures but more often than not require surgical repair.  Good luck.


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Arthur Goldstein, M.D.


Problems or questions related to the field of urology; ie urinary stone disease, urinary cancers (kidney, bladder, prostate, testis, etc.), urinary infections, etc. I no longer answer questions related to erection problems or male sexual dysfunction.


I am retired from the active practice of urology. My 34 years was totally in the clinical field and involved the entire gamut of genitourinary problems, with special interest in endourology.

American Medical Association, American Urological Association, American College of Surgeons

College degree - BS Medical degree - MD Master of Science - MS

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