Empagliflozin-associated emphysematous cystitis: a systematic review of published case reports

Background: Emphysematous cystitis (EC) is a rare but potentially life-threatening urinary tract infection characterized by gas accumulation within the bladder wall and/or lumen, most commonly associated with gas-producing microorganisms. Sodium-glucose cotransporter-2 (SGLT2) inhibitors, including empagliflozin, promote urinary glucose excretion, raising questions about a possible association with genitourinary infections. However, the relationship between empagliflozin use and EC remains uncertain, with evidence currently limited to published case reports. Aim: To review the reported cases of emphysematous cystitis (EC) associated with empagliflozin use and to summarize the demographics, clinical features, treatment modalities and outcomes. Methodology: A systematic review was conducted using the databases PubMed/MEDLINE, Embase, Scopus and Web of Science from inception until October 2026. The review included published case reports and several patients who developed EC while taking empagliflozin. Patient characteristics, laboratory findings, radiographic findings, management strategies, and clinical outcomes were extracted and qualitatively evaluated. Results: We examined seven patient cases with ages ranging from 62 to 90 (median 76). Two patients received empagliflozin for heart failure, and five patients had type 2 diabetes. Hematuria, dysuria, frequent urination, and suprapubic discomfort were common symptoms that emerged between two weeks and eight months following treatment. Urinary retention, bladder outlet obstruction, chronic renal disease, advanced age, and recent catheterization were among the contributing variables. Klebsiella pneumoniae was the most frequently isolated microorganism, based on microbiological culture results. Computed tomography (CT) was the principal imaging modality used to confirm the diagnosis of emphysematous cystitis. Management generally included discontinuation of empagliflozin, antibiotic therapy, and bladder drainage or decompression when indicated. Five patients recovered, whereas two patients died. Conclusion: Empagliflozin-associated emphysematous cystitis is a rare but serious condition mostly seen in elderly patients with multiple health issues and urinary tract abnormalities. Early detection and treatment are crucial to minimize risks. More research is needed to understand its causes and frequency.