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Emphysematous Pyelonephritis (EPN) Treatment & Management

  • Author: Sugandh Shetty, MD, FRCS; Chief Editor: Edward David Kim, MD, FACS  more...
Updated: Dec 30, 2015

Approach Considerations

Patients with emphysematous pyelonephritis (EPN) should be treated with aggressive medical management and, possibly, prompt surgical intervention.[18, 19, 20] Conservative treatment using percutaneous drainage with antibiotics is indicated as follows:

  • Patients with compromised renal function
  • Early cases associated with gas in the collecting system alone and patient is in otherwise in stable condition
  • Class 1 and class 2 EPN
  • Class 3 and class 4 EPN - In the presence of fewer than 2 risk factors (eg, thrombocytopenia, elevated serum creatinine levels, altered sensorium, shock)

Huang and Tseng reported a 66% success rate with percutaneous drainage and antibiotics in patients with EPN, while Aswathaman et al found an 80% success rate.[21] Huang and Tseng also reported a 90% success rate with surgical treatment, in patients who underwent nephrectomy. The use of nephrectomy is indicated as follows:

  • Treatment of choice for most patients
  • No access to percutaneous drainage or internal stenting (after patient is stabilized)
  • Gas in the renal parenchyma or "dry-type" EPN
  • Possibly bilateral nephrectomy in patients with bilateral EPN
  • Class 3 and class 4 EPN - In the presence of more than 2 risk factors (eg, thrombocytopenia, elevated serum creatinine, altered sensorium, shock)

No contraindications exist for the treatment of EPN. The infection often has a fulminating course and can be fatal if left untreated. However, surgical intervention should be performed only after stabilization of the patient’s cardiorespiratory status. The diagram below outlines the management of EPN.

Algorithm for the management of emphysematous pyel Algorithm for the management of emphysematous pyelonephritis.

Antibiotics, Drainage, and Other Conservative Management

Prompt hydration, fluid resuscitation, and treatment with systemic antibiotics are the mainstays of management in emphysematous pyelonephritis (EPN). A monitored-care facility may be needed for patients in shock. Control of diabetes and maintenance of adequate fluid balance should be achieved quickly.

Initial antibiotic therapy consists of intravenous ampicillin, gentamicin, and metronidazole and is administered until the culture sensitivities are available. In patients with penicillin allergies, vancomycin is used in place of ampicillin. In patients with renal compromise, doses must be adjusted according to creatinine clearance.

Start imaging studies immediately. Any obstruction found should be relieved with either percutaneous drainage or stent placement. The decision regarding the use of percutaneous drainage versus a double-J stent probably depends on the patient's condition. Placement of a stent requires mild sedation or general anesthesia, whereas a percutaneous procedure can be performed with only a local anesthetic. In cases of bilateral EPN or in cases of EPN in a solitary kidney, percutaneous drainage has been useful. EPN with gas in the collecting system alone or gas and fluid in the perinephric space may respond well to percutaneous drainage.

Patients with stones and EPN deserve special mention. The presence of a stone often leads to obstruction, which must be urgently relieved with percutaneous drainage or stenting. Definitive treatment for stones should be deferred until later.

In an analysis of 48 cases, Huang and Tseng concluded that class 1 and class 2 EPN could be managed with percutaneous drainage and antibiotics.[2] In class 3 and class 4 EPN, the presence of fewer than 2 risk factors (eg, thrombocytopenia, elevated serum creatinine levels, altered sensorium, shock) indicated that percutaneous drainage and antibiotics could also be used. However, in the presence of more than 2 risk factors, nephrectomy (discussed below) yielded better results.

Sharma et al also experienced success with conservative management, but early diagnosis was important.[22]



Nephrectomy is the treatment of choice in most patients with emphysematous pyelonephritis (EPN). However, patients with EPN are extremely ill and need resuscitative measures in the intensive care unit. Surgical intervention should be performed only after stabilization of the cardiorespiratory status. A retroperitoneal flank incision is the preferred approach to avoid peritoneal contamination. Nephrectomy may be associated with significant bleeding and injury to surrounding structures.

Gas in the renal parenchyma or dry-type EPN should be treated immediately with nephrectomy. Bilateral nephrectomy may be necessary in patients with bilateral EPN. Mortality rates were 15-20% in 2 series in which nephrectomy was the treatment of choice in EPN, while in a study by Huang and Tseng, nephrectomy had a 10% mortality rate.[2, 5, 6]

Contributor Information and Disclosures

Sugandh Shetty, MD, FRCS Associate Professor of Urology, Oakland University William Beaumont School of Medicine; Attending Physician, Department of Urology, William Beaumont Hospital

Sugandh Shetty, MD, FRCS is a member of the following medical societies: American Urological Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Ajay K Singh, MB, MRCP, MBA Associate Professor of Medicine, Harvard Medical School; Director of Dialysis, Renal Division, Brigham and Women's Hospital; Director, Brigham/Falkner Dialysis Unit, Faulkner Hospital

Disclosure: Nothing to disclose.

Chief Editor

Edward David Kim, MD, FACS Professor of Surgery, Division of Urology, University of Tennessee Graduate School of Medicine; Consulting Staff, University of Tennessee Medical Center

Edward David Kim, MD, FACS is a member of the following medical societies: American College of Surgeons, Tennessee Medical Association, Sexual Medicine Society of North America, American Society for Reproductive Medicine, American Society of Andrology, American Urological Association

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Repros.

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Kidneys, ureter, and bladder imaging showing a streaky gas pattern over the entire right kidney in a patient with emphysematous pyelonephritis.
Emphysematous pyelonephritis. Kidneys, ureter, and bladder imaging showing gas over the region of the right kidney. White arrows outline the area. The faint outline of a staghorn calculus can be seen in the right kidney.
Emphysematous pyelonephritis. Renal sonogram showing hyperechoic shadows suggestive of gas along the lower pole of the kidney.
Emphysematous pyelonephritis. CT scan showing gas in the left kidney, with stones and xanthogranulomatous pyelonephritis.
CT scan showing right renal and perinephric gas in a patient with emphysematous pyelonephritis.
CT scan showing gas in both kidneys and the inferior vena cava in a patient with bilateral emphysematous pyelonephritis.
Algorithm for the management of emphysematous pyelonephritis.
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