A rare case of emphysematous cystitis and intravesical fungus balls caused by Candida tropicalis.

BACKGROUND: The concurrent fungal emphysematous cystitis (EC) and bladder fungus balls in patients with urinary tract infection is rare. Diagnosis and management remain challenging because of nonspecific clinical manifestations, limited imaging features, and the lack of standardized treatment strategies. CASE PRESENTATION: A 62-year-old woman with poorly controlled type 2 diabetes mellitus (DM) presented with EC and bladder fungus balls caused by Candida tropicalis. Imaging revealed an intravesical mass surrounded by a large amount of gas. Conservative management, including antifungal therapy with fluconazole, insulin therapy, and continuous bladder irrigation with saline, was initially administered. However, persistent pain and intravesical gas required surgical intervention. Cystoscopy revealed multiple free-floating, oval, white fungal balls within the bladder, most measuring approximately 2.0 × 1.5 cm. Using a large-caliber endoscopic access sheath, transurethral cystoscopic irrigation was performed to fragment and evacuate the fungal balls. Postoperatively, the patient received systemic fluconazole therapy and bladder irrigation, resulting in recovery. CONCLUSION: The coexistence of fungal EC and bladder fungus balls should be considered in patients with DM and refractory or severe urinary tract infections when computed tomography (CT) demonstrates intravesical gas surrounding a bladder mass. Although systemic antifungal therapy, bladder irrigation, and glycemic control are primary treatment options, surgical intervention may be necessary when fungal balls are resistant to irrigation or when clinical improvement is not achieved. Transurethral cystoscopic irrigation using a large-diameter endoscopic access sheath appears to be an effective and safe treatment approach.