Three cases of emphysematous pyelonephritis are presented. All 3 patients were diabetics, they all had Escherichia coli and there was evidence of ureteral obstruction in 1 case only. All 3 patients underwent nephrectomy and survived. Initial evaluation should be performed to rule out ureteral obstruction. Treatment should consist of a brief trial of high dose antibiotic therapy with serious consideration of nephrectomy in the face of persistent symptoms or gas. Incision and drainage are reserved for poor surgical risk patients. All patients should remain on antibacterial therapy and have frequent followup examinations.