An enterovesical fistula (EVF) is a communication between the lumen of the bladder and any part of the intestines. EVF occur due to a number of factors that include infection, abdominal trauma, malignancies, chronic inflammation and surgery.

The most common form of EVF is a colovesical fistula. Rectovesical fistulae are more often observed after surgical procedures. Some larger EVF develop a system of numerous channels, frequently complicated by abscess formation, and the development of bowel obstruction [1].

Symptoms of EVF consist of both urinary and gastrointestinal complaints, which may occur simultaneously with those of the primary etiology [2]. Urinary symptoms include suprapubic pain, pneumaturia, and signs of fecal contamination of the urogenital tract, such as recurrent urinary tract infections, debris, foul smelling urine, fever and sepsis [3] [4] [5]. Gouveneur’s sign, which is frequency, dysuria, tenesmus and suprapubic pain, is highly suggestive of EVF [2]. Fecaluria is confirmation of the presence of an EVF, however pneumaturia can occur due to infections by certain micro-organisms.

• Recurrent Urinary Tract Infection

  Enterovesical fistula is a rare cause of recurrent urinary tract infections. This condition is unusual in young people as common etiologies include diverticular disease and cancer. [ncbi.nlm.nih.gov]

  Urinary symptoms include suprapubic pain, pneumaturia, and signs of fecal contamination of the urogenital tract, such as recurrent urinary tract infections, debris, foul smelling urine, fever and sepsis. [symptoma.com]

  Presenting features include fecaluria, pneumaturia and recurrent urinary tract infection [5] [6] [7]. [scirp.org]

• Soft Tissue Mass

  A list-mode dynamic data acquisition with diuresis intravenous injection revealed linear FDG activity extending from the upper-left portion of the bladder to a soft tissue mass in the lower-left pelvic region. [ncbi.nlm.nih.gov]

  Compared with other methods, the advantage of a CT scan lies in its ability to demonstrate accompanying soft tissue masses forming the fistula between the bladder and the bowel; identify intestinal diverticula; identify adhesions between the intestine [birpublications.org]

  soft tissue masses [21]. [urotoday.com]

• Weight Gain

  This case highlights the need to be aware of the rare but important occurrence of Crohn's enterovesical fistula as a cause for urinary symptoms in a child with inadequate weight gain. [ncbi.nlm.nih.gov]

• Episodic Pain

  Although the urinary tract infection was treatable with antibiotics, frequent episodic pain, due to urethritis secondary to the fistula, was not alleviated with opioid and topical treatment. [ncbi.nlm.nih.gov]

• Fishing

  At least there are FBs in the lower gastrointestinal tract like chicken bones and fish bones or Foley’s catheter in the bladder. [omicsonline.org]

• Lower Abdominal Pain

  A 43-year-old male patient with follicular B-cell lymphoma was referred for a FDG PET/CT scan due to severe left lower abdominal pain to rule out recurrent cancer. [ncbi.nlm.nih.gov]

  She also gave a history of associated lower abdominal pain. There were no other co-morbidities. On examination, patient was pale (packed cell volume was 29%). Pfannensteil scar was noted. The uterus was eighteen-week size. [scirp.org]

  Sign Up A 17-year-old female presents with a 5-day history of vague lower abdominal pain and increased urinary urgency and frequency. She has also noticed bubbles of air in her urine, that is malodorous. [knowledge.statpearls.com]

• Polydipsia

  Patients with complications of urinary diversions often appear acutely ill, with classic signs including easy fatigability, weakness, anorexia, polydipsia, and as seen in our patient, nausea, vomiting, and diarrhea. [consultant360.com]

• Tingling

  He denied fever, chills, weight change, cough, dyspnea, chest pain, hematochezia, melena, dysuria, hematuria, urinary urgency, numbness, and tingling. History. [consultant360.com]

• Urinary Urgency

  He denied fever, chills, weight change, cough, dyspnea, chest pain, hematochezia, melena, dysuria, hematuria, urinary urgency, numbness, and tingling. History. [consultant360.com]

  Sign Up A 17-year-old female presents with a 5-day history of vague lower abdominal pain and increased urinary urgency and frequency. She has also noticed bubbles of air in her urine, that is malodorous. [knowledge.statpearls.com]

• Urinary Incontinence

  incontinence References [ edit ] Bhatia J (8 January 2010). [en.wikipedia.org]

• Testicular Swelling

  Other associated symptoms include fever, abdominal/pelvic pain, haematuria, dysuria, testicular swelling and leakage of urine from the anus. [birpublications.org]

The diagnosis of EVF, initiated by clinical evaluation, is a challenge as there is no standard workup. Therefore, a significant part of investigation and management is dependent on medical imaging. Imaging can give information about the location of the fistula, as well as complications that may arise, exemplified by abscess or stricture formation [6]. Possible imaging modalities include:

• Cystoscopy: This is routinely done, although it lacks specificity for EVF. It may only reveal edematous and inflamed tissue. It correctly identifies EVF in about half of cases [3].
• Colonoscopy: This has little success in identifying EVF [7]. It is important that it is done, however, to visualize any colorectal cancer, a known etiology of EVF.
• Ultrasound: The concurrent application of pressure on the lower abdomen improves ultrasonographic diagnosis of EVF by eliciting the beak sign.
• Computerized tomography (CT) scanning: CT is the imaging modality of choice in the detection of colovesical fistulae [8]. It is excellent at visualizing collections of air or contrast outside the intestinal lumen. Three dimensional CT gives even more anatomical detail [9].
• Magnetic resonance imaging: This is advantageous as it does not involve radiation. T1 and T2 weighted images may be obtained, showing the extent of the fistula, and fluid accumulation in the tissue with associated muscle inflammation respectively. Because it is expensive, MRI is not routinely carried out [10].

Poppy seed test: Patients are asked to ingest 50 grams of poppy seeds, which are excreted in urine within a few days, confirming an EVF. Its detection rate is near perfect [7]. It cannot, however, indicate the location of the fistula or what part of the bowel is involved.

Biochemical testing may involve:

• Urinalysis: Signs of bacterial colonization, and leukocytes, are positive findings in EVF.
• Bourne test (variant): In the presence of a fistula, oral administration of charcoal causes it to appear in the urine.
• Urine culture: This will show growth of numerous bacterial species.

1. McBeath RB, Schiff M Jr, Allen V, Bottaccini MR, Miller JI, Ehreth JT. A 12-year experience with enterovesical fistulas. Urology. 1994;44(5):661–665.
2. Pontari MA, McMillen MA, Garvey RH, Ballantyne GH. Diagnosis and treatment of enterovesical fistulae. American Surgeon. 1992;58(4):258–263.
3. Daniels IR, Bekdash B, Scott HJ, Marks CG, Donaldson DR. Diagnostic lessons learnt from a series of enterovesical fistulae. Colorectal Disease. 2002;4(6):459–462.
4. Najjar SF, Jamal MK, Savas JF, Miller TA. The spectrum of colovesical fistula and diagnostic paradigm. American Journal of Surgery. 2004;188(5):617–621.
5. Melchior S, Cudovic D, Jones J, Thomas C, Gillitzer R, Thüroff J. Diagnosis and surgical management of colovesical fistulas due to sigmoid diverticulitis. The Journal of Urology. 2009;182(3):978–982.
6. Solkar MH, Forshaw MJ, Sankararajah D, Stewart M, Parker MC. Colovesical fistula—is a surgical approach always justified? Colorectal Disease. 2005;7(5):467–471.
7. Kwon EO, Armenakas NA, Scharf SC, Panagopoulos G, Fracchia JA. The poppy seed test for colovesical fistula: big bang, little bucks! The Journal of Urology. 2008;179(4):1425–1427.
8. Golabek T, Szymanska A, Szopinski T, et al. Enterovesical fistulae: aetiology, imaging, and management. Gastroenterol Res Pract. 2013;2013:617967.
9. Shinojima T, Nakajima F, Koizumi J. Efficacy of 3-D computed tomographic reconstruction in evaluating anatomical relationships of colovesical fistula. Int J Urol. 2002;9(4):230-232.
10. Ravichandran S, Ahmed HU, Matanhelia SS, Dobson M. Is there a role for magnetic resonance imaging in diagnosing colovesical fistulas?. Urology. 2008;72(4):832-837.