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]

• Hodgkin Lymphoma

  Histopathological examination of resected small bowel revealed a diffuse histiocytic non-Hodgkin's lymphoma of the small bowel. The bladder mucosa was shown to be normal. [ncbi.nlm.nih.gov]

  Allograft: A Case Report. ( 28540837 ) Akateh C....El-Hinnawi A. 2017 3 Enterovesical fistula, a rare complication of Meckel's diverticulum: A case report. ( 28732299 ) M A B....M B.M. 2017 4 Enterovesical fistula caused by regressive change of non-Hodgkin's [malacards.org]

• Soft Tissue Mass

  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]

• 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]

• Bullet Wound

  Even more rare situations are iatrogenic lesions after surgery [ 3, 16 - 19 ], and bullet wounds involving at the same time bowel and bladder [ 20, 21 ]. [omicsonline.org]

• Suggestibility

  An upper gastrointestinal series performed postpartum was suggestive of Crohn's disease and confirmed an enterovesical fistula. Surgical repair was successfully performed three months following delivery, revealing Crohn's disease. [ncbi.nlm.nih.gov]

  During 5-month follow-up, the symptoms suggestive of enterovesical fistula did not recur. [ecco-ibd.eu]

  These findings suggest that computed tomography is the most accurate diagnostic tool available for demonstrating enterovesical fistulas. [mayoclinic.pure.elsevier.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.

Reports of surgical or pharmacologic treatment of vesicoenteric fistula in terminally ill patients with cancer are rare. [ncbi.nlm.nih.gov]

Results During the first 24 hours after the treatment patient suffered from temporal mild hypertension. No other AE were observed. Control cystoscopies after 2 and 3 weeks revealed complete healing of the fistula. [ecco-ibd.eu]

However, only a minority of fistulae subsides under this treatment [26]. Thus, surgery remains the treatment of choice [31]. [urotoday.com]

Treatment / Management Treatment of enterovesical fistula includes treatment of the fistula itself and the underlying disease if it is treatable. Therefore, confirming the fistula etiology should be done before planning treatment. [knowledge.statpearls.com]

Treatment and prognosis Surgical resection of the fistula and abnormal segment of bowel is usually required for cure, although in the setting of malignancy this suggests advanced disease (T4) making surgery complex. [radiopaedia.org]

[…] underwent multistage repair. [69] In general, the overall outcome and prognosis are excellent in patients with non–radiation-induced or cancer-induced fistulae. [emedicine.medscape.com]

[…] earliest treatment for colovesical fistula was defunctioning colostomy, proposed by Barbier de Melle in 1843. [9] However, it is rare for the fistula to close following this procedure alone [10] and it is therefore reserved now for patients with a poor prognosis [jscisociety.com]

Symptoms of EVF consist of both urinary and gastrointestinal complaints, which may occur simultaneously with those of the primary etiology. [symptoma.com]

This condition is unusual in young people as common etiologies include diverticular disease and cancer. When an enterovesical fistula occurs in women of childbearing age, Crohn's disease is a likely cause. [ncbi.nlm.nih.gov]

Uterine atrophy or absence may be predisposing etiologies. Etiology Fistula formation is believed to evolve from a localized perforation that has an adherent adjacent viscus. The pathologic process is almost always intestinal. [thehealthscience.com]

Crohn’s disease is the third leading etiology (5-7%). Other etiologies include chemotherapy and/or radiation complications, urogenital malignancies, and procedure related complications. [pulmonarychronicles.com]

Open Access Authors: 1, &, Younes Jabbour 1, Tarik Karmouni 1, Khalid Elkhader 1, Abdellatif Koutani 1, Ahmed Ibn attya Andaloussi 1 Publication date (Electronic): 01 October 2014 Journal: The Pan African Medical Journal Publisher: The African Field Epidemiology [scienceopen.com]

Epidemiology Frequency Colovesical fistulae are the most common type of fistulous communication between the urinary bladder and the bowel. [thehealthscience.com]

Epidemiology Among the 6081 CD patients screened, 97 patients with entero-urinary fistulas were identified, thus giving an overall frequency of 1.6% (95% CI 1.3–1.9). [academic.oup.com]

Epidemiology Colovesical fistulae are the most common type of fistulous communication between the bowel and the urinary bladder. heT incidence in patients with diverticular disease approximately 2%. [knowledge.statpearls.com]

Epidemiology High incidence in Scandinavia, N-V Europe and N-E of North America Maximum incidence y; More in Caucasians and Jewish population More in women 2 CROHN’s DISEASE Ethiology: Unknown, probably multifactorial; Potential factors involved: Genetic [slideplayer.com]

Inflammatory pathophysiology Diverticulitis accounts for approximately 50%-70% of vesicoenteric fistulae, almost all of which are colovesical. [thehealthscience.com]

Pathophysiology An enterovesical fistula usually refers to a predisposing pathophysiologic process. Therefore, the pathophysiology depends on the predisposing cause or disease. [knowledge.statpearls.com]

The mechanisms by which colovesical pathophysiology causes hyperchloraemic metabolic acidosis are discussed. [nzma.org.nz]

Inflammatory pathophysiology Diverticulitis accounts for approximately 50-70% of vesicoenteric fistulae. Diverticular fistulae are almost entirely colovesical. [arabmedmag.com]

A high index of suspicion is required to prevent a delay in the diagnosis of this disease condition. As seen in this case report, diagnosis and surgical repair of enterovesical fistula was done three years after myomectomy. [scirp.org]

Women who take antibiotics regularly to prevent bladder infections may need to discuss contraceptive options with their doctor. [merck.com]

When fistulae enter the bladder close to the trigone, avoid periureteral dissection to prevent devascularization. [emedicine.medscape.com]

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.