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Enterovesical Fistula

Vesicointestinal Fistula

An enterovesical fistula (EVF) is a connection between the lumens of the intestines and the bladder. It is an abnormal and rare condition that is usually secondary to another gastrointestinal condition, such as cancer or trauma.


Presentation

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]
  • He had a recurrent urinary tract infection history for 6 months.[ncbi.nlm.nih.gov]
  • RESULTS: Recurrent urinary tract infection (UTI) accounted for 73% and was the most common presenting symptom. Fecaluria (43%) and urine per rectum (40%) were another two common presenting symptoms.[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]
  • Many patients also present with recurrent urinary tract infections not eradicated with multiple courses of antibiotics.[visualdx.com]
Gangrene
  • A 37-year-old man presented with a large periurethral abscess and Fournier's gangrene. During the ensuing evaluation and treatment, he was found to have previously undiagnosed Crohn's disease with a complex enterovesical fistula.[ncbi.nlm.nih.gov]
  • […] appendicitis. [11, 12, 13, 14] Enterovesical fistula formation due to lymphadenopathy associated with Fabry disease has been reported. [15] Rarely, the bladder is the origin of the inflammatory process, as noted in a case report from Spain of bladder gangrene[thehealthscience.com]
  • Colovesical fistula secondary to vesical gangrene in a diabetic patient. J Urol. 1991 Oct. 146(4):1115-7. [Medline]. Abbas F, Memon A. Colovesical fistula: an unusual complication of prostatomegaly. J Urol. 1994 Aug. 152(2 Pt 1):479-81. [Medline].[emedicine.medscape.com]
Chronic Infection
  • Fistulae from the bowel to the ureter and the renal pelvis are also possible but uncommon in the absence of trauma, chronic infection, or surgical interventions.[thehealthscience.com]
  • The discomfort associated with the existence of persistent urinary fistulae (fecaluria), associated complications of CD (intestinal obstruction, abscess, and abdominal mass) [1,13,16,17] , or the threat to renal function in chronic infection [1,13,30][urotoday.com]
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]
  • soft tissue masses [21] .[urotoday.com]
Pseudotumor
  • “Inflammatory pseudotumor of the urinary bladder. A clinicopathological, immunohistochemical, ultrastructural, and flow cytometric study of 13 cases.” Am J Surg Pathol 17(3): 264-274. PubMed ; CrossRef Benchekroun, A., H. A. el Alj, et al. (2003).[urotoday.com]
Suprapubic Pain
  • 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]
  • Patients with enterovesical fistulae typically present with suprapubic pain, dysuria, frequency, and symptoms of urinary tract infection.[visualdx.com]
  • Symptoms include suprapubic pain, irritative voiding symptoms, and symptoms associated with chronic urinary tract infection (UTI).[thehealthscience.com]
Tenesmus
  • Gouveneur’s sign, which is frequency, dysuria, tenesmus and suprapubic pain, is highly suggestive of EVF. Fecaluria is confirmation of the presence of an EVF, however pneumaturia can occur due to infections by certain micro-organisms.[symptoma.com]
  • Gouverneur syndrome or suprapubic pain, frequency, dysuria, and tenesmus are the hallmarks of enterovesical fistulae. Many patients also present with recurrent urinary tract infections not eradicated with multiple courses of antibiotics.[visualdx.com]
  • The hallmark of enterovesical fistulae may be described as Gouverneur syndrome, namely, suprapubic pain, frequency, dysuria, and tenesmus.[thehealthscience.com]
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]
  • The sonographic detection of a meconium concretion in the fetal bladder strongly suggests the presence of an enterovesical fistula.[ncbi.nlm.nih.gov]
  • This suggests that treatment with octreotide may have enabled closure of the fistula. Thus, octreotide should be considered a viable therapeutic option in terminally ill patients with inoperable internal fistula.[ncbi.nlm.nih.gov]
  • Cystoscopy was suggestive of the diagnosis in 18 of 20 patients so examined. Treatment consisted of ileocecal resection with primary anastomosis (25) or exteriorization (4).[ncbi.nlm.nih.gov]
  • Unexplained hyperchloremic metabolic acidosis with hypokalemia may suggest the presence of an enterovesical fistula in patients with a surgical history of malignant pelvic tumor and neurogenic bladder dysfunction.[ncbi.nlm.nih.gov]
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]
Bladder Neck Obstruction
  • Reflex neuropathic bladder, not elsewhere classified N31.2 Flaccid neuropathic bladder, not elsewhere classified N31.8 Other neuromuscular dysfunction of bladder N31.9 Neuromuscular dysfunction of bladder, unspecified N32 Other disorders of bladder N32.0 Bladder-neck[icd10data.com]
Urinary Incontinence
Foul Smelling Urine
  • 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]

Workup

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.

Treatment

  • Reports of surgical or pharmacologic treatment of vesicoenteric fistula in terminally ill patients with cancer are rare.[ncbi.nlm.nih.gov]
  • Treatment of this entity should be individualized according to each patients clinical status.[ncbi.nlm.nih.gov]
  • One-stage resection of the inflamed bowel with fistula and affected the bladder wall was proved to be an effective treatment for these three patients, while a long term follow up is specifically necessary in the patient with Crohn's disease.[ncbi.nlm.nih.gov]
  • However, only a minority of fistulae subsides under this treatment [26] . Thus, surgery remains the treatment of choice [31] .[urotoday.com]

Prognosis

  • 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]
  • […] 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]

Etiology

  • 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]
  • The etiology, symptoms on presentation, diagnostic tools, and modality of treatment were analyzed.[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]

Epidemiology

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

Pathophysiology

  • 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]

Prevention

  • 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]
  • Maintenance therapy may be required in some cases with severe relapse and complicated and extensive involvement to prevent fistulae recurrence after surgery.[urotoday.com]

References

Article

  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.

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Last updated: 2019-07-11 21:00