eMedicine World Medical Library

Colovesical Fistula

Last Updated: August 9, 2004
Synonyms and related keywords: enterovesical fistula, intestinovesical fistula, vesicocolic fistula, rectovesical fistula, ileovesical fistula, appendicovesical fistula, pneumaturia, fecaluria, urinary tract infections, UTIs

  AUTHOR INFORMATION  

Author: Joseph Basler, MD, Chief, Section of Urology, Audie Murphy Veterans Affairs Hospital; Associate Professor, Department of Surgery, Division of Urology, University of Texas Health Science Center, Bexar County Hospital

Coauthor(s): Angela Kamerer, MD, Attending Urologist, Gaston Urological Associates; Captain Ann Sresthadatta Fenton, MD, MPH, Staff Physician, Department of Surgery, Division of Urology, Wilford Hall Air Force Medical Center

Joseph Basler, MD, is a member of the following medical societies: American Urological Association, Society for Basic Urologic Research, Society of Urologic Oncology, and Southwestern Oncology Group

Editor(s): Erik T Goluboff, MD, Program Director, Assistant Professor, Department of Urology, Columbia-Presbyterian Medical Center, Columbia University; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, Pharmacy, eMedicine; Grannum R Sant, MD, Residency Program Director, Charles M Whitney Professor and Chairman, Department of Urology, Tufts University School of Medicine; J Stuart Wolf, Jr, MD, Director of Michigan Center for Minimally Invasive Urology, Associate Professor, Department of Urology, University of Michigan Medical Center; and Stephen W Leslie, MD, FACS, Founder and Medical Director, Lorain Kidney Stone Research Center, Clinical Assistant Professor, Department of Urology, Medical College of Ohio
  INTRODUCTION  

Normally, the urinary system is completely separated from the alimentary canal. Connections can occur as a result of (1) incomplete separation of the 2 systems during embryonic development (eg, failure of the urorectal septum to divide the common cloaca), (2) infection, (3) inflammatory conditions, (4) cancer, (5) injury, or (6) iatrogenically as a result of surgical misadventures or postoperative complications. In the general practice of medicine, the most common misconnection of the 2 systems occurs as a result of bowel disease that occurs adjacent to and erupts into the bladder. While fistulae can also occur from the bowel to the ureter and the renal pelvis, these occurrences are uncommon in the absence of trauma or surgical interventions. This article focuses on the more common causes, presentations, and treatments of enterovesical fistulae.

For excellent patient education resources, visit eMedicine's Cancer and Tumors Center and Kidneys and Urinary System Center. Also, see eMedicine's patient education articles Bladder Cancer and Bladder Control Problems.

History of the Procedure: As early as the second century AD, Rufus of Ephesus described fistulae between the bowel and the bladder. The common causes of acquired vesicoenteric fistulae have shifted from diseases of the past (eg, typhoid, amebiasis, syphilis, tuberculosis) to diverticulitis, malignancy, Crohn disease, and iatrogenic causes. Treatments have also evolved. In 1888, some suggested that colovesical fistulae "might be cured by a course of Bristol water and ass's milk." Although more invasive, certainly less colorful, and possibly more palatable, a single-stage surgical approach is more commonly employed today.

Problem: A fistula is an abnormal communication between 2 epithelialized surfaces. Vesicoenteric fistulae, also known as enterovesical or intestinovesical fistulae, occur between the bowel and the bladder. Vesicoenteric fistulae can be divided into 4 primary categories based on the bowel segment involved, as follows: (1) colovesical, (2) rectovesical (including recto-urethral), (3) ileovesical, and (4) appendicovesical fistulae. A colovesical fistula is the most common form of vesicointestinal fistula and is most commonly located between the sigmoid colon and the dome of the bladder. Rectourethral and rectovesical fistulae are observed in the postoperative setting, such as after prostatectomy, as a consequence of chronic infection or tissue destruction accompanying massive decubiti, or in the setting of acute infections such as Fournier gangrene.

Frequency: Colovesical fistulae are the most common type of fistulous communication between the urinary bladder and the bowel. The relative frequency of colovesical fistulae is difficult to ascertain because multiple disease processes and surgical procedures could be complicated by such fistulae.

The incidence of fistulae in patients with diverticular disease, the most common cause of colovesical fistula, is generally accepted to be 2%, although referral centers have reported higher percentages. Only 0.6% of carcinomas of the colon lead to fistula formation.

Colovesical fistulae occur more commonly in males, with a male-to-female ratio of 3:1. The lower incidence in females is thought to be due to interposition of the uterus and adnexa between the bladder and the colon. A 50% previous hysterectomy rate was found among women with colovesical fistulae. Other types of fistulae (typically iatrogenic such as enterovaginal, ureterovaginal, and vesicovaginal) occur more commonly than colovesical fistulae in women.

Etiology: Fistula formation is believed to evolve from a localized perforation that has an adherent adjacent viscus. The pathologic process is almost always intestinal. Pathologic processes characteristic of particular intestinal segments cause those segments to adhere to the bladder. Therefore, the location of the segment can suggest intestinal pathology.

Colovesical fistulae primarily result from diverticular disease. Ileovesical fistulae are most likely associated with Crohn disease. Rectovesical fistulae occur more frequently in the setting of trauma or malignancy. Appendicovesical fistulae tend to be associated with a history of appendicitis.

Pathophysiology: Fistulae may be either congenital or acquired (eg, inflammatory, surgical, neoplastic). Congenital vesicoenteric fistulae are rare and are often associated with an imperforate anus.

Inflammatory pathophysiology

Diverticulitis accounts for approximately 50-70% of vesicoenteric fistulae. Diverticular fistulae are almost entirely colovesical. Diverticulitis complicated by a phlegmon or an abscess may adhere to the bladder and may eventually produce perforation into the bladder, causing a fistula. This complication occurs in 2-4% of cases of diverticulitis, although referral centers have reported a higher incidence.

Crohn disease accounts for approximately 10% of vesicoenteric fistulae and is the most frequent cause of an ileovesical fistula. Ileovesical fistulae develop in 10% of patients with regional ileitis. The transmural nature of the inflammation characteristic of Crohn colitis often results in adherence to other organs. Subsequent erosion into adjacent organs can then give rise to a fistula. The mean duration of Crohn disease at the time of first symptoms of fistula formation is 10 years, and the average patient age is 30 years.

Less common inflammatory causes of colovesical fistulae include Meckel diverticulum, genitourinary coccidioidomycosis, and pelvic actinomycosis. Appendicovesical fistulae may complicate appendicitis. Enterovesical formation from lymphadenopathy associated with Fabry disease has been reported. Rarely, the bladder can be the origin of the inflammatory process, as noted in a case report from Spain of bladder gangrene that caused a colovesical fistula in a patient with diabetes mellitus.

Malignant pathophysiology

Malignancy accounts for approximately 20% of vesicoenteric fistulae. Colorectal cancer is the most common malignancy associated with a vesicoenteric fistula. Malignancy is the second most common cause of colovesical fistulae.

Transmural carcinomas of the colon and rectum may adhere to adjacent organs and may eventually invade directly, causing development of a fistula. Such an event is uncommon today because most carcinomas are diagnosed and treated before this advanced stage develops.

Occasionally, carcinomas of the bladder, cervix, prostate, and ovary are implicated, and incidents involving small bowel lymphoma have been reported. Rectovesical fistulae are frequently associated with malignancy. Interestingly, bladder carcinoma rarely, if ever, is associated with fistula formation. The reason for this may be earlier detection of bladder cancer.

Iatrogenic and/or traumatic pathophysiology

Iatrogenic fistulae are usually induced by surgical procedures, possibly tissue radiation, cancer, and/or infection. Surgical procedures, including prostatectomies, resections of benign or malignant rectal lesions, and laparoscopic inguinal hernia repair, are well-documented causes of rectovesical and rectourethral fistulae. Unrecognized rectal injury at the time of radical prostatectomy is an uncommon but well-documented etiology of rectourethral fistula.

External beam radiation or brachytherapy may cause bowel injury. Radiation-associated fistulae usually develop years after radiation therapy for a gynecologic or urologic malignancy. Fistulae develop spontaneously after perforation of the irradiated intestine, with the development of an abscess in the pelvis that subsequently drains into the adjacent bladder. Radiation-associated fistulae usually are complex and often involve more than one organ (eg, colon to bladder). Fistulae as a result of cytotoxic therapy have been reported in a patient undergoing a CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisolone) regimen for non-Hodgkin lymphoma.

Urethral disruption from blunt abdominal trauma or a penetrating injury can result in fistulae, but the fistulae typically are urethrorectal in nature. Foreign bodies in the bowel (eg, swallowed chicken bones or toothpicks) and peritoneum (eg, lost gallstone during laparoscopic cholecystectomy) have been reported to cause colovesical fistulae.

Clinical: The presenting symptoms and signs of enterovesical fistulae occur primarily in the urinary tract. Symptoms include suprapubic pain, irritative voiding symptoms, and symptoms associated with chronic urinary tract infection (UTI). Signs include abnormal urinalysis findings, malodorous urine, debris in the urine, hematuria, and UTIs.

The hallmark of enterovesicular fistulae may be described as Gouverneur syndrome, namely, suprapubic pain, frequency, dysuria, and tenesmus. Chills and fever are less common, and a colovesical fistula manifesting as sepsis is uncommon. Sepsis has been reported in 70% of patients with urinary outlet obstruction. The fistula may be asymptomatic and is seldom accompanied by dramatic or sudden abdominal symptoms or diarrhea. In most series, patients have been treated for recurrent UTI for 4-12 months before a diagnosis of fistula is made.

Pneumaturia and fecaluria may be intermittent and must be carefully sought in the history. Pneumaturia occurs in approximately 60% of patients but is nonspecific because it can be caused by gas-producing organisms (eg, Clostridium, yeast) in the bladder, particularly in patients with diabetes mellitus (ie, fermentation of diabetic urine) or in those undergoing urinary tract instrumentation. Pneumaturia is more likely to occur in patients with diverticulitis or Crohn disease than in those with cancer. Fecaluria is pathognomonic of a fistula and occurs in approximately 40% of cases. The flow through the fistula predominantly occurs from the bowel to the bladder. Patients very rarely may pass urine from the rectum.

Symptoms of the underlying disease causing the fistula may be present. Abdominal pain is a more frequent occurrence in patients with Crohn disease, but an abdominal mass is observed in fewer than 30% of patients. In patients with Crohn disease who have a fistula, abdominal mass and abscess occur more frequently.
  INDICATIONS  

The documented presence of a fistula that is causing symptoms or adversely affecting quality of life is an indication for surgical intervention in patients with enterovesical fistulae. Fistulae should be repaired in patients with abdominal pain, dysuria, malodorous urine, incontinence, urinary outlet obstruction, recurrent UTIs, bouts of sepsis, and pyelonephritis. Patients who are poor operative risks may be treated with medical therapy but may ultimately require at least diverting surgery if symptoms persist. Patients with terminal cancer often are better treated conservatively or with simple diversions.

  RELEVANT ANATOMY AND CONTRAINDICATIONS  

Relevant Anatomy: Fistula formation is believed to evolve from a localized perforation to which an adjacent viscus adheres. The pathologic process almost always is intestinal and characteristic to particular intestinal segments that adhere to the bladder. The segments that can most commonly be found in proximity to the bladder are the rectum, sigmoid colon, ileum, jejunum, and appendix. Furthermore, the segment of bowel that is involved can suggest the intestinal pathology.

Colovesical fistulae primarily result from sigmoid diverticular disease. Ileovesical fistulae are most likely associated with Crohn disease. Rectovesical fistulae occur more frequently in trauma, surgery, or malignancy. Appendicovesical fistulae tend to be associated with a history of appendicitis.

Contraindications: Poor overall general health, inability to tolerate general or regional anesthesia, and terminal cancer are contraindications for aggressive management to cure a fistula. Patients with these contraindications may be served better with medical therapy or less invasive diversions (eg, colostomy, ureterostomy, percutaneous drainage).


  WORKUP  

Lab Studies:

  • Urinalysis: Urinalysis usually shows a full field of WBCs, bacteria, and debris. A variant of the Bourne test (see Bourne test) using orally administered charcoal also is helpful. Charcoal in the urine is detected either visually or microscopically in the centrifuged urine of patients.
  • Microbiology: Urine culture findings are most commonly interpreted as mixed flora. The predominant offending organism is Escherichia coli. Attempts should be made to characterize the predominant organisms and obtain sensitivities to guide further therapy.
  • Serum studies: The blood urea nitrogen (BUN), creatinine, and electrolytes should be obtained; findings typically are within the reference range. The results of CBC typically are normal. Leukocytosis can be present in cases associated with focal areas of undrained abscess or development of florid cystitis or pyelonephritis. Anemia may be present with chronic disease and may be associated with malignancy.

Imaging Studies:

  • CT scanning
    • CT scanning of the abdomen and pelvis is the most sensitive test for detecting a colovesical fistula, and CT scanning should be included as part of the initial evaluation of patients with suspected colovesical fistulae. CT scanning can demonstrate small amounts of air or contrast material in the bladder, localized thickening of the bladder wall, or an extraluminal gas-containing mass adjacent to the bladder (see Images 1-3).
    • Preoperative CT scans of 9 consecutive patients with colovesical fistulae secondary to diverticulitis accurately predicted the presence and location of fistulae in 8 patients and led to suspicion in 1 patient.
    • In another study, 11 of 12 patients with surgically confirmed colovesical fistulae were identified preoperatively with CT scanning. CT scanning also excluded fistulae in 20 patients with uncomplicated acute diverticulitis.
    • The value of CT scanning in the process of fistula identification can be enhanced by avoiding oral contrast ingestion and having the patient evacuate rectally administered barium. CT scanning also plays an important role in preoperative surgical planning by demonstrating the extent and degree of pericolonic inflammation.

    • In another study, 3-dimensional CT scanning provided improved imaging of the anatomic relationships. Additionally, multidetector row CT urography is useful for identification of urinary tract abnormalities including fistulae.
  • Barium enema
    • Barium enema (BE) imaging rarely reveals a fistula but is useful in delineating diverticular disease from cancer. BE imaging can demonstrate the nature and extent of colonic disease.
    • A 1988 series by Woods demonstrated the fistula through BE imaging in 42% of cases.
    • Radiography of centrifuged urine samples obtained immediately after a nondiagnostic BE, called the Bourne test, may enhance the yield of the BE. Barium detected in the urine sediment confirms the presence of a fistula. In one study, the Bourne test results were positive in 9 of 10 patients. For 7 of these patients, the Bourne test was the only positive evidence of an otherwise occult colovesical fistula.
  • Cystography
    • Cystography may demonstrate contrast outside the bladder but is less likely to demonstrate a fistula.
    • Radiographic signs have been described. The herald sign is a crescentic defect on the upper margin of the bladder that is visualized best in an oblique view. The herald sign represents a perivesical abscess. A "beehive on the bladder" sign is associated with the vesical end of the fistulous tract.
    • Because of the superiority of CT scanning as a tool for making the diagnosis and guiding treatment planning, cystography is no longer used in the evaluation of a fistula.
  • Ultrasonography: Ultrasonography of colovesical fistulae has been described. Ultrasonographic examination of suspected fistulous sites has been enhanced with the technique of manual compression of the lower abdomen, which reveals an echogenic "beak sign" connecting the peristaltic bowel lumen and the urinary bladder. As with cystography, ultrasonography is rarely used for primary imaging of fistulae.
  • Magnetic resonance imaging
    • MRI can be used to identify enterovesical fistulae. In a study of 25 patients with Crohn disease, 16 patients had enterovesical, deep perineal, or cutaneous fistulae. One false-negative result occurred in a patient who had a colovesical fistula.
    • T1-weighted images provide delineation of the extension of the fistula relative to sphincters and adjacent hollow viscera and show inflammatory changes in fat planes.
    • T2-weighted images show fluid collections within the fistula, localized fluid collections in extraintestinal tissues, and inflammatory changes within muscles.
    • MRI may be useful in identifying deep perineal fistulae, but it is not generally used in the routine workup of colovesical fistulae.

Diagnostic Procedures:

  • Cystoscopy is an essential component of the diagnostic evaluation. The findings on this procedure can suggest the presence of a fistula, and cystoscopy can be used for evaluation for possible malignancy.
    • Cystoscopy can be useful in paring down the list of differential diagnoses, and it enables the physician to obtain a biopsy of the fistula to check for malignancy. Localized erythema, papillary/bullous mucosal changes, and occasionally, material oozing through an area suggest 80-90% of diagnosed cases (see Image 4). Inflammatory mucosal changes of edema and pseudopolyp formation have been termed the herald patch.
    • The initial diagnosis of a fistula is made using cystoscopy in 30-50% of cases. Cystoscopy findings confirm enterovesical fistulae in 60-75% of patients.
    • The presence of a localized area of edema and congestion is a typical finding in the early stages of a fistula. Bullous edema and mucosal papillomatous hyperplasia surround a fistula as it matures. Often, the fistula opening is not identified. Fecal material or mucus may be observed in the bladder. An attempt may be made to catheterize the tract or inject contrast retrograde to confirm the presence of fistula using plain radiography or fluoroscopy. Lesions are most commonly observed on the dome of the bladder. A lesion on the left dome of the bladder typically is diverticular. A lesion on the right posterior wall or the right dome of the bladder is more likely associated with Crohn ileitis or an appendicovesical fistula.
  • Colonoscopy: Colonoscopy, like BE, is not particularly valuable in detecting a fistula, but it is helpful in determining the nature of the bowel disease that caused the fistula and typically is part of the evaluation.
  • Laparoscopy/laparotomy
    • The use of laparoscopy has been described in diagnosing a pediatric patient with an appendicovesical fistula.
    • Adult laparoscopy is commonly used for diagnosing abdominal pain in women and may become a more frequently used diagnostic tool in men.
    • Exploratory laparotomy is used for diagnosis and therapy in all types of fistulae.
Histologic Findings: Histologic findings associated with a biopsy of fistulous sites are usually consistent with chronic inflammation. Even in the case of carcinoma, inflammation is the usual finding on the bladder side. In more advanced cases, mucin-producing adenocarcinoma may be identified. The differential diagnosis must include primary adenocarcinoma of the bladder or poorly differentiated urothelial carcinoma. The clinical scenario and findings through laparotomy usually are helpful in determining the diagnosis.

Staging: Staging is appropriate when the etiology of the fistula is carcinoma. The staging of colorectal carcinoma is discussed in other eMedicine articles such as Colon, Adenocarcinoma, Rectal Carcinoma, and Colon Cancer, Adenocarcinoma.
  TREATMENT  

Medical therapy: Nonsurgical treatment of colovesical fistulae may be a viable option in select patients who can be maintained on antibacterial therapy for symptomatic relief for a prolonged period.

Conservative treatment of colovesical fistulae has been performed in patients with diverticulitis who are deemed to be a surgical risk. In highly select patients, nonoperative therapy has been reported as a viable treatment option. Six patients observed for 3-14 years encountered little inconvenience and were without significant complications while on intermittent antibacterial therapy alone. Recent interest in conservative management has led to animal experiments showing that colovesical fistulae can be well tolerated in the absence of distal urinary or bowel obstruction (which could lead to sepsis). If a fistula closes spontaneously, which occurs in as many as 50% of patients with diverticulitis, requirements for resection depend on the nature of the underlying colonic disease. Some patients tolerate a colovesical fistula so well that surgery is deferred indefinitely.

Enterovesical fistulae due to Crohn disease may be managed conservatively with sulfasalazine, corticosteroids, antibiotics (eg, metronidazole), and 6-mercaptopurine. Six patients continued with medical therapy alone after a mean of 5 years with no instances of pyelonephritis. Two patients had successful control of their urinary symptoms. Eleven patients eventually underwent bowel resection, but persistence of the enterovesical fistula was the primary indication for elective surgery in only 2 patients.

Patients with advanced carcinoma may be treated with catheter drainage of the bladder alone or supravesical percutaneous diversion.

Surgical therapy:

Open surgery

Colovesical fistulae can almost always be treated with resection of the involved segment of colon and primary reanastomosis. When the etiology of the fistula is inflammation, the general principle is resection of the primarily affected diseased segment of intestine with or without closure of the defect in the bladder. Healing of the bladder usually is uneventful and is allowed to occur with temporary urethral catheter drainage. Suprapubic tube diversion is an option but is not necessary in this author's experience.

Staged repairs may be more judicious in patients with large intervening pelvic abscesses or in those with advanced malignancy or radiation changes. Most cases do not involve abscesses. If an abscess is present, spontaneous drainage through the fistula into the bladder may alleviate the immediate need for drainage if adequate bladder emptying under low pressure is occurring. Further operations may be delayed pending culture results and after adequate antibiotic therapy has reduced the inflammation. A one-stage operation is recommended for patients with a well-organized fistula and with no systemic infection who are in good general health.

A diverting colostomy, with or without urinary diversion, may be used in cases of advanced cancer for palliation or severe radiation damage as a long-term solution.

Endoscopic treatment

A review of the literature reveals one reported case of a colovesical fistula treated with transurethral resection with no evidence of recurrence in more than 2 years of follow-up.

Laparoscopic treatment

Several reports suggest that laparoscopic resection and reanastomosis of the offending bowel segment is possible as a minimally invasive treatment.

Preoperative details: The usual preoperative medical evaluation and staging (in the case of suspected or diagnosed cancer) should be performed. In addition, a mechanical and antibiotic bowel preparation is performed preoperatively. At this author's institution, this includes an oral gavage with GoLYTELY (or its equivalent), tap water or soapsuds enemas until clear, and oral neomycin and erythromycin base. A second-generation cephalosporin is generally administered intravenously for antibiotic prophylaxis. Other variations on this bowel preparation have also been used successfully. The goal is to clear as much fecal content and as many bacteria as possible before resection to allow uncomplicated healing after successful surgery.

Intraoperative details: The colon is mobilized proximal and distal to the fistula. Pinching the colon off the bladder by blunt dissection may be possible, but usually, this requires a careful and tedious sharp dissection.

Inflammatory fistulae

Diverticulitis is generally managed by bluntly dissecting the colon from the bladder, resecting the colon, and performing a primary anastomosis. Often, when the colon is freed from the bladder, an actual opening in the bladder is not observed. Many of these fistulous tracts are tiny, and if the opening into the bladder is not apparent, the bladder can be distended with infusion via a catheter of fluid that contains methylene blue. A large visible opening can be closed in 2 layers with interrupted absorbable sutures. Smaller lesions can be left alone.

A report of fibrin sealant closure of a contaminated fistula has been described, with no evidence of fistula recurrence at 4 years. The diseased bowel is resected, and a primary anastomosis is usually created. If suitable omentum is available, it may be interposed with tacking sutures between the bladder and bowel. Extensive inflammatory involvement of the bladder wall, once thought to require partial bladder resection, does not necessarily require removal of any part of the bladder. Excision of involved bladder tissue is necessary only for carcinoma.

Carcinoma-related fistulae

To avoid tumor spillage, a circumscribing incision around the tumor mass and through the bladder wall is undertaken. Frozen sections of the margins are sent to the histology laboratory for analysis. Further resection is undertaken as indicated, and if results of frozen section analysis eventually return as negative, a multilayered closure and omental interposition are performed. This may help reduce postoperative complications and the risk of recurrence.

Radiation-induced fistulae

Surgery for radiation-induced fistulae can be difficult. In severe cases, the colorectal and adjacent organs are matted together with no natural planes, making mobilization and resection hazardous. In this situation, performing a diverting proximal colostomy or ileostomy is advisable. In milder cases where resection can be performed safely, a descending anal anastomosis, with or without a colonic J pouch, can be performed.

The urinary system can be left intact, with catheter drainage. Healing in this situation is slow and may require longer periods of catheterization. In situations where healing is not expected, a transverse colon conduit can often be successful at restoring quality of life. Ileal and sigmoid conduits are less favorable because they often have been in the field of radiation.

Ureters

Most colovesical fistulae enter the bladder well away from the trigone. When fistulae enter the bladder close to the trigone, take care to avoid periureteral dissection. If identification is difficult, ureters can be stented intraoperatively or observed either endoscopically or through the vesicotomy after intravenous injection of indigo carmine or methylene blue. A report describes fibrin seal closure of a contaminated fistula with no evidence of recurrence after 4 years of observation.

Bladder

Surgical management of the bladder is varied. The technique of bladder repair (ie, excision versus oversewing) is not critical, and small defects do not require any particular repair. As long as adequate bladder drainage is provided, variations in bladder management are unlikely to have an impact on the patient outcome. When available, omentum should be applied to the serosal surface. No difference in patient outcome has been observed with regard to the type of suture employed, the number of layers of closure, or the type of postoperative bladder drainage.

Postoperative details: A nasogastric tube can be left in place until bowel function returns. More rapid return of bowel function may be obtained with the use of rectal suppositories (for high nonrectal fistulae). Concomitant treatment with parenteral or low-residue enteral feeding may be appropriate. Treatment with steroids is continued in patients with Crohn disease, but slower healing of the bladder should be anticipated. Bladder drainage is continued, taking care to assure low-pressure unobstructed flow of urine.

Follow-up care: After repair of the fistula for benign disease, the urinary catheter is left in place for 5-7 days or longer. The patient remains on appropriate antibiotics (ie, based on preoperative culture and sensitivity). At the next observation, a repeat urine culture and a sensitivity evaluation are obtained. Gravity cystography can be performed to confirm healing before catheter removal. Antibiotics are continued for 24-48 hours after catheter removal until the culture results are documented as negative.

Thereafter, the primary enteric process is treated as indicated, and the patient is observed periodically, using urinalysis and cultures as indicated. The patient is usually aware of the symptoms of recurrence, and he/she should be encouraged to return early if any symptoms of infection, pneumaturia, or fecaluria occur.

In the case of cancer resection, observational colonoscopy and CT scanning are obtained as indicated by tumor histology and stage. Periodic cystoscopy may also be indicated because local recurrence may be possible in the detrusor muscle. Cystoscopy is especially important if the margin status of the tumor was questionable.

Certainly, any hematuria in the postoperative period should be carefully evaluated with upper tract imaging and cystoscopy.

  COMPLICATIONS  

In a 1998 study, Woods encountered a 3.5% operative mortality rate and a complication rate of 27%. Fistula recurrences have been reported in 4-5% of patients. Most other studies have not found operative mortality rates that are this high, except in the cases of severely ill patients with other significant medical problems.

Short-term complications include the usual potential problems after general surgery (eg, fever, atelectasis, slow return of bowel function, catheter-related UTI, deep vein thrombosis [DVT], wound breakdown and infection). These complications are largely preventable with measures that include incentive spirometry, early ambulation, a thromboembolic hose or anticoagulation in susceptible patients, and appropriate wound closure techniques.

Long-term complications include persistent bladder leak (usually observed after radiotherapy for carcinoma), recurrence of a fistula (also more likely after radiotherapy), pelvic/abdominal abscess (from a leaking anastomosis), cutaneous fistulization (also from a leaking anastomosis), and bowel obstruction (from adhesions or recurrent diverticulitis).

Consider recurrent cancer in the abdomen or previously involved bladder wall when patients return with signs of bowel obstruction, new hematuria, or irritative voiding. Repeat CT scanning, serum carcinoembryonic antigen (CEA) measurement, urine culture and cytology, and cystoscopy are indicated in these settings.

  OUTCOME AND PROGNOSIS  

In a retrospective record review of 76 patients diagnosed with enterovesical fistula over a 12-year period, no statistically significant difference in the complication rate existed between groups treated with single-stage repair and groups treated with multistage repair.

In general, for patients with non–radiation-induced or cancer-induced fistulae, the overall outcome and prognosis are excellent. Such patients usually respond well to resection of the diseased colon and have no significant urinary sequelae.

The prognosis for patients with colon carcinoma and fistulization is less favorable because the involvement of the bladder usually heralds a more aggressive tumor that often is metastatic at the time of detection.

Radiation-induced fistulae are more likely to recur, but the long-term patient prognosis may be better if the malignancy for which the radiation was administered has been controlled.

  FUTURE AND CONTROVERSIES  

Future treatment of typical enterovesical fistulae may focus on development and refinement of laparoscopic techniques to allow resection with a minimal hospitalization. New modalities in neoadjuvant chemotherapy may allow further bladder preservation strategies. Trends in radiation oncology that permit minimization of collateral organ damage (eg, conformal external beam radiotherapy) and the use of tumor-specific radiosensitizing agents may be highly useful in preventing radiation-induced fistulae. Improved surgical techniques, including laparoscopic procedures that greatly enhance visualization of the operative field, hold promise for fewer fistula-related complications of gynecologic and urologic procedures.

  PICTURES  

Caption: Picture 1. Colovesical fistula. CT scan showing the adherence of the sigmoid colon to the lateral edge of the bladder.
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Picture Type: CT
Caption: Picture 2. Colovesical fistula. A lower cut of the CT scan from Image 1. Note the sigmoid colon in direct proximity to the fistula and the air in the bladder.
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Picture Type: CT
Caption: Picture 3. Colovesical fistula. A CT scan one cut further inferiorly from Images 1-2 showing the typical air pattern in the bladder and more obvious inflammatory changes at the site of the vesicoenteric fistula.
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Picture Type: CT
Caption: Picture 4. An endoscopic view of the colovesical fistula (upper right) presented in Images 1-3. Note the prominent edema and erythema characteristic of the fistula (ie, herald patch). Occasionally, a whitish discharge with the consistency of toothpaste can be observed emanating from the orifice. The presentation of a vesicoenteric fistula includes the presence of air, fecal material, and polymicrobial recurrent urinary tract infection.
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Picture Type: Photo
Caption: Picture 5. A white mucinous exudate is observed emanating from the site of a colovesical fistula in a patient with both a sigmoid diverticular abscess and colon cancer.
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Caption: Picture 6. Colovesical fistula. After a bladder wash-out, the fistula (see Image 5) appears as a raised, edematous, sessile lesion in the bladder. The air bubble is observed at the top of the photo, and some remnant mucus threads are adherent at the bottom.
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Picture Type: Photo
Caption: Picture 7. Colovesical fistula. The edema surrounding the fistula often extends for a considerable distance around the bladder wall. A cobblestone appearance is typical when chronic inflammation is present.
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Caption: Picture 8. Colovesical fistula identified on CT scan in a patient with diverticular disease and fecaluria. Arrow – fistula, B – bladder, C – sigmoid colon with diverticulae.
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Picture Type: CT
Caption: Picture 9. Same patient as Image 8 with colovesical fistula visualization on sagittal MRI. Arrow – fistula, B – bladder, C – sigmoid colon.
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Picture Type: MRI
Caption: Picture 10. Colovesical fistula. Same patient as Images 8 and 9. Operative view from superior and anterior showing the bladder (B) and colon (C) with area of erythema at the site surrounding the fistula.
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Picture Type: Photo
Caption: Picture 11. Colovesical fistula. Cystoscopic view of an anastomotic urethrorectal fistula that occurred after radical prostatectomy. The patient remains asymptomatic with occasional pneumaturia. This is an uncommon complication of radical prostatectomy.
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  BIBLIOGRAPHY  

  • Abbas F, Memon A: Colovesical fistula: an unusual complication of prostatomegaly. J Urol 1994 Aug; 152(2 Pt 1): 479-81.
  • Ambrosetti P, Robert J, Witzig JA, et al: Value of computerized tomography in acute diverticulitis of the left colon. Schweiz Med Wochenschr 1993 May 29; 123(21): 1118-20.
  • Amendola MA, Agha FP, Dent TL, et al: Detection of occult colovesical fistula by the Bourne test. AJR Am J Roentgenol 1984 Apr; 142(4): 715-8.
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