Intestinovesical Fistula Due to Ingested Dental Plate

THE JOURNAL OF UROLOGY

Vol. 67, No. 3, March 1952 Printed in U.S.A.

INTESTINOVESICAL FISTULA DUE TO INGESTED DENTAL PLATE W. A. MILNER, M. J. STAPLETON

AND

C. MAMON AS

From the Departments of Urology and Surgery, Albany Medical College and Hospital, Albany, N. Y.

Vesico-intestinal fistula, or more properly intestinovesical fistula, occurs relatively infrequently. 1 It is usually due to diverticulitis of the sigmoid colon, carcinoma of the rectum, various inflammatory diseases, such as appendicitis and regional ileitis and trauma. 2 Sporadically in the literature, it has been reported as a result of an ingested foreign body or as the final location of a migrating foreign body from other tissues of the body. 3 Congenital fistulas form a relatively small group. Traumatic cases are usually due to surgery, accidents or firearms. Intestinovesical fistula, as the name implies, is a communication between the bowel and the bladder either directly or indirectly by first connecting with an abscess cavity and thence into the bowel or bladder. The fistula may be constantly patent or only intermittently so, causing considerable diagnostic confusion as a result. 4 Inflammatory fistulas are usually narrow, tortuous tracts; neoplastic ones are usually wide direct communications. Congenital fistulas are usually associated with imperforate anus. Fistulas resulting from ingested foreign bodies and migrating foreign bodies have associated ulcerative and inflammatory conditions. Most cases of intestinovesical fistula reported are due to diverticulitis or carcinoma. Fistulas caused by foreign bodies in the bowel are quite unusual. Most series usually mention one or two cases. Peters, who analyzing 542 accurate cases of fistula, listed 27 as due to foreign bodies. 4 Higgins in a series of 35 cases from the Cleveland Clinic lists one due to a pin perforating the appendix and causing vesical communication. 5 , 6 Dick reported no case of foreign body fistula in a series of 18 cases from the Lahey Clinic. 7 Barnes and Hill have placed the general incidence of intestinovesical fistula as one in 600 patients with urologic disease. 1 This is the first case of ingested foreign body causing a vesico-intestinal fistula in 15 cases of fistula at this institution. The literature on the general aspects of intestinovesical fistula has been well reviewed by various writers, dating from the time of Cripps, 8 who published the Barnes, R. W. and Hill, M. R.: Calif. & West. Med., 56: 350-354, 1942. Kellog, W. A.: Am. J. Surg., 41: 135-186, 1938. 3 Fowler, H. A.: Tr. Am. A. Genito-Urin. Surg., 25: 297-311, 1932. 4 Peters, H., Jr.: Internat. Abstr. Surg., 69: 582-589 in Surg. Gynec. and Obst., December 1939. 5 Higgins, C. C.: J. Urol., 36: 694-709, 1936. 6 Higgins, C. C.: Surg. Clin. N. Amer., pp. 1303-1309, 1939. 7 Dick, V. A.: Bulletin Lahey Clinic, 6: 21-25, 1948. 8 Cripps, H.: Quoted by Peters, H. Jr., in Internat. Abstr. Surg., 69: 582-589 in Surg. Gynec. & Obst., December 1939. 313 1

2

314

W. A. MILNER, lVI. J. STAPLETON AND C. MAlVIONAS

first comprehensive review on the subject. Since then, Kellogg,2 Higgins, 5 , 6 and Peters 4 have published outstanding contributions. More specifically on fistulas caused by foreign bodies, Fowler3 has compiled a classification from the literature. Most foreign bodies in the bladder reach there through the urethra. They may also reach there from the ureters, penetrating wounds and injuries and by migration from adjacent structures. In a series of 36 cases of migrating foreign bodies, collected by Monarschkin in 1926, only five had perforated the bowel. 9 In 1936, Herbst and Miller, 10 in an excellent review, point out that it is difficult to cull out these cases because it was not specifically stated whether the foreign body had been ingested or had been introduced into the bladder. Specific cases where foreign bodies entered the bladder other than through the urethra are as follows: Kingdon 10 in 1842 reported fistula due to a needle passing from the appendix into the bladder. Roberts 10 reported a case of bladder stone formed from a slate pencil ingested 6 months previously. A case of an elderly physician is mentioned who after 9 years of pneumaturia and fecaluria passed a partridge bone per urethram. Harrison10 reported a case of fistula caused by an ingested rabbit femur. Pins have been the most common foreign body producing fistula. 4 ooden splinters, crochet needles, and ingested bullets have also been reported. 11 Herbst 10 reported a chicken bone and Baron12 a whiskbroom bristle. Migratory bodies such as shell fragments, 13 · 14 needles, Kirschner wires, 15 bullets, 16 etc., have been reported. Our case is believed to be the first recorded instance of intestinovesical fistula due to an ingested partial dental plate. Intestinovesical fistula occurs more often in the male, 3: 1. This is said to be due to the fact that diverticulitis is more common in the male and that the uterus in the female acts as an anatomical barrier between the bowel and bladder.2, 4, 5, 6 Traumatic, congenital and neoplastic fistulas have obvious explanation for their formation. Appendiculovesical fistulas depend on an appendiceal abscess burrowing into the bladder or upon a very long pelvic appendix with subsequent appendicitis and adherence to the bladder.17 In cases of diverticulitis, developing fistulas, fecal material and bacteria fill a diverticulum. An acute inflammatory reaction develops, the opening into the bowel is closed off, peridiverticulitis occurs with formation of dense adhesions between the bladder and bowel. The inflammation may subside or suppuration may occur followed by the development of a fistula between the two organs. 5 , 6 Ingested foreign bodies form a fistula by impinging on a transverse fold of the

,v

9 Monarschkin: Quoted by Fowler, H. A., in Tr. Am. A. Genito. Urin. Surg., 25: 297311, 1932. 10 Herbst, R.H. and Miller, E. M.: J. A. M.A., 106: 2125-2128, 1936. 11 Penhallow, D. H.: Ann. Surg., 95: 792--794, 1932. 12 Baron, S. and Lipshutz, H.: J. Urol., 55: 358-362, 1946. 13 Lattimer, J. K.: J. Urol., 55: 483-485, 1946. 14 Bors, E. and Bowie, C. F.: J. Urol., 55: 358-362, 1946. 15 Branham, D. W. and Richey, H. M.: J. Urol., 57: 869, 1947. 16 Walker, A. S. and Kaufman, D.R.: Urol. and Cu tan. Rev., 46: 217-219, 1942. 17 Meisel, H.J., Kagan, H. ~- and Miller, J.M.: J. Urol., 61: 43-45, 1949.

INTESTIJ\'OVESICAL FISTULA FROM IKGEST}JD DENTAL PLATE

315

bowel. Suceessive bowel movements cause further movement through the coats by ulceration or in the ease of sharp objects by direct penetration. An inflammatory mass then forms and the foreign body is surrounded. As it continues to be extruded the inflammatory reaction spreads and attachment to neighboring; structures, such as the bladder may oceur. The foreign body then enters the bladder and the tract seals behind it or the tract remains patent.11 During the process of development, the course is eharacterized by predominantly bowel symptoms at first, then there is a free interval with no symptoms when the foreign body has penetrated one organ and lies in a loose capsule of granulation tissue. Then, as progress continues, symptoms develop in the organ about to be entered. Thus a foreign body passing from the bowel is manifested by crampy abdominal pain, loose movements, etc., and then there is a quiet period with no symptoms and then as it penetrates the bladder dysuria, pyuria. hematuria, pneumaturia and fecaluria develop. The time interval varies from a few weeks to yearsn The symptoms and signs of foreign body intestinovesical fistulas do not differ very much from those of fistulas due to other causes. The most significant findings are I) pneumaturia, 2) fecaluria and 3) passage of urine from the rectum. Although pneumaturia is very common it is not pathognomonic 18 as it may occur in yeast infections, cystitis emphysematosa, and after catheterization and instrumentation. However, it is a very valuable presumptive sign. Fecalnria is pathognomonic, but is not always present and may occur intermittently, depending on the consistency of the stools. Passage of urine in the feces is very important and associated with vesical neck obstruction or severe cystitis with thick walled bladder ,vith marked intravesical pressure. 4 Frequency, urgency, pain and strangury are more marked in foreign body fistula. The intestinal symptoms may also be more severe. Patients with persistent cystitis and upper tract infection with ehanging flora and peculiar urinary coloring must be checked for the possibilities of fistula. The diagnosis depends to a great extent on a precise history of pneumatnria, fecaluria and bowel disturbances. 'I'he precise diagnosis may only be arrived at through open surgery. 18 Cystoscopy is the best single diagnostic measure. The bladder at the site of fistula usually has a circumscribed area of bullous edema which may obscure the fistulous opening. In a few eases ureteral probing in this zone has resulted in a catheter passing through the fistula. Occasionally, feces and gas or vegetable fibers may be observed coming through the fistula. Injection of methylene blue into the bladder or rectum and subsequent visualization of it in the adjacent viscus has been tried Enemas of methylene blue with peroxide have provided an effervescent medium which may enter the bladder while the cystoscopist is studying the bladder or in reverse while the proctoscopist is studying the rectum and sigmoid. Ingested chareoal may be passed from the bladdeL Barium enemas may outline the fistulous tract 19 and in extreme cases not only outline the tract but produce a pyelogram 20 as well. This is quite rare. The chief advantage of the 18 19

20

Ewell, G. H. and Jackson, J. A.: J. Urol., 46: 693-6rl8, 1941. Leigh, T. F.: Am. J. Roentgenol., 58: 451-454, October 1947. Oldham, J.B .. Brit. ,J. Urol., 11: 247-24\l, 1939.

316

W. A. MILNER, M. J. STAPLETON AND C. MAMONAS

barium enema is to outline the bowel and give a clue as to the etiology of the fistula. Far better in some instances, is the use of dilute diodrast which by its low viscosity passes readily from bowel to bladder or vice versa and gives an important clue. Sodium iodide is too toxic if absorbed in large quantities and should not be used. As stated previously, it may be impossible to visualize the tract except at surgery. At any rate, it is always important to harbor a high index of suspicion in persistent urinary infections with bizarre odors and flora. Also in cases where known bowel disturbances have been associated with vesical symptoms, one should be suspicious. The therapy in foreign body fistula is primarily surgical.2· 4 • 5 • 6 • 7 Heretofore, surgery was performed in stages with preliminary colostomy as the first step. Occasionally, the operation was completed in one step. This was the exception, however. Today, armed with modern surgical methods and aided by bowel sterilization with sulfonamides and antibiotics, this is all done in one stage, the fistula being excised and the rent in the bladder and bowel sutured. 21 This is primarily a procedure for the general surgeon7 as the vesical component requires little more than suture of the defect and an indwelling urethral catheter for about five days. The prognosis in this type of case is excellent. CASE REPORT

A.H., No. A-85584, a 52 year old single white male grill proprietor, was admitted January 30, 1949, complaining of pneumaturia for 2 months and fecularia for l month. Eight months before admission, he lost his partial upper dental plate while on a drinking spree. He was certain he had swallowed it but was reassured by his cronies that he must have misplaced it. A thorough search having failed to locate it, he visited a physician who fluoroscoped him and found nothing. He was asymptomatic until 2 months prior to admission when he noticed gas and air coming out of his urethra either during the act of micturition or at the end. One month prior to admission, he passed fecal material per urethram. During the past month, he developed urgency and frequency, 10-12 times, but usually passed very small quantities of urine, often focally contaminated. Occasionally, bright red blood passed in the urine. Urine was not passed per rectum and there was no unusual change in bowel habits. There was a 15 pound weight loss in 6 months. Past history revealed life-long bronchial asthma and hayfever. A minor nasal operation had been performed. He suffered from chronic dyspnea and imbibed frequently to excess with poor food intake and frequency and hematuria during alcoholic sprees. The family history and review of systems revealed nothing. Physical examination revealed a poorly nourished white male, chronically dyspneic. The dyspnea was uninfluenced by position. There was mild cyanosis of nail beds and lips. There was moderate obstruction of the right nares. Chest and lungs revealed the characteristic findings of emphysema and chronic bronchial asthma. The heart and abdomen were normal. The genitalia were normal and the prostate was small and fibrotic. 21

Ormond, J. K.: J. Urol., 61: 554-556, 1949.

INTESTINOVESICAL FISTULA FROM INGESTED DENTAL PLATE

317

Urinalysis revealed numerous white cells. The hemogram was normal. Blood sugar was 80 mg. per cent, nonprotein nitrogen 33, total protein 6.2, albumin 3.8, globulin 2.4. The acid phosphatase was 2.3. An x-ray of the abdomen revealed two curved metallic foreign bodies in the approximate region of the sigmoid colon (fig. 1). Excretory urograms revealed normal functioning upper tract. Smear of the urinary sediment revealed gram positive cocci in chains. On culture there were nonhemolytic streptococci. Chest films revealed old healed pleurisy and apical tuberculosis. Cystoscopy on the day following admission revealed a small fistulous tract in the left dome of the bladder. There was a small opening with mucoid material exuding. Attempts to pass a catheter through the opening were unsuccessful. Proctoscopy revealed an obstruction at 14 cm. No fistulous tract was seen, but it was believed that obstruction might be associated with inflammatory reaction from the fistula. Unfortunately, the use of colored dyes such as methylene

FIG. 1

blue, barium enema, or cystography were not attempted as the diagnosis was obvious. The diagnosis of vesico-intestinal fistula due to foreign body, in this case a dental partial plate, was made and the patient was prepared for surgery. Sulfasuxidine, streptomycin and procaine penicillin were used preoperatively and on the fourth day of preparation laparotomy was performed. The peritoneal cavity was entered through a midline suprapubic incision with the patient under spinal anesthesia. It was at once apparent that a fistulous communication existed between the upper end of the sigmoid and the superior posterior portion of the bladder. This fistula was approximately 6 cm. in length and on palpation, the dental plate could be felt in it between the sigmoid and the bladder. The fistula was excised together with indurated tissue surrounding it (fig. 1). The rent in the bladder was closed in two layers, using No. 0000 plain catgut and a reenforcing layer of No. 0000 silk over this. The defect in the bowel was closed in three layers in similar fashion. The peritoneum was closed without drainage. An 18F Coude catheter was inserted into the bladder per urethram and left indwelling. The patient made an uneventful recovery. The catheter was removed on the

318

W. A. MILKER, M. J. STAPLETON AND C. MAMONAS

fifth postoperative day and the patient voided normally with clear urine. He was discharged on the ninth postoperative day. There has been no recurrence of symptoms to date. DISCUSSION

Often it is difficult to state whether a foreign body in the bladder has been ingested or entered the bladder by ,cvay of the urethra. The mechanics of formation of the fistula in certain instances will close the fistulous communication behind the advancing object. As the object enters the bladder it will frequently be attached to the bladder at its point of entry or a white scarred area will be observed in the bladder wall. Conversely, a foreign body entering the bladder through the urethra may frequently form a calculus and roll about free in the bladder without a point of attachment or of scarring. Cases seen in routine practice in the absence of obstructive uropathy, with persistent cystitis and recurrent urinary infection must be suspected of fistulous communication or of foreign body. There is no routine program to follow in establishing the diagnosis. The history and cystoscopy are the two most valuable aids. In the case presented, it is amazing that such an object with hooked projections at each end could progress so far before being arrested in its passage. SUMMARY

A unique case of intestinovesical fistula due to a swallowed partial plate is presented. The literature has been reviewed. Mechanisms in the formation of various types of fistulas have been presented and the clinical and diagnostic features have been discussed.

75 Willett St., Albany, N. Y.