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Urologic Aspects of Vesicoenteric Fistulas
0022-5347/78/1196-0744$02.00/0
Vol.
THE JOURNAL OF UROLOGY
Copyright ©
1978
by The Williams & Wilkins Co.
119,
June
Printed in U.S.A.
UROLOGIC ASPECTS OF VESICOENTERIC FISTULAS CULLEY C. CARSON, REZA S. MALEK* AND WILLIAM H. REMINE From the Departments of Urology and Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
ABSTRACT
The classic symptoms of pneumaturia and fecaluria were not present in many of 100 patients (male to female ratio of 2.4) with vesicoenteric fistulas who presented with fever, abdominal mass or cystitis. There was a urinary tract infection in 95 per cent of the patients studied but only 29 per cent had a mixed infection. Roent enographic studies suggested a fistul in 18 to 35 er cent of t~e studied but cystoscopy was sm ent). Inflammatory owe 1sease m 63 nd colorectal ade mgst common e 10 og,.c ac ors. Bladder carcinoma was t e cause in only 5 per cent. Treatment consisted of single or multistage surgical repair or fecal diversion in 95 operable patients, with gratifying results, and of expectant management in the 5 inoperable patients. A vesicoenteric fistula is usually a complication of inflammatory or neoplastic processes. Its characteristic symptoms of pneumaturia and fecaluria have been recognized for centuries. However, these symptoms frequently are absent, overlooked by the clinician or overshadowed by atypical and varied manifestations, with resulting delay in recognition of the condition or misdiagnosis. In an effort to increase familiarity with the diverse manifestations of vesicoenteric fistulas and to improve diagnostic accuracy our experience with 100 consecutive cases seen between 1967 and 1974 was reviewed. CLINICAL MATERIAL
matory or neoplastic processes other than those mentioned and involved the adjacent viscera. TREATMENT AND RESULTS
Of the 100 patients 95 were treated surgically and 5 were managed expectantly. Approximate! t o-thirds of the atients with inflam wen - age bowel resecti n and c r f the fistul tlie remammg r , most (27 per cent) had a 2-stage procedure, namely bowel resection and diverting colostomy followed by restoration of bowel continuity. A few patients had only fecal diversion (4 per cent) or no surgical treatment (3 per cent). Among patients with a colonic malignancy more under-
The 71 men and 29 women (male:female ratio of approximately 2.4:1) ranged in age from 16 to 87 years (mean 58 TABLE 1. Symptoms in 100 patients years). Symptoms had been present for 1 day to 17 years, with No. Pts. a mean of 14 months (table 1). Abnormal physical findings Pneumaturia 67 were noted in 63 patients (table 2). All patients had microhe- Abdominal pain 57 maturia and leukocyturia. Urine culture in 96 patients (table Dysuria 55 40 3) disclosed a significant urinary tract infection in 91 (95 per Fever 38 cent). Escherichia coli was the most common offender and 29 Fecaluria Frequency 28 per cent of the patients had a mixed infection. Hematuria 14 Roentgenologic studies included plain films of the abdomen Mucus in urine 12 8 in 82 patients, excretory urography (IVP) in 73, barium enema Urine per rectum 8 in 64, retrograde or voiding cystography in 35 and upper Blood per rectum Testicular pain 7 gastrointestinal series in 14. Appearance of air or barium in Diarrhea 5 the bladder or of contrast medium in the bowel was suggestive Other 10 of a fistula (figs. 1 and 2). The diagnostic accuracy of these studies is shown in table 4. · Proct i oidosco was ia TABLE 2. Physical findings in 100 patients stu 1ed 14 er cent and c st s dia ostic in 6 o No. Pts. atients (77 per cent . Of the fi tulas so visua ize 5 Abdominal mass 28 w~e;r_::e~o;n;_;:,;~e::..tp:;;;_o;;;st::,:;e::_r;:,:io~r""b~l~a~d~d~e:_r..:w!.,a~l~l._m~~~~~':"""~--~---Fever 26 si e. e next most common site was the bladder dome. An Abdominal tenderness 16 5 unsuspected ves1cal or prostafac neoplasm each was 1dent1fied Cutaneous fistula 5 in 1 patient (table 5). Epididymo-orchitis Normal 37 The underlying cause of fistulization was colonic diverticulitis in 51 per cent of the patients, colorectal adenocarcinoma in 16 per cent, Crohn's disease in 12 per cent and bladder TABLE 3. Urine cultures in 96 patients carcinoma in 5 per cent. Fistulas in the remaining 16 per cent No. Pts. of the patients were caused by a variety of traumatic, inflamE.coli 72 Streptococcus faecalis 18 14 Klebsiella/Aerobacter Accepted for publication July 15, 1977. Proteus 12 Read at annual meeting of North Central Section, American Pseudomonas 8 Urological Association, Palm Beach, Florida, October 17-24, 1976. Yeast 1 *Reguests for reprints: Mayo Clinic, 200 First St., S.W., RochesNo infection 9 ter; Mmnesota 55901. 744
745
VESICOENTERIC FISTULAS
A young man was referred to our clinic for evaluation and treatment of recurrent urinary tract infection. An IVP disclosed normal upper urinary tracts except for a caliceal diverticulum on the right side (fig. 3, A). The diverticulum had been thought to be the source of recurrent HV",~Ooncn its excision had been advised elsewhere. Cystoscopic u,.,~.H,,.,u suggested the presence of a fistula on the right side of bladder. Insertion of a ureteral catheter into the tract and retrograde injection of contrast medium AA,.,hr~ the presence of the fistula (fig. 3, B). An communication was identified and excised. remained asymptomatic and free of infection. Routine urinalysis may, occasionally, disclose_ ch:1mcteristica'11y··stffatecf"muscle··noerS'···crI'iaoaon1'.""o"c;ii(l~I-d§Xi~~~--fi&rn U:naig'e!it:eamtestinaTfooiTreslctueTnTh?i?atient with a fistula (fig~ "4J: 'ffowever". recurrent ctocumentecf urin~ry tract· {n:re·(;-·
Fm. l. Colovesical fistula. KVP shows normal appearance of incompletely filled bladder and irregular distribution of contrast medium in large bowel (arrows).
Fm. 2. Ileovesical fistula. Barium study of small intestine shows that air and barium have entered bladder through fistulous communication (Fis.) with diseased small bowel.
tht:e·~};Wlr~~~~ ~~;~~~~:Jt!g:ffici~!~:!~ar!t{~~?!~~:! X , . _ . _ . . -u:. orcnitts;ts·a miicn'~more·Trfaueµt Ulldrug•...aruLshoul.cL ai:eicise P . .
-J.~·-···-···"·""""'""···"'···"··'""~----····'·······1i..• .,•.
t;;r;E.
sliS'!Jic1.'onofthepresen~~--;;r;;i: Contrary to expectations uriffacy·tract1'n1ection"in'mo=st patients with a fistula to result from a single species (usually E. coli) rather than from a mixture of bacterial species (81 versus 29 per cent). in a few (5 studies of the upper and lower intestinal tracts and an IVP were suggestive of a fistula in only 18 to 21 per cent of the patients evaluated (table 4) Similarly, proctoscopy was diagnostic in only 14 per cent of the patients studied. Despite the relatively low success rate identifying a fistula with these studies none of them should be overlooked in a suspect case. They provide additional mation about the status of the remainder of the intestinal and urinary tracts and may greatly influence the approach. Retrograde or voiding cystography seems to be almost twice as successful as an IVP in demonstrating the fistulous communication (35 versus 18 per cent) but a thorough cv:,wscc1n examination of the bladder and its contents (for example, fecal material, mucus and the like) was the most singularly successful diagnostic technique (79 per cent). Transurethral attempts to catheterize the suspect tract, which is most corn-monly on the left posterior wall or dome of the bladder B), and to biopsy the bladder lesion (erythema with or ulceration), whether or not an obvious fistulous on,ornmrr visualized, are important in establishing the diagnosis and TABLE
went multistage than a single stage procedure (44 versus 31 per cent) but 25 per cent had only fecal diversion because of an inoperable malignancy. Indwelling suprapubic or urethral catheters were removed 4 to 10 days postoperatively. In the immediate postoperative period 7 patients died and major complications developed in 9. Of the 93 patients followed for 3 months to 8 years (mean 44 months) fistulas recurred in 6 (6.5 per cent). Three of these patients had Crohn's disease and the remaining 3 had carcinoma of the prostate, colon or endometrium.
4. Roentgenologic procedures Suggestive of Fistula
% ---------------~-------------··---
Cystogram Upper gastrointestinal series Barium enema
35
IVP
18
21 20 2
Plain abdominal film
TABLE
5. Cystoscopic findings in 87 patients
No. Pts. DISCUSSION
A vesicoenteric fistula occurs in only 1 of 3,000 surgical hospitalizations. l It ,£,g,!J;,)e suspected_!r2!E,.,~.J}~,Q.f.X-Qk,ll.J;l/iW; ria and fecaluria. · · t
f
Fistula Localized inflammation Bullous edema Feces Erythema Particulate matter Granulation tissue Cystitis Mass Other Normal
28 14
13 10 9
9 8 5 4 4
20
746
CARSON, MALEK AND REMINE
Fm. 3. Appendicovesical fistula. A, IVP demonstrates caliceal diverticulum -in right kidney. Remainder of upper urinary tracts and bladder outline are normal. B, in retrograde study injection of urographic contrast medium through a ureteral catheter passed transurethrally into appendicovesical fistula that filled cecum and ascending colon. other investigators the results of surgical management have been most gratifying.H Neoplastic fistulas do not imply a hopeless prognosis and, indeed, the 3-year survival rate in patients with such fistulas is 45 per cent in our series. Therefore, these findings, as well as the low mortality and recurrence rates, suggest that surgical intervention in the clinically operable patient with a fistula is the treatment of choice. REFERENCES
1. Pugh, J. I.: On the pathology and behaviour of acquired non-
2. 3. Fm. 4. Undigested muscle fiber in urine of patient with fistula. Note characteristic striations ofrhabdomyocyte. excluding a urothelial malignancy. Careful bimanual examination is important also. It is suggested in the literature that colonic diverticulitis is the most common cause of vesicoenteric fistula and this was true in our series. 1- 3 In the experience at this clinic and that of
4. 5. 6.
traumatic vesico-intestinal fistula. Brit. J. Surg., 51: 644, 1964. Best, J. W. and Davis, R. M.: Vesicointestinal fistulas. J. Urol., 101: 62, 1969. Mayo, C. W. and Blunt, C. P.: Vesicosigmoidal fistulas complicating diverticulitis. Surg., Gynec. & Obst., 91: 612, 1950. Abeshouse, B. S., Robbins, M.A., Gann, M. and Salik, J. 0.: Intestinovesical fistulas. J.A.M.A., 164: 251, 1957. Aldrete, J. S. and ReMine, W. H.: Vesicocolic fistula-a complication of colonic cancer. Long•term results of its surgical treatment. Arch. Surg., 94: 627, 1967. Ward, J. N., Lavengood, R. W., Jr., Nay, H. R. and Draper, J. W.: Diagnosis and treatment of colovesical fistulas. Surg., Gynec. & Obst., 130: 1082, 1970.
Vol.
THE JOURNAL OF UROLOGY
Copyright ©
1978
by The Williams & Wilkins Co.
119,
June
Printed in U.S.A.
UROLOGIC ASPECTS OF VESICOENTERIC FISTULAS CULLEY C. CARSON, REZA S. MALEK* AND WILLIAM H. REMINE From the Departments of Urology and Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota
ABSTRACT
The classic symptoms of pneumaturia and fecaluria were not present in many of 100 patients (male to female ratio of 2.4) with vesicoenteric fistulas who presented with fever, abdominal mass or cystitis. There was a urinary tract infection in 95 per cent of the patients studied but only 29 per cent had a mixed infection. Roent enographic studies suggested a fistul in 18 to 35 er cent of t~e studied but cystoscopy was sm ent). Inflammatory owe 1sease m 63 nd colorectal ade mgst common e 10 og,.c ac ors. Bladder carcinoma was t e cause in only 5 per cent. Treatment consisted of single or multistage surgical repair or fecal diversion in 95 operable patients, with gratifying results, and of expectant management in the 5 inoperable patients. A vesicoenteric fistula is usually a complication of inflammatory or neoplastic processes. Its characteristic symptoms of pneumaturia and fecaluria have been recognized for centuries. However, these symptoms frequently are absent, overlooked by the clinician or overshadowed by atypical and varied manifestations, with resulting delay in recognition of the condition or misdiagnosis. In an effort to increase familiarity with the diverse manifestations of vesicoenteric fistulas and to improve diagnostic accuracy our experience with 100 consecutive cases seen between 1967 and 1974 was reviewed. CLINICAL MATERIAL
matory or neoplastic processes other than those mentioned and involved the adjacent viscera. TREATMENT AND RESULTS
Of the 100 patients 95 were treated surgically and 5 were managed expectantly. Approximate! t o-thirds of the atients with inflam wen - age bowel resecti n and c r f the fistul tlie remammg r , most (27 per cent) had a 2-stage procedure, namely bowel resection and diverting colostomy followed by restoration of bowel continuity. A few patients had only fecal diversion (4 per cent) or no surgical treatment (3 per cent). Among patients with a colonic malignancy more under-
The 71 men and 29 women (male:female ratio of approximately 2.4:1) ranged in age from 16 to 87 years (mean 58 TABLE 1. Symptoms in 100 patients years). Symptoms had been present for 1 day to 17 years, with No. Pts. a mean of 14 months (table 1). Abnormal physical findings Pneumaturia 67 were noted in 63 patients (table 2). All patients had microhe- Abdominal pain 57 maturia and leukocyturia. Urine culture in 96 patients (table Dysuria 55 40 3) disclosed a significant urinary tract infection in 91 (95 per Fever 38 cent). Escherichia coli was the most common offender and 29 Fecaluria Frequency 28 per cent of the patients had a mixed infection. Hematuria 14 Roentgenologic studies included plain films of the abdomen Mucus in urine 12 8 in 82 patients, excretory urography (IVP) in 73, barium enema Urine per rectum 8 in 64, retrograde or voiding cystography in 35 and upper Blood per rectum Testicular pain 7 gastrointestinal series in 14. Appearance of air or barium in Diarrhea 5 the bladder or of contrast medium in the bowel was suggestive Other 10 of a fistula (figs. 1 and 2). The diagnostic accuracy of these studies is shown in table 4. · Proct i oidosco was ia TABLE 2. Physical findings in 100 patients stu 1ed 14 er cent and c st s dia ostic in 6 o No. Pts. atients (77 per cent . Of the fi tulas so visua ize 5 Abdominal mass 28 w~e;r_::e~o;n;_;:,;~e::..tp:;;;_o;;;st::,:;e::_r;:,:io~r""b~l~a~d~d~e:_r..:w!.,a~l~l._m~~~~~':"""~--~---Fever 26 si e. e next most common site was the bladder dome. An Abdominal tenderness 16 5 unsuspected ves1cal or prostafac neoplasm each was 1dent1fied Cutaneous fistula 5 in 1 patient (table 5). Epididymo-orchitis Normal 37 The underlying cause of fistulization was colonic diverticulitis in 51 per cent of the patients, colorectal adenocarcinoma in 16 per cent, Crohn's disease in 12 per cent and bladder TABLE 3. Urine cultures in 96 patients carcinoma in 5 per cent. Fistulas in the remaining 16 per cent No. Pts. of the patients were caused by a variety of traumatic, inflamE.coli 72 Streptococcus faecalis 18 14 Klebsiella/Aerobacter Accepted for publication July 15, 1977. Proteus 12 Read at annual meeting of North Central Section, American Pseudomonas 8 Urological Association, Palm Beach, Florida, October 17-24, 1976. Yeast 1 *Reguests for reprints: Mayo Clinic, 200 First St., S.W., RochesNo infection 9 ter; Mmnesota 55901. 744
745
VESICOENTERIC FISTULAS
A young man was referred to our clinic for evaluation and treatment of recurrent urinary tract infection. An IVP disclosed normal upper urinary tracts except for a caliceal diverticulum on the right side (fig. 3, A). The diverticulum had been thought to be the source of recurrent HV",~Ooncn its excision had been advised elsewhere. Cystoscopic u,.,~.H,,.,u suggested the presence of a fistula on the right side of bladder. Insertion of a ureteral catheter into the tract and retrograde injection of contrast medium AA,.,hr~ the presence of the fistula (fig. 3, B). An communication was identified and excised. remained asymptomatic and free of infection. Routine urinalysis may, occasionally, disclose_ ch:1mcteristica'11y··stffatecf"muscle··noerS'···crI'iaoaon1'.""o"c;ii(l~I-d§Xi~~~--fi&rn U:naig'e!it:eamtestinaTfooiTreslctueTnTh?i?atient with a fistula (fig~ "4J: 'ffowever". recurrent ctocumentecf urin~ry tract· {n:re·(;-·
Fm. l. Colovesical fistula. KVP shows normal appearance of incompletely filled bladder and irregular distribution of contrast medium in large bowel (arrows).
Fm. 2. Ileovesical fistula. Barium study of small intestine shows that air and barium have entered bladder through fistulous communication (Fis.) with diseased small bowel.
tht:e·~};Wlr~~~~ ~~;~~~~:Jt!g:ffici~!~:!~ar!t{~~?!~~:! X , . _ . _ . . -u:. orcnitts;ts·a miicn'~more·Trfaueµt Ulldrug•...aruLshoul.cL ai:eicise P . .
-J.~·-···-···"·""""'""···"'···"··'""~----····'·······1i..• .,•.
t;;r;E.
sliS'!Jic1.'onofthepresen~~--;;r;;i: Contrary to expectations uriffacy·tract1'n1ection"in'mo=st patients with a fistula to result from a single species (usually E. coli) rather than from a mixture of bacterial species (81 versus 29 per cent). in a few (5 studies of the upper and lower intestinal tracts and an IVP were suggestive of a fistula in only 18 to 21 per cent of the patients evaluated (table 4) Similarly, proctoscopy was diagnostic in only 14 per cent of the patients studied. Despite the relatively low success rate identifying a fistula with these studies none of them should be overlooked in a suspect case. They provide additional mation about the status of the remainder of the intestinal and urinary tracts and may greatly influence the approach. Retrograde or voiding cystography seems to be almost twice as successful as an IVP in demonstrating the fistulous communication (35 versus 18 per cent) but a thorough cv:,wscc1n examination of the bladder and its contents (for example, fecal material, mucus and the like) was the most singularly successful diagnostic technique (79 per cent). Transurethral attempts to catheterize the suspect tract, which is most corn-monly on the left posterior wall or dome of the bladder B), and to biopsy the bladder lesion (erythema with or ulceration), whether or not an obvious fistulous on,ornmrr visualized, are important in establishing the diagnosis and TABLE
went multistage than a single stage procedure (44 versus 31 per cent) but 25 per cent had only fecal diversion because of an inoperable malignancy. Indwelling suprapubic or urethral catheters were removed 4 to 10 days postoperatively. In the immediate postoperative period 7 patients died and major complications developed in 9. Of the 93 patients followed for 3 months to 8 years (mean 44 months) fistulas recurred in 6 (6.5 per cent). Three of these patients had Crohn's disease and the remaining 3 had carcinoma of the prostate, colon or endometrium.
4. Roentgenologic procedures Suggestive of Fistula
% ---------------~-------------··---
Cystogram Upper gastrointestinal series Barium enema
35
IVP
18
21 20 2
Plain abdominal film
TABLE
5. Cystoscopic findings in 87 patients
No. Pts. DISCUSSION
A vesicoenteric fistula occurs in only 1 of 3,000 surgical hospitalizations. l It ,£,g,!J;,)e suspected_!r2!E,.,~.J}~,Q.f.X-Qk,ll.J;l/iW; ria and fecaluria. · · t
f
Fistula Localized inflammation Bullous edema Feces Erythema Particulate matter Granulation tissue Cystitis Mass Other Normal
28 14
13 10 9
9 8 5 4 4
20
746
CARSON, MALEK AND REMINE
Fm. 3. Appendicovesical fistula. A, IVP demonstrates caliceal diverticulum -in right kidney. Remainder of upper urinary tracts and bladder outline are normal. B, in retrograde study injection of urographic contrast medium through a ureteral catheter passed transurethrally into appendicovesical fistula that filled cecum and ascending colon. other investigators the results of surgical management have been most gratifying.H Neoplastic fistulas do not imply a hopeless prognosis and, indeed, the 3-year survival rate in patients with such fistulas is 45 per cent in our series. Therefore, these findings, as well as the low mortality and recurrence rates, suggest that surgical intervention in the clinically operable patient with a fistula is the treatment of choice. REFERENCES
1. Pugh, J. I.: On the pathology and behaviour of acquired non-
2. 3. Fm. 4. Undigested muscle fiber in urine of patient with fistula. Note characteristic striations ofrhabdomyocyte. excluding a urothelial malignancy. Careful bimanual examination is important also. It is suggested in the literature that colonic diverticulitis is the most common cause of vesicoenteric fistula and this was true in our series. 1- 3 In the experience at this clinic and that of
4. 5. 6.
traumatic vesico-intestinal fistula. Brit. J. Surg., 51: 644, 1964. Best, J. W. and Davis, R. M.: Vesicointestinal fistulas. J. Urol., 101: 62, 1969. Mayo, C. W. and Blunt, C. P.: Vesicosigmoidal fistulas complicating diverticulitis. Surg., Gynec. & Obst., 91: 612, 1950. Abeshouse, B. S., Robbins, M.A., Gann, M. and Salik, J. 0.: Intestinovesical fistulas. J.A.M.A., 164: 251, 1957. Aldrete, J. S. and ReMine, W. H.: Vesicocolic fistula-a complication of colonic cancer. Long•term results of its surgical treatment. Arch. Surg., 94: 627, 1967. Ward, J. N., Lavengood, R. W., Jr., Nay, H. R. and Draper, J. W.: Diagnosis and treatment of colovesical fistulas. Surg., Gynec. & Obst., 130: 1082, 1970.