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Vesico-Appendiceal Fistulas
VESICO-APPENDICEAL FISTULAS JOHN DEJ. PEMBERTON Division of Surgery
THOMAS L. POOL Section on Urology, The Mayo Clinic AND
JOSEPH M. MILLER Fellow in Surgery, The Mayo Foundation, Rochester, Minnesota
Although vesico-intestinal fistulas occur but infrequently, their diagnosis and treatment comprise one of the more serious problems confronting the urologist and surgeon. The majority of these tracts lead from the sigmoid to the bladder and are the result of perforating diverticulitis of the sigmoid, pelvic inflammatory disease which is specific or nonspecific in origin, and carcinoma of the bowel. In a total of 592 vesico-intestinal fistulas of all types, Kellogg offered the following statistics for the more frequently occurring types : fistulas of the sigmoid, 63 per cent; fistulas of the rectum, 16 per cent; fistulas of the ileum, 4 per cent; and fistulas of the appendix, 4 per cent. Although fistulas of the appendix were, according to Kellogg, rather infrequent in appearance, the appendix was involved in 27 cases in this group. Higgins, reporting a total of 382 cases, stated that 13 such fistulas were of appendicular origin. When the cecum is in a normal anatomic position, inflammation of the appendix, unless the latter is of exceptional length, will not result in adherence or close approximation of the appendix to the bladder, but if the latter conditions do result, inflammation of the appendix may involve the wall of the bladder and a fistula may be formed thereby. It is possible in many instances of vesico-appendiceal fistula to elicit a history of acute appendicitis, either recent or remote, from the patient. Some patients will deny the previous existence of an inflammatory process involving the appendix, and in these cases a subclinical condition must be assumed to have been present. Although slight variations referable to the causative factor may be present, the general syndrome presented by patients suffering from vesico-intestinal fistula is essentially the same. A history of distress, perhaps of an acute nature, in either one or the other of the lower ab274
VESICO-APPENDICEAL FISTULAS
dominal quadrants, is usually obtained. Simultaneously with the latter, or perhaps later in the course of events, burning and frequency of urination occur. Micturition may occur hourly and it may be accompanied by a scalding pain either during or at the completion of the act. Chills and elevations of temperature may occur. With the creation of a :fistula, bubbles of gas may be passed through the urethra and such passage usually occurs at the end of micturition, but the passage of feces will not occur so frequently as the passage of flatus. The latter may not be passed at any time, however, as is illustrated by the condition of one of the patients in the present series. Pneumaturia, although it may be helpful in the diagnosis of fistula, is not pathognomonic of vesico-intestinal :fistula. The causation of pneumaturia has been discussed fully by Kelly and MacCallum, Hinman, and Riley and Bragdon. Introduction of air into the bladder during catheterization or other therapeutic procedures will result in passage of the introduced air later, and this reflux of air should be dearly distinguished from true pneumaturia. Gas which enters the bladder from the intestinal tract is another cause of pneumaturia. In occasional cases of chronic infections of the renal pelvis or bladder, pneumaturia may also occur. Symptoms referable to the urinary bladder alone may be the presenting complaints when the patient is seen first, and only after careful and repeated examinations may the true causative factor in the colonic tract be discovered. From the diagnostic standpoint, a history of passage of gas and feces through the urethra is pathognomonic of the condition. The degree of pyuria present varies; occasionally erythrocytes in small numbers are seen on microscopic examination of the urine. Less frequently is gross hematuria noted. Cystoscopy is, of course, necessary and is invaluable in the diagnosis . In vesi<;:o-appendiceal fistulas, the opening is usually present on the right side of the bladder. Frequently the aperture may not be seen, for a mass of granulation tissue or a depressed necrotic region in the bladder may be the only evidence that a fistula exists. By means of the cystoscope, gas may be seen to bubble through the opening, and occasionally, feces may exude. When a suspicion exists that a fistulous tract is present, a lead catheter may be passed very gently through the aperture and a substance opaque to the roentgen rays may be injected. The resulting shadows may be seen to outline the fistulous tract and part of the colon. Force should not be used, because the possibility of creating a
276
PEMBERTON, POOL AND MILLER
false passage thereby is a definite menace. Cystograms may be of value in that the media may outline the abnormal tract. Five patients who had vesico-appendiceal fistula have been seen and treated at The Mayo Clinic. Two of the cases have been reported briefly, elsewhere, by Rankin and Judd. Three men and 2 women ranging in age from 30 to 54 years comprise the group. Definite acute appendicitis had been present previously in 3 patients, and a fourth gave a history suggestive of the same disease. The fifth patient did not report any past symptoms which might be construed as being referable to appendiceal inflammation. Observations made in this particular case will be considered in detail subsequently. Pyuria, varying in degree, was present in all cases. Cystoscopic examination revealed diffuse inflammatory changes in 2 patients, with the same changes present at the left base of the bladder in a third. In the 2 remaining patients, the observations were limited to the right base of the bladder. Cystograms were made for but 2 patients: a sacculated bladder was found in 1 and for the other, the results of roentgenologic examination were normal. The left portion of the urinary tract was visualized once by retrograde pyelograms in the patient who had inflammatory changes at the left base of the bladder, but the results of such investigation were considered to be normal. In 2 other cases, intravenous urograms revealed that the upper urinary tract did not show abnormalities. All patients underwent operation. Appendectomy and closure of the opening into the bladder was performed in 3 cases, resulting in 1 death from general peritonitis. In the fourth patient, for whom the diagnosis was rather obscure, the bladder was opened through a suprapubic incision to investigate an ulcer of the bladder. The ulcerated region as seen through the cystoscope was found to communicate with the bowel close to the ileocecal valve and apparently to the old stump of the appendix. An opening was made into the peritoneum, a definite aperture in the cecum near the ileum was closed, and the bladder was closed from the peritoneal side. The last 18 cm. of small bowel were very much inflamed, so a Witzel type of enterostomy was performed about 5 inches (12.5 cm.) above the region. Appendectomy and cholecystectomy were performed for the remaining patient, but the patient succumbed postoperatively to acute nephritis. No evidence of peritonitis was found at postmortem examination. Illustrative of patients who have this condition is a 36 year old man who gave a history on admission to The Mayo Clinic of having passed cloudy urine
VESICO-APPENDICEAL FISTULAS
during a period of 4 years. He had noticed that occasionally the urine became dear and remained so for a variable period of time. Three weeks prior to his registration at the clinic this patient's presenting symptoms were frequency and dysuria, with terminal hematuria noted on two occasions. Local treatment to the bladder had been instituted but without result. Results of physical examination at the clinic were essentially negative save for those involving the prostate gland, which was boggy and tender to palpation. Urinalysis revealed the presence of an occasional erythrocyte and also pyuria, which was graded 3, on a basis of 1 to 4. Escherichia coli was cultured from the urine. A roentgenogram of the regions of the kidney, ureter, and
FIG. 1. Roentgenogram revealing calculus over vesical region FIG. 2. Visualization of right colon by media injected through a lead catheter
bladder revealed an hourglass shadow over the vesical region (fig. 1). Results of the excretory urogram were essentially normal except for this shadow. Under anesthesia the patient underwent cystoscopic examination and litholapaxy. A stone measuring about 1.5 by 4 cm. was found to be free in the bladder, and it was crushed and evacuated. Little or no obstruction was found at the vesical neck and a foreign body could not be found in the bladder. The cause of the formation of the calculus was therefore not clear at this time. The patient's convalescent period was uneventful and he left the hospital on the fourth postoperative day. Elixir of ammonium mandelate was prescribed, but because this patient tolerated it poorly, sulfanilamide was substituted. Six days after the patient left the hospital, fecal material was found in his
278
PEMBERTON, POOL AND MILLER
unne. On further questioning, the patient stated that he had passed such urine before his coming to the clinic. To obtain free drainage of the bladder for him, he was readmitted to the hospital and a retention catheter was left in place. Paradoxically, during his stay there for 2½ days, the urine remained crystal-clear. Roentgenographic studies of the colon and terminal portion of the ileum and a cystogram were made, but the results thereof were considered normal. Fecal material again was passed in the patient's urine, and again he underwent cystoscopy. At this time, a small opening 0.75 cm. in diameter, with some inflammatory reaction around it, was found to be situated about 1 cm. posterior to the right ureteral meatus. Because of marked irritability of the bladder, the patient was anesthetized and a no. 5 French lead catheter was gently inserted through this orifice. After injecting opaque media through the catheter, a roentgenogram was taken, and the right colon was found to be outlined by barium (fig. 2). At operation, an extremely long appendix, the tip of which was adherent to the urinary bladder, was found and removed. A single suture served to close the aperture in the bladder. Drainage of the latter for a period of 12 days was obtained by means of a urethral catheter. The patient experienced an uneventful postoperative course, and additional treatment for the residual infection of the urinary tract was continued after his dismissal from the hospital. Because of circumstances beyond the control of the patient, he considered it necessary to return home, although moderate pyuria was still present. Continued chemotherapy was to have been continued under the guidance of his home physician. SUMMARY AND CONCLUSIONS
Results from the operative treatment of fistulas such as those described herein generally are good, although the number of reported cases permits analysis of small series only. A recent report by Kellogg reveals that 100 per cent cure was obtained in 5 cases. The treatment of choice is appendectomy and simple closure of the opening in the bladder. Drainage of the latter is obtained by the insertion of a urethral catheter. Cultures of the urine should be made and appropriate chemotherapy should be instituted. REFERENCES HIGGINS, C. C.: Vesico-intestinal fistula. J. Urol., 36: 694-709, 1936. HINMAN, FRANK: The Principles and Practice of Urology. Philadelphia, W. B. Saunders Company, 1935, 1111 pp. KELLOGG, W. A.: Vesico-intestinal fistula. Am. J. Surg., 41: 135-186, 1938. KELLY, H. A., AND MACCALLUM, W. G.: Pneumaturia. J. A. M. A., 31: 375-381, 1898. RANKIN, F. W., AND JUDD, E. S.: Vesico-appendiceal fistulae; report of two cases. Surg., Gynec. & Obst., 32: 153-155, 1921. RILEY, F. G., AND BRAGDON, F. H.: Pneumaturia in diabetes mellitus; report of a case. J. A. M.A., 108: 1596-1599, 1937.
THOMAS L. POOL Section on Urology, The Mayo Clinic AND
JOSEPH M. MILLER Fellow in Surgery, The Mayo Foundation, Rochester, Minnesota
Although vesico-intestinal fistulas occur but infrequently, their diagnosis and treatment comprise one of the more serious problems confronting the urologist and surgeon. The majority of these tracts lead from the sigmoid to the bladder and are the result of perforating diverticulitis of the sigmoid, pelvic inflammatory disease which is specific or nonspecific in origin, and carcinoma of the bowel. In a total of 592 vesico-intestinal fistulas of all types, Kellogg offered the following statistics for the more frequently occurring types : fistulas of the sigmoid, 63 per cent; fistulas of the rectum, 16 per cent; fistulas of the ileum, 4 per cent; and fistulas of the appendix, 4 per cent. Although fistulas of the appendix were, according to Kellogg, rather infrequent in appearance, the appendix was involved in 27 cases in this group. Higgins, reporting a total of 382 cases, stated that 13 such fistulas were of appendicular origin. When the cecum is in a normal anatomic position, inflammation of the appendix, unless the latter is of exceptional length, will not result in adherence or close approximation of the appendix to the bladder, but if the latter conditions do result, inflammation of the appendix may involve the wall of the bladder and a fistula may be formed thereby. It is possible in many instances of vesico-appendiceal fistula to elicit a history of acute appendicitis, either recent or remote, from the patient. Some patients will deny the previous existence of an inflammatory process involving the appendix, and in these cases a subclinical condition must be assumed to have been present. Although slight variations referable to the causative factor may be present, the general syndrome presented by patients suffering from vesico-intestinal fistula is essentially the same. A history of distress, perhaps of an acute nature, in either one or the other of the lower ab274
VESICO-APPENDICEAL FISTULAS
dominal quadrants, is usually obtained. Simultaneously with the latter, or perhaps later in the course of events, burning and frequency of urination occur. Micturition may occur hourly and it may be accompanied by a scalding pain either during or at the completion of the act. Chills and elevations of temperature may occur. With the creation of a :fistula, bubbles of gas may be passed through the urethra and such passage usually occurs at the end of micturition, but the passage of feces will not occur so frequently as the passage of flatus. The latter may not be passed at any time, however, as is illustrated by the condition of one of the patients in the present series. Pneumaturia, although it may be helpful in the diagnosis of fistula, is not pathognomonic of vesico-intestinal :fistula. The causation of pneumaturia has been discussed fully by Kelly and MacCallum, Hinman, and Riley and Bragdon. Introduction of air into the bladder during catheterization or other therapeutic procedures will result in passage of the introduced air later, and this reflux of air should be dearly distinguished from true pneumaturia. Gas which enters the bladder from the intestinal tract is another cause of pneumaturia. In occasional cases of chronic infections of the renal pelvis or bladder, pneumaturia may also occur. Symptoms referable to the urinary bladder alone may be the presenting complaints when the patient is seen first, and only after careful and repeated examinations may the true causative factor in the colonic tract be discovered. From the diagnostic standpoint, a history of passage of gas and feces through the urethra is pathognomonic of the condition. The degree of pyuria present varies; occasionally erythrocytes in small numbers are seen on microscopic examination of the urine. Less frequently is gross hematuria noted. Cystoscopy is, of course, necessary and is invaluable in the diagnosis . In vesi<;:o-appendiceal fistulas, the opening is usually present on the right side of the bladder. Frequently the aperture may not be seen, for a mass of granulation tissue or a depressed necrotic region in the bladder may be the only evidence that a fistula exists. By means of the cystoscope, gas may be seen to bubble through the opening, and occasionally, feces may exude. When a suspicion exists that a fistulous tract is present, a lead catheter may be passed very gently through the aperture and a substance opaque to the roentgen rays may be injected. The resulting shadows may be seen to outline the fistulous tract and part of the colon. Force should not be used, because the possibility of creating a
276
PEMBERTON, POOL AND MILLER
false passage thereby is a definite menace. Cystograms may be of value in that the media may outline the abnormal tract. Five patients who had vesico-appendiceal fistula have been seen and treated at The Mayo Clinic. Two of the cases have been reported briefly, elsewhere, by Rankin and Judd. Three men and 2 women ranging in age from 30 to 54 years comprise the group. Definite acute appendicitis had been present previously in 3 patients, and a fourth gave a history suggestive of the same disease. The fifth patient did not report any past symptoms which might be construed as being referable to appendiceal inflammation. Observations made in this particular case will be considered in detail subsequently. Pyuria, varying in degree, was present in all cases. Cystoscopic examination revealed diffuse inflammatory changes in 2 patients, with the same changes present at the left base of the bladder in a third. In the 2 remaining patients, the observations were limited to the right base of the bladder. Cystograms were made for but 2 patients: a sacculated bladder was found in 1 and for the other, the results of roentgenologic examination were normal. The left portion of the urinary tract was visualized once by retrograde pyelograms in the patient who had inflammatory changes at the left base of the bladder, but the results of such investigation were considered to be normal. In 2 other cases, intravenous urograms revealed that the upper urinary tract did not show abnormalities. All patients underwent operation. Appendectomy and closure of the opening into the bladder was performed in 3 cases, resulting in 1 death from general peritonitis. In the fourth patient, for whom the diagnosis was rather obscure, the bladder was opened through a suprapubic incision to investigate an ulcer of the bladder. The ulcerated region as seen through the cystoscope was found to communicate with the bowel close to the ileocecal valve and apparently to the old stump of the appendix. An opening was made into the peritoneum, a definite aperture in the cecum near the ileum was closed, and the bladder was closed from the peritoneal side. The last 18 cm. of small bowel were very much inflamed, so a Witzel type of enterostomy was performed about 5 inches (12.5 cm.) above the region. Appendectomy and cholecystectomy were performed for the remaining patient, but the patient succumbed postoperatively to acute nephritis. No evidence of peritonitis was found at postmortem examination. Illustrative of patients who have this condition is a 36 year old man who gave a history on admission to The Mayo Clinic of having passed cloudy urine
VESICO-APPENDICEAL FISTULAS
during a period of 4 years. He had noticed that occasionally the urine became dear and remained so for a variable period of time. Three weeks prior to his registration at the clinic this patient's presenting symptoms were frequency and dysuria, with terminal hematuria noted on two occasions. Local treatment to the bladder had been instituted but without result. Results of physical examination at the clinic were essentially negative save for those involving the prostate gland, which was boggy and tender to palpation. Urinalysis revealed the presence of an occasional erythrocyte and also pyuria, which was graded 3, on a basis of 1 to 4. Escherichia coli was cultured from the urine. A roentgenogram of the regions of the kidney, ureter, and
FIG. 1. Roentgenogram revealing calculus over vesical region FIG. 2. Visualization of right colon by media injected through a lead catheter
bladder revealed an hourglass shadow over the vesical region (fig. 1). Results of the excretory urogram were essentially normal except for this shadow. Under anesthesia the patient underwent cystoscopic examination and litholapaxy. A stone measuring about 1.5 by 4 cm. was found to be free in the bladder, and it was crushed and evacuated. Little or no obstruction was found at the vesical neck and a foreign body could not be found in the bladder. The cause of the formation of the calculus was therefore not clear at this time. The patient's convalescent period was uneventful and he left the hospital on the fourth postoperative day. Elixir of ammonium mandelate was prescribed, but because this patient tolerated it poorly, sulfanilamide was substituted. Six days after the patient left the hospital, fecal material was found in his
278
PEMBERTON, POOL AND MILLER
unne. On further questioning, the patient stated that he had passed such urine before his coming to the clinic. To obtain free drainage of the bladder for him, he was readmitted to the hospital and a retention catheter was left in place. Paradoxically, during his stay there for 2½ days, the urine remained crystal-clear. Roentgenographic studies of the colon and terminal portion of the ileum and a cystogram were made, but the results thereof were considered normal. Fecal material again was passed in the patient's urine, and again he underwent cystoscopy. At this time, a small opening 0.75 cm. in diameter, with some inflammatory reaction around it, was found to be situated about 1 cm. posterior to the right ureteral meatus. Because of marked irritability of the bladder, the patient was anesthetized and a no. 5 French lead catheter was gently inserted through this orifice. After injecting opaque media through the catheter, a roentgenogram was taken, and the right colon was found to be outlined by barium (fig. 2). At operation, an extremely long appendix, the tip of which was adherent to the urinary bladder, was found and removed. A single suture served to close the aperture in the bladder. Drainage of the latter for a period of 12 days was obtained by means of a urethral catheter. The patient experienced an uneventful postoperative course, and additional treatment for the residual infection of the urinary tract was continued after his dismissal from the hospital. Because of circumstances beyond the control of the patient, he considered it necessary to return home, although moderate pyuria was still present. Continued chemotherapy was to have been continued under the guidance of his home physician. SUMMARY AND CONCLUSIONS
Results from the operative treatment of fistulas such as those described herein generally are good, although the number of reported cases permits analysis of small series only. A recent report by Kellogg reveals that 100 per cent cure was obtained in 5 cases. The treatment of choice is appendectomy and simple closure of the opening in the bladder. Drainage of the latter is obtained by the insertion of a urethral catheter. Cultures of the urine should be made and appropriate chemotherapy should be instituted. REFERENCES HIGGINS, C. C.: Vesico-intestinal fistula. J. Urol., 36: 694-709, 1936. HINMAN, FRANK: The Principles and Practice of Urology. Philadelphia, W. B. Saunders Company, 1935, 1111 pp. KELLOGG, W. A.: Vesico-intestinal fistula. Am. J. Surg., 41: 135-186, 1938. KELLY, H. A., AND MACCALLUM, W. G.: Pneumaturia. J. A. M. A., 31: 375-381, 1898. RANKIN, F. W., AND JUDD, E. S.: Vesico-appendiceal fistulae; report of two cases. Surg., Gynec. & Obst., 32: 153-155, 1921. RILEY, F. G., AND BRAGDON, F. H.: Pneumaturia in diabetes mellitus; report of a case. J. A. M.A., 108: 1596-1599, 1937.