Management of a case of colovesical fistula with fecaluria as first sign

Abstract

Introduction. Fecaluria and pneumaturia are the patognomonic signs of an abnormal communication between the bladder and the intestinal tract. Therefore, when a history of digestive signs, symptoms or digestive diseases is missing, this borderline pathology leads the patients in the care of urologists. From diagnosis to treatment the management of these cases can be difficult and challenging. Materials and Methods. A 48 year old patient, without any significant medical history, presented to the emergency room for fecaluria, pneumaturia and an episode of haematuria. He had no prior digestive symptoms. The contrast enhanced abdominal and pelvic CT scan revealed a pelvic mass involving the sigmoid colon and the dome and the posterior wall of the bladder. The cystoscopy objectifies a tumor mass involving the right postero-lateral bladder wall, with extravasation of faeces. A biopsy was taken and the frozen section found mainly uncertain inflammatory type tissue. A colonoscopy couldn’t be done because of an impassable obstacle at 15 cm from the anus. Together with general surgeons we decided for en bloc resection of the tumor with partial cystectomy, right ureterocystoneostomy and rectosigmoid resection with mechanic end to end anastomosis. Results. The postoperative period was uneventful. The histopathological examination revealed an abscessed sigmoid diverticulum with vesico-sigmoid fistula and perilesional inflammatory tissue. Two years after the surgery the patient is asymptomatic with a normal function of the right kidney and restored bladder capacity. Conclusions. Being a borderline pathology, patients with fecaluria and pneumaturia and lack of digestive symptoms are referred and managed by the urologists. Despite extensive investigations, even when preoperative biopsies reveal inflammatory tissue the patients should be treated as oncologic cases. A close cooperation with general surgeons for en bloc multiorgan resection within oncologic safety margins is mandatory.

Keywords

• colo-vesical fistula
• colonic diverticulitis
• fecalurie
• pneumaturia
• haematuria