• General Considerations
  • Enterovesical fistulas can form between any segment of bowel in the pelvis (colon, ileum, etc.) and the bladder and or ureter.
• Etiology
  • The most common cause of enterovesical fistula is diverticular disease of the colon (50 to 70 percent)
  • Other common causes include:
    • Neoplastic disease (colon cancer)
    • Inflammatory bowel disease (Crohn's disease)
    • Radiation therapy
    • Trauma.
• Presentation
  • May present with recurrent UTIs
  • Fecaluria, pneumaturia, and hematuria.
  • Presentation with sepsis or GI symptoms is rare.
  • Gouverneur's syndrome
    • Suprapubic pain, urinary frequency, dysuria, and tenesmus
    • Hallmark of enterovesical fistula
• Evaluation
  • Charcoal test.
    • Oral activated charcoal can confirm the diagnosis of enterovesical fistula.
    • Several hours after ingestion, flecks of charcoal can be noted in the urine.
  • Cystoscopy and possible biopsy.
    • Endoscopic visualization has the highest yield for the identification of enterovesical fistula.
      • Eighty to 100 percent of cases demonstrate bullous edema, erythema, or exudation of feculent material from the fistula site
      • Generally, colonic fistulas occur on the left side and dome of the bladder, whereas small bowel fistulas occur on the dome and right side of the bladder.
      • Biopsy of the fistula is indicated in cases where malignancy is suspected.
  • Colonscopy and barium enema.
    • Although less common than diverticular disease, it is important to exclude primary intestinal malignancy as the cause for the fistula.
  • CT or MRI of the pelvis.
    • Air in the bladder in the absence of prior lower urinary instrumentation is highly suggestive of an enterovesical fistula.
  • VCUG
    • May demonstrate the fistulous connection.
    • In some cases, however, the fistula can act as a "flap valve" and contrast will not be seen entering the bowel.
• Therapy
  • Bowel rest and hyperalimentation.
    • Total parental nutrition may allow the closure of some enterovesical fistulae.
  • Medical therapy.
    • This is most applicable in enterovesical fistula secondary to Crohn's disease.
    • Appropriate use of corticosteroids, sulfasalazine, and antibiotics may promote spontaneous resolution.
  • Surgery.
    • Either one-stage or a multistage approach
      • Depends on the presence or absence of:
        • Inflammation
        • Malignancy
        • Adjacent organ involvement
      • For those cases managed with staged procedures, a temporary fecal diversion is performed at the time of fistula repair.
      • The surgery involves laparotomy, separation of the bladder from the bowel, excision of the fistula tract, and primary closure of the involved viscera.
        • Partial cystectomy and/or bowel resection may be necessary.
        • Interposition of well -vascularized tissue such as omentum between the bowel and bladder may promote healing and prevent recurrence.

References

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