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Case 46

Colovesical fistula

An elderly patient with change in bowel habit and dysuria

This patient presented with a history of change of bowel habit and lower abdominal pain. There had been a brief episode of rectal bleeding a few weeks earlier, and some dysuria.

The General Practitioner had recently prescribed a course of antibiotics for a suspected urinary tract infecton, but this had not helped.

A barium enema was arranged to investigate the rectal bleeding.

Findings

There are two regions of irregular, strictured colon; one at the rectosigmoid junction and another more proximally in the sigmoid. There is evidence of mucosal ulceraton. Furthermore, there is barium visible outlining the bladder on the PA view, which is more sharply delineated anteriorly on the lateral view. Contrast can be seen within a fistula connecting the colon tho the bladder on the lateral view.

Diagnosis

Moderately differentiated adenoarcinoma of the colon with colovesical fistula.

Discussion

The patient had a colonic carcinoma, and had developed a fistula to the bladder. On closer questioning a history was obtained of faecal matter being present in the urine. Some patients also complain of pneumaturia (passing air per urethra).

There are several conditions that may cause colonic strictures. If you excuse "Infiltration" for the commonest cause, malignancy, you can consider them all to begin with the letter "I"

Infiltration

Primary carcinoma and metastases, such as from breast

Inflammation

Diverticular disease and inflammatory bowel disease

Infection

Tuberculosis - usually caecal, and lymphogranuloma venereum - rectal

Ischaemia

Mesenteric ischaemia

Irradiation

Radiotherapy for pelvic tumours

Infestation

Amoebiasis

In the rectosigmoid region primary adenocarcinoma and diverticular disease are usually the cause. Both may cause fistulae, as may Crohn's disease (but not ulcerative colitis).

In this case the two involved segments are unusual, suggestive of "skip lesions" and therefore Crohn's disease. There are no visible diverticulae, though occasionally they may be obliterated if there is diverticulitis of the whole of a short involved segment. However infiltrating adenocarcinoma was demonstrated on biopsy. The extent of involvement then raises the possibility of pelvic seeding of metastases, such as from breast, though no such primary was identified in this patient and the disease was assumed to have arisen primarily in the bowel.

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