Enterovesical fistulas in Crohn disease

Fistulas to the urinary system in Crohn's disease: clinical features and outcomes

OBJECTIVES

Most reports of fistulas to the urinary system in Crohn's disease are relatively small. We sought to describe the clinical features and outcomes of these patients.

METHODS

A centralized diagnostic index identified all Crohn's disease patients with urinary tract fistulas who were evaluated at our institution between 1976 and 2000. Medical records were abstracted for patient demographics, presenting symptoms, diagnostic tests, and all therapies.

RESULTS

A total of 78 patients (56% men) were identified. Patients presented with pneumaturia (68%), dysuria (64%), recurrent urinary tract infections (32%), and fecaluria (28%). Cystoscopy and CT of the abdomen/pelvis had the highest diagnostic yield (74% and 52%, respectively). Fistulas originated from the ileum (64%), colon (21%), rectum (8%), and multiple sites (7%). Urinary tract sites included bladder (88%), urethra (6%), urachus (3%), ureter (1%), and other (1%). Median follow-up was 1.1 yr (0-22.3 yr). A total of 70 patients (90%) had surgery, with medical treatment first attempted in four patients with antibiotics and/or immunosuppressants. One patient had adequate symptom relief without surgery on antibiotic suppression alone. Six patients required a partial cystectomy, but no patient had a cystectomy or nephrectomy. Only three surgical patients had recurrent urinary system fistulas.

CONCLUSIONS

Urinary tract fistulas in Crohn's disease occurred more often in men. Patients with these fistulas presented with pneumaturia, dysuria, recurrent infections, and fecaluria. The most helpful diagnostic tests were cystoscopy and CT of abdomen/pelvis. Surgery resulted in durable remission. Medical therapy for these fistulas deserves further study.

Management of urinary complications in Crohn's disease

Among the 127 patients who underwent surgical treatment for Crohn's disease at Tohoku University Hospital, urinary complications were noted in 13 patients (10.2%), including urolithiasis in 6 patients (4.7%), a ureteral obstruction in 4 (3.1%), and urinary fistula in 3 (2.4%). In patients with urolithiasis, conservative therapy was effective. An ureteral obstruction was detected on the right side in all 4 of these cases because of the inflamed terminal ileum. In 2 of the 4 cases, the symptoms improved by either preoperative total parenteral nutrition or elemental diet therapy. A resection of the inflamed intestine was necessary in all cases. In patients with urinary fistulas, a resection of the inflamed intestine combined with a reconstruction of the urinary tract was carried out after total parenteral nutrition. In conclusion, conservative therapy with preoperative total parenteral nutrition or elemental diet therapy proved to be effective for a ureteral obstruction since it improved the intestinal inflammation. As a definitive treatment, surgery is still necessary for the management of urinary fistulas and ureteral obstruction. Based on our findings, patients with urolithiasis in Crohn's disease should thus be treated conservatively in the same way as patients without Crohn's disease.

Detection of colovesical fistula in the emergency department: report of a case

A case of colovesical fistula is described, revealing the pathognomonic findings of terminal pneumaturia and fecaluria. The sensitivity and specificity of various procedures that can be performed in the emergency department for confirmation of the diagnosis are evaluated. Dye studies including methylene blue, the Bourne test, the modified diatrizoate (gastrograffin) test, barium enema and cystography, cystoscopy and colocystoscopic examination, and computed tomography and nuclear medicine scans are discussed as diagnostic modalities. Surgical treatment of colovesical fistula is briefly reviewed. As colovesical fistula are thought to occur in 2% to 22% of patients with known diverticular disease, it is reasonable to question all patients with recurrent urinary tract infection, especially those with known disease of the colon, regarding symptoms of terminal pneumaturia and fecaluria.

The vesicosigmoidal fistula: diagnosis and surgical treatment

The authors report their experience in the diagnosis and treatment of 10 cases of vesicosigmoidal fistula. In accordance with the literature the most frequent presenting symptoms were of urinary origin. For the diagnosis urography was helpful, cystography and cystoscopy allowed the observation of a fistulous orifice, while barium enema confirmed, or removed probable doubts about the nature of the intestinal pathology. Surgical treatment varied from one-stage to multi-stage procedures.

Isolated pneumaturia

Sixteen patients with pneumaturia as their only urologic complaint were evaluated during a 38-year period. In three patients, a vesico-enteric fistula was documented. Five patients had an otherwise asymptomatic urinary tract infection. In eight patients, no pathologic process could be identified. These eight patients were women and had a benign course on follow-up. Urine culture gave positive results in all cases with a documented pathologic condition but gave negative results in all cases in which no explanation for pneumaturia could be found. Because of the difficulty in diagnosing a vesico-enteric fistula, all patients with isolated pneumaturia should have a thorough medical and urologic evaluation.

Acquired vesicocolonic fistula in a child: a complication in management of a neurogenic bladder

A 6-year-old girl with meningomyelocele and a neurogenic bladder was managed with clean intermittent catheterization. After 3 months she developed a vesicocolonic fistula, demonstrated on cystography. This is the first such complication reported since this type of management was popularized.