From the Guidelines
A colovesicular fistula is an abnormal connection between the colon and urinary bladder that requires prompt surgical intervention to prevent complications and improve quality of life. The condition is most commonly caused by diverticulitis, colorectal or pelvic malignancies, radiation, iatrogenic injury, and postoperative complications, as noted in the study by 1. Patients typically present with pneumaturia, fecaluria, recurrent urinary tract infections, and abdominal pain.
Key Considerations
- The clinical presentation of pneumaturia or fecaluria is pathognomonic for rectovesicular fistulae, as stated in the study by 1.
- Diagnosis involves a combination of imaging studies such as CT scan with contrast, cystoscopy, colonoscopy, and sometimes a barium enema.
- The definitive treatment is surgery, which typically includes resection of the affected colon segment and primary anastomosis, along with repair or partial resection of the bladder if necessary.
Pre-Surgical Management
- Before surgery, patients should receive broad-spectrum antibiotics to control infection, such as ciprofloxacin 500mg twice daily plus metronidazole 500mg three times daily.
- In some cases, a temporary diverting colostomy may be needed.
Conservative Management
- Conservative management with antibiotics alone is generally reserved for patients who are poor surgical candidates, but this approach does not resolve the fistula.
Underlying Pathophysiology
- The underlying pathophysiology involves inflammation or malignancy causing adherence between the colon and bladder, eventually eroding through both walls to create the fistulous tract, as supported by the study by 1.
Importance of Early Intervention
- Early surgical intervention is crucial to prevent complications like sepsis and to improve quality of life by eliminating distressing symptoms.
From the Research
Definition and Causes of Colovesicular Fistula
- A colovesicular fistula is an abnormal communication between the bowel and the urinary bladder 2, 3.
- The main causes of colovesicular fistula are complicated diverticular disease, colonic and bladder cancer, and iatrogenic complications 3.
- Diverticular disease is the most common etiology, accounting for approximately 95% of cases 2 and 91% of cases 4.
Symptoms of Colovesicular Fistula
- The most common symptoms of colovesicular fistula are pneumaturia, fecaluria, and urinary tract infections 2, 3, 5.
- Pneumaturia and fecaluria were present in 90.1% of cases in one study 5.
- Urinary tract infections were present in 46.6% of cases in another study 2.
Diagnostic Investigations
- Diagnostic investigations aim to confirm the presence of a fistula 2.
- Cystoscopy, barium enema, and colonoscopy are the most frequently performed diagnostic methods 2, 6, 5.
- Abdomen computed tomography (CT) scan is also a useful diagnostic tool 2, 5.
- Cystoscopy was the most accurate test to detect fistulae in one study, followed by barium enema 5.
Treatment of Colovesicular Fistula
- Surgical treatment is the final approach for colovesicular fistula and consists of resection and reanastomosis of the offending intestinal segment, with or without bladder closure 2, 3.
- A single-stage surgical strategy is often selected 3.
- Laparoscopic treatment of colovesicular fistula is feasible and safe if performed by skilled surgeons 3, 4.
- Robotic surgery for colovesicular fistula treatment is also safe and feasible, but further studies are needed to evaluate its advantages over laparoscopy 3.
- Resection and primary anastomosis should be the treatment of choice for colovesicular fistulae, with an acceptable risk of anastomotic leak and mortality 5.