What are the treatment options for feces in the urine?

Treatment Options for Feces in the Urine

The most effective treatment for fecal material in urine is surgical intervention, as this condition typically indicates an enterovesical fistula requiring definitive repair to prevent ongoing contamination, infection, and renal damage. 1, 2

Diagnosis and Evaluation

• Fecal material in urine (fecaluria) is most commonly caused by an enterovesical fistula, an abnormal connection between the bowel and urinary tract 1
• Common presenting symptoms include:
  • Pneumaturia (air in urine) - present in 68% of cases 1
  • Recurrent urinary tract infections (UTIs) - present in 32% of cases 1
  • Fecaluria (fecal material in urine) - present in 28% of cases 1
• Most effective diagnostic tests include:
  • Cystoscopy - 74% diagnostic yield 1
  • CT scan of abdomen/pelvis - 52% diagnostic yield 1
  • Cystography - 90% diagnostic yield 2
  • Barium enema - 75% diagnostic yield 2

Etiology

• The most common causes of enterovesical fistulas include:

  • Malignancy (36% of cases) 2
  • Inflammatory bowel disease, particularly Crohn's disease 1
  • Diverticulitis 2
  • Post-operative radiotherapy (17% of cases) 2
  • Iatrogenic injury (17% of cases) 2

• Most common sites of fistula origin:

  • Ileum (64% of cases) 1
  • Colon (21% of cases) 1
  • Rectum (52% of cases) 2
  • Sigmoid colon (39% of cases) 2

Treatment Options

1. Surgical Management (Primary Treatment)

• Surgical intervention is the definitive treatment for enterovesical fistulas with a 90% success rate 1
• Surgical options include:
  • Resection of the involved bowel segment with primary anastomosis 1
  • Partial cystectomy may be required in some cases (needed in 8% of patients) 1
  • Complete fistula excision with repair of both urinary and intestinal tracts 2
  • Single-stage operation is appropriate for patients in good nutritional state without severe inflammation, radiation injury, intestinal obstruction, or advanced malignancy 2
  • Multi-stage operations with temporary fecal diversion may be necessary in complex cases 3

2. Medical Management (Temporary/Adjunctive)

• Antimicrobial therapy:

  • Appropriate for managing concurrent UTIs but not curative for the fistula itself 4
  • Should cover both urinary and enteric pathogens 4
  • Empiric therapy should target Enterobacteriaceae, gram-positive cocci, and anaerobes 4
  • Fourth-generation cephalosporins are appropriate if Extended-Spectrum beta-lactamase (ESBL) is absent 4
  • Carbapenems represent a valid therapeutic option for multidrug-resistant infections 4

• Antibiotic suppression:

  • May provide temporary symptom relief but is rarely sufficient as definitive therapy 1
  • Only 1 out of 78 patients in a clinical study achieved adequate symptom relief with antibiotic suppression alone 1

3. Temporary Diversion Options

• Temporary fecal management systems:
  • Rectal tubes can effectively divert fecal matter away from fistulas 3
  • Should be used for limited periods (10-14 days) to avoid intra-rectal damage 3
  • May serve as a bridge to definitive surgical repair 3

Special Considerations

• Risk factors that may complicate management:

  • Poor nutritional status 2
  • Severe local inflammation 2
  • Prior radiation injury 2
  • Intestinal obstruction 2
  • Advanced malignancy 2
  • Advanced age 2

• A multidisciplinary approach involving urologists, colorectal surgeons, and infectious disease specialists is essential for optimal management 3

• Postoperative follow-up is crucial to monitor for recurrence, which is relatively uncommon (only 3 out of 70 surgical patients had recurrent fistulas in one study) 1

Prognosis

• With appropriate surgical intervention, the prognosis is generally good with durable remission 1
• No patient required complete cystectomy or nephrectomy in a 10-year follow-up study 1
• Recurrence rates are low (approximately 4%) following appropriate surgical management 1