Who should evaluate a patient with a suspected rectal to prostatic urethral fistula?

Evaluation of Rectal to Prostatic Urethral Fistula

A multidisciplinary team including urologists, colorectal surgeons, and interventional radiologists should evaluate patients with suspected rectourethral fistula, with urologists typically taking the lead role given the urethral involvement.

Primary Specialists Required

Urology

• Urologists should be the primary evaluating specialists for rectourethral (prostatic urethral) fistulas, as these involve the urinary tract and often result from urologic procedures 1, 2
• Urologic evaluation is essential for assessing urethral involvement, stricture disease, and planning urinary diversion strategies 3
• The urologist coordinates surgical repair planning, as most successful repairs utilize transperineal approaches requiring urologic expertise 1

Colorectal Surgery

• Colorectal surgeons must be involved early in the evaluation and management, particularly for assessing rectal involvement and planning fecal diversion 3, 2
• These specialists evaluate the need for colostomy, which is often required as initial management (performed in 11/20 patients in one series) 2
• Colorectal surgeons assess sphincter function and determine feasibility of eventual stoma closure 3

Interventional Radiology

• Radiologists play a critical diagnostic role in confirming fistula presence and characterizing anatomy 4
• CT pelvis with IV contrast has 76.5% sensitivity for fistula detection and 94.1% sensitivity for defining etiology 4
• MRI pelvis with IV contrast provides superior soft-tissue resolution for evaluating fistulous tracts and active inflammation 3, 4

Diagnostic Imaging Approach

First-Line Imaging

• CT pelvis with IV contrast should be the initial imaging study for suspected rectourethral fistula, as it provides good sensitivity and defines underlying etiology 4
• Water-soluble contrast should be placed in the bowel or bladder to opacify fistulous tracts 4
• Cystography demonstrates high detection rates for enterovesicular fistulae 4

Advanced Imaging

• MRI pelvis with and without IV gadolinium contrast is superior for complex cases, providing excellent visualization of fistulous tract anatomy and associated inflammation 3, 5
• The multiplanar imaging capability and high soft-tissue resolution make MRI particularly suitable when repeat imaging is needed 3
• Fluoroscopic studies (voiding cystourethrography) can evaluate bladder or urethral fistulas but have been largely supplanted by CT and MRI 3

Clinical Presentation Recognition

Pathognomonic Signs

• Pneumaturia (air in urine) and fecaluria (fecal matter in urine) are diagnostic of rectovesical/rectourethral fistula 4
• Recurrent urinary tract infections are common presenting manifestations 4
• Patients may present with urinary symptoms mimicking other conditions, requiring high clinical suspicion 4

Common Etiologies to Assess

• Most rectourethral fistulas result from prostatectomy complications (40% have previous pelvic irradiation/ablation) 1
• Other causes include diverticulitis, Crohn's disease, colorectal malignancies, radiation therapy, and iatrogenic injury 4
• Prior urethral instrumentation for stricture disease is a significant risk factor 6

Multidisciplinary Team Coordination

Initial Management Team

• Emergency surgeons or general surgeons may be involved initially if the patient presents acutely, particularly for establishing urinary and fecal diversion 3
• Intensivists should be consulted for patients with septic complications 3
• The team should coordinate early regarding need for temporary diversions (colostomy, suprapubic cystostomy) 3, 2

Definitive Repair Planning

• High-volume centers performing ≥25 repairs typically use transperineal approaches with tissue flaps, achieving 87.5% initial closure rates 1
• Plastic surgeons may be involved for complex reconstructions requiring tissue interposition (gracilis muscle flaps used in 72% of repairs) 1, 2
• The surgical approach should be determined by a multidisciplinary team based on fistula location, prior radiation, and patient anatomy 3, 1

Critical Pitfalls to Avoid

• Do not delay specialist consultation in favor of prolonged conservative management, as only 5% of cases resolve without surgical intervention 2
• Avoid single-specialty evaluation, as these complex fistulas require coordinated urologic and colorectal expertise for optimal outcomes 3, 2
• Do not overlook the need for imaging confirmation before planning repair, as clinical examination alone is insufficient to characterize fistula anatomy 4
• Recognize that permanent fecal/urinary diversion should be reserved for patients with devastated, nonfunctional systems (occurs in only 10.6% and 8.3% respectively) 1