Specialist Referral for Rectovesical Fistula
Patients with rectovesical (rectal-bladder) fistula require immediate referral to a multidisciplinary team that includes an experienced colorectal surgeon, urologist, and gastroenterologist, with the colorectal surgeon serving as the primary surgical specialist. 1, 2
Primary Specialist Referrals
Colorectal Surgery (Essential)
- An experienced colorectal surgeon should be the primary surgical specialist for all rectovesical fistulas, as they possess the expertise to assess fistula anatomy, perform examination under anesthesia (EUA), and execute definitive surgical repair. 1
- Colorectal surgeons correctly classify 91% of perianal and pelvic fistulae at EUA, making their involvement critical for accurate anatomic assessment. 1
Urology (Essential)
- A urologist must be involved given the bladder component of the fistula, particularly for cystoscopic evaluation and management of urinary tract complications. 2, 3
- Cystoscopy is the most accurate diagnostic test for detecting rectovesical fistulae (46.2% detection rate) and should be performed by urology. 4
Gastroenterology (Conditional but Important)
- Gastroenterology referral is mandatory when Crohn's disease is suspected or confirmed as the underlying etiology, as medical optimization with biologics must precede any surgical intervention. 1, 5
- For Crohn's-related fistulas, infliximab combined with immunomodulators is first-line therapy, requiring gastroenterology management before surgical consideration. 5
Etiology-Specific Referral Pathways
Diverticular Disease (Most Common - 72%)
- Refer directly to colorectal surgery for surgical planning, as these fistulas typically require sigmoid resection with primary anastomosis. 4
- Bladder repair is usually unnecessary; Foley catheter drainage alone is sufficient in 68% of cases. 6
Crohn's Disease (Second Most Common - 10-30%)
- Refer first to gastroenterology to initiate anti-TNF therapy (infliximab) and achieve mucosal healing before any surgical intervention. 1, 5
- Surgery should be deferred until endoscopic examination confirms mucosal healing of the rectosigmoid segment; operating on active inflammation significantly worsens outcomes. 5
- Colorectal surgery referral follows only after medical therapy failure, bowel obstruction, or abscess formation. 1, 5
Malignancy (15%)
- Immediate colorectal surgery and oncology referral for staging and treatment planning. 4
Post-Surgical/Iatrogenic
- Return to the original operating surgeon if recent (within 6 months), otherwise refer to colorectal surgery with urology co-management. 3, 7
Additional Specialist Considerations
Interventional Radiology
- Consider referral for CT-guided drainage if abscess is present, as abscesses must be drained before initiating anti-TNF therapy in Crohn's disease. 1
Nutrition/Dietetics
- Mandatory referral for patients with proximal fistulas or high output, as nutritional optimization is critical before surgical intervention. 1
- Malnutrition with BMI <20 kg/m² is an independent risk factor for poor fistula outcomes. 1
Critical Timing Considerations
- Do not delay referral; rectovesical fistulas can lead to recurrent polymicrobial urinary tract infections, sepsis, and significant quality of life impairment. 2
- For Crohn's disease, the multidisciplinary team should include colorectal surgery, gastroenterology, and radiology from the outset, as this approach is considered best practice. 1
- Surgical repair should not be attempted until at least 4 weeks after any acute intervention to allow postoperative changes to settle. 8
Common Pitfalls to Avoid
- Never refer to general surgery alone; rectovesical fistulas require subspecialty colorectal expertise for optimal outcomes. 1
- Do not proceed directly to surgery in suspected Crohn's disease without gastroenterology evaluation and medical optimization first. 1, 5
- Avoid single-specialty management; these complex fistulas mandate true multidisciplinary collaboration for treatment planning. 1, 2