Recto-vesical fistula (report of an unusual case).
Recto-vesical fistula refers to the cases having fistulous tract between the bladder and the rectum. The common aetiologies in the reported series are diverticulitis, Crohn's disease, irradiation, traumatic, bladder or colo-rectal carcinomas., Tuberculosis as a rare reported aetiology, passing urine per rectum as an uncommon symptom and an associated small contracted bladder with vesico-ureteric reflux prompted us to report this case.
A thirty five year old male patient presented with the chief complaint of passing urine per rectum and repeated history of fever with chills. He had a history of right sided nephrectomy done 20 years back for Koch's kidney for which he had taken adequate treatment.
Per abdomen examination revealed no abnormality. Genitals were normal. Vas deferens was not beaded. Per rectal examination revealed a nodule 8 cm above the anal verge. Seminal vesicles were palpable.
Patient's haemoglobin, on admission, was 8 gm%; BUN, 80 mg% and serum creatinine 7.0 mg%. Urine culture was negative for acid fast bacilli.
Intravenous pyelography showed left sided hydronephrotic kidney with hydroureter and absent right kidney [Fig. 1]. Cystogram showed left sided vesico-ureteric reflux and dye in the rectum [Fig. 2]. Barium enema was normal. Cystoscopy showed a fistulous opening, about 2 cm in size, lateral and above the left ureteric opening. The bladder was inflamed. Ureteric catheter could be passed through the opening which could be felt in the rectum. It was a small, contracted bladder with a capacity of 50 ml. Biopsy was taken from the fistulous opening site, which showed only chronic inflammatory pathology without any caseation or epitheloid cells.
As a part of the treatment, a right transverse defunctioning colostomy was done. Because of inabiliy to do suprapubic cystostomy due to the small contracted bladder, per urethral Foley's catheter was kept. Following this, per rectal urinary discharge had stopped. After 3 weeks methylene blue when injected through the colotomy, appeared in the urine. On clamping the urethral catheter, per rectal urinary discharge reappeared.
A midline infra-umbilical exploration was done. The bladder was opened and a fistulous opening was identified A biopsy was taken. Mobilisation was done between the bladder and the rectum. The fistulous tract was oversewn. Since it was a small, thimble bladder, the sigmoid loop was dissected, mobilised and augmented sigmoidocystoplasty was done. Omental patch was kept over the anastomosis. The left ureter was resected and implanted submucosally in the sigmoid bladder as an antireflux procedure. Sigmoido-sigmoidostomy was done.
There was no immediate post-operative complication. The urethral catheter was kept for 3 weeks. Barium enema done after 3 weeks was normal; hence the colostomy was closed. On removal of the urethral catheter, there was a suprapubic leak but no discharge per rectum. The urethral catheter was again put for 3 more weeks but leak did not stop . A cystogram was done which showed the vesico-cutaneous fistulous tract [Fig. 3]. Suprapubic fistulous tract was excised. The tract healed after giving proper urinary antibiotics and 2 weeks of urethral catheterisation.
Post-operatively, BUN was 20 mg%, and serum creatinine 1.6 mg%. Biopsy showed chronic inflammatory pathology but no caseation or epitheloid cells. Intravenous urography showed less hydronephrosis, no fistulous tract and no vesico-ureteric reflux. Cystoscopy did not show any fistulous opening and the capacity of bladder increased upto 300 ml.
The patient is coming for regular follow-up for the last one year with no complaints and normal blood biochemistry.
As described by several authors,, the common causes of recto-vesical fistula are diverticulitis, Crohn's disease, irradiation, trauma, and carcinomas. It is more common on the left side. The common presentation is faecaluria, pneumaturia, haematuria, and recurring fever with chills. Sometimes, the patient presents with enteric symptoms like pain in the left lower quadrant or suprapubic pain. Patients with tuberculous aetiology with small and contracted bladder, as in our case, present with history of passing urine per rectum.
On investigation, urine of these patients shows pus cells, blood and faecal particles. Cystography and cystoscopy show fistulous opening and signs of bladder inflammation like bullous oedema, granulating tissue, ulcerated area, and inflammatory nipple. Methylene blue given by enema and charcoal administered orally, both appear in the urine., Bourne's test of screening and radiography of the centrifuged urine samples obtained even after 12-24 hours of non-diagnostic barium enema for occult fistula was not found necessary in this case,' as the fistula was demonstrated by cystoscopy and cystography.
There are 3 basic mechanisms described for a fistula in a case of tuberculosis: (1) inflammatory weakening of the small and the contracted bladder, (2) rupture of a parietal abscess, and (3) perforation of a tuberculous ulcer in the dome of the bladder.4 In our case, the first mechanism seems to be the cause of the fistula.
Conservative treatment of the fistula with intermittent antibiotics with or without colostomy alone to prevent urinary contamination has been reported in patients of severe illnesses and advanced carcinomas. Ventrodorsal vesical repair has been described which was not possible in this case because of small, contracted bladder. Only colostomy, colostomy with ileal conduit, colostomy with anostomosis of ureters into a sigmoid pouch and end-to-side stgmoidorectostomy were not done in this case because of non-malignant pathology. Good results have been reported with partial transverse reverence of the omentum and suturing it to the lateral abdominal wall and anastomosis, which was done in this case.
Anti-tuberculous chemotherapy was not given in this case as it was burnt out pathology with no active evidence of tuberculosis.
We thank the Dean and the Head of the Department of Surgery, T. N. Medical College and B. Y. L. Nair Charitable Hospital, Bombay-400 008, for their kind permission to publish this report.