Article Text

Gangrenous cystitis: a rare cause of colovesical fistula

Abstract

A case of gangrenous cystitis presenting as a colovesical fistula in an elderly woman is described. The literature on this rare condition is reviewed.

  • gangrenous cystitis
  • colovesical fistula

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Vesico-enteric fistulae occur in 2–3 per 10 000 hospital admissions and are commonly associated with diverticular disease, cancer, inflammatory bowel disease, radiation, trauma and infection. We report a rare case of colovesical fistula secondary to bladder necrosis.

Case report

Following a fall, an 85-year-old woman underwent a Thompson's left hemi-arthroplasty for a fractured neck of femur. She was noted to be demented, in atrial fibrillation and had a medical history of a mild cerebrovascular accident from which she had made a good recovery. Her haematinics and renal function were normal. Seven days post surgery she was noted to be incontinent of urine with abdominal distension. A residual urine volume of 850 ml was recorded. The following day a residual volume of 1 litre was noted and an indwelling catheter was left in place with 4 hourly intermittent drainage. Five days later the urine was faeculent with watery and offensive stool per rectum. Her white cell count was 36 × 109/l and her renal function was normal. Abdominal X-ray confirmed air in the bladder but further investigation proved unrewarding. Because of her distress and the faeculent discharge per urethra it was decided to proceed to laparotomy and colostomy.

At operation the pelvis was walled off by small bowel and adhesions. On division of the adhesions a large space containing the catheter was entered. The only viable bladder was a small area of trigone. A large fistula between the sigmoid colon and gangrenous bladder was identified. The bladder space was drained, the fistulous opening closed and a proximal defunctioning stoma formed. Postoperatively she did not recover and died 48 hours later. Post-mortem examination confirmed the surgical findings. Microscopy confirmed the presence of widespread full thickness necrosis of the bladder wall and adhesion between bladder and adjacent small and large bowel. Early bronchopneumonia was identified microscopically. There was no evidence of diverticular disease, neoplasia, inflammatory bowel disease or vasculitis. Culture of the urine grew a mixed growth of gut organisms.

Discussion

Prior to the use of antibiotics, gangrenous cystitis was a common problem attributed to vascular impairment, prolonged labour, and infection superimposed on urinary retention.1

With improved obstetric care and common use of antibiotics only 12 cases have been reported since 1934, only one of which resulted in colovesical fistula.2 In this case we think that chronic overdistention of the bladder was an important aetiological factor.

Learning points

  • gangrenous cystitis is a rare cause of colovesical fistula

  • aetiology is thought to be associated with vascular impairment and infection superimposed on urinary retention

  • in an otherwise fit patient, treatment should be early and aggressive

The management of this condition is difficult.3 In an otherwise fit patient, the treatment should be early and aggressive. Whilst regeneration of the bladder has been reported when the trigone is spared,4 when extensive necrosis is present aggressive treatment with urinary and colonic diversion may be the only alternative.5

References

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