Case Report
Urologia Internationalis
Urol Int 2014;92:250–252 DOI: 10.1159/000353351
Received: April 8, 2013 Accepted after revision: May 28, 2013 Published online: January 21, 2014
Coloseminal Fistula Complicating Sigmoid Diverticulitis Maximilien Barret a, d Charles-André Cuenod b, d Raymond Jian a, d Christophe Cellier a, d Anne Berger c, d Departments of a Gastroenterology and Digestive Endoscopy, b Radiology and c Digestive Surgery, Hôpital Européen Georges Pompidou, GHU Ouest, Assistance Publique-Hôpitaux de Paris, and d Faculté de Médecine, AP-HP, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
Key Words Diverticulitis · Colon fistula · Seminal vesicle · Urinary fistula
Abstract We report on a 32-year-old man with a history of chronic lower abdominal pain and urogenital symptoms, leading to the diagnosis of coloseminal fistula complicating diverticular disease. We reviewed the literature on this rare clinical entity and would like to stress the role of pelvic imaging with rectal contrast to investigate complicated forms of diverticular disease. © 2014 S. Karger AG, Basel
A 32-year-old man was referred to our institution because of lower abdominal pain. He had a medical history of urolithiasis treated by lithotripsy. The patient reported chronic urogenital symptoms with pelvic discomfort during sexual intercourse and discolored semen, pollakiuria with pneumaturia, and hypogastric pain. No fever or shivering episodes had occurred. Clinical examination, including digital rectal examination, was normal, as well as complete blood count and C-reactive protein. Repeated abdominal imaging [ultrasonography and abdominal © 2014 S. Karger AG, Basel 0042–1138/14/0922–0250$39.50/0 E-Mail [email protected] www.karger.com/uin
computed tomography (CT) scan] did not show a recurrence of urolithiasis but it did show diverticular disease of the sigmoid colon. An abdominal CT scan with water enema revealed features of subacute colonic diverticulitis with a small air bubble within the bladder (fig. 1a, arrow) and a diverticular abscess fistulated to the right seminal vesicle (fig. 1b, arrow). Pelvic magnetic resonance imaging (MRI) (fig. 2) showed the fistula (arrow) between the sigmoid colon (white arrowhead) and the right seminal vesicle (black arrowhead). A single-stage laparoscopic sigmoidectomy with a primary end-to-end stapled anastomosis and resection of both the abscess and the right seminal vesicle was performed. The postoperative course was unremarkable, and the symptoms completely resolved after a 1-year follow-up. Coloseminal fistulas are uncommon, especially since seminal vesicles are usually protected from sigmoidal abscesses by the bladder. Seven cases have so far been reported: complicating surgery for rectal or prostatic neoplasms [1–3], after radiotherapy [4, 5], a complication of Crohn’s disease [6], and only 1 case with diverticular disease [7]. Clinical presentation is usually subacute with symptoms mimicking colovesical fistulas, namely pneumaturia and dysuria. Abdominal CT scans with rectal contrast or water enema, or pelvic MRI with water enema Maximilien Barret, MD, MSc Department of Gastroenterology and Digestive Endoscopy Hôpital Européen Georges Pompidou 20, rue Leblanc, FR–75015 Paris (France) E-Mail maxbarret5744 @ yahoo.fr
a
b
Fig. 1. Axial enhanced CT scanner images of the pelvis with water enema. a An air bubble is found within the bladder (arrow) suggesting a fistula between the bladder and the digestive structures. b An air bubble is also found
in the right seminal vesicle (arrow).
a
b
Fig. 2. MRI of the pelvis. a Axial image of a T1-weighted sequence with fat suppression and gadolinium injection.
The right seminal vesicle sticks to the sigmoid colon and has a high signal due to the gadolinium uptake induced by local inflammation (arrow). b Sagittal T2-weighted image: the seminal vesicle (black arrowhead) sticks to the sigmoid colon (white arrowhead). A fistula is found between the sigmoid colon and the seminal vesicle (white arrow). The rectum and the colon are filled with a water enema.
appear to be the best diagnostic modalities [4, 7]. Medical treatment options, such as antibiotherapy or finasteride, allow for symptom reduction before surgical management in order to reduce seminal secretion or percutaneous drainage [8]. Reported surgical procedures include vasovasostomy, vasotomy, colostomy, or surgical resection [4, 7].
Sigmoid diverticulitis is a frequent condition: the prevalence of colonic diverticulosis affects 30% of the general population above 60 years of age, and 10–25% of patients with colonic diverticulosis will develop diverticulitis [9]. Diverticulitis is usually treated with a 7-day course of antibiotics. However, recurrent or complicated (i.e. accompanied by abscess, fistula, obstruction, or free intra-abdominal perforation) diverticulitis requires surgery. The
Coloseminal Fistula
Urol Int 2014;92:250–252 DOI: 10.1159/000353351
251
following interventions for diverticular disease are recommended. (1) Urgent Hartmann’s procedure (sigmoid colectomy, end sigmoid or descending colostomy, and closure of the rectal stump) for patients with diffuse peritonitis or for those who fail nonoperative management of acute diverticulitis. Resection and anastomosis with temporary diverting ileostomy may also be performed, depending on the severity of intra-abdominal contamination. (2) Elective open or laparoscopic sigmoid colectomy may be advised after a first attack of uncomplicated diverticulitis in young (under 50 years) or immunosuppressed patients, and if an episode of complicated diverticulitis has been managed nonoperatively, in order to prevent recurrent sepsis [9].
Investigating persistent lower abdominal pain associated with urogenital symptoms, a CT scan with rectal contrast may suggest a diagnosis of the indolent form of complicated diverticular disease; however, our case illustrates the importance of pelvic MRI with water enema, which allows for optimal characterization of any pelvic lesion and can guide the surgeon and so make appropriate treatment possible.
Disclosure Statement The authors have no conflicts of interest to declare.
References 1 Carlin J, Nicholson D, Scott N: Two cases of seminal vesicle fistula. Clin Radiol 1999; 54: 309–311. 2 Goldman HS, Sapkin SL, Foote RF, Taylor JB: Seminal vesicle-rectal fistula: report of a case. Dis Colon Rectum 1989;32:67–69. 3 Calder J: Seminal vesicle fistula. Clin Radiol 2000;55:328. 4 Placer C, Elósegui JL, Andrés Mujika J, Enriquez-Navascués JM: Symptomatic coloseminal vesicle fistula after radiochemotherapy and surgery for rectal cancer. Cir Esp 2007;81: 110.
252
Urol Int 2014;92:250–252 DOI: 10.1159/000353351
5 Celebrezze JP Jr, Medich DS: Rectal ulceration as a result of prostatic brachytherapy: a new clinical problem. Dis Colon Rectum 2003;46:1277–1279. 6 Hamidinia A: Recto-ejaculatory duct fistula: an unusual complication of Crohn’s disease. J Urol 1984;131:123–124.
7 LaSpina M, Facklis K, Posalski I, Fleshner P: Coloseminal vesicle fistula: report of a case and review of the literature. Dis Colon Rectum 2006;49:1791–1793. 8 Kollmorgen T, Kollmorgen C, Lieber M, Wolff B: Seminal vesicle fistula following abdominoperineal resection for recurrent adenocarcinoma of the rectum. Dis Colon Rectum 1994;37:1325–1327. 9 Rafferty J, Shellito P, Hyman NH, Buie WD: Practice parameters for sigmoid diverticulitis. Dis Colon Rectum 2006;49:939–944.
Barret /Cuenod /Jian /Cellier /Berger
Copyright: S. Karger AG, Basel 2014. Reproduced with the permission of S. Karger AG, Basel. Further reproduction or distribution (electronic or otherwise) is prohibited without permission from the copyright holder.
Urologia Internationalis
Urol Int 2014;92:250–252 DOI: 10.1159/000353351
Received: April 8, 2013 Accepted after revision: May 28, 2013 Published online: January 21, 2014
Coloseminal Fistula Complicating Sigmoid Diverticulitis Maximilien Barret a, d Charles-André Cuenod b, d Raymond Jian a, d Christophe Cellier a, d Anne Berger c, d Departments of a Gastroenterology and Digestive Endoscopy, b Radiology and c Digestive Surgery, Hôpital Européen Georges Pompidou, GHU Ouest, Assistance Publique-Hôpitaux de Paris, and d Faculté de Médecine, AP-HP, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
Key Words Diverticulitis · Colon fistula · Seminal vesicle · Urinary fistula
Abstract We report on a 32-year-old man with a history of chronic lower abdominal pain and urogenital symptoms, leading to the diagnosis of coloseminal fistula complicating diverticular disease. We reviewed the literature on this rare clinical entity and would like to stress the role of pelvic imaging with rectal contrast to investigate complicated forms of diverticular disease. © 2014 S. Karger AG, Basel
A 32-year-old man was referred to our institution because of lower abdominal pain. He had a medical history of urolithiasis treated by lithotripsy. The patient reported chronic urogenital symptoms with pelvic discomfort during sexual intercourse and discolored semen, pollakiuria with pneumaturia, and hypogastric pain. No fever or shivering episodes had occurred. Clinical examination, including digital rectal examination, was normal, as well as complete blood count and C-reactive protein. Repeated abdominal imaging [ultrasonography and abdominal © 2014 S. Karger AG, Basel 0042–1138/14/0922–0250$39.50/0 E-Mail [email protected] www.karger.com/uin
computed tomography (CT) scan] did not show a recurrence of urolithiasis but it did show diverticular disease of the sigmoid colon. An abdominal CT scan with water enema revealed features of subacute colonic diverticulitis with a small air bubble within the bladder (fig. 1a, arrow) and a diverticular abscess fistulated to the right seminal vesicle (fig. 1b, arrow). Pelvic magnetic resonance imaging (MRI) (fig. 2) showed the fistula (arrow) between the sigmoid colon (white arrowhead) and the right seminal vesicle (black arrowhead). A single-stage laparoscopic sigmoidectomy with a primary end-to-end stapled anastomosis and resection of both the abscess and the right seminal vesicle was performed. The postoperative course was unremarkable, and the symptoms completely resolved after a 1-year follow-up. Coloseminal fistulas are uncommon, especially since seminal vesicles are usually protected from sigmoidal abscesses by the bladder. Seven cases have so far been reported: complicating surgery for rectal or prostatic neoplasms [1–3], after radiotherapy [4, 5], a complication of Crohn’s disease [6], and only 1 case with diverticular disease [7]. Clinical presentation is usually subacute with symptoms mimicking colovesical fistulas, namely pneumaturia and dysuria. Abdominal CT scans with rectal contrast or water enema, or pelvic MRI with water enema Maximilien Barret, MD, MSc Department of Gastroenterology and Digestive Endoscopy Hôpital Européen Georges Pompidou 20, rue Leblanc, FR–75015 Paris (France) E-Mail maxbarret5744 @ yahoo.fr
a
b
Fig. 1. Axial enhanced CT scanner images of the pelvis with water enema. a An air bubble is found within the bladder (arrow) suggesting a fistula between the bladder and the digestive structures. b An air bubble is also found
in the right seminal vesicle (arrow).
a
b
Fig. 2. MRI of the pelvis. a Axial image of a T1-weighted sequence with fat suppression and gadolinium injection.
The right seminal vesicle sticks to the sigmoid colon and has a high signal due to the gadolinium uptake induced by local inflammation (arrow). b Sagittal T2-weighted image: the seminal vesicle (black arrowhead) sticks to the sigmoid colon (white arrowhead). A fistula is found between the sigmoid colon and the seminal vesicle (white arrow). The rectum and the colon are filled with a water enema.
appear to be the best diagnostic modalities [4, 7]. Medical treatment options, such as antibiotherapy or finasteride, allow for symptom reduction before surgical management in order to reduce seminal secretion or percutaneous drainage [8]. Reported surgical procedures include vasovasostomy, vasotomy, colostomy, or surgical resection [4, 7].
Sigmoid diverticulitis is a frequent condition: the prevalence of colonic diverticulosis affects 30% of the general population above 60 years of age, and 10–25% of patients with colonic diverticulosis will develop diverticulitis [9]. Diverticulitis is usually treated with a 7-day course of antibiotics. However, recurrent or complicated (i.e. accompanied by abscess, fistula, obstruction, or free intra-abdominal perforation) diverticulitis requires surgery. The
Coloseminal Fistula
Urol Int 2014;92:250–252 DOI: 10.1159/000353351
251
following interventions for diverticular disease are recommended. (1) Urgent Hartmann’s procedure (sigmoid colectomy, end sigmoid or descending colostomy, and closure of the rectal stump) for patients with diffuse peritonitis or for those who fail nonoperative management of acute diverticulitis. Resection and anastomosis with temporary diverting ileostomy may also be performed, depending on the severity of intra-abdominal contamination. (2) Elective open or laparoscopic sigmoid colectomy may be advised after a first attack of uncomplicated diverticulitis in young (under 50 years) or immunosuppressed patients, and if an episode of complicated diverticulitis has been managed nonoperatively, in order to prevent recurrent sepsis [9].
Investigating persistent lower abdominal pain associated with urogenital symptoms, a CT scan with rectal contrast may suggest a diagnosis of the indolent form of complicated diverticular disease; however, our case illustrates the importance of pelvic MRI with water enema, which allows for optimal characterization of any pelvic lesion and can guide the surgeon and so make appropriate treatment possible.
Disclosure Statement The authors have no conflicts of interest to declare.
References 1 Carlin J, Nicholson D, Scott N: Two cases of seminal vesicle fistula. Clin Radiol 1999; 54: 309–311. 2 Goldman HS, Sapkin SL, Foote RF, Taylor JB: Seminal vesicle-rectal fistula: report of a case. Dis Colon Rectum 1989;32:67–69. 3 Calder J: Seminal vesicle fistula. Clin Radiol 2000;55:328. 4 Placer C, Elósegui JL, Andrés Mujika J, Enriquez-Navascués JM: Symptomatic coloseminal vesicle fistula after radiochemotherapy and surgery for rectal cancer. Cir Esp 2007;81: 110.
252
Urol Int 2014;92:250–252 DOI: 10.1159/000353351
5 Celebrezze JP Jr, Medich DS: Rectal ulceration as a result of prostatic brachytherapy: a new clinical problem. Dis Colon Rectum 2003;46:1277–1279. 6 Hamidinia A: Recto-ejaculatory duct fistula: an unusual complication of Crohn’s disease. J Urol 1984;131:123–124.
7 LaSpina M, Facklis K, Posalski I, Fleshner P: Coloseminal vesicle fistula: report of a case and review of the literature. Dis Colon Rectum 2006;49:1791–1793. 8 Kollmorgen T, Kollmorgen C, Lieber M, Wolff B: Seminal vesicle fistula following abdominoperineal resection for recurrent adenocarcinoma of the rectum. Dis Colon Rectum 1994;37:1325–1327. 9 Rafferty J, Shellito P, Hyman NH, Buie WD: Practice parameters for sigmoid diverticulitis. Dis Colon Rectum 2006;49:939–944.
Barret /Cuenod /Jian /Cellier /Berger
Copyright: S. Karger AG, Basel 2014. Reproduced with the permission of S. Karger AG, Basel. Further reproduction or distribution (electronic or otherwise) is prohibited without permission from the copyright holder.
