Treatment

The management of colovesical and other enterovesical fistulas depends on symptomatology, complications, and primary aetiology. In patients with long-standing fistulas and recurrent urinary tract infections, initial management focuses on optimizing physiology by treating urosepsis and addressing nutritional deficiencies. Any abscess should be drained.

Conservative management is a favorable option in patients with enterovesical fistulas secondary to Crohn's disease or tuberculosis, where medical therapy is the cornerstone of treatment. This approach is indicated in patients who are poor surgical candidates due to advanced age, significant comorbidities, or limited life expectancy.

Conservative treatment includes bowel rest, total parenteral nutrition in acute settings, broad-spectrum antibiotics, and continuous bladder drainage.

Surgery, if necessary, is dictated by the underlying cause:

• diverticulitis - bluntly dissect the colon from the bladder, resect it, and perform a primary anastomosis. If resection is not possible, consider a Hartmann's procedure.
• carcinoma - treat with care to ensure that tumour cells do not spill into the pelvis. Remove a disk of bladder wall in continuity with the colon, close the bladder, and catheterise for 7-10 days.

Complication rates range from 8% to 49%, including anastomotic leak, bladder leak, and need for reoperation, with overall mortality up to 63%.

Reference

1. Zizzo M et al. Management of colovesical fistula: a systematic review. Minerva Urol Nephrol. 2022 Aug;74(4):400-408.