A 45-year-old man was initially seen in the emergency room with left testicular swelling and pain. He had no history of urinary frequency, urgency, dysuria, hematuria, urethral discharge, flank pain, or fevers. The patient described good baseline voiding function and had no features on history suggestive of bladder outlet obstruction. On physical examination, the patient appeared reasonably well and was afebrile. Abdomen was soft and benign. The left testicle and epididymis were swollen and tender to palpation. Overlying skin was warm and slightly erythematous. Right scrotal examination was unremarkable. Prostate was neither enlarged nor tender. White blood count was within reference range, urinalysis suggested infection, and scrotal Doppler ultrasonogram suggested left epididymoorchitis. The patient was sent home with a 14-day course of ciprofloxacin. Urine culture ultimately grew pansensitive Escherichia coli. Two weeks later, the patient presented back to the emergency room with pain and redness of his contralateral testicle and epididymis with complete resolution of the left epididymoorchitis. At this time, the patient was admitted to the hospital for treatment of right epididymoorchitis. Urinalysis revealed infection, and urine culture grew E. coli again. Intravenous ceftriaxone was administered, and the patient was discharged again on oral antibiotics with a plan for outpatient cystoscopy. At the patient's first office visit after discharge, his right testicle remained swollen and red. His abdomen was slightly bloated, soft, and nontender. He was sent to the emergency room for full evaluation, including abdominal and pelvic computed tomography (CT) and scrotal ultrasonography.
On history obtained on the third hospital admission, the patient described a 10- to 14-day history of passing debris in his urine. Noncontrast CT scan showed an air bubble in the bladder with thickening of the sigmoid colon and anterior bladder wall, suggestive of colovesical fistula. This suspicion was confirmed with subsequent pelvic CT with gravity cystogram (Fig. 1). Upon further inquiry, the patient had had a single brief episode of diverticulitis treated with oral quinolone as an outpatient 18 months previously with no subsequent problems.
Cystoscopy showed an inflamed and edematous posterior bladder wall with a wisp of feces extruding from the center of the inflamed area. No other mucosal lesions were evident. Cup biopsy and fulguration revealed inflammation only. Barium enema did not reveal the fistulous tract. Colonoscopy revealed a fistula in the region of the sigmoid colon, which was confirmed after methylene blue injected into the bladder leaked into the colon. An attempt to close the fistula with a sigmoid stent was unsuccessful as the stent could not be passed beyond the rectosigmoid junction.
The patient underwent laparotomy for definitive surgical management. A small-to-moderate-size diverticular abscess was identified behind the bladder. Sigmoid resection with diverting colostomy and Hartmann pouch was performed, along with excision of the fistulous tract and primary 2-layer closure of the bladder with insertion of suprapubic catheter, Foley catheter, and placement of pelvic drains.
Pathology confirmed diverticulitis of the sigmoid colon with diverticular abscess. No malignancy was identified.
The patient experienced a full recovery postoperatively. He had a normal cystogram on follow-up with removal of his catheters and underwent uneventful reversal of colostomy. His scrotal examination is normal on follow-up. The patient is voiding well with sterile urine.
Most cases of orchitis, unless viral in origin, are secondary to contiguous spread from an ipsilateral epididymitis.1 Thus, epididymal and testicular infections often coexist and are together termed as epididymoorchitis.1,8 Epididymitis results from infection that spreads from the bladder, urethra, or prostate via the ejaculatory ducts and vas deferens to the epididymis.1,2,8 Therefore, the organisms most commonly responsible for epididymoorchitis are those that cause genitourinary tract infections.2 In heterosexual men younger than 35 years, epididymoorchitis is usually caused by Chlamydia trachomatis and Neisseria gonorrhoeae.2,7,17 In men who have sex with men, the causative organisms are mostly E. coli and Haemophilus influenzae.2 These patients have bacteriuria, but no urethritis. In the pediatric age group and patient population older than 35 years, the coliforms are predominant organisms that cause epididymoorchitis.7 In our patient, E. coli was implicated in causing epididymoorchitis. There was response to treatment with intravenous ceftriaxone and metronidazole; the latter drug was added to empirically cover gut anaerobes. Although anaerobes are not of much concern in the medical management of epididymoorchitis, they probably happened to be so in this case.
Laboratory evaluation for epididymoorchitis generally includes urinalysis, urine culture, microscopy, culture and nucleic acid amplification test from a urethral swab. Color Doppler imaging should be considered to differentiate epididymoorchitis from torsion testis in a patient who presents with acute scrotal pain.3-6 Our patient's recurrent infection, history suggestive of fecaluria, and a prior episode of lower abdominal pain prompted evaluation for a colovesical fistula secondary to diverticulitis resulting in recurrent episodes of epididymoorchitis. In 1 study, fecaluria was reported in up to 36% of cases of colovesical fistula.14 In another study with 90 cases of colovesical fistula, pneumaturia and fecaluria were present in 90.1% of all cases.13
Colovesical fistulae comprise 65% of diverticular fistula.9,12 Diverticulitis is the most common cause of colovesical fistula.10,11,13,14,16 Because the majority of diverticular inflammation occurs in the sigmoid colon, fistula formation occurs most commonly in this segment, as was the case in our patient.
Evaluation for colovesical fistulae includes CT, colonic endoscopy, barium enema, and cystoscopy.13 Najjar et al14 reported 90% ability of CT to identify a colovesical fistula. Another study, by Garcea et al,13 reported cystoscopy to be the most accurate test to detect colovesical fistula, followed by barium enema. Colonoscopy, in the latter study, was found to be the most reliable means of excluding a colonic malignancy. In our patient, cystoscopic visualization of feces protruding into the urinary bladder was possible. Colonoscopy along with the injection of dye into the bladder that leaked into the colon confirmed the diagnosis of colovesical fistula. Computed tomography offers the advantage of visualization of the structures adjacent to the fistula. We recommend CT to be done as the initial diagnostic test for suspected colovesical fistula, and cystoscopy and colonoscopy if CT is nondiagnostic.
Treatment is mainly surgical and consists of resection and primary anastomosis.13 Noninvasive techniques such as the application of human fibrin glue have also been recommended for the closure of fistulae.15 Endoscopic injection of fibrin glue offers a safe, minimally invasive approach that may be especially useful in patients with high surgical risk.15 We were unsuccessful at the attempt to close the fistula by this technique.
The above case is the third reported case of epididymitis as a presentation of colovesical fistula, but first to have epididymoorchitis as the presenting sign.17,18 Although colovesical fistulae are not uncommon, spread to the epididymis and testis is very unusual.
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