Editing Functional: Urinary Fistulae (section)

==== Diagnosis and Evaluation ====

* '''History and physical exam'''
** '''<span style="color:#ff0000">Pneumaturia is the most common presenting symptom'''
**'''<span style="color:#ff0000">Classic presentation of vesicoenteric fistula''' (described as Gouverneur syndrome) '''<span style="color:#ff0000">consists of (4):'''
**#'''<span style="color:#ff0000">Suprapubic pain'''
**#'''<span style="color:#ff0000">Urinary frequency'''
**#'''<span style="color:#ff0000">Dysuria'''
**#'''<span style="color:#ff0000">Tenesmus''' 
**Symptoms of vesicoenteric fistulae may originate from the urinary or GI tract; however, in general, '''<span style="color:#ff0000">storage LUTS are more common at presentation.''' 
** '''<span style="color:#ff0000">Recurrent UTIs or cystitis refractory to antibiotic therapy may suggest a colovesical fistula'''

* '''Imaging'''
** '''Cross-sectional imaging'''
*** Modality of choice
*** '''<span style="color:#ff0000">CT with contrast</span>'''
****'''<span style="color:#ff0000">Generally considered to be the most sensitive and specific modality for the diagnosis of colovesical fistulae</span>'''
**** '''<span style="color:#ff0000">Findings on CT that are suspicious for colovesical fistulae (3):</span>'''
****# '''<span style="color:#ff0000">Bladder wall thickening adjacent to a loop of thickened colon</span>'''
****# '''<span style="color:#ff0000">Air in the bladder (in the absence of previous lower urinary manipulation)</span>'''
****# '''<span style="color:#ff0000">The presence of colonic diverticula</span>'''
[[File:CT colovesical fistila.jpg|alt=Bladder wall thickening adjacent to a loop of thickened bowel|505x505px|CT scan with IV and oral contrast, coronal view, demonstrating bladder wall thickening adjacent to a loop of thickened bowel. 57M with history of diverticulitis, dysuria, urinary frequency, and fecaluria.|thumb|none]]

** '''Cystography and transrectal contrast studies (e.g., barium enema)'''
***'''Although commonly used are less likely to demonstrate the fistula'''

* '''Other'''
** '''<span style="color:#ff0000">Endoscopy</span>'''
*** '''<span style="color:#ff0000">The finding of bullous edema during cystoscopy is nonspecific; however, in the appropriate clinical setting, this can be very suggestive of a colovesical fistula.</span>'''
**** '''80-100% of cases of colovesical fistulae have an abnormality noted on cystoscopy'''
** Bourne test
*** Performed after a nondiagnostic barium enema.
*** The first voided urine after the barium enema is immediately centrifuged and then examined radiographically. Radiodense particles in the urine are considered a positive test result and evidence for a vesicoenteric fistula
** Activated charcoal
*** Oral administration of activated charcoal, which, in the setting of a fistula, will appear in the urine as black particles