Editing Functional: Urinary Fistulae (section)

=== Rectourethral fistula ===

==== Causes ====
* '''Acquired rectourethral fistula may occur in the male under a variety of clinical circumstances, including those related to prostatectomy''' for benign or malignant disease, cryotherapy, pelvic radiotherapy, anorectal surgery, external penetrating trauma, urethral instrumentation, locally advanced prostatic or rectal malignancy, infection (e.g., TB), ruptured prostatic abscess, or inflammatory disease (e.g., Crohn disease)
** '''The incidence of rectourethral fistula after radical retropubic prostatectomy is low but owing to the frequency with which the operation is performed, it is the most common cause of rectourethral fistula.'''
*** '''Rectal injury during radical prostatectomy occurs in < 1-2% of patients'''

==== Diagnosis and Evaluation ====
* '''History and Physical exam'''
**Symptoms may include fecaluria, hematuria, UTI, nausea, vomiting, and fever
* '''Imaging'''
**'''Lower tract imaging'''
***'''VCUG or retrograde urethrogram usually provides a definitive diagnosis of rectourethral fistula'''
**'''Upper tract imaging should be performed in patients to exclude a related ureteral injury'''
*'''Other'''
**'''In patients with a history of pelvic malignancy, biopsy of the fistula is suggested to evaluate for a local recurrence of the tumour''' 
***Cystoscopy and sigmoidoscopy visualize the fistula tract in the vast majority of cases and provide a mechanism for biopsy
** '''Assessment of continence and sphincteric function in patients with rectourethral fistula after radical prostatectomy'''
***Given the location of most rectourethral fistulas at or near the vesicourethral anastomosis and the membranous urethra, there is a risk for persistent severe stress incontinence postoperatively after rectourethral fistula repair

==== Management ====
* Most rectourethral fistula will require surgical repair, although some will close with conservative management.
* '''Rectourethral fistula that follows open or laparoscopic prostatectomy may heal spontaneously with catheter drainage, bowel rest, and intravenous hyperalimentation'''.
** '''In some cases, fecal diversion is necessary.'''
** '''Staged repairs might be considered in (5):'''
**# Large fistulae
**# Associated with radiation therapy
**# Uncontrolled local or systemic infection
**# Immunocompromised states
**# Inadequate bowel preparation at the time of definitive repair
* Transrectal approaches with and without division of the anal sphincter have been described for the operative repair of rectourethral fistula.
** '''The York-Mason procedure''' is a transrectal, transsphincteric approach that has been found to be effective and to have low morbidity