Michael Perrotti, MD
BASICS
DESCRIPTION
Passage of gas in the urine
EPIDEMIOLOGY
Incidence
This is a rare disorder.
RISK FACTORS
• Diverticular disease
• Other disease of the colon
• Crohn disease
• Advanced age
• Diabetes
PATHOPHYSIOLOGY
• Most commonly there is an abnormal connection between the enteric and urinary system secondary to inflammation
• Much less common in gas-producing bacterial urinary tract infection (UTI) (Escherichia coli, Klebsiella pneumoniae) seen most frequently in elderly diabetic females
ASSOCIATED CONDITIONS
• Diverticulitis of sigmoid colon
• Colon cancer
• Crohn disease
• Diabetes
• Iatrogenic (radical prostatectomy, radiation)
GENERAL PREVENTION
• Colon health
• Prompt treatment of UTI
DIAGNOSIS
HISTORY
• Pneumaturia
• Dysuria
• Irritative urinary symptoms
• Fecaluria
PHYSICAL EXAM
• Depends upon etiology
• May have no significant findings if acute diverticular abscess has resolved
• In emphysematous cystitis there is frequently fever and abdominal tenderness
DIAGNOSTIC TESTS & INTERPRETATION
Lab
• Urine analysis
• Urine culture
• Complete blood count
• Comprehensive metabolic profile
Imaging
• Computerized tomography scan identifies air or orally administered contrast in the bladder, colonic and bladder wall thickening, abscess (1)[A]
• Barium enema (definitive: 25%; suggestive: 100%)
Diagnostic Procedures/Surgery
• Colonoscopy may directly visualize the fistula, and is essential to inspect the remainder of the colon
• Cystoscopy may visualize the actual fistula, or identify suggestive localized inflammation and edema
Pathologic Findings
• Diverticular disease with abscess
• Colon malignancy
• Crohn disease
• Bladder malignancy
• Radiation or surgical induced fistula
• UTI
DIFFERENTIAL DIAGNOSIS
• Emphysematous cystitis
• Emphysematous pyelonephritis
• Urethral rectal fistula
• Vesical enteric fistula
TREATMENT
GENERAL MEASURES
• Antibiotic therapy
• Percutaneous drainage of gas and purulent material
• Relief of urinary obstruction
MEDICATION
First Line
• Parenteral antibiotic therapy for all patients with gas-producing UTI [A]
– Ampicillin sulbactam 1.5 g IV q6h
– Ticarcillin clavulanate 3.1 g IV q6h
– Piperacillin tazobactam 3.375 g IV q6h
– Meropenem 500 mg IV q8h
– Imipenem 500 mg IV q6h
– Doripenem 500 mg IV q8h
• Antibiotic therapy for acute diverticulitis
– Ciprofloxacin 500 mg PO BID with metronidazole 500 mg PO TID [A]
– Amoxicillin clavulanate 875 mg/125 mg PO BID
– Ampicillin sulbactam 3 g IV q6h
– Piperacillin tazobactam 3.375 g IV q6h
– Ticarcillin clavulanate 3.1 g IV q6h
– Ceftriaxone 1 g IV q24h with metronidazole 500 mg IV q8h
SURGERY/OTHER PROCEDURES
• Emphysematous UTI
– Percutaneous management of purulent material and gas
– Percutaneous nephrostomy placement for emphysematous pyelonephritis
– Emergent nephrectomy is associated with very high mortality
• Enterovesical fistula
– Enterovesical fistulae typically do not close spontaneously
– The portion of bowel responsible for the fistula is excised in a 1-stage procedure with resection and primary anastomosis
– Ureteral stent placement may be performed preoperatively to allow identification of the ureter intraoperatively
– Resection of the bladder is rarely necessary
– A small defect in the bladder can be managed with suture repair, indwelling Foley catheter, and closed suction drain in the pelvis
ONGOING CARE
PROGNOSIS
• Gas-producing UTI (2)[A]
– Parenteral antibiotic therapy is successful in the majority of patients with gas limited to bladder
– Patients with gas in the upper urinary tract are at increased risk of mortality and require percutaneous drainage with parenteral antibiotics
– Gas in the perinephric space and pararenal tissues are at increased risk of mortality
• Diverticular abscess and enteric vesical fistula
– Patients have an excellent prognosis after elective resection of the disease bowel segment
– In many cases this can be performed laparoscopically (3)[B]
COMPLICATIONS
• Patients with inflammatory disorders such as Crohn may have complex and recurrent fistulae
• Patients with fistulae following radiation therapy may have impaired healing and experience recurrence
FOLLOW-UP
Patient Monitoring
• Management of associated illness
• Prompt treatment of disease flare
Patient Resources
NA
REFERENCES
1. Jaret TW, Vaughan ED Jr. Accuracy of computerized tomography in the diagnosis of colovesical fistula secondary to diverticular disease. J Urol. 1995;153:44–46.
2. Huang JJ, Tseng CC. Emphysematous pyelonephritis: Clinicoradiological classification, management, prognosis and pathogenesis. Arch Intern Med. 2000;160:797–805.
3. Bartus CM, Lipof T, Sarwar CM, et al. Colovesical fistula: Not a contraindication to elective laparoscopic colectomy. Dis Colon Rectum. 2005;48:233–236.
ADDITIONAL READING
Golabek T, Szymanska A, Szopinski T, et al. Enterovesical fistulae: Aetiology, imaging, and management. Gastroenterol Res Pract. 2013;2013:617967.
See Also (Topic, Algorithm, Media)
• Cystitis, Emphysematous
• Fistula, Enterovesical
• Inflammatory Bowel Disease (Ulcerative Colitis and Crohn disease), Urologic Considerations
• Pneumaturia (Gas in Urine) Image 
• Urinary Tract Infection (UTI), Adult Female
• Urinary Tract Infection (UTI), Adult Male
CODES
ICD9
• 596.1 Intestinovesical fistula
• 599.0 Urinary tract infection, site not specified
• 599.84 Other specified disorders of urethra
ICD10
• N32.1 Vesicointestinal fistula
• N39.0 Urinary tract infection, site not specified
• R39.89 Other symptoms and signs involving the genitourinary system
CLINICAL/SURGICAL PEARLS
• Pneumaturia is the distinct sensation by the patient of passage of air from the urinary tract.
• Pneumaturia should be considered secondary to an enteric vesical fistula until proven otherwise.
• The CT scan finding of air in the bladder is abnormal and of high diagnostic value in the evaluation of the patient with suspected pneumaturia and is likely to reveal associated pathology.
• The most common cause of pneumaturia is diverticular disease.