Dear Dr. Hamid.
A 66 years old chinese gentleman was admitted with complaint of per
rectal bleeding associated with altered bowel habits and weight loss
for the past 2 weeks. He also complaint of having dysuria, hemturia and
passing fecal matter trough his genitalia. Upon further investigation,
his hemoglobin levels was 8.4 g/dl with CEA level of 9.1. Renal profile
showed UREA levels of 23. Colonoscopy was done and reported that there
was a mass just above the dentate line and it obstruct penetration of
colonoscope hence assesment of deeper area of rectum and colon
unsucessful. Upon insertion of continuous bladder drainage, there were
fecal matter passing trough his genitalia.
1) What was the cause of recto-vesicle fistula in elderly?
2) How would you manage this gentleman?

Medical Student (IMU)

Dear Member,

1.In this situation, the rectovesical fistula(abnormal connection between the
rectum and the bladder)is most probably due to the rectal cancer which has
infiltrated through the wall of the rectum and then through the adjacent wall of
the bladder.(The wall of the rectum and the wall of the bladder is in close
proximity anatomically speaking).

2.The Management;

i.diagnosis of the cancer by getting the biopsy of the tumour at
colonoscopy.confirmation of cancer from the histological examination

ii. staging of the rectal cancer by ct scan of the pelvis and abdomen.local
pelvic infiltration, secondaries in the pelvic lymph nodes and paraortic lymph
nodes and in the liver will be detected to determine the stage.
advanced cancer will be managed conservatively focussing to alleviate
symptoms(palliative).
early or localised cancer will entail aggressive surgical management to cure the
patient from the cancer.
in view of the fistula, it is assumed that the patient already has advanced
rectal cancer and hence conservative management is the philosophy of management
here.
the ct scan will also provide the urogram information about obstructive
uropathy(blockage of renal system)in view of high urea

iii.since there is connection between the bladder and the rectum,and feces goes
into the urine hence infecting it,antibiotics need to be given over prolong
period

iv.since the patient is anaemic, blood tranfusion is required.

v.if the ureter(s) is/are blocked, internal ureteric stent(s) should be inserted
to improve the renal function

vi.the tumour should be managed by using radiotherapy+chemotherapy

dr hamid