Presentation
Flank pain, complicated UTI, and history of neurogenic bladder
Patient Data
Pelvic organs/bladder: the suprapubic catheter appears to terminate in the vagina, just inferior to the cervix. The suprapubic catheter balloon also appears to be within the vagina. The urinary bladder itself appears relatively decompressed. There is a significant amount of pericystic fat stranding. There is increased circumferential bladder wall thickening, which is suspicious for cystitis.
Kidneys/Ureters: atrophic kidneys. There is a complicated cortical cyst projecting from the superior pole of the right kidney posteriorly. Moderate bilateral hydroureteronephrosis. No urolithiasis. No obstructive mass lesion was seen bordering either ureter. Perinephric fat stranding bilaterally. There is no perinephric collection to suggest abscess formation.
Case Discussion
In this case, the suprapubic catheter was placed because the patient has a neurogenic bladder. However, the suprapubic catheter appears to have eroded through the posterior aspect of the urinary bladder, thus resulting in a vesicovaginal fistula. The distal tip of the catheter and the inflated balloon appear to be within the vaginal canal, just inferior to the cervix. There was no free fluid or free air in the abdomen or pelvis. Although the urinary bladder appears relatively decompressed, there is moderate bilateral hydroureteronephrosis. No obvious obstructive mass lesion or stone was seen.
Urology believed that this patient would benefit from a urinary diversion given her recurrent urinary tract infections involving a non-functional bladder, a vesicovaginal fistula, and her impaired wound healing. However, this patient has already undergone a subtotal colectomy with extended right hemicolectomy/terminal iliectomy for inflammatory bowel disease complicated by multiple enteroenteric fistulas about her ileocolic anastomosis, leading to an eventual end ileostomy. Therefore, her bowel diversion may limit her ability to have a urinary diversion.
Case courtesy of Ross Kuprien, M.D.
Additional contributor: Benjamin Jiao, D.O.
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