Emphysematous epididymitis as presentation of unusual seminal vesicle fistula secondary to sigmoid diverticulitis: case report

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Abdominal Imaging

ª Springer Science+Business Media, Inc. 2004 Received: 28 January 2004 / Accepted: 18 February 2004 / Published online: 17 November 2004

Abdom Imaging (2005) 30:113–116 DOI: 10.1007/s00261-004-0216-1

Emphysematous epididymitis as presentation of unusual seminal vesicle fistula secondary to sigmoid diverticulitis: case report B. Coulier,1 A. Ramboux,2 P. Maldague3 1

Departments of Diagnostic Radiology, Clinique St Luc, Rue St Luc 8, 5004, Bouge (Namur), Belgium Department of Abdominal Surgery, Clinique St Luc, Rue St Luc 8, 5004, Bouge (Namur), Belgium 3 Department of Gastroenterology, Clinique St Luc, Rue St Luc 8, 5004, Bouge (Namur), Belgium 2

Abstract This case report describes a sigmoid diverticulitis with torpid development, long-term symptoms of bladder irritability, and an emphysematous epididymitis caused by a direct seminal vesicle fistula. The diagnosis was suggested by scrotal ultrasound visualizing gas in the scrotum; the complex pelvic fistulous tract was specifically delineated by multislice computed tomography. This may be the first reported case of seminal vesicle fistula directly related to colonic diverticulitis and causing emphysematous epididymitis.

antibiotic therapy. He presented with a chief complaint of 4 days of left scrotal pain and swelling associated with discomfort in the left iliac fossa. There were no gastro-

Key words: Left-side colonic diverticulitis—Ultrasound—Multislice computed tomography—Fistula—Seminal vesicle—Epididymitis

Diverticulitis can have a variety of unusual presentations. This case report describes a sigmoid diverticulitis with torpid development, long-term symptoms of bladder irritability, and an emphysematous epididymitis caused by the development of a direct seminal vesicle fistula. To our knowledge, this is the first reported case of seminal vesicle fistula directly related to colonic diverticulitis. The diagnosis was suggested by scrotal ultrasound demonstrating gas in the scrotum, and the complex fistulous tract was specifically delineated by multislice computed tomography (msCT).

Case report A 67-year-old diabetic male was referred to our department of medical imaging with a 3-week history of urinary tract infection and dysuria that seemed to be resistant to Correspondence to: B. Coulier; email: [email protected]

Fig. 1. A, B Left scrotal ultrasound. The testis (T) is surrounded by a multiloculated pyocele (stars); the epididymal complex is swollen and dedifferentiated and contains gas bubbles (arrow); free gas is visible in the pyocele (arrowhead).

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B. Coulier et al.: Emphysematous epididymitis secondary to sigmoid diverticulitis

Fig. 2. A–C Multiaxial msCT reconstructions show an irregular thickening of the sigmoid (star) connected to a small prerectal abscess (arrowhead) by an irregular fistulous tract (white arrow); the small abscess penetrates and injects gas into the seminal vesicle and into the vas deferens (black arrow).

intestinal symptoms. Abdominal examination demonstrated some pain in the left iliac fossa without splinting or rebound tenderness. The left scrotum was red, swollen, and painful. Ultrasound examination (Fig. 1) showed a normal bladder, but the left testis was moderately swollen and surrounded by a multiloculated pyocele. The epididymal complex was extremely swollen, dedifferentiated, and contained gas bubbles in its lower portion. Free gas was also visible within the pyocele. A causative link was immediately suspected between the suggestion of thickening of the sigmoid colon and the scrotal bubbles, and the patient immediately underwent pelvic and scrotal msCT with intravenous and rectal contrast material. Axial and selected multiplanar reconstructions (Figs. 2, 3) clearly showed thickening of the sigmoid colon and a sinuous fistulous tract joining this altered sigmoid segment to a small prerectal abscess that had developed in the Douglas pouch. This abscess had secondarily perforated into the left seminal vesicle, which contained intestinal gas. Gas was also found in the vas

deferens along its course as far as the swollen and inflammed left scrotum. Laboratory tests were normal, with a white blood cell count of 7000 and C-reactive protein level of 1.9 mg/dL. The patient underwent a Hartmann surgical procedure associated with left scrotal exploration and drainage. Continuity of the colon was restored 5 months later.

Discussion The acquired form of colonic diverticular disease is extremely common in Western society [1] and is a 20th century phenomenon, probably induced by diet, that currently has reached epidemic proportions because it affects one-third of the population older than 40 years and two-thirds of the population older than 85 years [2, 3]. The longer diverticulosis is present, the likelihood of developing diverticulitis increases. Diverticulitis will develop in 10% of individuals with diverticulosis after 5 years, in 25% after 10 years, and in 35% after 20 years [2]. Most diverticula arise in the

B. Coulier et al.: Emphysematous epididymitis secondary to sigmoid diverticulitis

Fig. 3. A Sagittal MIN projection through the pelvis shows the gas-injected course of the vas deferens from the gaseous seminal vesicle to the inguinal canal. B Sagittal msCT reconstruction through the inflammatory left scrotum presents free gas in the paratesticular pyocele (arrow).

sigmoid region, and 95% of complications occur there. Impaction of fecal material in a diverticulum causes obstruction with inflammation and probably represents the prodrome [4] of the very broad spectrum of diverticulitis, from a benign course that responds quickly to antibiotics to perforation that results in large pelvic and peritoneal abscesses [5]. Occasionally, in elderly patients, in particular, a large perforation produces severe fecal contamination of the entire peritoneal cavity with life-threatening sepsis. The classic and typical clinical presentation of acute left-side colonic diverticulitis is pain and guarding in the left lower abdominal quadrant associated with parameters of inflammation (e.g., fever or elevated C-reactive protein) [1, 3]; however, the rate of misdiagnosis of diverticulitis based solely on clinical and laboratory criteria is high, with reported error rates of 34% to 67% [1], and

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even higher in women and patients younger than 40 years. Diseases clinically mistaken for diverticulitis include appendicitis, colon cancer, fecal stasis, irritable bowel syndrome, and urinary or gynecologic diseases. In the reported case, the clinical diagnosis was made retrospectively through genitourinary symptoms. The diagnosis and treatment of diverticulitis have been altered dramatically by the development and application of CT. With virtually no risk to the patient [5], CT can diagnose diverticulitis in acutely ill patients, even those with peritoneal signs, and the disease can be staged; such information greatly facilitates the decision to treat the patient medically, surgically, or by percutaneous drainage followed by elective surgery [1, 3, 6, 7]. At present, CT is the technique of choice for diagnosing this pathology. This choice is reinforced by the availability of msCT with its possibilities for multiplanar reconstructions obtained with thinner collimation and higher resolution [1]. These advantages of msCT are particularly well illustrated in the reported case. Among the complications of colonic diverticulitis, fistular formation represents a diagnostic challenge. The genitourinary tract is affected most often because of its anatomic relation to the sigmoid [4]. Fistular formation in diverticular disease occurs in most cases as a result of the direct extension of an abscess but may occur as the result of a rupture of a single diverticulum. In females [2], fistulas have been described between the sigmoid and the fallopian tube, the retained cervix, and the uterus; these three varieties are the rarest. The most common cologenital fistula to complicate diverticular disease is the sigmoid vaginal lesion, of which there are two varieties: the less common type occurs in the presence of a uterus or retained cervix, and the more common type perforates the apical vaginal scar some years after a total hysterectomy [2]. In both sexes, approximately 2% of patients with diverticulitis develop colovesical fistulas [4, 8]. Diverticulitis is the most common cause of colovesical fistula, with other causes including inflammatory bowel disease, neoplasm, trauma, congenital anomaly, radiation necrosis, and pelvic abscess from different causes [4, 8, 9]. The male-to-female ratio is 4.1:1, and it has been suggested that the presence of the uterus affords protection against the development of colovesical fistulas in females [8]. In the prodromal stage, vesical irritability is produced by adjacent inflamed loops of bowel or by abscess. As shown in the reported case, these symptoms of bladder irritability may be the only symptoms of diverticulitis, and the urine culture remains sterile. The disease may then progress with erosion into the bladder causing severe tenesmus due to acute cystitis. At the chronic stage, a fistula develops, characterized by fecaluria (30% to 75%), pneumaturia (40% to 90%), and long-term infection [8]. In males, infection of the genital organs is presumed to be mostly secondary to retrograde extension of the

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infection of the urinary tract [4]; direct extension of colonic diverticulitis to genital organs is very rarely reported [4, 10]. Only two cases of direct involvement of the prostate have been described [10, 11]; and among the five cases of seminal vesicle fistula reported since 1966 [9], two were related to Crohn disease and three concerned adenocarcinoma of the rectum. Our case probably represents the first reported one directly related to colonic diverticulitis. No single study can detect all cases of difficult fistulae and their likely causes. A combination of techniques may be necessary, such as cystoscopy, sigmoidoscopy, Gastrografin enema, or direct retrograde dye studies [2, 4, 8, 9]. CT may demonstrate not only left-side acute colonic diverticulitis but also the presence of colovesical fistula or fistulization into the seminal vesicle [8, 9, 12]. Current imaging of difficult pelvis fistulae has been revolutionized by magnetic resonance imaging, particularly in complex fistula-in-ano [8, 13]. Unless the diagnosis was extremely facilitated by the presence of sigmoid gas injecting the fistulous tract, the seminal vesicle, and the vas deferens, but also by the preliminary evocating ultrasound study of the patient’s scrotum, our case undoubtedly confirms the high performance of msCT in complex abdominal situations thanks to its possibilities of multiplanar reconstructions obtained with thinner collimation and higher resolution.

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