Pneumaturia

Question 1

A 72 year old woman presents with pneumaturia and a temperature of 38.4C. How would you manage this patient?

Answer 1

Impression
This presentation likely represents an enterovesicular fistula formation, however am concerned about an emphysematous UTI, important complications to consider/rule-out/treat including pyelonephritis and urosepsis.

DDx
- Colovesicalur fistula (less likely due to absence of faecalant urine) - usually due to diverticulitis, or sometimes malignancy, or recent surgery.
- infective: emphysematous UTI, simple UTI, pyelonephritis +/- urosepsis
- neoplasia: RCC, urothelial carcinoma
- other fistula formation (cutaneo-vesicular, secondary to suprapubic catheter?)
- in-dwelling catheterisation

Goals
- Ascertain likely aetiology through thorough Hx/Ex/Ix,
- Supportive and Definitive management in consultation with urology +/- renal, likely with empirical IV ABx. ?urosepsis

Question 2

Pneumaturia - assessment

Answer 2

Assessment
- Begin with assessment of HD stability, if intact then move to history, want to rule out sepsis given fevers in the stem

Question 3

History

Answer 3

History
- sx: haematuria, bubbling in urine, irritative LUTs, features of systemic infection (fevers, rigors, LOC/change in consciousness), presence of faeces or dark coloured urine (evidence of enterovesical fistula), sx of cystitis (burning, frequency, incontinence)
- RISKS: abdo surgery, immunocompromised (DM, medications)
- PMHx: immunosuppression (Drugs, disease, DM)
- PSHx: recent surgeries, most likely cause of a fistula
- Medications, allergies, SNAP

Question 4

Examination

Answer 4

Examination
- general appearance (pallor, surgical scars, obvious fistula etc) - vitals
- abdo exam: renal angle tenderness, abdo pain, peritionitis, shifting dullness (free fluid in the abdomen), suprapubic pain (cystitis).
- systems review: systemic features of infection +/- malignancy

Question 5

Investigations

Answer 5

Investigations
- Bedside: urinalysis, urine MCS, VBG
- Bloods: FBC, UEC, LFT,CRP/ESR
- imaging: AXR for air in abdomen, CT KUB, could also do CT abdo with oral/rectal contrast to identify fistula, or could perform cystogram
- other: cystoscopy, colonoscopy +/- biopsy

Question 6

Management

Answer 6

Management
Mainstay of management is control any infection/sepsis, then decide on definitive management course.

Definitive
- Urology referral
- UTI - ABx with trimethoprim 300mg OD
- Pyelonephritis - augmentin 14 days
- Urosepsis - Gent + Amp IV

If fistula;
Consider requirement for surgical fixation (in setting of enterovesicular fistula)
- Gastroenterology if not malignancy
- Med/rad onc if malignant

Supportive
- TPN if necessary
- Fluids
- Analgesia +/- antiemetics +/- antipyretics
- Appropriate review/ F/U