Acute epididymo-orchitis (AEO) is an uncommon complication of colovesical fistula (CVF). We present the first documented case of a patient requiring emergency orchidectomy for recurrent AEO, complicated by intratesticular necrosis and a scrotal wall abscess, secondary to an undiagnosed diverticular CVF. Definitive management involved a laparoscopic high anterior resection, employing trans anal natural orifice specimen extraction, to cure the fistula. This case underscores the importance of maintaining a high index of suspicion for rare anatomical abnormalities such as CVF in patients presenting with recurrent bacterial AEO, across specialties for both the urologist and colorectal surgeon. Early and thorough investigation is crucial to avoid the severe complications of untreated diverticular disease-particularly in individuals with significant intra-abdominal adiposity, where classic signs of peritoneal inflammation may be absent. Delayed diagnosis can lead to serious outcomes, including testicular loss and life-threatening sepsis.

A fistula is an irregular connection between two epithelialized surfaces. It can be classified or named based on which organs it connects. A connection between the colon and the bladder is termed a “colovesicular fistula.” To understand this disease process and the operative planning, clinicians must understand the intricate anatomy of the pelvis and the organs it contains. Anatomy Sigmoid Colon Sigmoid colon begins as the descending colon crosses the pelvic brim. The sigmoid colon is relatively mobile compared to the more fixed descending colon. Sigmoid colon varies in length ranging from 15 to 50 cm (average of 38 cm). The rectosigmoid junction (defined by [1] located at the level of the sacral promontory or [2] where the taeniae converge) marks the transition from the sigmoid colon to the rectum. The rectum is bordered anteriorly by Denonvilliers’ fascia, which separates the rectum from the prostate/seminal vesicles in men, and separates the rectum from the vagina in women. Histologically the colon has four layers, from deep to superficial: 1. Mucosa (columnar epithelium). 2. Submucosa (contains most of the collagen within the bowel wall and is the strength layer). 3. Muscularis Propria (contains inner circular and outer longitudinal layers) - the outer longitudinal layer is separated into the three taenia coli on the colon. 4. Serosa  Blood Supply The blood supply to the rectum and sigmoid colon is primarily from the inferior mesenteric artery (IMA). IMA gives off the left colic to the ascending colon, sigmoidal branches to the sigmoid colon and the superior rectal artery to the proximal rectum. The terminal branches of these arteries form an anastomotic arcade with the adjacent branches. Urinary Bladder The urinary bladder is situated in the retropubic space (Retzius) and is considered extra-peritoneal. In a male patient, the posterior bladder wall lies adjacent to the anterior sigmoid colon and rectum. In the female patient, the superior bladder abuts the lower uterus, and the bladder base sits adjacent to the anterior portion of the vaginal wall. The uterus separates the colon from the bladder making fistula between them much less common in females. Ureters The ureters leave the renal pelvis and course anterior to the psoas muscle. They diverge medially at the pelvic brim crossing anterior to the iliac vessels near their bifurcation. They course along the pelvic sidewall and pass under the uterine artery in women and finally enter the bladder at the lateral aspect of the base.

An enterovesical fistula (EVF) is an abnormal connection between the intestinal tract and urinary bladder, typically developing with symptoms of pneumaturia and fecaluria. We herein present the case of an 81-year-old man with 10-day watery diarrhea. After ineffective empiric antidiarrheal treatment, computed tomography and cystography revealed EVF and gas in the bladder lumen and within its wall. His diarrhea improved after urethral catheter placement. EVF can occasionally cause diarrhea in a delicate pressure balance between the bladder and intestine. Clinicians should be aware of this unusual condition and include "urinary diarrhea" in the differential diagnosis of diarrhea.

Colovesical fistula (CVF) is an abnormal connection between the urinary system and the bowel. It is a known complication of acute diverticulitis. Common symptoms include pneumaturia, fecaluria, and abdominal pain, amongst others. In this case, we report a rare case of acute renal failure due to a relatively asymptomatic colovesical fistula causing left-sided emphysematous pyelonephritis complicated by renal abscess. After appropriate surgical treatment and antibiotic therapy, the CVF, pyelonephritis, and abscess resolved. Unfortunately, renal function did not return to baseline, likely due to injury and poor functioning of the left kidney. Urology is considering radical nephrectomy to prevent recurrent of future infection. This case highlights a previously unknown and severe patient presentation of CVF and signifies the importance of maintaining a high index of suspicion of a fistula when a patient presents with recurrent urinary tract infections, acute renal failure, and colon pathology.

Background: Colovesical fistulas are abnormal communications between the colon and urinary bladder, most commonly caused by diverticular disease. Although colovesical fistulas are rare, they should be suspected in patients presenting with recurrent urinary tract infections, pneumaturia, or fecaluria. We integrated two case reports with a retrospective national cohort analysis to assess the surgical treatment of colovesical fistulas. Methods: We report two cases of colovesical fistulas, both secondary to sigmoid diverticulitis, treated surgically via minimally invasive approaches. A retrospective analysis using the National Inpatient Sample database from 2016 to 2022 was conducted to compare outcomes of open surgery with those of minimally invasive surgery. Propensity score matching and multivariable regression analyses were used to evaluate clinical outcomes. Results: The first patient underwent hand-assisted laparoscopic sigmoidectomy with fistula takedown and has remained asymptomatic at 8 months, while the second patient underwent robotic-assisted sigmoidectomy with staged ileostomy reversal and has remained asymptomatic at 1 month. National data analysis showed no significant difference in mortality (<1% versus <1%, p = 0.931), wound complications (1.4% versus 1.0%; p = 0.554), or postoperative sepsis or shock (7.1% versus 5.6%; p = 0.114) between open and minimally invasive surgical approaches. However, the minimally invasive surgery group had significantly shorter length of stay than the open surgery group (6.9 versus 7.3 days, p < 0.001). Conclusions: Minimally invasive repair of colovesical fistulas was associated with shorter hospital stays than open surgery, with no significant differences in major complications. Early identification and timely surgical management are critical for achieving favorable outcomes.

Cervical cancer is rarely reported in patients with congenital adrenal hyperplasia (CAH), a condition that may alter risk through hormonal and anatomical factors. When combined with human immunodeficiency virus (HIV), the risk of progression from cervical intraepithelial neoplasia (CIN) to invasive carcinoma may be amplified, yet remains underreported. We report the case of a 57-year-old woman with a history of classic CAH, HIV, cervical intraepithelial neoplasia grade III (CIN III), hypertension, and asthma who presented with abdominal pain and pneumaturia. Imaging revealed air within the vaginal cuff and endometrial canal, raising concern for a fistula. Further evaluation confirmed invasive cervical cancer complicated by vesicovaginal fistula formation. This case highlights the complex interplay between immunosuppression and hormonal dysregulation in cervical cancer pathogenesis. Despite known risk factors, the diagnosis was delayed due to atypical presentation and poor follow-up. Fistula formation added further morbidity and required coordinated multidisciplinary care. In patients with CAH and HIV, cervical cancer may present atypically and be complicated by fistula development. Clinicians should maintain a high index of suspicion and pursue early, coordinated evaluation in patients with overlapping immunologic and endocrine comorbidities.

Enterovesical fistula (EVF) is a rare condition that can be difficult to diagnose due to its nonspecific symptoms, such as recurrent urinary tract infections (UTIs), pneumaturia, and fecaluria. We report a case of EVF in which early diagnosis was facilitated by clinically integrated interpretation of urine Gram stain findings in the context of the patient's overall presentation. An 89-year-old woman with a history of rheumatoid arthritis and long-term corticosteroid use presented with fever and right knee pain, initially suspected to be a rheumatoid flare. However, synovial fluid analysis was negative for infection or crystals, prompting further evaluation. Urinalysis revealed bacteriuria and leukocyturia, and urine Gram stain demonstrated a polymicrobial pattern with numerous polymorphonuclear leukocytes. Given the patient's clinical status and lack of common risk factors for polymicrobial colonization, the findings raised suspicion for fecaluria and a possible EVF. A contrast-enhanced computed tomography (CT) scan subsequently confirmed an EVF due to mucinous adenocarcinoma of the cecum invading the bladder. The patient underwent successful ileocecal resection and bladder fistula closure. Although not routinely used to diagnose EVF, urine Gram stain can provide early diagnostic clues when interpreted in real time alongside clinical findings. When polymicrobial patterns are observed in urine, especially in patients with recurrent or atypical UTIs, they may offer a critical diagnostic clue to EVF. In this case, the integration of polymicrobial patterns with bedside assessment led to early suspicion and imaging. The case also highlights how serious infections in older patients may present with atypical or misleading symptoms, emphasizing the need for diagnostic vigilance. This case highlights the potential utility of urine Gram stains as a rapid, cost-effective tool for the early detection of EVF. Clinicians should consider EVF in older adult patients with atypical UTIs, and interpret polymicrobial Gram stain findings in the clinical context to guide timely diagnosis and appropriate management.