The above findings suggest an inflammatory process involving the anorectal and sigmoid part of the colon, with complicated diverticulitis and a suspicious colovesical fistula. The possibility of an inflammatory process on top of neoplastic change should be excluded, and histopathological correlation is still pending.

In this case, there is no history of urinary bladder catheterization procedures. Additionally, the presence of a significant air-fluid level in the urinary bladder, associated with adjacent colonic diverticulitis, as well as questionable wall thickening involving the anorectal and sigmoid part of the colon and some loss of the fat plane in between the anterior wall of the rectosigmoid junction and the superior posterior wall of the urinary bladder, with the presence of a small air locule in between, strongly suggests the development of a colovesical fistula.

Colovesical fistula (CVF) is considered one of the most common complications of diverticular disease, inflammatory bowel disease like Crohn's disease, and cancer. Pneumaturia is one of the most common symptoms of CVF, present in about 90% of patients. CT scan provides a sensitivity of about 90% in the diagnosis of CVF.

Surgery is the first-line treatment for such a case, with antibiotic cover before the surgical procedure, as in this case, along with close follow-up and a surgical plan accordingly.