Vesicocutaneous fistula

80-year old male with historyHistory prostate cancer s/p. Previous prostatectomy presented andwith 2-week history of UTI presented with, worsening pain and fever.

This case demonstrates typical appearance of vesicocutaneous fistula that was initially suspected onroutine CT A/P and CT cystogram and was subsequently, subsequently confirmed on MRI pelvis. In addition, patient had bladder neck/proximal urethral calculus as well as osteomyelitis of pubic bones with pubic symphysis septic joint. 

Initial routine CT A/P with IV contrast demonstrated bladder wall thickening with inflammatory stranding in the retropubic space. The inflammatory changes extended into the suprapubic soft tissues suggestive of phlegmon and cellulitis as well as raising the possibility of vesico-cutaneous fistula. In addition, a 10 mm calculus was also noted in the bladder neck/proximal urethra. A CT cystogram was requested by Urology to confirm the presence of fistula.

CT cystogram demonstrated contrast extravasation along the anterior aspect of the bladder/prostatic urethra, extending through the pubic symphysis into the suprapubic soft tissues. These findings were suggestive of a fistula in the bladder or the proximal urethra. The urethral stone was dislodged back into the bladder during placement of Foley catheter. Erosive changes were also noted in the pubic symphysis, suggestive of possible osteomyelitis. 

MRI of the pelvis was then performed without and with contrast which demonstrated aA defect in the lower anterior wall of the bladder (best seen on sagittal T2 FS images) communicating with collection in the suprapubic soft tissues, consistent with vesicocutaneous fistula was noted"Vesicocutaneous Fistula". In addition, the pubic bones and the superior pubic rami demonstrated T1 hypointensity/T2 hyperintensity with post-contrast enhancement, consistent with osteomyelitis.