Roentgenologic Abnormalities of the Urinary Bladder Secondary to Crohn s Disease

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Roentgenologic Abnormalities of the Urinary Bladder Secondary to Crohn s Disease NORMAN JOFFE1 Urinary tract symptoms and signs may result from secondary involvement of the urinary bladder in

1 Roentgenologic Abnormalities of the Urinary Bladder Secondary to Crohn s Disease NORMAN JOFFE1 Urinary tract symptoms and signs may result from secondary involvement of the urinary bladder in patients with Crohn s disease. In a small but significant proportion of these individuals, urinary tract symptoms represent the initial or predominant mode of presentation. Such patients may be erroneously treated for primary infection of the lower urinary tract for prolonged periods before the intestinal origin of the disease process is discovered. Roentgenologic abnormalities of the urinary bladder may provide early and important clues to the correct diagnosis. The various abnormalities of the urinary bladder which may occur secondary to Crohn s disease are described and illustrated, and the roentgenologic differential diagnosis is discussed. Introduction A variety of abnormalities of the urinary tract may be observed in patients with Crohn s disease of the small bowel and/or colon [1, 2]. They include : an increased incidence of nephnolithiasis, especially in patients who have undergone resection of diseased small or large bowel [3, 4] ; the nephrotic syndrome secondary to amyloidosis [5] ; retroperitoneal, psoas, or penirenal abscesses [6, 7] ; and ureteric obstruction with hydroureter and hydronephrosis [8]. These complications generally occur in association with disease which is severe or of long duration. Urinary tract complications such as uretenic obstruction may not be recognized unless specifically searched for by excretory urography [9]. Urinary tract symptoms may also occur as a result of secondary involvement of the urinary bladder in patients with Crohn s disease [6, 10-12]. Such symptoms in patients with known inflammatory bowel disease generally provide no serious diagnostic problem, since the primary cause is already established. However, in some patients urinary tract symptoms are the initial or predominant mode of presentation, and failure to recognize the intestinal origin of the disease may result in serious complications. Since roentgenologic abnormalities of the urinary bladder may facilitate correct diagnosis, it is important for radiologists to be aware of them. This paper describes and illustrates the roentgenologic changes. Material Urinary tract symptoms were the initial or predominant mode of presentation in 1 2 patients with roentgenographic abnormalities of the urinary bladder secondary to regional enteritis. Eight were male and four female; ages ranged from 19 to 44 years (mean. 32). Difficulty with mictunition, increased frequency, dysuria, nocturia, and penile or suprapubic pain were the initial symptoms in six patients. While urinary symptoms also dominated the clinical picture in the remaining six, Crohn s disease had been diagnosed 1-16 years earlier. Lower abdominal cramps and/or diarrhea were frequently absent or relatively mild. Such complaints were often elicited only by direct questioning following excretory urography. Pneumaturia and fecaluria were never the initial presenting complaints, although one or the other subsequently developed in three patients in whom enterovesical fistulae were demonstrated by radiology or surgery. Prior to referral to our hospital, most of the patients in this group, including the six with undiagnosed Crohn s disease, were treated for acute or chronic cystitis, recurrent lower urinary tract infection, or even prostatitis. In all 12 cases, Crohn s diease of the ileum was the primary disease process responsible for the abnormal - ities of the bladder and the associated urinary symptoms. One of three patients with extrinsic involvement of the rectosigmoid region secondary to adjacent ileal disease had rectal pain and tenesmus; an ileosigmoid fistula was demonstrated in one case. Discussion Involvement of the urinary bladder secondary to Crohn s disease is generally the result of direct extension of the inflammatory process from a contiguous loop of bowel with or without an intervening abscess. Initially there is fixation of the inflamed bowel to the peritoneal surface of the bladder with tethering of the bladder wall. This may interfene with normal muscular contraction and cause difficulty in mictunition [13]. Secondary inflammatory changes develop within the wall of the bladder and may progress over a period of weeks, months, or even years resulting in thickening of all its layers with associated mucosal edema on polypoid changes. Clinically there is frequency of micturition, dysunia, and urgency. The patient may also experience suprapubic pain or discomfort. Infection and ulceration of the bladder mucosa may give rise to gross or microscopic hematunia. If the secondary nature of the lesion is not recognized, further progression of the inflammatory process may result in perforation into the bladder lumen with the establishment of a vesicointestinal fistula. Fecal particles may be detected in the urine, or bubbles of gas may escape, especially at the end of mictunition. Fistulous tracts may be direct or indirect and generally involve the posterior and superior aspect of the bladder. In the former there is a direct communication between the bladder and an adherent loop of bowel. Indirect fistulae are generally tnanspenitoneal with an intervening abscess between the bowel and the bladder. If an incipient or established fistula is present, cystoscopy may reveal localized hyperemia, bullous edema, or polypoid epithelial proliferation ; the latter may simulate a vesical neoplasm [1 4]. The fistulous opening is frequently not visualized by cystoscopy, 1 Department of Radiology, Beth Israel Hospital and Harvard Medical School, 330 Brookline Avenue, Boston, Massachusetts Am J Roentg.nol 127: ,

,,. 298 JOFFE r; Fig. 1-33-year-old male with 3 week history of urinary tract complaints. Excretory urogram showing smooth, extrinsic pressure deformity of bladder dome.

2-31 -year-old male with urinary tract complaints and one episode of hematuria ; no intestinal symptoms but Crohn s disease of terminal ileum demonstrated 4 years earlier.

Surgery revealed Crohn s disease of distal ileum with abscess and ileovesical fistula.

2 ,,. 298 JOFFE r; Fig year-old male with 3 week history of urinary tract complaints. Excretory urogram showing smooth, extrinsic pressure deformity of bladder dome. Barium studies revealed Crohn s disease of distal ileum Fig year-old male with urinary tract complaints and one episode of hematuria ; no intestinal symptoms but Crohn s disease of terminal ileum demonstrated 4 years earlier. A, Excretory urogram showing extrinsic pressure deformity of bladder dome. B, Postvoid film showing defect and residue of contrast. Surgery revealed Crohn s disease of distal ileum with abscess and ileovesical fistula. even in the presence of pneumaturia or fecalunia [1 2, 15, 16] Roentgenologic Findings The roentgenologic abnormalities depend on the stage and degree of the secondary inflammatory process. They Fig year-old female with urinary tract complaints and no intestinal symptoms. Excretory urogram showing deformity of bladder dome with spiculated appearance due to fixation and tethering of bladder wall. Barium studies revealed Crohn s disease of distal ileum. are essentially the same whether the urinary symptoms represent the initial or predominant mode of clinical presentation on develop late in the course of known inflammatory bowel disease. Roentgenologic abnormalities are generally well demonstrated by excretory urography but may be confirmed or further evaluated by retrograde cystography. Initially, fixation of the inflamed bowel to the bladder wall may result in deformity of the dome of the contrast-filled bladder. This may appear as a smooth extrinsic pressure defect (figs. 1 and 2) or there may be a spiculated appearance (fig. 3). The deformity may be localized or involve the entire supenor contour and may be associated with a soft tissue mass. Since the changes are commonly secondary to inflammatory disease of the distal ileum, they are often limited to the night side of the bladder (figs. 1-3). In the early stages the deformity may be relatively mild; it frequently is attributed to incomplete distention of the bladder on the excretory urogram (fig. 44). If the deformed contour persists following voiding, the observer should be alerted to its pathologic significance (figs. 28 and 5B). Since the bladder-bowel fixation interferes with normal muscular contraction, a moderate or large postvoid residue of contrast in the bladder may also be observed (figs. 2B and SB). Extrinsic deformity of the bladder dome may also occur in association with pelvic abscess secondary to Crohn s disease (fig. 4B). Despite marked abnormalities of the bladder, the ureters and upper urinary tracts are usually normal. Only one of our 1 2 cases demonstrated evidence of partial unilateral uretenic obstruction. After the inflammatory process has extended into the bladder wall, two further types of roentgen abnormality may be observed. There may be a diffuse nodular deformity of the bladder dome (figs. S and 6) or a localized, smooth, on irregular filling defect simulating a vesical neoplasm (figs. 7 and 8). The latter abnormality is particularly common in association with an incipient or established vesicointestinal fistula. Demonstration of a fistulous communication by excretory urography, retrograde cystography, and barium studies of the bowel is uncommon, probably due to their long tortuous nature or the valvelike effects produced by the lining inflammatory tissue.

CROHN S DISEASE AND THE BLADDER 299 Fig. 4-30-year-old female with lower urinary tract infection. Two months later, onset of fever, lower abdominal pain.

B, Repeat excretory urogram 2 months later showing large soft tissue mass compressing left superior contour of bladder.

3 CROHN S DISEASE AND THE BLADDER 299 Fig year-old female with lower urinary tract infection. Two months later, onset of fever, lower abdominal pain. and tender suprapubic mass A, Excretory urogram showing minimal deformity of bladder dome (arrow). B, Repeat excretory urogram 2 months later showing large soft tissue mass compressing left superior contour of bladder. Small gas collection present Just medial to distal portion of normal left ureter. Surgery revealed extensive Crohn s disease of ileum and cecum with large pelvic abscess. Fig year-old male with urinary tract complaints and suprapubic pain. A, Excretory urogram showing nodular deformity (arrow) of bladder dome. B. Postvoid film showing persistence of deformity and large residue of contrast. Barium studies demonstrated Crohn s disease of distal ileum. At surgery, chronic abscess cavity found between diseased bowel and bladder wall but no fistula.

300 JO FEE Fig. 6-36-year-old male with urinary tract complaints and penile pain; no intestinal symptoms. Excretory urogram showing irregularity and nodularity of bladder dome.

Roentgenologic Differential Diagnosis The roentgenographic abnormalities must be diffenentiated from both primary and secondary inflammatory on neoplastic processes involving the bladder.

4 300 JO FEE Fig year-old male with urinary tract complaints and penile pain; no intestinal symptoms. Excretory urogram showing irregularity and nodularity of bladder dome. Barium studies showed Crohn s disease of distal ileum with secondary involvement of sigmoid colon. Roentgenologic Differential Diagnosis The roentgenographic abnormalities must be diffenentiated from both primary and secondary inflammatory on neoplastic processes involving the bladder. These primarily include inflammatory disease of the female genital tract (e.g., tuboovanian or other pelvic abscesses), acute appendicitis with or without peniappendiceal abscess fonmation, cysts and neoplasms of the female genital tract, pnimary bladder carcinoma, tuberculous cystitis, and benign proliferative lesions (e.g., cystitis cystica and cystitis gland ulanis). Differentiation from inflammatory or neoplastic disease of the female genital tract is largely based on associated clinical symptoms and signs and bimanual pelvic examination. Ultrasound may be helpful. If the diagnosis is still uncertain, exclusion of primary bowel disease by barium studies should always be undertaken. Barium enema examination may be helpful in the diagnosis of appendiceal abscess. Tuberculous cystitis is differentiated by associated involvement of the ureters and kidneys and identification of the causative organism in the urine. Cystitis cystica and cystitis glandulanis represent metaplastic changes in the epithelium and are frequently associated with inflammation of the bladder. Both tend to occur in the region of the tnigone but may occur elsewhere and give rise to filling defects or irregularity of the bladder contour [1 7, 1 8]. Diagnosis depends on cystoscopy, biopsy, and exclusion of primary bowel disease by barium studies. Primary vesical neoplasms are differentiated by cystoscopy and biopsy. If urinary symptoms include pneumaturla or fecaluria, the differential diagnosis consists essentially of vesicointestinal fistula. The reported incidence of such fistulae in large series of patients with Crohn s disease is shown in table 1, while the comparative incidence of nontraumatic causes of vesicointestinal fistulae is summarized in table 2. In patients over the age of 50, diverticulitis of the sigmoid colon or carcinoma of the rectosigmoid are the most likely causes. The diagnosis is generally established by barium enema examination, although the fistulous communication itself may not always be demonstrated. If the barium enema Fig year-old male with 8 month history of suprapubic pain (diagnosed prostatism ), urinary tract complaints, and cloudy urine. A, Excretory urogram showing smooth defect on bladder dome. Retrograde cystogram showed similar localized defect ; cystoscopy revealed area of polypoid mucosal proliferation. B, Small bowel examination showing Crohn s disease of distal ileum with ileoileal and ileosigmoid fistulae. These findings and ileovesical fistula demonstrated at surgery.

CROHN S DISEASE AND THE BLADDER 301 Fig. 8-26-year-old female with urinary tract complaints and cloudy urine; no intestinal symptoms.

5 CROHN S DISEASE AND THE BLADDER 301 Fig year-old female with urinary tract complaints and cloudy urine; no intestinal symptoms. Cystoscopy revealed 4 cm necrotic mass on anterior wall of bladder; no fistula visualized. A, Retrograde cystogram showing filling defect (arrows) on bladder dome, B. Small bowel examination showing Crohn s disease of distal ileum with fistulous communication (arrow) to anterosuperior aspect of bladder. Findings confirmed at surgery. is normal, the possibility of Crohn s disease should be considered, especially in younger patients. Barium examination of the small bowel is mandatory. Other causes of nontraumatic vesicointestinal fistulae include primary bladder carcinoma, acute perforative appendicitis, tuberculosis, amebiasis, actinomycosis, perforated Meckel s diverticu - lum, and foreign body perforations of the bowel. REFERENCES 1. Bagley RJ, Clements JL Jr, Patrick JW, Rogers JV, Weens HS: Genitourinary complications of granulomatous bowel disease. Am J Roentgenol : , Chapin LE, Scudmore HH, Bagenstoss AH, Bargen JA: Regional entenitis : associated visceral changes. Gastroenterology 30: , DerenJJ, PorushJG, Levitt MS. Khilani MT: Nephrolithiasisas a complication of ulcerative colitis and regional enteritis. Ann Intern Med 56 : , Grossman MS, Nugent FW: Urolithiasis as a complication of chronic diarrheal disease. Am J Dig Dis 12 : , Werther JL Schapira A, Rubenstein 0, Janowitz HO: Amyloidosis in regional enteritis,amjmed29 : , Ginzburg L Oppenheimer G : Urologic complications of regional enteritis. J Urol 59 : , Kyle J : Psoas abscess in Crohn s disease. Gastroenterology 61 : , Rominger CJ, Flandreau RH, McGinnis FT, Schnell C: Ureteral obstruction from regional enteritis. Am J Roentgenol 86: , Enker WE, Block GE : Occult obstructive uropathy complicating Crohn s disease. Arch Surg 1 01 : , Kyle J. Murray CM : Ileovesical fistula in Crohn s disease. Surgery 66 : , TABLE 1 Incidence of Ileovesisal Fistulae in Crohn s Disease Reference No Cases Crohns Disease - Incidence Van Patter et al. [1 9] Crohn and Yarnis [20J Daffner et al. [ Atwell et al. [22] KyleandMurray[1O] No. of Fistulae % 1 1. Robinson RHOB : Vesico-intestinal fistula with special reference to Crohn s disease. Br J Urol 25 : Williams AJ : Vesicointestinal fistula and Crohn s disease. Br J Surg 42 : , Scorer CG : Vesicointestinal fistula. Proc R Soc Med 51 : , Goldstein MH, Bragg 0, Sherlock P: Granulomatous bowel disease presenting as bladder tumor : report of a case. Am J Dig Dis 16 : , Abeshouse BS, Robbins MA, Gann M, Salik JO : Intestinovesical fistulas. Report of seven cases and review of the literature.jama 164: , Pugh JI : On the pathology and behaviour of acquired nontraumatic vesicointestinal fistula. BrJSurg 51 : , Brogdon BG, Sebbiger ML Colston JAC: Cystitis glandularis. Radiology 85 : , 196S 1 8. Dann RH, Anger PH, Enterline HT : Benign proliferative processes presenting as mass lesions in the urinary bladder. Am J Roentgenol : , Van Patter WN, Baien JA, Dockerty MB, Feldman WH, Mayo CW, Waugh JM : Regional enteritis. Gastroenterology 26 : , 1 954

6 302 JOFFE TABLE 2 Nontraumatic Causes of Vesicointestinal Fistulae Etiology Reference Total Cases with Fistuiae Neopiastic inflammatory Cause of Inflammation Pugh [16] 30* 13 (43.3) 17 (56.6) Sigmoid diverticulitis, 13; Crohn s disease, 2; appendicitis, 1 Counis and Block [23] (35) 199 (51.9) Sigmoid diverticulitis, 169; Cnohn s disease, 5; appendicitis, 7 Williams [12] (43.2) 51 (34.4) Sigmoid diverticulitis, 23; Crohn s disease, 8; appendicitis, 4 Abeshouse [1 5] (33) 31 0 (47) Individual causes not indicated Note--Numbers in parentheses are percentages. Acquired nontraumatic only. 20. Crohn BB, Yarnis H : Regional Ileitis, 2d ed. New York, Grune 22. Atwell JO, Duthie HL, Goliger JC: The outcome of Crohn s & Stratton disease. Br J Surg 52 : , 196S 21. Daffner J, Brown C : Regional entenitis. Clinical aspects and 23. Counis CD, Block MA : Intestinovesical fistula. Surgery 4: diagnosis in 1 00 patients. Ann Intern Med 49 : , , 1963

Case Presentation: Mr. S

Case Presentation: Mr. S History Seen as inpatient in May, but has significant prior history and is a poor historian 53 y.o. Male no PMH, has been out of contact with medicine for years aside from hernia