Clinical Geriatrics

Case Presentation

Mr. O, a 71-year-old man, presented to the Emergency Department (ED) with chief complaints of dark urine, urgency, occasional dysuria, suprapubic pain, and foul-smelling urine for 1 month. No frequency, hematuria, or flank pain was reported. In the 2 days prior to the ED visit, he began having chills, fever, and nausea.

The patient had a past medical history significant for depression, diverticulosis with history of lower gastrointestinal (GI) bleeding, alcohol abuse, pancreatitis, hypertension, osteoarthritis, peptic ulcer disease, and chronic obstructive pulmonary disease.

On presentation, Mr. O was afebrile, and physical exam was unremarkable except for mild tenderness in the suprapubic region. He refused a rectal exam, so this was not assessed at that time. Initial investigations showed normal sodium and potassium levels, creatinine of 1.4 mg/dL, and blood urea nitrogen of 19 mg/dL. Complete blood count showed white blood cell (WBC) count of 15,600/µL with 91% neutrophils. Urinalysis showed dark-brown urine with mucus 4+, 2800 WBC/HPF, 370 red blood cell (RBC)/HPF, and many WBC clumps.

The patient was treated with intravenous ciprofloxacin with good response; the urine culture showed multiple microorganisms, and one of the two blood cultures grew pan-sensitive Proteus mirabilis. Mr. O subsequently was transferred to the Geriatrics Evaluation and Management unit for his subsequent deconditioning. During hospitalization, he had recurrent episodes of cystitis, with urine cultures showing polymicrobial organisms. Search for the cause of his recurrent urinary tract infections (UTIs) were unrevealing except for a mildly enlarged prostate; however, this was not sufficient to explain the infections since the postvoid residual volumes were not elevated, and the patient persistently grew multiple organisms on the urine culture. Upon further review of the history, Mr. O reported “passing air while urinating occasionally” in the previous 3 months with foul-smelling urine. Computed tomography (CT) scan of the abdomen was ordered and showed multiple diverticulae without diverticulitis, air within the urinary bladder, and suggestion of a communicating loop of sigmoid colon. Cystoscopy showed bullous edema of the left base of the bladder just posterior to the left ureteral orifice consistent with CT scan findings of colovesical fistula (CVF). Colonoscopy was performed and showed only a sessile polyp in the sigmoid colon; no malignancy or inflammatory changes were seen.

Discussion

Recurrent UTIs are common in older persons. Search for etiology is very important in order to establish definitive treatment to prevent recurrence. Recurrent UTIs can be caused by multiple disease entities in older adults, which can be divided into neurologic abnormalities and obstructive ones. Neurologic abnormalities resulting from central nervous system involvement or peripheral nervous system involvement can lead to hypotonic bladder, resulting in urine stasis and increased risk of UTIs.

Obstructive causes can result from urethral strictures, prostatic obstruction, renal calculi, genitourinary malignancy, urethral or ureteral fibrosis, and indwelling bladder catheters. Rarer causes include anatomical abnormalities resulting in obstruction, stasis, or reflux of urinary flow, predisposing the patient to recurrent UTIs. One of these anatomical abnormalities is CVF. CVF is a rare but important cause of recurrent UTIs; it can lead to significant morbidity and mortality if not recognized early enough in the disease course.