Modern management of diverticular disease in men

Abstract

The presentation of diverticular disease and its complications are varied: it is common and most people with diverticulosis are asymptomatic. In this article the authors review the burden of diverticular disease and its causes, and present two clinical cases of complicated diverticulitis with a urology theme.

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trendsinmenshealth.com Trends in Urology & Men’s Health ❘ July/August 2019 ❙ 29
Gastrointestinal ●
Colonic diverticular disease is a
condition where small ‘out-
pouchings’ of the inner lining of the
colon herniate through the bowel wall
(see Figure 1). Most people with
diverticulosis are asymptomatic;
however, diverticula can bleed,
become inamed, or in some cases
perforate, leading to abscess
formation within the abdomen. Over
time, inammation can cause
stricturing of the bowel or stulation
into other organs, such as the bladder.
Diverticular disease is very
common, affecting 5% of men in
their 40s and up to 50% men in their
80s.1 Most cases of diverticulosis
are identied as an incidental nding
on colonoscopy or computed
tomography (CT). Diverticular
disease is thought to be caused by
insufcient bre in the diet,2
although a recent study found that
other lifestyle characteristics were
also associated with its
development, such as high intake of
red meat, high body mass index
(BMI), smoking and low vigorous
physical activity.3 Dietary
modications, weight loss, staying
well hydrated and avoiding
constipation can therefore reduce the
risk of developing diverticular disease;
however, once diverticula have
formed the process of developing
diverticulosis cannot be reversed.
Case one: diverticulitis
presenting
as urinary retention
Our rst case is a 52-year-old man
who presented with acute urinary
retention. He had presented to
another hospital two days previously
with the same problem and had been
managed with an ‘in-and-out’ catheter
and tamsulosin. Abdominal
examination demonstrated signs of
focal peritonitis in his left iliac fossa.
His inammatory markers were
elevated; C-reactive protein (CRP) 149
mg/L and white cell count (WCC) 13.8
x 10 9/L. A CT scan demonstrated
perforated sigmoid diverticulitis with
a large pelvic collection containing
faeculent material, pus and gas. A
CT-guided pelvic drain was sited that
immediately drained 100ml of pus. The
patient was treated with intravenous
antibiotics, total parenteral nutrition
(TPN) and bowel rest.
A repeat CT scan one week later
demonstrated a signicant reduction
in the size of the pelvic collection,
which was associated in an
improvement in the patient’s
symptoms and inammatory
markers. Three days later an
ultrasound demonstrated a marked
resolution of the collection and the
drain was removed and the patient
discharged home. Over the next
three months the patient was
monitored clinically and underwent
further CT and MRI. There was no
evidence of a recurrent pelvic
abscess clinically or on radiological
imaging. Despite developing
intra-abdominal sepsis, the patient
managed to avoid major abdominal
surgery and was successfully treated
with interventional radiology and
remains well.
Modern management of
diverticular disease in men
Kathryn Oakland, Head of Digestive Diseases and Renal Department; Sina Dorudi, Consultant Colorectal Surgeon, London
Digestive Centre, Princess Grace Hospital, London
The presentation of
diverticular disease and its
complications are varied: it
is common and most people
with diverticulosis are
asymptomatic. In this article
the authors review the
burden of diverticular
disease and its causes, and
present two clinical cases of
complicated diverticulitis
with a urology theme.
Figure 1. Illustration of colon diverticulitis. Small
growths appear on the outer colon wall (seen
coloured brown). They may develop at weak
points along the length of the gut and their
frequency increases with age. The remains of
digested food may collect in these inamed
growths, and the condition is also associated
with abscess formation

trendsinmenshealth.com
30 ❙ Trends in Urology & Men’s Health ❘ July/August 2019
● Gastrointestinal
Treatment of complicated
diverticulitis
Complicated diverticulitis can be
classied using the Hinchey system
(see Table 1).4
Treatment options for
complicated diverticular disease
include antibiotics, CT-guided
percutaneous drainage or surgery. In
the past, management involved
major abdominal surgery in the form
of a sigmoid colectomy and
formation of colostomy (Hartmann’s
procedure), which was associated
with signicant morbidity and
mortality. A recent systematic review
of 8766 pooled patients with a
pericolic or pelvic abscess compared
antibiotics alone, percutaneous
drainage and surgery, nding that
percutaneous drainage was
associated with fewer recurrent
abscesses in comparison with
antibiotics alone. In the same
analysis, surgery was associated
with a mortality rate of 12.1%.5
Once the initial perforation and
abscess has been treated, treatment
options include an elective resection
or ‘watch and wait’ conservative
therapy. A further systematic review
has demonstrated that in the longer
term, recurrent abscess formation
was found in 39% of patients
awaiting elective surgery.6 The
quality of evidence supporting
elective surgery versus ‘watch and
wait’ in these patients is limited, and
patients should be fully appraised of
all options, including the morbidity of
surgery and risk of stoma formation,
but also the likelihood of further
attacks of severe diverticulitis if they
elect for conservative management.
Case two: colovesical stula
caused by diverticular disease
Our second case is a 54-year-old
man who presented with abdominal
pain, fevers and dysuria. He had
experienced several milder episodes
over the previous two years and had
been treated by his GP with oral
antibiotics without hospital
admission. An ultrasound showed an
inammatory mass around the
sigmoid colon with a small abscess
and some adjacent thickening of the
bladder wall. There was no air in the
bladder. The patient was treated
with intravenous antibiotics and
bowel rest. He settled initially but
several days later his abdominal pain
worsened, he developed fevers and
experienced problems passing urine;
reporting intermittent stops to his
urinary stream. His midstream urine
(MSU) grew no organisms and his
blood cultures were clear. A CT scan
showed that the inammatory mass
now extended to the dome of the
bladder, which contained bubbles of
extraluminal gas (see Figure 2). The
patient was treated with a further
week of intravenous antibiotics,
bowel rest and total parenteral
nutrition (TPN). He was then
commenced on an elemental diet to
allow further bowel rest and was
discharged home.
On review a month later, the
patient’s abdominal pain was
improved and he reported no further
episodes of pneumaturia or other
urinary symptoms, but he still had a
palpable abdominal mass. A repeat
CT scan demonstrated that although
the extraluminal gas bubbles had
resolved, the inammatory colonic
mass had persisted. He received
another course of oral antibiotics,
but over the next few weeks he
developed low-grade fevers and his
abdominal pain became more
severe. He reported several further
episodes of pneumaturia and passed
faecal matter urethrally.
Ten weeks after the patient’s
initial admission to hospital he was
admitted for a sigmoid colectomy
and repair of colovesical stula. At
laparotomy it was found that he had
a large inammatory mass involving
the sigmoid colon, bladder and small
bowel. It was unsafe to proceed to
full resection. The descending colon
and splenic exure was mobilised
and a colostomy was formed.
Immediately after the operation,
his fevers and urinary symptoms
settled. He passed no further faecal
matter in his urine and his MSU
cleared. He is scheduled for elective
sigmoid resection and closure of his
colostomy in six months.
Diagnosis of colovesical
stulae
Colovesical stulae are a rare
complication of diverticular disease,
occurring in 1% of cases.7
Symptoms include pneumaturia,
faecaluria, haematuria, urinary
frequency and urgency and
suprapubic pain. Most cases of
pneumaturia do not give a classical
history of bubbles in the urine,
instead reporting ‘stop-starts’ in
their urinary stream that represent
the passage of gas via the urethra.
Many patients will experience
recurrent urinary tract infections,
typically with organisms usually
found in the bowel, such as
Escherichia coli, coliforms and
enterococcus.
The keystone to diagnosing a
colovesical stula is radiological
imaging. The modality of choice is
CT, which is diagnostic in over 90%
cases.8 CT ndings consistent with a
colovesical stula are air in the
bladder, passage of contrast
medium in the bladder (either oral or
rectal contrast) and bladder wall
thickening adjacent to a loop of
inamed colon. It is unusual to be
able to delineate the stula tract on
CT, however.
The stula is more reliably
depicted on MRI, which can provide
detailed soft tissue evaluation. MRI
ndings fall into three patterns: an
Stage Description
I
II
III
IV
Localised abscess
Pelvic abscess
Purulent peritonitis (pus in the
abdominal cavity)
Faeculent peritonitis
Table 1. Hinchey classication of complicated
diverticular disease4

trendsinmenshealth.com Trends in Urology & Men’s Health ❘ July/August 2019 ❙ 31
Gastrointestinal ●
intervening abscess between the
bowel wall and bladder wall; a visible
stula track; or a complete loss of
the fat plane between the bladder
and bowel wall.9 Other imaging,
such as a plain abdominal
radiograph, barium enema,
cystoscopy or colonoscopy have low
rates of detection of colovesical
stulae. Abdominal ultrasound is
less diagnostic than CT, but avoids
radiation exposure.
Treatment of colovesical
sulae
There are two options for treatment
of colovesical stulae – conservative
therapy or surgery. Conservative
therapy involves antibiotics and
bowel rest. In the case described
above, the patient was initially
managed with TPN and then
commenced on an elemental diet.
The elemental diet consisted of
simple carbohydrates, single amino
acids of short-chain peptides, fats
and vitamins. As its components are
delivered in their simplest chemical
form, the usual processes of
digestion are not required and nearly
all of the nutrients are absorbed high
up the small bowel, leaving virtually
no residue in the large bowel. A case
series of 50 patients with colovesical
stulae demonstrated no difference
in rates of sepsis or disease-specic
mortality in patients who received
conservative treatment versus those
that underwent surgery.10
The aim of surgery is to resect
the diseased segment of bowel and
close the bladder defect. Bowel
resection may be in the form of
sigmoid colectomy, left
hemicolectomy or anterior resection
with a defunctioning ileostomy.
Treatment of the bladder component
may involve stulotomy with sutured
or stapled repair of the bladder
defect, or the bladder can be left to
heal via secondary intention.11
Surgery can be laparoscopic or
open. In the rst few weeks after
stula formation, friable intra-
abdominal adhesions develop that
greatly enhance the risk of damage
to intra-abdominal organs during
surgery.12 The timing of surgery in
respect to the onset of symptoms of
the stula is therefore critical to
minimise the risk of complications,
and most surgery is undertaken in
an elective setting. Fistula
recurrence is a potential long-term
complication that may require
further surgical intervention.11
Summary
In summary, the presentation of
diverticular disease and its
complications are varied. Severe
intra-abdominal sepsis and stula
formation does not necessarily
mandate bowel resection, but as the
risk of recurrence is high, patients
should be fully counseled on the
risks of conservative therapy versus
the risks of surgery, including stoma
formation.
Declaration of interests
Kathryn Oakland is an employee of
HCA Healthcare UK; Sina Dorudi has
received fees for professional
services from HCA Healthcare UK.
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Figure 2. CT evidence of colovesical stula and
complicated diverticulitis