Research associate University of Arizona College of Medicine Phoenix, AZ
Mohanad T. Al-Qaisi, MD1, Wendy Lamb, MD2, Hugo Pinillos, MD2; 1University of Arizona College of Medicine, Phoenix, AZ; 2Carl T. Hayden VA Medical Center, Phoenix, AZ
Introduction: Rectal pain in patients with prostate cancer is usually concerning. It could be related to treatment complications (surgery or radiation), local spread of neoplasm, or metastatic process. Rectoprostatic fistula is a rare complication.
Methods: 69-year-old gentleman with past medical history of liver cirrhosis due to Hepatitis C (that was treated and on SVR) and prostate cancer treated with radiation (HDR brachytherapy and EBRT, completed 6 months prior to onset of symptoms) who presented with rectal pain. Patient reported sharp, severe pain, up to 9 out of 10, deep inside his anus, especially with defecation. It was difficult for him to stand, walk or sit. Patient denied any itching, spasm, rectal bleeding or lower abdominal pain. He reported feeling some swelling around the anus. Due to severity of pain, he had two visits to the emergency room and was told it might be related to radiation proctitis. He noticed changes to his bowel habits since radiation, feeling of incomplete evacuation and prolonged time on toilet. Anusol HC suppositories only provided transient help. He had colonoscopy that showed a deep large ulcer just proximal to the dentate line. Pathology did not reveal malignancy. Severe pain continued. CT scan of the pelvis with rectally administered contrast (Image-2, 3) showed rectoprostatic fistula between the anterior lower rectum and right apical prostate with air dissecting into the right obturator internus muscle, likely related to radiation, new from prior imaging (Image-1). Patient was then sent to general surgery where laparoscopic sigmoid loop colostomy was performed for diversion of the fecal stream and suprapubic catheter placement by interventional radiology for urinary diversion. Patient was referred to an outside institution for reconstructive surgery. Discussion: Rectoprostatic fistula is a rare condition. It is related to prostate surgery, abscess or following radiation. Occasionally, fistula can occur congenitally or as a result of pelvic trauma. Literature on this subject is limited. Pathogenesis is thought to be related to poor blood supply and submucosal changes after surgery or radiation, which makes the rectum more vulnerable to deeper injury, causing ulcerations and fistulae. Severe presentations could occur, and patients report persistent hematochezia, anemia, and transfusion dependence that benefit from endoscopic therapy. Spontaneous closure with antibiotic use could happen, but some cases require laparoscopic or surgical interventions.
Image 1: Axial CT pelvis: prostate and rectum prior to radiation
Image 2: Axial plane CT pelvis after rectal contrast material. Gas and barium in rectoprostatic fistula
Image 3: Sagittal plane CT pelvis after rectal contrast material. Gas and barium in rectoprostatic fistula
Disclosures: Mohanad Al-Qaisi indicated no relevant financial relationships. Wendy Lamb indicated no relevant financial relationships. Hugo Pinillos indicated no relevant financial relationships.