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Diverticular disease presenting at a special clinic.

Vesico-colonic fistula is a well known but uncommon complication of diverticulitis,l presenting with well-recognised features such as pneumaturia, cystitis, and faecaluria.2 Presentation with urethral discharge alone however must be very rare. A 69-year-old, retired merchant seamen attended the Special Clinic of this hospital in November 1977 with a three-week history of dysuria and nocturia without day-time frequency, which were unresponsive to courses of pyridium and cetiprin prescribed by his general practitioner. He had been treated for gonorrhoea 30 years previously and came to the clinic because one week before he had developed a urethral discharge. He denied any sexual intercourse since his treatment for gonorrhoea. On examination he had a mucopurulent urethral discharge. The urine was hazy with heavily blood-stained threads. A Gramstained urethral smear showed no evidence of Gram-negative diplococci but numerous leucocytes were seen. Inoculation of mucopus on to modified Thayer-Martin medium failed to produce a growth of N gonorrhoeae. Serological tests for syphilis gave negative results. No abnormalities were found on examination of the abdomen or the prostate gland. A presumptive diagnosis of nongonococcal urethritis (NGU) with associated cystitis was made and co-trimoxazole two tablets every 12 hours was prescribed. Escherichia coli (>108/1) were grown on culture of the urine. Four days later at his next attendance a 10-day history of pneumaturia was obtained and, on further questioning, he admitted to the passage of faeculent material from the urethra. He had had no recent abdominal pain or bowel disorder. A vesico-colonic fistula was diagnosed and the patient referred to the surgical department for further investigation. Barium enema failed to show a fistula but fairly extensive diverticular disease of the sigmoid colon was evident. Excretion urography was normal. Cystoscopy showed a small fistula with faecal material exuding through it. Surgical correction was clearly necessary and a small vesico-colonic fistula was found at operation. After separation of the sigmoid colon from the bladder the defect was closed and a sigmoid colectomy with end-to-end anastomosis performed. Histology showed the sinus to be lined with granulation tissue extending through the muscularis. E coli is an uncommon pathogen in the aetiology of NGU, but as it was recovered from the urine in this patient it apparently had a pathogenic role in his urethritis. Coliforms passed easily from the bowel causing a urethral discharge, which brought his condition to our attention. At present the patient is symptomfree with sterile urine 11 months after operation. The aetiology of NGU in elderly men obviously requires unbiased consideration. We should like to thank Dr C D Alergant and Mr C R Helsby for their assistance. Yours faithfully, P B Carey Department of Venereology, Royal Liverpool Hospital, Liverpool L7 8XP