Colovesical Fistula

To the Editor.—  Fecaluria results from communication between the bowel and bladder and is a pathognomonic sign of colovesical fistula.¹ These fistulas are most often associated with either sigmoid diverticulitis or carcinoma of the lower bowel or bladder. Recently, what appeared to be a routine urinary tract infection developed in one of our elderly female patients. Escherichia coli, sensitive to all antibiotics tested, was cultured from the urine.Despite seven days of intravenous ampicillin treatment, cultures remained positive. Parenteral gentamicin sulfate was substituted for an additional week without success. Several days later, the patient's urine, which had previously been clear, abruptly turned dark brown and contained particulate matter (Figure). A colovesical fistula was then suspected as the cause of the recalcitrant urinary tract infection. Communication between the bowel and bladder was subsequently verified at cystoscopy.We think this photograph is a visually impressive and instructive example of this diagnostic