無發燒患者於拯救性機器手臂根除攝護腺切除術後，以龜頭炎作為首發表現的直腸膀胱廔管之罕見案例報告

陳鐸文、林威宇¹

嘉義長庚紀念醫院 外科部 泌尿科¹

A Rare Case Report of Rectovesical Fistula Presenting with Balanitis as the Initial Manifestation in an Afebrile Patient after Salvage Robot-Assisted Radical Prostatectomy

Duo-Wun Chen, Wei-Yu Lin ¹

Chiayi Chang Gung Memorial Hospital, Dept. Of Surgery, Division Of Urology, Chia-Yi, Taiwan 

Background:

Rectovesical fistula (RVF) is a rare but serious complication following pelvic surgery or radiation therapy. Typical presentations include pneumaturia, fecaluria, and recurrent urinary tract infection. However, atypical manifestations may delay diagnosis and treatment.

Case Presentation:

An 81-year-old male patient with prostate cancer, stage T3bN1M0 who had treated with radiotherapy in 2008 and then underwent salvage robotic-assisted radical prostatectomy in 2025 admitted this time with complaints of penile erythema, dysuria, and diarrhea. Although there is no fever initial, lab data revealed leukocytosis, elevated CRP level, and image found bilateral hydronephrosis. According to above condition, he was initially treated as balanitis and urinary tract infection. However, during hospitalization, although targeted antibiotics as ertapenem was used for E-coli and enterococcus urine culture and still afebrile, penis erythema was still, furthermore, greenish fluid which consisted fecal contamination was observed in the Foley catheter which highy suspect fistula formation. Subsequent cystography and abdominal CT confirmed rectovesical fistula. The patient underwent urinary diversion with bilateral percutaneous nephrostomy and stool diversion via colostomy. After procedure, transient fever developed but gradual improvement had found by his clinical condition and lab data, including WBC count and CRP level.

Conclusion:

This case highlights that balanitis may represent an atypical and misleading initial presentation of rectovesical fistula. Chronic fecal contamination and urinary stasis may lead to high bacterial burden and masked systemic response, resulting in afebrile but severe infection. In patients with complex pelvic surgical or radiation therapy history, those with afebrile but urogenital infection sign may be a clue that related to fistula. The early consideration of fistula is crucial to avoid delayed diagnosis and management.