A foreign body in the urinary bladder leads to bladder stone and vesicorectal fistula: A case report

The case in this study was presented, the features in the diagnosis and treatment of rare complications such as bladder stone and vesicorectal fistula caused by the injection needle, which is a foreign body in the bladder. A 1-year-old male child came to our outpatient department with chief complaints of straining during micturition, dribbling of urine and history of high-grade fever, chills & rigor. A kidney, ureter, and bladder (KUB) X-ray revealed an approximately 1.5 cm bladder stone with radiopaque linear foreign body. On diagnostic cystoscopy anterior, posterior urethra was normal, fecal debris, stone and a needle was seen coming out through posterior wall of bladder. Open anterior cystolithotomy was done to remove 1.5-cm stone and a foreign body described as injection needle 24 gauge surrounded with fecal debris coming out through posterior wall was also removed. Fistulous tract was present and probed with 5 Fr feeding tube. A diversion colostomy was done. Patient discharged with colostomy and in follow up after 1 month micturating cystourethrogram (MCU) and distal loopogram of colon were normal; no fistulous communication present. Colostomy was closed after 3 months. There has been many cases reported in literature about insertion of different foreign bodies in bladder but foreign body ( injection needle) leading to bladder stone and vesicorectal fistula is first of its kind as far as our knowledge is concerned.


Introduction
Foreign body in urinary bladder in children usually found as a result of iatrogenic injuries, self-insertion, sexual abuse, assault. A wide variety of foreign bodies have been reported in the bladder, such as wooden sticks, thermometers, needles, pens, household batteries, parts of foley catheters, broken parts of endoscopic instruments, and knotted suprapubic catheters [1][2][3][4]. In addition, secondary bladder stones may occur following urinary stasis and infections caused by foreign bodies. Here, the foreign bodies can act as a nidus for stone development [5].

ISSN 2148-2969
Approximately 20% of all vesicoenteric fistulas are rectovesical [6]. The common causes of acquired vesicoenteric fistula are typhoid, amoebiasis, syphilis, tuberculosis, diverticulitis, malignancy, Crohn's disease and iatrogenic [7]. It is extremely rare that the foreign body and urinary bladder stones can cause vesicorectal fistula. Here, we present a rare case of vesicorectal fistula caused by the injection needle as a foreign body in the bladder.

Case report
A 1 year old boy with a past history of recurrent urinary tract infections (UTIs) brought to the outpatient department with complaint of hematuria, dysuria, and UTI resistant to treatment with oral antibiotics. He had history of perineal insertion of a needle by a local medical practitioner 6 month back. There was no significant finding in examination. He was normocephalic, with no gross head and spine deformities. The abdomen was normal with no costovertebral angle tenderness and no suprapubic tenderness. Other systems were normal. A kidney, ureter, and bladder (KUB) X-ray showed a straight wire like radio-opaque shadow and an irregular shaped bladder stone (1.5 cm) with its tip (Fig. 1). The renal ultrasonography was normal. Urine culture grew more than 100,000 colony-forming units/mL of Escherichia coli. Bladder ultrasonography showed a 1.5 cm calcified focus at the base of the bladder with a foreign body. Cystoscopy showed a stone, fecal debris in bladder and a needle emerging from posterior bladder wall (Fig. 2a, b, c). Open cystolithotomy was planned for the patient, and he was operated under general anesthesia. After opening the urinary bladder, a single calculus inside the lumen was seen. After extracting the stone, the urinary bladder was irrigated with normal saline. A needle emerging from posterior wall of bladder was seen and removed carefully. Fistulous tract was seen and probed with 5 fr feeding tube ( Fig. 3a, b, c, d). A diversion colostomy was done. The bladder was closed in two layers. The postoperative period was uneventful. The patient was discharged on the fifth postoperative day.
Patient discharged with colostomy and in follow up after 1 month micturating cystourethrogram (MCU) and distal loopogram of colon were normal no fistulous communication present (Fig. 4a and b). The colostomy was closed.

Discussion
Urinary bladder stones due to foreign bodies have been frequently reported in literature.
These foreign bodies may be sub-classified into iatrogenic and non-iatrogenic bodies. Iatrogenic bodies include suture material, shattered foley catheter balloons, eggshell calcifications that form on a catheter balloon, staples, urethral stents, migrating contraceptive devices, erosions of surgical implants, and prostatic urethral stents. As in this case a needle is inserted by a local medical practitioner. Non-iatrogenic bodies include objects pierce the anterior abdominal wall to reach the bladder and objects placed into the bladder by the patients through the urethra for recreational and various other reasons. The most common motive for self-insertion of foreign body in the lower urinary tract is different forms of sexual gratification, curiosity, autoerotic stimulation, psychiatric illness, and trauma [3,8]. Perforation of the urinary bladder by foreign bodies from adjacent organs is extremely rare [9]. These may occur from gastrointestinal (GI) tract or female genital organ. In rare cases foreign bodies can erode the GI tract and produce enterovesical fistula [ In general, most bladder stones are removed via endoscopy. However, in this case supra pubic cystostomy was planned as vesicorectal fistula was suspected. Diversion colostomy was done, fistula heals within 3 month followup. In case of large fistula, after repair the urinary catheter is left in place for 5-7 days or longer. The patient remains on appropriate antibiotics. A cystography can be performed to confirm healing before catheter removal [7]. To the best of our knowledge, no exact similar foreign body was reported as nidus for urinary bladder stone and vesicorectal fistula. One case has been reported of stone formation around hair pin [28] and other case formed around copper wires [29]. None of the cases complicated as acquired vesicorectal fistula. This would be the first reported case of vesicorectal fistula and bladder stone due to iatrogenic foreign body (injection needle) in a child.

Conclusion
The above-mentioned presentation is an exceptional one, where an iatrogenic body (injection needle) had manifested as a vesical calculus and vesicorectal fistula. Appropriate intervention as per the condition of the patient gives excellent results.

Compliance with ethical statements
Conflicts of Interest: None. Financial disclosure: None. Consent: All photos were taken with parental consent.