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Our purpose is to make a case for early operative intervention. A 37-year-old man presented with a large periurethral abscess and Fournier's gangrene. During the ensuing evaluation and treatment, he was found to have previously undiagnosed Crohn's disease with a complex enterovesical fistula. This case stands in contrast to other reports that downplay the morbidity of enterovesical fistula associated with Crohn's disease and advise medical management until gastrointestinal complications require operative intervention.

Presenting symptoms, diagnostic progression, etiology, therapy, and complications of 44 patients with enterovesical fistulae who came to three Yale teaching hospitals over a 9-year period were reviewed. Patients with diverticulitis as the cause of their fistula were older and came to the hospital with pneumaturia/fecaluria. Patients with pelvic cancer were more likely to have fecaluria, gastrointestinal symptoms, or hematuria. Patients with Crohn's disease were an average of 20 years younger than the patients with cancer or diverticulitis and they came to the hospital with pneumaturia, abdominal pain, abdominal mass, and tenderness. Computerized axial tomography scanning, cystoscopy, charcoaluria, and barium enema were useful in making the diagnosis; intravenous pyelography and colonoscopy were not. One-tenth of the patients were not candidates for operation, and one-quarter of the patients did not undergo complete operative resolution with restoration of enteric and urinary continuity. Nine patients underwent a two-stage repair consisting of resection/repair of the fistula with proximal fecal diversion and subsequent re-establishment of bowel continuity. These patients had a higher morbidity than the 19 patients who underwent one-stage repair. Enterovesical fistula is a challenging entity, the etiology of which may be suspected upon taking the patient's history or performing the physical assessment; however, the definitive diagnosis of enterovesical fistula can remain elusive. Single-stage repair can be achieved with low morbidity and mortality in many candidates.