Imaging-Guided Management of a Bladder–Rectal Fistula after Gunshot Trauma: Implications of Delayed Imaging Phases in Trauma Decision-Making

Colo-vesical fistula is a condition characterized by an abnormal connection between the colon and the urinary bladder. Traumatic rectovesical fistulas (RVFs) are rare entities, most commonly resulting from penetrating trauma, including gunshot injuries. Symptoms shown by these patients are commonly pneumaturia and fecaluria, highly suggestive of a pathological communication between the bowel and the bladder. However, localization of the fistulous tract typically requires cross-sectional imaging. Herein, we report the case of a 29-year-old man admitted to our Emergency Department with a RVF resulting from a gunshot injury. Initial imaging studies were inconclusive, while the definitive diagnosis of traumatic RVF was established using abdominal computed tomography with an ultra-delayed acquisition performed 35 minutes after contrast administration. Clinical symptoms remain a key guide in the diagnostic process, and when standard imaging fails to identify the fistulous tract, ultra-delayed imaging acquisitions should be considered to facilitate timely surgical management and improve patient outcomes.