Urethroperineal Fistula Repair
A urethroperineal fistula connects the urethra to perineal skin. Establish whether it is an isolated skin tract, an accessory congenital urethral channel, or part of a fistula involving the rectum, an abscess, or a reconstructed urinary tract. These conditions require different operations; rectourethral fistula closure rates and diversion protocols cannot be applied to all of them.[1][2][3]
For bowel communication, see Transperineal RUF Repair and the male fistula treatment atlas.
Etiology and Classification
| Pattern | Consequence for planning |
|---|---|
| Congenital posterior urethroperineal fistula | Differentiate it from Y-type urethral duplication and rectourethral fistula before sacrificing any channel. The normal functional urethra must be demonstrated.[1][2][4] |
| Congenital anterior urethrocutaneous fistula | Assess the distal urethra, meatus, curvature and associated hypospadias; repair is anatomy dependent.[5] |
| Acquired urethrocutaneous tract | Look for distal obstruction, urethral stones, infection, prior injury or surgery, and compromised local tissue.[6][7] |
| After transmasculine genital reconstruction | Define the reconstructed urethra and look for coexisting stricture or vaginal remnant; isolated skin closure may leave the underlying problem untreated.[7] |
| Associated bowel disease or rectal communication | Plan with colorectal surgery. A perineal opening can be the external component of a rectourethral fistula, including in Crohn's disease.[3] |
The “25 reported cases” description belongs to a 2014 congenital posterior fistula report, not a current incidence estimate. Likewise, pelvic-fracture urethral injury rates do not measure the incidence of urethroperineal fistula.[1]
Diagnosis and Preoperative Evaluation
Document urinary leakage, voiding symptoms, infections, prior urethral procedures, radiation, bowel symptoms and baseline continence. Examine the opening and surrounding skin, tissue quality and genital anatomy. Painful swelling or purulent drainage requires assessment for an abscess and source control.[6][8]
RUG and, when needed, VCUG map a stricture, proximal urethra and fistulous connection. Endoscopy adds information about the internal opening, stones, a stenosis and the bladder outlet; combined antegrade and retrograde assessment is useful in selected posterior injuries. MRI is an adjunct when complex posterior anatomy or associated pelvic pathology remains uncertain, rather than a mandatory test for every cutaneous opening.[8]
For a congenital posterior tract, radiographic and endoscopic confirmation of a usable orthotopic channel is particularly important. A published misdiagnosis as a rectourethral fistula illustrates why an external opening alone cannot determine the operation.[2][4]
Congenital UPF — Surgical Approach
Excision of the accessory tract has succeeded in reported congenital posterior fistulas after confirmation that the dorsal urethra is normal. Excision or fulguration of the ventral tract must not be extrapolated to a Y-type duplication in which that channel supplies essential drainage. Refer uncertain anatomy to an experienced pediatric reconstructive team; the evidence consists of small series and case reports.[1][2][4]
Congenital anterior fistulas are a separate problem. Depending on the urethral defect and associated abnormalities, repair can range from local closure to formal urethroplasty; there is no universally curative single maneuver.[5]
Acquired UPF — Surgical Planning
- Control infection and provide reliable urinary drainage. An abscess, obstructing calculus or diseased urethral segment may require drainage, debridement or staged reconstruction rather than immediate closure of the skin opening.[6]
- Address associated obstruction and tissue loss. Closure, urethroplasty and any interposition are selected according to the actual defect and available tissue. In reconstructed genital anatomy, coordinate treatment of a stricture or symptomatic remnant with fistula management.[7]
- Separate urinary closure from the skin repair when feasible. Vascularized coverage can be useful in difficult repairs, but evidence for a particular flap cannot be transferred indiscriminately between penile UCF, perineal skin fistula and RUF. A three-patient recurrent metoidioplasty UCF series described a free rectus fascia interposition graft; this is limited evidence and the graft is not a vascularized muscle flap.[9]
- Use a bowel-fistula pathway when the rectum is involved. Fecal diversion and its timing are determined by the bowel injury, contamination and planned repair. An isolated urethra-to-skin tract does not itself establish a need for colostomy.[3]
For extensive anterior urethral disease, the reconstruction discussion may include perineal urethrostomy. Its suitability depends on the proximal urethra and outlet; it is not a universal solution for radiation-damaged posterior fistulas.
Outcomes and Follow-Up
Counsel using studies that match the patient's anatomy and etiology. There is no defensible pooled “87–100% success” estimate for all urethroperineal fistulas. Published RUF series report closure, bowel restoration, continence and urethral patency as separate outcomes; use those results when counseling patients with rectal involvement.
Catheter duration and imaging follow the actual urethral repair. When urethroplasty is performed, EAU guidance supports assessing for extravasation before catheter removal; a significant persistent leak warrants continued drainage and reassessment. Prolonged antibiotics solely because a catheter remains in place have not shown benefit as routine urethroplasty prophylaxis. Treat an established infection according to cultures and its clinical context.[10]
Follow-up should assess recurrent leakage, wound healing, infection, emptying, urethral patency and continence. Bowel continuity is relevant only when a bowel fistula or diversion was part of the treatment.
References
1. Bello JO. "Congenital posterior urethroperineal fistula: a review and report of the 25th case in literature." Urology. 2014;84(6):1492–1495. doi:10.1016/j.urology.2014.09.002
2. Cheng JW, Ahn JJ, Cain MP, et al. "Misdiagnosis of congenital posterior urethroperineal fistula and comparison with urethral duplications and rectourethral fistula." Urology. 2021;158:193–196. doi:10.1016/j.urology.2021.09.013
3. Stamler JS, Bauer JJ, Janowitz HD. "Rectourethroperineal fistula in Crohn's disease." Am J Gastroenterol. 1985;80(2):111–112. PubMed.
4. Bates DG, Lebowitz RL. "Congenital urethroperineal fistula." Radiology. 1995;194(2):501–504. doi:10.1148/radiology.194.2.7824732
5. Caldamone AA, Chen SC, Elder JS, et al. "Congenital anterior urethrocutaneous fistula." J Urol. 1999;162(4):1430–1432. PubMed.
6. Zeng M, Zeng F, Wang Z, et al. "Urethral calculi with a urethral fistula: a case report and review of the literature." BMC Res Notes. 2017;10(1):444. doi:10.1186/s13104-017-2798-z
7. Elyaguov J, Isakov R, Nikolavsky D. "Evaluation and management of urologic complications following transmasculine genital reconstructive surgery." Neurourol Urodyn. 2023;42(5):979–989. doi:10.1002/nau.25100
8. European Association of Urology. Urethral Strictures: Diagnostic Evaluation. 2026. Guideline chapter.
9. Johnsen NV, Voelzke BB. "Autologous rectus fascia graft interposition repair of urethrocutaneous fistulae in female-to-male metoidioplasty patients." Urology. 2018;116:208–212. doi:10.1016/j.urology.2018.03.013
10. European Association of Urology. Urethral Strictures: Perioperative Care of Urethral Surgery. 2026. Guideline chapter.