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Urethrocutaneous Fistula

A urethrocutaneous fistula (UCF) is an epithelialized communication between the urethral lumen and the skin of the penis, scrotum, or perineum. UCF is a common complication after pediatric hypospadias repair and can recur after fistula closure; an earlier pediatric report cites a 2–10% UCF rate after hypospadias surgery.[1][20][36] The 2026 EAU guideline reports 3–4% after distal TIP repair, while one referral-center series reported up to 30% after proximal repair; operative complications declined with increasing surgeon experience.[44][2] In adults, UCF arises from urethroplasty wound breakdown, failed childhood hypospadias presenting in adulthood, perineal trauma, Fournier's sequelae, lichen sclerosus, and chronic catheterization. Heterogeneous post-hypospadias fistula-repair series report pooled closure rates of 73.2% after simple primary closure, 94.3% with tunica vaginalis coverage and 94.6% with a scrotal flap; noncomparative data limit technique ranking and extrapolation to other UCF causes.[5]

For tissue-graft and -flap fundamentals, see Flaps in GU Reconstruction. For the complex-fistula framework that applies to recurrent / hostile-tissue cases, see the Fistulas landing page. For operative selection across all repair routes, see the Male Fistula Repair database.

Etiology​

SettingNotes
Post-hypospadias repairThe dominant cause; complication of TIP, Mathieu, onlay, or tubularized urethroplasty[1][2]
Post-urethroplasty (stricture surgery)Fistula occurred in ~3% of a 69-man refractory anterior-stricture series that included 58 men with prior procedures and 11 without, and in 4/85 (4.7%) adults after urethroplasty for failed-hypospadias strictures[12][13]
Failed childhood hypospadias presenting in adulthoodUCF in 24% of adult-failed-hypospadias presentations[3]
TraumaStraddle injury, penetrating perineal/penile injury, pelvic fracture
Infection or debridementPeriurethral abscess[16], urethral defect after Fournier's debridement[50], tuberculosis[9]
Lichen sclerosus (BXO)One reported man with LS-related urethral disease and a scrotal fistula underwent staged buccal mucosal reconstruction.[10] Genital-piercing-associated LS has also been described.[11] For LS-related penile stricture, EAU recommends single-stage oral mucosa graft urethroplasty absent adverse local conditions and avoiding genital skin augmentation .[40]
Neurogenic bladderDecubitus ulcers (33%), wound infections (24%), condom catheter complications (19%), traumatic catheterization (19%); 17/21 required permanent surgical or suprapubic-tube diversion in one selected urinary-cutaneous-fistula cohort[8]
Urethral calculiChronic stone impaction eroding the urethra[6]
Penile piercingChronic urine exposure through the tract; can trigger lichen sclerosus[11]
CongenitalExtremely rare; a 2018 systematic review found 63 published cases of congenital anterior urethrocutaneous fistula, most subcoronal (46%); defective urethral plate or abnormal infolding of the urethral groove[7][17][33][34][37]
Post-circumcisionInjury to the urethra during cutting, crushing, or suturing near the frenulum; 41 fistulas were reported among about 14.9 million PEPFAR-supported voluntary medical male circumcisions in 15 African countries during 2015–2019, with 40/41 cases in patients under 15 years old[38]

Pathophysiology​

After hypospadias repair or urethroplasty, UCF reflects breakdown of the urethral closure with subsequent epithelialization of the tract. Contributing mechanisms:[14][15][3]

  • Ischemia of the neourethra (inadequate vascular supply to tubularized tissue)
  • Tension on the suture line
  • Infection or hematoma disrupting the repair
  • Inadequate "waterproofing" tissue coverage over the neourethra
  • Distal obstruction (meatal stenosis, distal stricture) raising intraluminal pressure, an important treatable contributor to persistence or recurrence

In a reported periurethral-abscess case, infection caused ventral urethral necrosis and a long urethral defect.[16]

Congenital UCF is felt to result from a defective urethral plate or abnormal infolding of the urethral groove during embryogenesis; many patients are uncircumcised at presentation.[7]

Classification​

Horton, Devine, and Graham (1980) — selects the operation[4]​

TypeRepair
Early, acuteConservative — catheter drainage
Mature single — small (< 4 mm)Local primary closure
Mature single — large (> 4 mm)Rotational or advancement skin flap
Chronic, multiple, largeTissue from a distance (TVF, scrotal flap)
Severe "surgical cripples"Total urethral reconstruction

Size (Elbakry)[18]​

  • Small < 4 mm: primary closure
  • Large > 4 mm: flap coverage

Location​

  • Coronal: most common; 78% of recurrences in one pediatric series[18]
  • Anterior shaft, mid-shaft, penoscrotal
  • Perineal: adults, particularly after stricture surgery or Fournier's

Risk Factors After Hypospadias Repair​

A 2026 systematic review and meta-analysis (14 studies, 3,794 patients) reported the following associations.[1] The stent-duration and defect-length estimates each came from only two studies:[1]

FactorOR (95% CI)Certainty
Proximal hypospadias2.03 (1.12–3.70)Moderate
One-stage repair (vs staged)1.67 (1.05–2.67)Moderate
Shorter stenting (< 7 d)3.96 (1.88–8.37)Low
Longer urethral defect (≥ 2 cm)1.57 (1.05–2.33)Low

Other reported associations (with different designs and populations):

  • Soft tissue interposition: one surgeon's 243-repair series reported UCF in 3/14 without versus 7/229 with interposition (21.4% versus 3.1%; p < 0.05).[19] A separate 425-child distal/mid-shaft series reported 19/261 without versus 11/164 with a periurethral layer (7.3% versus 6.7%; p = 0.8).[19][35]
  • Distal hypospadias repair, single-layer versus double-layer dartos cover: fistula in 156/3077 (5.1%) versus 5/855 (0.6%) across reviewed series (p = 0.004)[15]
  • Surgeon experience: operative complications fall substantially with volume; reoperation for proximal hypospadias reaches 50% at referral centers[2]
  • Glans width: the 2026 EAU pediatric guideline identifies width < 14 mm as an independent risk factor for urethral complications, including fistula and stenosis, after hypospadias repair.[44]

Non-significant in the meta-analysis: age at surgery, chordee severity, suture material, TIP versus other urethroplasty methods.[1]

Clinical Presentation​

  • Urinary leakage from a cutaneous opening on the penis, perineum, or scrotum
  • Abnormal stream: spraying, double or forked stream, ventral dribbling
  • Recurrent UTI
  • Skin maceration around the fistula
  • Cosmetic concerns, particularly in adolescents
  • In neurogenic-bladder adults: perineal or scrotal skin breakdown and chronic wound drainage[8]

Diagnostic Evaluation​

  1. Physical exam: number, size, and location of openings; quality of penile skin and prior surgical scars
  2. Distal and reconstructed urethral assessment: inspect the meatus and assess for distal stricture by calibration or cystoscopy as anatomy warrants; treat clinically significant obstruction before or with fistula repair.[18][20] Postoperative stenosis was not associated with recurrence in one 102-child cohort.[36] In recurrent post-hypospadias UCF, distend the reconstructed urethra to detect a diverticulum before planning isolated closure; one 28-patient revision series found diverticula in 7 and distal strictures in 4.[41]
  3. Retrograde urethrogram (RUG): fistula site and concurrent stricture 4.[1] Dye injection (methylene blue or povidone) per meatus: identifies all openings when multiple fistulas suspected[20] 5.[1] VCUG: concurrent pathology

Management​

Timing and conservative management​

  • Elective repair commonly waits about 6 months after the inciting hypospadias operation for tissue maturation; infection, obstruction or urinary retention requires earlier treatment, and definitive timing is individualized.[18][21]
  • In one pediatric post-hypospadias series, 6/62 fistulas (9.6%) closed without surgery: three spontaneously and three after one dilation.[21] Prolonged catheter drainage has been described for tiny fistulas.[14] For selected early fistulas ≤ 2 mm, a 2026 review described recatheterization or adhesive treatment but found heterogeneous, mostly high-bias evidence and no pooled closure estimate.[42]

Recurrence​

In a 102-child series, 2-year recurrence after fistula repair was 23.5%. Recurrence was associated with fistula size of 2–4 mm, repair at another center and the number of prior recurrences; skin-flap repair was associated with lower recurrence.[36] About 46% of recurrences appeared after 12 months in that cohort.[36] The 2026 EAU Paediatric Urology guideline strongly recommends long-term follow-up after hypospadias repair to detect late urethral, voiding, curvature, and ejaculatory problems and assess patient satisfaction.[44]

Prerequisite — rule out and treat distal obstruction​

Assess the distal outlet and address a clinically significant stenosis or stricture when found.[20] In a primary hypospadias repair series, 11/30 postoperative fistulas co-occurred with meatal stenosis; a separate UCF-repair cohort found no significant association between postoperative stenosis or stricture and recurrence.[35][36]

Surgical technique selection​

TechniqueBest fitSuccess
Local closure, with or without subcutaneous coverSelected post-hypospadias fistulas with viable adjacent tissue; Elbakry studied defects < 4 mm, while Muruganandham reserved simple closure for defects < 2 mmElbakry: 30/42 (71%) after multilayer closure; Dekalo: 64/81 (79%) after single-layer urethral closure plus local subcutaneous cover (mean follow-up 7.9 years); broader synthesis: 73.2% after simple closure.[18][22][5][29]
Rotational / advancement skin flapLarge (> 4 mm) or selected coronal fistulas with viable local skin; multiply repaired coronal fistulas may need conversion to coronal hypospadias and urethral-plate retubularization[41]Elbakry: 13/15 (87%) large-fistula repairs succeeded with rotational/advancement flaps, with lower recurrence than simple closure in the same series.[18] Richter: 11/12 recurrent coronal repairs succeeded after retubularization; prior operations can compromise local Y–V/advancement-flap vascularity.[41]
De-epithelialized / full-thickness skin advancement flapSimple and complex fistulas; outpatient feasible94% overall (6.4% failure: 4.3% of 69 simple, 11.1% of 18 complex urethroplasty-type repairs)[24]
Purse-string closureSmall to mid-sized93% (26/28) vs 70% (16/23) linear, p = 0.015; single-center, nonrandomized[21]
PATIO repair (Preserve And Turn Inside Out)Selected penile fistulas, including coronal, preferably < 4 mm; technical learning curve, with day surgery feasible93.5% in one broad post-hypospadias UCF synthesis; 314/356 (88.2%) across fistula etiologies and inversion and ligation variants in a PATIO-focused review.[5][25][43]
Multilayer closure with longitudinal relaxing incisionTension-prone shaft fistulas46 fistulas in 34 patients all healed; technical description without a comparator[26]
Traction-assisted dissection + spermatic-fascia or TVF coverageRecurrent fistulas100% in 35 fistulas / 26 patients (12 recurrent), mean 7.4 yr[27]
Tunica vaginalis coverage (flap or free graft)Recurrent, proximal hypospadias, redo94.3% pooled success with tunica vaginalis coverage across heterogeneous post-hypospadias UCF repairs[5][20][28]
Scrotal flapRecurrent, penoscrotal location94.6% pooled success across heterogeneous post-hypospadias UCF repairs[5]
Gracilis muscle flapComplex adult UCF after major debridement when local coverage is unavailableIn one post-Fournier case, a gracilis flap covered the urethral repair and supported a skin graft; the fistula remained closed at six months.[48]

Catheter and dressing. The evidence is observational. In a nonrandomized series of 96 adults repaired under local anesthesia, fistula recurrence at three months was 3/51 without a catheter and 3/45 with one; wound infection occurred in 0/51 and 6/45, respectively.[23] In a selected cohort of 72 children, same-day repair without a stent or catheter left 64/81 repairs (79%) free of fistula recurrence at mean follow-up of 7.9 years,[22] and simple closures with a de-epithelialized flap were routinely done as outpatients without a stent.[24] Elbakry used suprapubic diversion for large or multiple fistulas; recurrence was 16% (4/25) with diversion versus 45% (10/22) without, an unadjusted comparison.[18] No randomized trial defines catheter duration for fistula repair; individualize by fistula complexity and reconstruction.

Tissue Interposition — the central technical lever​

A 2023 systematic review synthesized outcomes from 2,886 patients in 71 studies. These pooled proportions come from heterogeneous, mostly noncomparative series:[5]

Waterproofing layerPooled success
Tunica vaginalis flap (TVF)94.3%
Scrotal flap94.6%
PATIO repair93.5%
Biomaterials / dermal substitutes92%
Double dartos flaps81%
Single dartos flap78.8%
Simple primary closure73.2%
Skin-based flaps54.5%
Biocompatible adhesives56.5%

Fahmy algorithm (Eur Urol 2016) — flap selection[15]​

SettingPreferred coverage
Distal hypospadias — primaryDouble dartos flap (0.6% vs 5.1% with single, p = 0.004)
Proximal hypospadias — primaryTVF (single dartos has 8.8% fistula rate)
Repeat / redo casesTVF (6.4% vs 18.6% for dartos, p = 0.020)
Fistula repair after primary hypospadiasTVF favored (recurrence 5.1% vs 12.2% with dartos; difference not significant, p = 0.39)

TVF — technique and outcomes​

  • Harvested from the ipsilateral testis through a small scrotal incision; mobilized on its vascular pedicle through a subcutaneous tunnel to the penile shaft[20][28]
  • Provides well-vascularized, elastic, durable interposition
  • 100% success in recurrent fistulas (14 patients, mean 2.4 prior failed closures, 44-mo follow-up)[20]
  • In a single-center randomized trial of primary distal or mid-shaft TIP, 88 boys were allocated and 84 analyzed. Fistula at the three-month assessment occurred in 2/41 with TVF and 9/43 with dartos (p = 0.029), with no additional fistulas reported by 12 months; median operative time was 145 versus 100 minutes.[30]
  • A 2026 meta-analysis including that trial pooled four randomized primary-TIP comparisons: UCF occurred in 9/97 with TVF versus 34/112 with dartos at reported follow-up (RR 0.37, 95% CI 0.19–0.70). It did not assess UCF revision or separately compare TVF with double dartos.[46]
  • Donor-site complication: testicular ascent in about 7% at 12 months (0% with dartos; p = 0.071)[30]

UCF in Adults​

Adult UCF is operationally distinct from the pediatric setting.

After failed childhood hypospadias repair[3]​

  • Adults presenting with prior hypospadias complications: urethral stricture 72%, UCF 24%, persistent hypospadias 14%, hair in urethra 12%, severe chordee 14%[3]
  • In the full 50-man adult failed-hypospadias cohort, initial surgical success was 25/50 (50%); overall success after additional procedures was 38/50 (76%).[3]
  • Repair the underlying urethral lesion when present: in this 50-man cohort, 10 of 12 men presenting with UCF had associated stricture or persistent hypospadias and underwent reconstruction incorporating fistula closure; only two had isolated closure. Options in this cohort included staged urethroplasty, penile skin flap, buccal mucosa graft onlay and perineal urethrostomy; the 2026 EAU guideline recommends avoiding penile skin grafts or flaps in men with failed hypospadias repair and lichen sclerosus or scarred skin .[3][40]

After urethroplasty for stricture[12][13]​

  • Fistula occurred in 3% of a 69-man anterior-stricture urethroplasty series (58 had prior urethroplasty or urethrotomy); among 38 men scheduled for a two-stage repair, stage 1 and stage 2 revisions were required in 21% and 23%, respectively[13]
  • Failed-hypospadias-related strictures: high-grade postoperative fistula in 4/85 (4.7%) within 90 days; stricture recurrence at the reconstruction site requiring additional urethral manipulation in 29/85 (34%), with estimated failure-free survival of 57% at 10 years[12]

In neurogenic bladder[8]​

  • 17/21 patients in one selected urinary-cutaneous-fistula cohort eventually required surgical or suprapubic-tube diversion.[8]
  • In the selected mixed urinary-cutaneous cohort, 9/13 patients initially treated with fistula repair later required suprapubic-tube or conduit diversion.[8] In a separate 2026 series of 17 men with spinal cord injury and UCF, all received initial urinary diversion; 8 were then managed without fistula surgery, while 9 underwent surgery, including 3 cystectomies.[47]

Catheterless adult repair[23]​

  • Catheterless repair under local anesthesia was feasible in one adult series; catheter decisions depend on defect, reconstruction and reliable bladder emptying

Prevention (at primary hypospadias repair)​

Primary pediatric hypospadias studies associate fistula risk with anatomy, repair design, and neourethral coverage:[1][15][19][31][32]

  1. Soft tissue interposition over the neourethra was associated with UCF in 7/229 (3.1%) versus 3/14 (21.4%) without interposition in one surgeon’s observational series (p < 0.05).[19] A 56-child randomized primary TIP trial showed glans dehiscence by six months in 2/28 with flap coverage to the corona versus 9/28 with extension into the glanular neourethra.[45]
  2. Double dorsal dartos flap for pediatric hypospadias repair: a retrospective distal-hypospadias series reported fewer fistulas with double than single coverage.[32] A six-RCT synthesis, particularly relevant to distal TIP repair, estimated RR 0.37 (95% CI 0.20–0.68) for UCF with double versus single dartos; trial-sequential and fragility analyses called for further evidence.[49]
  3. Cover flap was associated with lower fistula rates across hypospadias severities in a retrospective series: reported ORs were 2.6 for anterior, 5.5 for midpenile, and 7.1 for posterior disease[31] 4.[1] One-stage repair was associated with higher fistula odds than staged repair across primary pediatric hypospadias studies (OR 1.67)[1] 5.[1] Individualize stent duration: the shorter-than-seven-day OR 3.96 association comes from only two studies[1]
  4. Meticulous gentle tissue handling, tension-free closure, watertight anastomosis
  5. Surgeon volume: operative complications fall with experience[2]

Congenital UCF​

Extremely rare. A 2018 systematic review of the published literature identified 63 cases of congenital anterior urethrocutaneous fistula; location was reported in most, and the subcoronal urethra was the most common site (29 of 63, 46%).[37] Presents in isolation or with chordee, hypospadias, or urethral duplication; in a series of 14 cases, 4 patients had distal hypospadias and 2 had chordee.[7] Repair is individualized: primary closure, Thiersch–Duplay urethroplasty, pedicle flap, hinged flap, or island pedicle tube/onlay urethroplasty depending on the anatomic defect.[7][17][33][34] Selection has been described by glans-bridge thickness: the fistula is circumscribed and closed in multiple layers, as for a urethrocutaneous fistula after hypospadias repair, when the bridge is adequate, or the ventral glans is opened through the distal urethra and repaired with Thiersch–Duplay tubularization, incising the urethral plate as needed, when the glans bridge is thin.[39]

Operative Principles​

  • Exclude and treat distal obstruction first: a treatable contributor to recurrence[18][36]
  • Allow tissue maturation for elective closure, commonly around six months after hypospadias repair; treat infection or obstruction promptly
  • Tissue interposition is the central technical lever: TVF or scrotal flap for recurrent, proximal, or redo cases; double dartos for primary distal hypospadias[5][15]
  • Avoid overlapping suture lines between urethral and skin layers
  • Simple closure may suit selected small shaft fistulas with healthy tissue[18]
  • In a selected neurogenic-bladder urinary-cutaneous fistula series, 9/13 patients initially repaired later needed suprapubic-tube or conduit diversion; discuss that possibility in similar complex cases.[8]

See Also​

Videos​

Urethrocutaneous Fistulae: Principles of Repair
Preeti Urology and Kidney Hospital (2021)

References​

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38. Lucas T, Hines JZ, Samuelson J, et al. "Urethrocutaneous fistulas after voluntary medical male circumcision for HIV prevention-15 African Countries, 2015-2019." BMC Urol. 2021;21(1):23. doi:10.1186/s12894-021-00790-y

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