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Urethroperineal Fistula Repair

A urethroperineal fistula (UPF) is an abnormal communication between the urethra and the perineal skin surface. It may be congenital (rare; ~ 25 reported cases in English literature) or acquired (most commonly from pelvic-fracture urethral injury, iatrogenic prostate-cancer treatment, Crohn's disease, or gender-affirming surgery). Management differs substantially by etiology.

For the closely related transperineal approach to rectourethral fistula see Transperineal Approach to RUF; for broader male fistula context see the male fistula treatment atlas.

Etiology and Classification​

Congenital posterior urethroperineal fistula (CUPF)​

Extremely rare anomaly (~25 cases). Urothelium-lined tract between posterior urethra and perineum. Often misdiagnosed as Y-type urethral duplication or rectourethral fistula. Critical distinction: the dorsal urethra is the functionally normal channel — excision of the ventral channel is curative. (This differs from hypospadiac urethral duplication, where excision of the ventral channel could be catastrophic.)[1][2][3][4]

Congenital anterior urethrocutaneous fistulas also exist, sometimes associated with hypospadias or chordee.[4]

Acquired UPF​

CauseNotes
Pelvic fracture urethral injury (PFUI)Most common traumatic cause — up to 5% of anterior pelvic ring fractures[5][6]
IatrogenicRadical prostatectomy, radiation, cryoablation, brachytherapy, urethral instrumentation, hypospadias repair[7][8]
Inflammatory bowel diseaseCrohn's rectourethroperineal fistulas — ~ 6–11% of all GU fistulas in Crohn's[9]
Chronic urethral calculi, infection, prolonged catheterizationLess common[10]
Gender-affirming surgeryAmong the most common complications after phalloplasty and metoidioplasty[11]

Diagnosis and Preoperative Evaluation​

Clinical presentation​

Urine leaking from a perineal opening, recurrent UTI, pneumaturia, or passage of urine per rectum if there is a rectal component. CUPF typically presents with a perineal opening that drains during micturition with otherwise normal voiding.[3][9][12]

Imaging​

ModalityRole
Retrograde urethrography (RUG)Preferred initial imaging for male urethral pathology[5]
VCUGDemonstrates the fistulous tract; helps distinguish CUPF from urethral duplication[3][13]
MRIConfirms diagnosis, delineates anatomy, surgical planning — particularly for posterior fistulas[13]
CystourethroscopyLocalize urethral orifice; assess concurrent stricture / stenosis[14]
EUAOften combined with cystoscopy[15]

Principles of Surgical Repair​

  1. First repair attempt is the most likely to succeed — refer to experienced fistula surgeons[16]
  2. Urinary and fecal diversion — for complex or posterior fistulas, preoperative fecal diversion (colostomy) and SP catheter are standard. Median diversion-to-repair interval ~ 5–6 mo; bowel diversion ≥ 12 weeks before definitive repair[15][17]
  3. Tissue interposition — well-vascularized tissue between repaired urethra and adjacent structures is critical for complex fistulas
  4. Multilayer closure — avoid overlapping suture lines[11][18]
  5. Low-pressure urinary environment — concurrent distal urethral stricture must be addressed to prevent pressurized flow compromising healing[11]

Congenital UPF — Surgical Approach​

CUPF repair is relatively straightforward: excision of the ventral accessory channel via a perineal approach is simple and curative, as the dorsal urethra is the normal functional channel.[1][3] Fulguration of the accessory tract is an alternative.[1] Urethral reconstruction is typically not required.[19]

Acquired UPF — Surgical Approaches​

ApproachIndicationsKey featuresSuccess
TransperinealMost urethral / perineal fistulas; preferred first-lineFamiliar to urologists; allows concurrent urethroplasty87–100%[17][20][21]
Transperineal + gracilis flapComplex, radiated, recurrent, or large fistulasGracilis muscle between urethra and rectum / perineum87–94%[17][20][21]
Transperineal + bulbospongiosus muscle (BSM) flapTraumatic posterior urethral stenosis + fistulaBSM strengthens anterior rectal wall94% (Hou 2025)[22]
Transperineal + inferior pubectomyPosterior fistulas with limited accessPartial pubectomy improves exposure86–89%[20][23]
Combined transpubic-perinealVery proximal or complex; failed prior repairsRectus or gracilis flap interposition78%[23]
TransabdominalSelect cases (large, proximal)Less commonly used84%[8]

Tissue Interposition Options​

  • Gracilis muscle flap — most commonly used, particularly for complex and radiated fistulas; up to 91% of complex repairs[17][24]
  • Bulbospongiosus muscle flap — traumatic posterior urethral stenosis + fistula; 94.4% (Hou)[22]
  • Dartos pedicle flap — anterior urethrocutaneous fistulas, especially post-hypospadias[23][25]
  • VRAM flap — reserved for the most complex cases with extensive tissue loss[24]
  • Rectus fascia graft — described for recurrent UCF in metoidioplasty patients[18]
  • Buccal mucosal graft (BMG) — when urethral tissue is insufficient for primary anastomosis, particularly in radiated fields[8][17]
  • Fibrin sealant haemostatic patch (TachoSil) — reinforcement in direct transperineal repair[26]

Concurrent Urethroplasty​

When posterior urethral stenosis coexists with the fistula (~ 18% of rectourethral fistula cases), simultaneous urethroplasty can be performed:[17]

  • Anastomotic repair in 78%
  • BMG in 22%
  • 87% fistula closure at median 55.7 mo

Outcomes​

  • Overall in well-resourced countries: median 94.6% closure for urogenital fistulas[16]
  • Non-radiated: 98% single-procedure closure[8]
  • Radiated: 86% single-procedure closure; higher 90-d complication rate (24% vs 2% non-radiated)[8]
  • Primary vs redo: 100% vs 70% without vs with prior failed repair[20]
  • Long-term (Wagner 2026) — open urorectal fistula repair after prostate cancer: 5-yr recurrence-free survival 96%, high satisfaction, negligible decisional regret[12]
  • Conservative management — spontaneous closure with catheter drainage in up to 15%, more likely in non-radiated[16]

Complications​

  • Urinary incontinence — most common long-term sequela, 61–75% after complex repair; ~ 30% ultimately require AUS[17][21]
  • Erectile dysfunction — up to 75% in pelvic-fracture-associated repairs[27]
  • Fistula recurrence — 2–14% depending on etiology and prior repair history[8][17][20]
  • Urethral stricture at the anastomotic site — manageable with optical internal urethrotomy or repeat urethroplasty[20][23]
  • Fecal incontinence — minority of patients; generally milder than urinary[12][21]
  • Wound complications — hematoma, infection, delayed healing, flap extrusion[15][27]

Postoperative Care and Follow-Up​

  • SP catheter removed at 6 weeks; urethral catheter 2–4 weeks depending on complexity[21][28]
  • Stoma reversal at 3–4 months after successful repair (range 12–28 wk)[21][26]
  • Imaging at catheter removal — most reconstructive urologists perform contrast urethrography to confirm healing[28]
  • Surveillance — uroflowmetry, PVR, and cystoscopy at 2–6 mo postoperatively, with long-term surveillance for delayed complications[8][28]

Definitive Perineal Urethrostomy as Endpoint​

For complex UPF where reconstruction is futile or undesirable, definitive perineal urethrostomy is a legitimate primary option — Klemm 2024 long-term PROs and Fuchs data report ~ 95% success. Particularly appropriate for hypospadias cripples, after multiple failed repairs, or by informed patient preference.

Key Takeaways​

  • CUPF — extremely rare; dorsal urethra is the normal channel; ventral accessory channel excision is simple and curative.
  • Acquired UPF — transperineal repair with gracilis (or BSM) interposition is the workhorse: 87–100% non-radiated, 86% radiated.
  • Concurrent urethroplasty for posterior urethral stenosis (~ 18% of RUF cases) — anastomotic or BMG, 87% fistula closure at 55.7 mo.
  • Tissue interposition is critical for complex / radiated / recurrent fistulas — gracilis is the workhorse; BSM, dartos, VRAM, rectus fascia, BMG, and TachoSil are alternatives.
  • First repair has the highest chance — primary 100% vs redo 70%.
  • Definitive perineal urethrostomy is a legitimate endpoint for complex / multiply-failed cases.

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. Bates DG, Lebowitz RL. "Congenital urethroperineal fistula." Radiology. 1995;194(2):501–504. doi:10.1148/radiology.194.2.7824732

4. Caldamone AA, Chen SC, Elder JS, et al. "Congenital anterior urethrocutaneous fistula." J Urol. 1999;162(4):1430–1432.

5. Johnsen N, Wessells H, Archer-Arroyo K, et al. Best Practices Guidelines: Management of Genitourinary Injuries. American College of Surgeons; 2025.

6. Coccolini F, Moore EE, Kluger Y, et al. "Kidney and uro-trauma: WSES-AAST guidelines." World J Emerg Surg. 2019;14:54. doi:10.1186/s13017-019-0274-x

7. Campbell JG, Vanni AJ. "Complex lower genitourinary fistula repair: rectourethral fistula and puboprostatic fistula." Urol Clin North Am. 2022;49(3):553–565. doi:10.1016/j.ucl.2022.04.012

8. Kaufman DA, Zinman LN, Buckley JC, et al. "Short- and long-term complications and outcomes of radiation and surgically induced rectourethral fistula repair with buccal mucosa graft and muscle interposition flap." Urology. 2016;98:170–175. doi:10.1016/j.urology.2016.06.065

9. Stamler JS, Bauer JJ, Janowitz HD. "Rectourethroperineal fistula in Crohn's disease." Am J Gastroenterol. 1985;80(2):111–112.

10. 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

11. 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

12. Wagner MC, Klemm J, Roessler N, et al. "Long-term patient-reported outcomes of open urorectal fistula repair after prostate cancer treatment." BJU Int. 2026. doi:10.1111/bju.70233

13. Ghadimi-Mahani M, Dillman JR, Pai D, Park J, DiPietro M. "MRI of congenital urethroperineal fistula." Pediatr Radiol. 2010;40 Suppl 1:S1–S5. doi:10.1007/s00247-010-1852-y

14. Huang Y, Xu W, Xie H, et al. "Cystoscopic-assisted excision of rectourethral fistulas in males with anorectal malformations." J Pediatr Surg. 2015;50(8):1415–1417. doi:10.1016/j.jpedsurg.2015.04.002

15. Gupta G, Kumar S, Kekre NS, Gopalakrishnan G. "Surgical management of rectourethral fistula." Urology. 2008;71(2):267–271. doi:10.1016/j.urology.2007.10.042

16. Hillary CJ, Osman NI, Hilton P, Chapple CR. "The aetiology, treatment, and outcome of urogenital fistulae managed in well- and low-resourced countries: a systematic review." Eur Urol. 2016;70(3):478–492. doi:10.1016/j.eururo.2016.02.015

17. Khouri RK, Accioly JPE, DeWitt-Foy ME, Wood HM, Angermeier KW. "Posterior urethral reconstruction at the time of rectourethral fistula repair: technique and outcomes." Urology. 2024;186:36–40. doi:10.1016/j.urology.2024.02.026

18. 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

19. Hong AR, Croitoru DP, Nguyen LT, et al. "Congenital urethral fistula with normal anus: a report of two cases." J Pediatr Surg. 1992;27(10):1278–1280. doi:10.1016/0022-3468(92)90273-a

20. Guo H, Sa Y, Fu Q, Jin C, Wang L. "Experience with 32 pelvic fracture urethral defects associated with urethrorectal fistulas: transperineal urethroplasty with gracilis muscle interposition." J Urol. 2017;198(1):141–147. doi:10.1016/j.juro.2017.01.071

21. Samplaski MK, Wood HM, Lane BR, et al. "Functional and quality-of-life outcomes in patients undergoing transperineal repair with gracilis muscle interposition for complex rectourethral fistula." Urology. 2011;77(3):736–741. doi:10.1016/j.urology.2010.08.009

22. Hou C, Huang J, Zhu W, et al. "Use of bulbospongiosus muscle for repair of traumatic posterior urethral stenosis combined with urethrorectal fistulas." BJU Int. 2025;135(6):1049–1057. doi:10.1111/bju.16709

23. Xu YM, Sa YL, Fu Q, Zhang J, Jin SB. "Surgical treatment of 31 complex traumatic posterior urethral strictures associated with urethrorectal fistulas." Eur Urol. 2010;57(3):514–520. doi:10.1016/j.eururo.2009.02.035

24. Paprottka FJ, Krezdorn N, Lohmeyer JA, et al. "Plastic reconstructive surgery techniques using VRAM or gracilis flaps in order to successfully treat complex urogenital fistulas." J Plast Reconstr Aesthet Surg. 2016;69(1):128–137. doi:10.1016/j.bjps.2015.08.026

25. Ahuja RB. "A de-epithelialised 'turnover dartos flap' in the repair of urethral fistula." J Plast Reconstr Aesthet Surg. 2009;62(3):374–379. doi:10.1016/j.bjps.2008.03.031

26. Giuliani G, Guerra F, Coletta D, et al. "Repair of transperineal recto-urethral fistula using a fibrin sealant haemostatic patch." Colorectal Dis. 2016;18(11):O432–O435. doi:10.1111/codi.13518

27. Wang L, Song W, Lv R, et al. "Precise treatment of pelvic fracture urethral injury associated with urethrorectal fistula." BJU Int. 2024;134(4):589–595. doi:10.1111/bju.16401

28. Hoare DT, Doiron RC, Rourke KF. "Determining perioperative practice patterns in urethroplasty: a survey of genitourinary reconstructive surgeons." Urology. 2021;156:263–270. doi:10.1016/j.urology.2021.05.067