A urethrocutaneous fistula is an abnormal opening between the urethra and the skin, so urine leaks through a second opening during urination. It most often occurs after hypospadias or urethral surgery, but can also follow trauma, infection, abscess or tissue breakdown. Treatment depends on fistula size, location, tissue quality and whether there is a urethral stricture downstream. Small fresh leaks may occasionally close with drainage and healing, while established fistulas usually need surgical closure. Before repair, the urologist must make sure urine can flow freely through the main urethra.

What does it look like?

• Urine comes from the normal meatus and from a second skin opening.
• Leakage becomes obvious when the bladder is fuller or the stream is stronger.
• The opening may be on the penis, perineum or near a previous incision.
• Some patients have recurrent local irritation or infection.

Common causes

• Previous hypospadias repair.
• Urethroplasty or other urethral surgery.
• Wound infection or breakdown.
• Urine leak after reconstruction.
• Trauma to the urethra.
• Periurethral abscess or severe infection.
• Poor tissue quality after repeated surgery or radiation.

Why a distal stricture must be excluded

If the urethra beyond the fistula is narrow, urine takes the path of least resistance through the skin opening. Closing the fistula without correcting obstruction can cause recurrence or another leak. Uroflowmetry, urethrography and cystoscopy may therefore be needed.

Tests

Can it close without surgery?

A very small early postoperative fistula can sometimes seal if infection is controlled and urine drainage is good. Once the tract is mature and epithelialised, spontaneous closure is much less likely.

Surgical repair

• Wait until acute inflammation and infection have settled and tissue is healthy enough for repair.
• Identify and correct any distal urethral stricture.
• Separate the skin opening from the urethral defect.
• Close the urethral opening without tension.
• Use well-vascularised tissue coverage between urethra and skin when appropriate.
• Avoid directly overlapping urethral and skin suture lines when possible.
• Use temporary catheter drainage according to the repair.

Complex fistulas after failed hypospadias

Multiple fistulas, penile curvature, hair-bearing urethra, lichen sclerosus or a long associated stricture may require full reconstructive reassessment rather than simply closing each hole. One-stage or staged urethroplasty may be more durable.

What to expect after successful closure

Once the catheter is removed, the urinary stream should pass through the intended urethral opening without persistent wetness from the skin fistula. A few drops from the wound immediately after surgery are not automatically recurrence, but ongoing urine leakage with every void should be assessed.

The surgeon also watches the stream. A fistula can close while the underlying urethra narrows again, so progressive straining or prolonged voiding is an important warning sign. Uroflowmetry or imaging is used when recurrence is suspected.

In complex hypospadias or redo cases, cosmetic maturation continues for months. The priority is first a dry, patent urethra; refinements are considered only after tissue has fully healed.

What to bring for consultation

• RGU and MCU/VCUG images or films, not only the written report.
• Uroflowmetry report and post-void residual if already done.
• Urine routine and urine culture reports.
• Serum creatinine and other relevant blood tests.
• Previous catheter, VIU/dilatation or urethroplasty discharge summaries.
• Details of any pelvic injury, prostate surgery, hypospadias surgery, radiation or recurrent infections.
• Current medicines, including blood thinners, and any history of self-dilatation.

Why the cause and location of a urethrocutaneous fistula matter

A urethrocutaneous fistula is an abnormal channel from the urethra to the skin. Urine may emerge from the penis, perineum or a previous incision. The key reconstructive question is whether the fistula is the primary problem or merely a pressure-release point above a distal obstruction.

After hypospadias surgery, a small fistula can occur despite an otherwise open urethra. After urethroplasty, fistula may reflect wound breakdown, infection or an unrecognised recurrent narrowing. In chronic inflammatory/infected disease, multiple fistulae can be associated with dense stricture and periurethral scarring. Closing the skin opening without correcting downstream obstruction risks recurrence.

Evaluation therefore includes examination, uroflow/PVR when the patient can void, RGU/VCUG and cystoscopy as needed to assess the underlying urethra. Small early postoperative leaks can occasionally close with adequate catheter drainage if the urethra is patent. Persistent fistula generally needs surgical repair after inflammation has settled, often with layered closure and healthy tissue interposition in complex or recurrent cases.

Treatment depends on whether the urethra below the fistula is open

If the urethra is patent and a small fresh postoperative fistula is leaking, prolonged catheter drainage can reduce pressure across the opening and occasionally allow spontaneous closure. The catheter must actually drain the bladder well; bypassing around a blocked catheter defeats the purpose.

When a distal stricture is present, that obstruction usually needs correction before or at the time of fistula repair. After inflammation has settled, the fistula is excised or freshened as appropriate and closed in layers, often with healthy vascularised tissue interposed in recurrent cases.

Hypospadias fistulae near the glans have different tissue constraints from perineal fistulae after urethroplasty. Multiple fistulae with severe stricture may require staged reconstruction rather than closing each skin opening separately. Long-term success depends on restoring a low-pressure, patent urethral channel beneath the skin repair.

How fistula repair is protected from recurrence

The repair needs a low-pressure urinary channel beneath it. Before closing the skin opening, the surgeon confirms that there is no untreated distal stricture, stone, infected cavity or obstructed catheter. Closing the fistula while pressure remains high makes breakdown much more likely.

During reconstruction, scarred fistula edges are freshened or excised as appropriate and the urethra is repaired in layers. A second healthy tissue layer—dartos, tunica vaginalis, muscle or another vascular flap depending on location—may be interposed so urethral and skin suture lines do not sit directly on top of each other.

A catheter diverts urine during healing. Recurrent leakage, wound swelling, fever or a weakening stream after catheter removal needs review. Multiple fistulae after hypospadias or urethroplasty can signal wider tissue failure, in which case staged reconstruction may be more durable than repeatedly closing individual holes.

FAQs

Related reading

• Urethral Stricture After Hypospadias Surgery
• Adult Failed Hypospadias: Reconstructive Options
• Redo Urethroplasty After Failed Surgery
• Urethroplasty Surgery Explained
• Vesicovaginal Fistula Repair Explained
• Urologist in Latur

References

• European Association of Urology. EAU Guidelines on Urethral Strictures: Disease Management in Males, 2026 https://uroweb.org/guidelines/urethral-strictures/chapter/disease-management-in-males
• European Association of Urology. EAU Guidelines on Urethral Strictures: Perioperative Care of Urethral Surgery, 2026 https://uroweb.org/guidelines/urethral-strictures/chapter/perioperative-care-of-urethral-surgery
• European Association of Urology. EAU Guidelines on Urethral Strictures: Diagnostic Evaluation, 2026 https://uroweb.org/guidelines/urethral-strictures/chapter/diagnostic-evaluation