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• Definition: a connection between the urethra and the outside skin (penis, scrotum, and/or perineum).

• Symptoms: urinary leakage from somewhere other than the tip of the penis.

• Fistulas are relatively common, and if present, are diagnosed when patients start urinating about 3-4 weeks postop. On occasion, fistulas develop beyond the 3 week period.

• Penis swelling increases your risk of a fistula on the underside of the phallus along the suture line.

  • Management: elevate the penis, rest, wound care (ointment daily, keep clean), eat healthy​

  • Example: some patients don't have any fistulas during their first month of recovery, but then note new fistulas develop on the underside of the penis. This occurs when patients have prolonged phallus swelling.

  • Swelling --> tension on a suture line --> higher chance of the suture line opening --> fistula

• Risk factors for fistula formation:​

  • Smoking, poor nutrition​

  • Tension on the urethral suture line 

  • A urethral stricture (blockage of the urine flow can lead to upstream pressure buildup within the urethra; this may lead to a fistula and/or prevent a fistula from healing)

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SURGERY FOR FISTULAS

• When is surgical repair indicated? 

  • If the fistula does not heal by 3 months after phalloplasty or metoidioplasty, then surgical repair is required​

• Fistula repair surgery

  • Involves separating the urethral tissue from the genital skin and removing the connection (or tract) between the two.

  • The urethral tissue is closed, followed by an interposing layer of neighboring tissue (if present) or graft to separate the urethral suture line from the genital skin suture line.

• Catheter duration?

  • Some patients need a catheter for 1-4 weeks, depending on the type and location of the repair. Type of repair depends on the number, location, size, and severity of the urethral defect(s). ​

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