Fistula

A fistula is an abnormal opening between two places that should not connect. In FTM surgery it almost always means a urethral fistula: a small hole in the newly built urethra that lets urine leak out through the skin somewhere other than the tip.

Where you'll meet it

Fistula comes up on every phalloplasty and metoidioplasty page, because it is the most common complication of urethral lengthening, the part of bottom surgery that extends the urethra so you can stand to pee. Surgeons will say it in consultations, quotes list "fistula repair" as an extra, and it is the complication people on forums are most often describing when they say their recovery "had a setback".

You will also see it, much more rarely, for a leak between the vaginal canal and the rectum or bladder after a vaginectomy. Unless a page says otherwise, assume urethral.

What it actually looks like

Urine appearing from a point along the underside of the shaft or at the join between the new urethra and the old one, usually first noticed in the weeks after the catheter comes out. Sometimes it is a dribble alongside a normal stream, sometimes a second stream. It is not usually painful in itself, though the skin around it can get sore.

How common it is

Common enough that surgeons talk about it as an expected risk rather than a rare one. Published series for phalloplasty with urethral lengthening put it somewhere between roughly one in six and one in three patients, depending on the technique, the surgeon and how the urethra was staged. Metoidioplasty rates are usually lower but not low. Without urethral lengthening the risk essentially disappears, which is one reason some people choose to skip it.

What happens next

Small fistulas often close on their own over a few weeks, sometimes with a catheter put back in to rest the urethra. Ones that do not close are repaired surgically, and surgeons generally wait three to six months for the tissue to settle before operating, so the repair is usually a separate, smaller procedure rather than an emergency. Repairs mostly work; a minority of people need more than one.

A fistula often travels with a stricture, a narrowing further along the urethra that raises pressure behind it, so the surgeon will usually check for both.

What you can do about the odds

Not much on the day, but a fair amount beforehand: stopping nicotine completely, which the eligibility section covers, choosing a surgeon who does urethral lengthening regularly, and asking them directly what their fistula rate is and whether repairs are included in the quote. A surgeon who gives you a straight number is telling you something useful; one who says it never happens is not.

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