Urethral Fistula

By Nick Peplow·Gender-affirming surgery coordinator

Last reviewed 27 September 2026· How this site is researched

A urethral fistula is a small hole in the new urethra that lets urine out through the skin somewhere other than the tip. It's one of the two urethral complications of metoidioplasty and phalloplasty with urethral lengthening, alongside stricture, and any surgeon who does these operations will raise it before you consent. If your urethra wasn't lengthened, as after a simple release or a phalloplasty without a urethra, this page doesn't apply to you.

Why it happens

The lengthened urethra is built from tissue that was never a tube: labia minora and vaginal lining in metoidioplasty, and a strip of the flap or a graft in phalloplasty. It's stitched into a tube and joined to your original urethra near the base. Every join is a weak point. If part of a suture line breaks down, through a thin blood supply, tension, infection or a pocket of fluid, urine seeps into the gap and works a track out to the skin.

A narrowing further along makes it worse. A stricture raises the pressure behind it every time you pee, and that pressure can push a fistula open or stop one closing.

How common it is

Common enough that surgeons treat it as a foreseeable event rather than a rare one. I don't quote a published figure here: fistula and stricture are usually counted together, and the totals move with the technique, with whether the join was made in one stage or two, and with whether a pinhole that closed by itself gets counted at all. Your surgeon's own figure is the one to plan around.

Where and when

Most fistulas sit at the join between the old and new urethra: at the base of the phallus, on the underside, or in the perineum behind the scrotum. They can appear anywhere along the tube.

They show up once urine starts running through the new urethra. The catheter usually comes out around two to four weeks after metoidioplasty and three to four weeks after phalloplasty, often after an X-ray with dye has checked for leaks. The first few weeks after that are the window. A later fistula, months out, usually has a stricture downstream of it.

What it looks like

• A second stream, or a dribble from the underside or base, while you pee
• Wetness at the base or in the perineum after peeing, with no obvious source
• A pinhole or small pit in the skin along the underside that stays moist
• A weaker stream from the tip, because some of the flow is escaping
• A tender swelling along the urethra before it opens, sometimes with soreness around the spot

On its own, without fever or trouble passing urine, a fistula is a phone call, not an emergency.

When to call and when to go to hospital

Message or call your surgeon's team within a day, with a photo if you can, if you notice:

• Urine coming out anywhere other than the tip
• A new opening or a patch of skin that stays wet
• A tender lump along the urethra that's getting bigger

Call the same day if there's:

• Fever, chills or feeling unwell
• Redness spreading from the site, or a foul-smelling discharge
• A suprapubic catheter that has stopped draining, with lower belly pain

Go to an emergency department, or call an ambulance, if:

• You can't pass urine at all, or only a trickle, and your lower belly is swelling and painful. That's retention, it usually means a stricture as well, and the stricture page explains what to tell the staff there.
• The skin of the phallus turns dark, dusky, cold or blackened. That's a blood-supply problem with the flap, not a fistula, and it needs treatment within hours.
• You have a high fever with a racing heart, confusion or feeling faint.

How it's managed

The first step is nearly always to wait. Small early fistulas often close on their own over a few weeks as the tissue heals. While you wait, your surgeon may:

• Leave the suprapubic catheter in, or put a catheter back, so urine bypasses the new urethra and the hole can heal dry
• Ask you to sit to pee for now, and sometimes to press on the spot while you go; they'll show you how
• Treat any infection with antibiotics
• Look downstream with a flow test, a scope or an X-ray with dye, because a fistula with a stricture below it won't close until the stricture is dealt with

Every experienced team I've coordinated patients with describes the same routine, almost word for word: catheter, wait, check for a stricture, repair if it hasn't closed. Ask your surgeon to walk you through theirs before surgery.

If it hasn't closed, surgical repair is usually planned for around six months after the operation that caused it. Surgeons wait because freshly healed tissue is swollen and holds stitches poorly. The track is cut out, the urethra closed in layers, and a layer of healthy tissue brought between the urethra and the skin so the two holes don't line up again. It's often a short stay, sometimes a day case, with a catheter for a week or two afterwards. Most repairs hold. A minority leak again and need a second attempt, and a larger or more complicated fistula may need extra tissue or a graft.

What a repair costs you

Mostly time. It's another operation, another catheter and often a stretch of sitting to pee again. Money comes second. The urethral lengthening page puts a separately billed urethral stage or revision at roughly $10,000–$25,000 self-pay in the US and $4,000–$10,000 in Thailand, with fistula and stricture repairs toward the lower end. Some packages include one urethral repair; most don't. In the US a repair usually needs its own authorisation. Abroad it means another trip. Revisions covers how follow-up surgery fits into the wider plan.

Living with it in the meantime

The waiting is tedious rather than painful. Sit to pee, keep the area clean and dry, and use a pad or absorbent underwear. Dark, loose trousers help more than anything clever. If the skin around the hole gets sore from being damp, a barrier cream of the kind used for nappy rash is the usual answer; check with your team first.

The people I've walked through a fistula repair almost all found the months of waiting harder than the operation that ended them. It helps to know it's coming. Many international patients are home by the time a fistula appears, so before you fly, agree how you'll send photos, who reviews them, and which local urologist or GP will see you in person.

Reducing your risk

Much of this is out of your hands. What you control: stop nicotine for as long as your surgeon asks, and longer if you can, keep diabetes tightly managed, follow the catheter instructions exactly, never pull or tug a catheter, and stick to the exercise and sex restrictions until you're cleared. Surgeon volume matters more here than almost anywhere else. Ask for their fistula rate as a number, for your operation, and ask whether a repair is included in the quote.

This is general information, not medical advice. Your surgical team decides what your particular fistula needs.