Urethrorectal fistula is a rare urological disease, which is often secondary to urethral injury. Fecaluria, pneumaturia, and the leakage of urine through the rectum during micturition were considered the indicative symptoms, which seriously affects the quality of life of patients. Because of its rarity and complexity, the treatment of urethrorectal fistula is still challenging. The traditional operation mainly uses simple fistula repair, but the recurrence rate is high and the effect is poor. In recent years, due to the application of various muscle flaps, satisfactory results have been obtained in the treatment of urethrorectal fistula. In this study, we will introduce a case of pelvic fracture posterior urethral atresia associated with rectal fistula.

A 35-year-old male, suffered from pelvic fracture urethral rupture associated with rectal fistula for 1 year. Unable to urinate by himself. He was directly managed by suprapubic cystostomy and diverting ileostomy at the time of trauma. The fistula location as well as the site and the extent of urethral atresia was determined by physical examination, retrograde urethrography and urethral magnetic resonance imaging (MRI) examination。

The patient was placed in the lithotomy position and an inverted T-shaped perineal incision was made. The skin was separated layer by layer until the urethra is exposed. The bulbospongiosus muscle flap was dissociated at the upper edge. The space between the bulbocavernous muscle and the bulbar urethra was longitudinally separated. When the bulbospongiosus muscle was dissociated to the urethral atresia segment, the urethra atresia segment was transected. Fibrous scar tissue of the distal and proximal urethral was completely excised, rectal fistula was identified and exposed. After dissociating rectal fistula during operation, 3-zero absorbable sutures was used to suture it in 2 layers. The suture after knotting was not cut, and keep it for reserve. Then, we preset suture at the distal and proximal urethral anastomosis respectively. Tension-free end-to-end urethral anastomosis was performed using 8 interrupted 5-zero polyglactin sutures. The bulbospongiosus muscle flap was sutured to cover the repaired rectal fistula with the previously retained suture in order to strengthen the fistula and interposition the rectal fistula and the urethral anastomosis. 40 days after operation, the patient urinated smoothly, the average uroflowmetry was 25.4 ml/s and the maximum uroflowmetry was 36.4ml/s. Retrograde urethrography and urethral MRI showed that the urethra is unobstructed and rectal fistula disappears 2 months postoperatively.

End-to-end anastomosis and rectal fistula repair combined with bulbospongiosus muscle interposition is a technically feasible and effective technique for the pelvic fracture posterior urethral atresia associated with rectal fistula.