Uro-symphyseal fistula (USF) is a rare but serious complication, characterised by abnormal communication between the prostate and pubic symphysis, often leading to osteomyelitis, urinary extravasation, and soft tissue infections. We present a case of an 81-year-old male with a history of EBRT for localized prostate cancer who developed a USF resulting in an infected thigh abscess. An 81-year-old male with a remote history of EBRT for prostate cancer (treated 18 years prior) presented with worsening perineal pain and fever. CT imaging demonstrated a PSF with extension of fluid collections into the pubic symphysis and medial adductor compartment of the thigh, consistent with an infected abscess. The patient underwent percutaneous drainage of the abscess and was initiated on broad-spectrum antibiotics. The patient was a non-operative candidate to other co-morbidities. This review synthesises current literature on the causes, diagnosis, and management of USF.

MEDLINE and CENTRAL databases were systematically searched for studies on USF published between 2000 and 2024. Full-text articles meeting inclusion criteria were reviewed for clinical data.

A total of 32 studies, encompassing 251 cases of USF, were identified in literature. MRI confirmed the diagnosis in 96% of cases. Suprapubic pain and mobility impairment were the most frequently reported symptoms. The most common underlying cause was previous radiation therapy for prostate cancer (94%), often accompanied by a history of endoscopic bladder outlet procedures (83%). Among patients with radiation-induced USF, conservative management was attempted in 32 cases, with an overall failure rate of 96% (n = 32). The majority patients underwent urinary diversion 186 (74%).

USF remains a challenging and rare clinical entity with significant morbidity. Early recognition, a multidisciplinary approach, and individualized treatment strategies are critical for optimal patient outcomes Prior radiotherapy is a major risk factor for USF, with most cases ultimately requiring definitive surgical management, including debridement/pubectomy, cystectomy, and urinary diversion.