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Urethropubic Fistula

Urethropubic fistula — also termed urinary-pubic symphysis fistula (UPF), urosymphyseal fistula, pubosymphyseal fistula, or (when the bladder side dominates) pubovesical fistula — is an abnormal communication between the urinary tract and the pubic symphysis / pubic bone, frequently accompanied by pubic bone osteomyelitis. It is a rare but severely debilitating late complication of pelvic radiation therapy for prostate cancer, frequently following endoscopic intervention in an irradiated field — most commonly treatment of a radiation-induced bladder-neck contracture or posterior urethral stenosis.[1][2][5]

The literature uses several near-synonymous terms for what is fundamentally a spectrum disorder. "Urethropubic" emphasizes the urethra-to-pubis communication; "pubovesical" emphasizes the bladder-to-pubis communication; "urinary-pubic symphysis fistula (UPF)" is the contemporary umbrella term that captures both. The diagnostic principles overlap, but the urinary origin, extent of infected bone, prior treatment and remaining bladder/outlet function change the reconstructive options. Not every patient has received radiation.[1][4]

Conservative management frequently fails in published post-radiation series. Definitive treatment commonly combines pubic-bone debridement, fistula excision and urinary reconstruction or diversion, often vascularized interposition, and culture-directed infection treatment. Cystectomy/diversion is common, but bladder- or organ-sparing repair is possible in selected patients, including after radiation.[1][2][13][14]

For operative selection across all repair routes, see the Male Fistula Repair database.

See also: Rectovesical Fistula — Pubovesical Fistula section, PFUI, Bony Pelvic Anatomy, The Retropubic Space, Radiation Tissue Effects, Fistulas landing page.

Epidemiology & Etiology​

Pelvic radiation therapy for prostate cancer is the predominant risk factor, present in 93% of cases in contemporary systematic review.[1] In Bugeja’s 16-patient series, all patients had received radiotherapy either as primary treatment or after prostatectomy.[2] Presentation can occur years after treatment; cohort estimates differ in whether they measure time from radiation, other cancer treatment or subsequent instrumentation.[3][4][9]

The Endoscopic-Trigger Pathway​

A dominant mechanism threads through most contemporary cases:[2][5]

  1. Prostate cancer treatment (radical prostatectomy ± radiation; primary radiation alone; brachytherapy)
  2. Bladder-neck contracture (BNC) or posterior urethral stenosis develops in the irradiated, ischemic field
  3. Endoscopic intervention — bladder-neck incision, urethral dilation, TURP, holmium laser procedures — attempts to relieve obstruction
  4. Urinary extravasation through the manipulated, radiation-damaged tissue enters the retropubic space
  5. Chronic infection establishes in the pubic bone (osteomyelitis)
  6. Fistula matures between bladder / urethra and pubic symphysis

In the systematic review, 83% of post-radiation cases had prior endoscopic outlet surgery. Bugeja reported bladder-neck contracture in 13/16 patients; these are related but different measures.[2][1] Even apparently minor endoscopic maneuvers (single dilation, brief BNC incision) in previously irradiated tissue can precipitate the cascade.[5]

Other Etiologies​

  • Other pelvic injury or instrumentation — investigate the urinary and bone anatomy rather than assume the post-radiation pathway applies
  • Radical gynecologic surgery / pelvic exenteration[6]
  • Female incontinence surgery — a recognized context for pubic symphysis infection; Ross’s 100-case septic-arthritis review was not a USF-only cohort[7]
  • Pelvic malignancy — exclude active disease when clinically indicated; pubic infection and a urinary fistula need separate confirmation[7]
  • Cryotherapy for prostate cancer[2]

Clinical Presentation​

The classic triad is chronic suprapubic / groin / pelvic pain, gait disturbance, and recurrent UTI in a patient with prior pelvic radiation and recent endoscopic manipulation:[2][3][4][7][8]

  • Chronic, debilitating pubic / pelvic / groin pain
  • Difficulty with ambulation or waddling gait
  • Pain exacerbated by walking
  • Recurrent UTIs
  • Urinary obstruction and urosepsis in advanced cases

The Misdiagnosis Problem​

UPF is commonly misdiagnosed as osteitis pubis — a sterile inflammatory condition — and managed with NSAIDs, activity modification, and empirical antibiotics for months to years before the true diagnosis is made.[2][4] The clinical mimics include septic arthritis of the pubic symphysis, pubic-bone osteonecrosis, and adductor tendinitis. The distinguishing historical features are prior pelvic radiation and recent endoscopic BOO intervention in a patient with compatible symptoms; obtain prompt imaging when a fistula or bone infection is suspected.

Diagnosis​

MRI — the Gold Standard​

Pelvic MRI is preferred to delineate fistula, bone involvement and soft-tissue infection. A systematic review reported MRI confirmation in 95% of included cases; this is not a prospective sensitivity estimate.[1][10] Reported findings in Sexton’s selected 16-patient series:[10]

  • High signal on T2-weighted sequences in the pubic symphysis and involved pubic rami
  • Low signal on T1-weighted sequences
  • Regional inflammatory myositis in the majority of patients
  • Diastasis of the pubic symphysis
  • Cortical bone erosion
  • Fluid collections — 75% of patients
  • Fistulous tract visualization on dedicated sequences

Combined MRI + Cystoscopy​

The combination of MRI and cystoscopy enables precise characterization of the fistula defect relative to the urinary sphincter complex and the rectum — both critical to operative planning.[1] Findings at cystoscopy suggestive of UPF include bladder-neck sloughing, mucosal necrosis, dystrophic calcification, and cavitation.

Adjunctive Studies​

  • Plain radiography is insensitive — no evidence of osteomyelitis in 63% of cases.[9][10]
  • CT demonstrates bone destruction, abscess, soft-tissue mass, and the fistulous tract, but is less sensitive than MRI.[9]
  • Retrograde urethrography can visualize the fistula and assess for concurrent stricture.
  • CT-guided bone biopsy directs antibiotic management when cultures are needed before surgical debridement.
  • Urine culture should be obtained, but does not replace bone/tissue cultures: in one selected series, 63% of patients with positive urine cultures had a matching bone organism.[12]

Pathophysiology — UPF as Osteomyelitis​

Pubic-bone osteomyelitis commonly accompanies UPF, with a fistulous tract maintaining urinary contamination of the involved bone. The pathology series below are selected surgical populations.[11][12]

Histopathology of Resected Pubic Bone[11]​

In Kahokehr’s selected 36-patient extirpative cohort:

  • Osteomyelitis: 32/36 (88.9%)
  • Chronic osteomyelitis — 41.7%
  • Combined acute and chronic osteomyelitis — 44.4%
  • Osteonecrosis — 11/36 specimens

Bone Cultures[12]​

In Nosé’s 36-patient extirpative cohort, 33/36 (91.7%) had positive bone cultures. Reported organisms included:

  • Candida — 22%
  • Enterococcus — 18%
  • Pseudomonas — 10%
  • Staphylococcus aureus — common in athletic / non-radiation populations[7]

The 63% match was among patients with positive preoperative urine cultures, not all positive bone cultures. Discordance remains substantial; use intraoperative bone/tissue specimens and infectious-disease input to refine treatment rather than assume urine identifies every bone pathogen.

For persistent fistula with infected or necrotic bone, definitive treatment usually requires debridement of involved pubic bone plus urinary source control. Extent of resection and nonsurgical alternatives depend on disease burden, tissue viability and operative fitness.[11]

Management​

Conservative Management — Limited Role​

A systematic review of heterogeneous published cases reported conservative-management failure in 96% after radiation and 72% without radiation; these are not prospective individual-risk estimates.[1] One of 16 patients in Bugeja’s series responded to conservative care.[2]

Conservative care can be appropriate for selected low-burden disease, patients who decline major surgery, or those whose comorbidity or goals favor palliation. Gupta described two patients managed conservatively because of low disease burden. Individualize drainage, antimicrobial treatment, pain control and monitoring; persistent urinary contamination and bone infection often require surgery for durable control.[4]

Definitive Surgical Management — The Four-Element Operation​

Definitive reconstruction commonly combines the following elements, individualized to anatomy and source-control needs:[1][2][4]

  1. Fistulous tract excision
  2. Pubic symphyseal debridement / partial pubectomy — guided by infected or nonviable tissue
  3. Vascularized tissue interposition — omental flap, rectus muscle or VRAM, or gracilis muscle
  4. Urinary-tract reconstruction or diversion

Urinary Management — Reconstruction vs Diversion​

The division between reconstruction and permanent diversion is driven primarily by bladder quality, radiation history, and the extent of fistula involvement at the bladder neck / trigone.

Cystectomy with ileal-conduit diversion — most common approach:[1][2]

  • In Patel’s review, 184 cystectomy/diversions versus 30 bladder-sparing operations were reported after radiation (86% versus 14% of those 214 operations)
  • Removes the radiated, contracted, infected lower urinary tract in one operation
  • Removes a poorly functioning reservoir when preservation is unlikely to provide useful function; major morbidity and recurrence remain possible

Bladder-sparing reconstruction — selected by anatomy, function and preferences; published treatment proportions are not eligibility thresholds:[1][2]

  • Salvage radical prostatectomy (if prostate still in situ)
  • Substitution or augmentation cystoplasty when bladder capacity is inadequate
  • Assess usable bladder capacity/compliance, outlet function, infection control and the patient’s ability to manage any augmentation or catheterization

Organ-sparing fistula repair with rectus abdominis muscle flap interposition — demonstrated in selected irradiated patients:[13]

  • Kaufman: all four patients had prior pelvic radiation and pubic osteomyelitis; all achieved closure after one repair at median 27 months without prostatectomy or diversion
  • Requires careful patient selection

Robot-Assisted Cystectomy with Holmium Laser Pubic Debridement​

A contemporary minimally invasive approach combining robotic cystectomy with holmium laser debridement of the pubic symphysis has been described in small selected series; comparative evidence does not establish lower morbidity than open pubectomy:[8][14]

Outcomes (Navaratnam series):[14]

  • 91.7% success at median 29-month follow-up
  • Median operative time 270 min
  • Median length of stay 5 days
  • Allows precise, contained debridement of necrotic bone through laparoscopic access

Antibiotic Therapy​

  • Pathogen-directed treatment based on bone/tissue cultures; urine findings may inform initial coverage but cannot substitute for infected-site cultures[12]
  • Individualize duration and route with infectious disease according to organisms, debridement and response; Ross’s historical six-week recommendation was for a heterogeneous pubic septic-arthritis cohort, not a universal USF protocol[7][16]
  • Suppressive antibiotics may be used in selected conservative plans[4]
  • Infectious-disease co-management is standard given the chronic polymicrobial nature and prolonged duration

Outcomes​

Symptom Resolution​

Prompt symptom improvement — particularly resolution of debilitating pain — is typical after definitive surgical management.[2][15] Bugeja reported symptom resolution in that series; this does not guarantee pain resolution for every patient.[2]

Durability​

Small selected series report good closure after bone debridement and urinary source control.[8][14] Persistent leakage, infection, tissue injury and outlet dysfunction can complicate recovery; retrospective series do not establish that all recurrence is caused by inadequate bone resection.

Morbidity and Recovery​

The operation carries high morbidity and prolonged recovery:[2]

  • Prolonged hospital length of stay
  • Significant blood loss in open cases
  • Wound and stoma complications
  • Prolonged convalescence
  • Postoperative requirement for urinary stoma care (when cystectomy performed)

Pelvic Ring Stability​

Selected series report preserved pelvic stability after limited pubic debridement; assess the planned resection and pre-existing pelvic or sacroiliac disease with orthopedics when indicated.[4]

Prevention​

Given the dominant etiologic pathway (radiation → BNC → endoscopic BOO treatment → UPF), prevention focuses on the third step:[5]

  • Exercise restraint with endoscopic intervention in radiated patients — accept higher thresholds for proceeding to BNC incision, dilation, or TURP.
  • Individualize outlet treatment according to the stenosis and tissue quality; the case series do not establish a safe procedure or a comparative fistula-prevention advantage for single dilation.
  • Inform patients of the UPF risk before any endoscopic manipulation in a radiated pelvis.
  • Early imaging (MRI) when any radiated patient with prior BOO treatment develops new pubic or groin pain — do not dismiss as osteitis pubis.

Clinical Pearls​

  • High index of suspicion in irradiated patients presenting with pubic pain, gait disturbance, and recurrent UTI — especially after any endoscopic BOO procedure.[1][2]
  • MRI pelvis should be obtained promptly when UPF is suspected — plain films are insensitive.[10]
  • Multidisciplinary team: reconstructive urology + infectious disease + orthopedic or plastic surgery (for flap).[4][12]
  • Plan adequate bone debridement and urinary source control when osteomyelitis is present; tailor resection to involved tissue and clinical circumstances.[11]
  • Discuss diversion and feasible reconstructive alternatives using remaining bladder/outlet function, disease extent, operative risk and patient goals.[1][2]
  • Even minimally traumatic endoscopic procedures in previously irradiated tissue can precipitate UPF; their occurrence despite sterile urine and gentle instrumentation does not quantify the risk of every intervention.[5]
  • Symptom relief can be substantial after successful surgery — this reframes the operation for patients weighing high morbidity against debilitating chronic pain.[2][15]

See Also​

References​

1. Patel N, Mehawed G, Dunglison N, et al. Uro-Symphyseal Fistula: A Systematic Review to Inform a Contemporary, Evidence-Based Management Framework. Urology. 2023;178:1–8. doi:10.1016/j.urology.2023.05.002

2. Bugeja S, Andrich DE, Mundy AR. Fistulation Into the Pubic Symphysis After Treatment of Prostate Cancer: An Important and Surgically Correctable Complication. Journal of Urology. 2016;195(2):391–398. doi:10.1016/j.juro.2015.08.074

3. Walach MT, Tavakoli AA, Thater G, et al. Pubic Bone Osteomyelitis and Fistulas After Radiation Therapy of the Pelvic Region: Patient-Reported Outcomes and Urological Management of a Rare but Serious Complication. World Journal of Urology. 2024;42(1):461. doi:10.1007/s00345-024-05155-2

4. Gupta S, Zura RD, Hendershot EF, Peterson AC. Pubic Symphysis Osteomyelitis in the Prostate Cancer Survivor: Clinical Presentation, Evaluation, and Management. Urology. 2015;85(3):684–690. doi:10.1016/j.urology.2014.11.020

5. Shapiro DD, Goodspeed DC, Bushman W. Urosymphyseal Fistulas Resulting From Endoscopic Treatment of Radiation-Induced Posterior Urethral Strictures. Urology. 2018;114:207–211. doi:10.1016/j.urology.2017.12.020

6. Hoyme UB, Tamimi HK, Eschenbach DA, Ramsey PG, Figge DC. Osteomyelitis Pubis After Radical Gynecologic Operations. Obstetrics and Gynecology. 1984;63(3 Suppl):47S–53S.

7. Ross JJ, Hu LT. Septic Arthritis of the Pubic Symphysis: Review of 100 Cases. Medicine. 2003;82(5):340–345. doi:10.1097/01.md.0000091180.93122.1c

8. Hebert KJ, Boswell TC, Bearrick E, et al. Robotic Puboprostatic Fistula Repair With Holmium Laser Pubic Debridement. Urology. 2022;160:228. doi:10.1016/j.urology.2021.10.019

9. Wignall TA, Carrington BM, Logue JP. Post-Radiotherapy Osteomyelitis of the Symphysis Pubis: Computed Tomographic Features. Clinical Radiology. 1998;53(2):126–130. doi:10.1016/s0009-9260(98)80059-7

10. Sexton SJ, Lavien G, Said N, et al. Magnetic Resonance Imaging Features of Pubic Symphysis Urinary Fistula With Pubic Bone Osteomyelitis in the Treated Prostate Cancer Patient. Abdominal Radiology. 2019;44(4):1453–1460. doi:10.1007/s00261-018-1827-2

11. Kahokehr AA, Boysen WR, Schild MH, et al. Urinary Pubic Symphysis Fistula Leads to Histopathologic Osteomyelitis in Prostate Cancer Survivors. Urology. 2021;148:297–301. doi:10.1016/j.urology.2020.07.038

12. Nosé BD, Boysen WR, Kahokehr AA, et al. Extirpative Cultures Reveal Infectious Pubic Bone Osteomyelitis in Prostate Cancer Survivors With Urinary-Pubic Symphysis Fistulae (UPF). Urology. 2020;142:221–225. doi:10.1016/j.urology.2020.04.095

13. Kaufman DA, Browne BM, Zinman LN, Vanni AJ. Management of Radiation Anterior Prostato-Symphyseal Fistulas With Interposition Rectus Abdominis Muscle Flap. Urology. 2016;92:122–126. doi:10.1016/j.urology.2016.01.029

14. Navaratnam A, Faraj K, Rose K, et al. Robot Assisted Cystectomy With Holmium Laser Debridement for Osteomyelitis of the Pubic Symphysis With Urinary Fistula. Urology. 2019;134:124–134. doi:10.1016/j.urology.2019.08.049

15. Devlieger B, Wagner D, Hopf J, Rommens PM. Surgical Debridement of Infected Pubic Symphysitis Supports Optimal Outcome. Archives of Orthopaedic and Trauma Surgery. 2021;141(11):1835–1843. doi:10.1007/s00402-020-03563-8

16. Haas C, Feinberg A, Koch GE, Patel HV. The Diagnosis and Management of Urosymphyseal Fistula with Pubic Osteomyelitis. Curr Urol Rep. 2025;26:62. doi:10.1007/s11934-025-01293-1