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Pubo-urethral or Pubo-Prostatic Fistula

Normally, the bladder, prostate and upper urethra sit right behind the pubic bone. 

Bladder

Urethra

Back

Front

Rectum

Pubic

Bone

Prostate

Normal Anatomy

Rectum

The pubic bone is part of the pelvic bone. The center of the pubic bone is called the pubic symphysis and is pointed out by the arrow.

The muscles of the inner thigh insert into the pubic bone and help with squeezing the thighs together and with balance while walking. 

Thigh

Muscle

Bladder

Pelvis

Pubic Bone

A pubo-urethral fistula is an abnormal hole that connects the pubic bone and the urethra. When this happens it is almost always after the prostate has been removed for cancer. The fistula is usually located between the re-connection of the bladder and the urethra. 

These fistulas always start with a procedure/surgery that makes a hole in the urethra/prostate/bladder. The most common scenario is a man with a history of prostate radiation who has developed a scar tissue blocking the urethra/bladder/prostate. The man undergoes a procedure/surgery to open that scar tissue. This surgery may be a dilation (stretching) of the scar or a cutting of the scar tissue using a camera through the urethra. The opening that is made in the scar tissue allows the urine to leak through to the pubic bone. The previous radiation prevents this opening from healing.

Small Pubo-Urethral Fistula

Fistula from urethra to pubic bone

Prostate removed for prostate cancer. Urethra and bladder reconnected with stitches

Because the fistula can also connect from the pubic bone to the prostate or the bladder, it can also be known as a pubo-prostatic or pubo-vesical fistula.  

This allows urine to leak onto the pubic bone, leading to infection of the bone (known as osteomyelitis).

Fistula from prostate to pubic bone

Destruction of pubic bone from infection

Small Pubo-Prostatic Fistula

Antibiotics can make the pain better and keep the infection under reasonable control; but, antibiotics cannot cure the osteomyelitis (bone infection). The only cure for the infection is surgery to fix the fistula and stop the urine from leaking onto the bone. Without surgery this infection will progress until the bone becomes destroyed; the infection can even be fatal. 

The bone infection leads to groin pain that is worsened by walking and, especially, by squeezing the thighs together. This is because muscles used for walking or for squeezing the thighs together insert into the pubic bone. So these muscles become inflamed from the bone infection.

 

Some men have such pain with walking that they need to use a cane, walker or wheelchair. Others can develop and abscess in the inner thigh as the infection spreads. 

ap man with pelvis and adductor muscle_infected.png
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