Diagnostic and Management Hurdles in Pelvic Osteomyelitis

Pelvic osteomyelitis (PO) is a rare, debilitating bone infection. It often arises insidiously, posing diagnostic and therapeutic challenges. We present a 74-year-old male patient with a history of diabetes mellitus, hypertension, and prostate cancer post-radiation therapy (RT), who presented with dysuria, groin swelling, and inner thigh pain. Imaging revealed a pubovesical fistula, small retropubic abscesses, and findings consistent with PO. Prior cultures showed extended-spectrum beta-lactamase (ESBL) <i>Klebsiella pneumoniae</i> and <i>Candida glabrata</i>. Despite the patient's refusal of urinary diversion, a six-week course of ertapenem and caspofungin resulted in clinical improvement and negative repeat cultures. This case highlights the importance of considering PO in patients with risk factors, the critical role of advanced imaging in diagnosis, and the multidisciplinary approach necessary for effective management. While conservative antibiotic therapy succeeded here, surgical intervention is often required for long-term resolution.