We present a rare case of perineal recurrence of prostate cancer post low dose rate brachytherapy. Increased levels of prostate-specific antigen were recorded 12 years post brachytherapy. Pelvic CT and MRI visualized a nodular lesion in the perineum, and positron emission tomography demonstrated choline-avidity. Ultrasound-guided biopsy of the nodule was performed, yielding histology consistent with prostatic adenocarcinoma. Metastatic prostatic seeding to the perineum is a rare complication of brachytherapy. We discuss the putative mechanism, approach to diagnosis, and management.