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UROGENITAL
TRAUMA
Male
sexual dysfunction after pelvic fracture
Metze M, Tiemann AH, Josten C
Universitätsklinikum Leipzig, Zentrum für Chirurgie, Klinik für
Unfall- und Wiederherstellungs- und plastische Chirurgie, Leipzig, Germany
J Trauma. 2007; 63: 394-401
- Background: The assessment of multiple aspects of male sexual function
after pelvic fracture.
- Methods: A cross-sectional retrospective study of male sexual function
was conducted. Patients admitted with traumatic pelvic fracture
between January
1995 and June 2001 were included. One hundred and two patients were invited
by mail. After performing a standardized clinical examination including
an interview, the patients were asked to answer a questionnaire
at home. Sexual
dysfunction was classified as erectile dysfunction (ED), ejaculatory
dysfunction, sensory loss in genital region, and pain during
sexual activity. ED was assessed
by the International Index of Erectile Function (IIEF). The pelvic injury
was classified using Tile’s classification.
- Results: Complete data of 77 men were available (age 35 +/- 13).
A total of 47 patients (61%) reported limitations in sexual
function. Persistent
ED was
found in 15 patients (19%). The patient’s report of ED could be verified
by a low IIEF score in 14 cases. Injury patterns, which may increase the incidence
of sexual dysfunction, could be identified. A ruptured symphysis appeared to
bear a risk of temporary ED. Comparing compression and distraction in type
B injuries, patients with distraction injury showed more severe sexual function.
Posterior ring disruptions seemed to increase the risk of persistent problems,
possibly caused by nerve damage.
- Conclusions: This study emphasizes that major pelvic trauma may
impair sexual function in men. The results demonstrate an objective
measurement
of ED by
the IIEF as well as an extended spectrum of complaints. The IIEF
questionnaire might be considered to identify patients that
need further medical
evaluation.
- Editorial Comment
Often times, years after the orthopedic complications of pelvic fracture have
long healed the urologic complications of urethral stricture and erectile
dysfunction continue to plague the patient. Impotence after pelvic fracture
appears to be is primarily vascular from either a pure arteriogenic or combined
arteriovenogenic cause. By the use of MRI and Doppler studies, Armenakas
et al. has shown that the corporeal veno-occlusive dysfunction and cavernous
arterial insufficiency after pelvic fracture are due to direct corporal cavernosal
fracture or avulsion, subsequent fibrosis which alters the elasticity of
the tunica albuginea and corporeal compliance, or to internal pudendal artery
injury. Only secondarily is impotence primarily neurogenic. Neurogenic impotence
is the result of prostatic plexus and/or neurovascular bundles nerve injury,
and from nervi erigentes (S2-S4) injury due to shearing forces of the pelvic
fracture that result in nerve stretching and tearing. Predictive signs of
potential erectile dysfunction as noted by MRI are avulsion of the corpus
cavernosum from the ischium, separation of the corporeal bodies, fracture
of the corporeal body, and superior or lateral displacement of the prostate
apex. Surgical correction for impotence (prosthetics, arterial reconstruction
and venous occlusion), however, should be deferred for at least 12 to 18
months from initial injury, because delayed return of erectile function can
occur spontaneously.
Dr. Steven B. Brandes
Associate Professor, Division of Urologic Surgery
Washington University in St. Louis
St. Louis, Missouri, USA
E-mail: brandess@wudosis.wustl.edu
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