UROGENITAL TRAUMA

Specific Fracture Configurations Predict Sexual and Excretory Dysfunction in Men and Women 1 Year after Pelvic Fracture
Wright JL, Nathens AB, Rivara FP, MacKenzie EJ, Wessells H.
Department of Urology, Surgery, Pediatrics and Epidemiology, University of Washington School of Medicine, Harborview Medical Center and Harborview Injury Prevention Research Center, Seattle, Washington, USA
J Urol. 2006; 176: 1540-5

• Purpose: We determined the prevalence and predictors of sexual and excretory dysfunction in patients 1 year after pelvic fracture.
• Materials and Methods: The multicenter Pennsylvania Trauma Outcomes Study enrolled 1,238 patients and contacted them 1 year after injury. Sexual limitations and excretory dysfunction (bladder/bowel incontinence) were defined based on responses from the Functional Capacity Index. Health related quality of life was determined using SF-36. The relationship between specific fracture patterns and dysfunction along with the effect of dysfunction on quality of life in patients with pelvic fracture were evaluated by multivariate analysis.
• Results: Of 1,160 eligible patients 292 (26%) had pelvic fractures. Sexual dysfunction was reported in 21% vs 14% of those with vs without pelvic fractures and bowel or bladder incontinence was reported in 8% vs 4%. On multivariate analysis men with sacroiliac fractures were at higher risk for sexual (RR 4.0, 95% CI 2.3 to 6.8) and excretory (RR 4.3, 95% CI 1.4 to 13.5) dysfunction. In women symphyseal diastasis was associated with sexual (RR 4.8, 95% CI 2.0 to 11.2) and excretory (RR 12.5, 95% CI 1.9 to 80.2) dysfunction. Of patients with pelvic fractures men with sexual dysfunction and women with excretory dysfunction had significantly worse quality of life than those without dysfunction.
• Conclusions: One year after trauma men with sacroiliac fractures and women with symphyseal diastasis were at increased risk for sexual and excretory dysfunction independent of overt pelvic organ injury. In patients with pelvic fracture male sexual dysfunction and female excretory dysfunction were associated with decreased quality of life. Our data highlight the need for further study of dysfunction following pelvic trauma and interventions to decrease the risk of long-term disability.
  
  
• Editorial Comment
  Erectile dysfunction after pelvic fracture is interplay of injury to the penile arterial inflow, venous outflow or nerve innervation. Clearly injuries to the pubic rami that result in bony distraction, may also displace and injury the crus of the penis. Such patients may suffer from venous leak or arterial insufficiency, or both. The arterial and nervous supply to the penis is partially protected by the fascial walls of Alcock’s canal, but is vulnerable to injury if the adjacent ischial bone is fractured. Erectile dysfunction (ED) after pelvic fracture has typically been associated with concomitant urethral disruption injury. Historically, with urethral injury ED rates are up to 75%. Surprisingly, Wright et al. determined that SI fractures have the highest rates of ED. Intuitively, one would assume pubic rami and open book fractures to have high rates of male ED. Clearly, quality of life as to urinary excretory control and erectile dysfunction after pelvic fractures are issues that the urologist should be familiar with. For it is the urologic consequences of pelvic fracture that are often prolonged, morbid and difficult to manage, long after the orthopedic injuries have healed.

Dr. Steven B. Brandes
Associate Professor, Division of Urologic Surgery
Washington University in St. Louis
St. Louis, Missouri, USA