Genitourinary Complications

Bladder rupture associated with pelvic fractures has a reported incidence as high as 20% (87-89). The majority of the time the bladder rupture will present with gross hematuria. Rupture of the bladder may be retroperitoneal (85%), intraperitoneal, or, infrequently, both (90). An intraperitoneal rupture commonly occurs at the dome of the bladder, when the patient has a full bladder, and is treated by primary repair. Retroperitoneal ruptures commonly occur on the anterolateral wall. Once identified by retrograde urethrogram or cystogram, primary repair is recommended to avoid the placement of a suprapubic catheter if anterior open reduction and internal fixation is carried out to treat the fractures.

Injury to the ureter has been reported only once in a pelvic fracture and rarely with isolated acetabular fractures (91). Once identified on CT, urologic consult and surgical repair is warranted.

Bladder entrapment during internal fixation of a pelvic or acetabular fracture has been reported only three times (92-94). The bladder entrapments were thought to be caused by either bony fragments penetrating the bladder during reduction and fixation or herniation of the filled bladder into the iliopubic fracture segment. Patients present with hematuria after fixation. The diagnosis is made using cystogram followed by CT. Surgical repair is required.

Female Genitourinary Complications

In the female population, traumatic injuries of the urethra are rare. This, at least in part, has been attributed to the relatively mobile and short course of the urethral channel behind the pubis. The incidence has varied from 1% to 6% (95,96). Because of the low incidence and rarity of blood at the meatus, this injury can be missed initially (96,97). If presenting with an associated bladder rupture and pelvic hematoma, the injury to the urethra may not be obvious. Once identified, the treatment remains controversial. The choices include immediate repair with realignment of the separated urethral ends indirectly over a catheter, with or without suprapubic catheter drainage, thus avoiding tissue dissection in the traumatized area, versus initial urinary diversion with delayed surgical reconstruction. As expected with injury to the female urethra, resulting incontinence is not uncommon and may necessitate additional surgery.

Vaginal lacerations may also accompany injury to the urethra. Vaginal lacerations occur in about 4% of pelvic fractures (98). Most present with bleeding, but at times with vaginal wall spasms bleeding may not be obvious, and if missed can lead to life-threatening sepsis. Detection, irrigation, debridement, and surgical repair of the injury are recommended (98).

With associated soft tissue injury accompanying pelvic and acetabular fractures, late genitourinary sequelae are common, but have been poorly documented in the literature. The largest study consisting of a retrospective review and questionnaire found that physiologic problems with arousal or orgasm were rare in females. However, female patients with pelvic fractures had a significantly higher rate of urinary complaints (21% vs. 7%), a significantly higher rate of gynecologic pain (19.6% vs. 9.5%), and a significant increase in the rate of postinjury cesarean section than the general female population (99).

Male Genitourinary Complications

Unlike female patients, males are more likely to have significant urologic injury related to pelvic and acetabular fractures, with incidences as high as 21%, the majority of these injuries to the urethra (as high as 16%). The urethra's longer length makes it more likely to be injured. Most commonly the injury occurs as an avulsion of the membranous urethra from the bulbar urethra rather than a shearing through the membranous urethra. Some degree of urethral sphincter function is preserved in a significant percentage of patients (100). With partial preservation of the urethral sphincter, incontinence is not a frequent sequelae in males with a urethral injury. Although an abundance of literature is available evaluating treatment options, the choice remains controversial. Recent studies favor early primary repair or endoscopic realignment to avoid suprapu-bic drainage if anterior open reduction and internal fixation is necessary for the treatment of the fractures. However, others still favor suprapubic drainage and delayed repair. The sexual and physiologic functions of the genitourinary system seem unchanged regardless of the urologic treatment.

Most of the injuries to the genitourinary system occur with anterior pelvic fractures and occasionally acetabular fractures. However, posterior ring fractures, which damage the lower sacral nerves, can result in sexual dysfunction, and should be discussed with the patient early if suspected. Recent work using the Brief Male Sexual Function Inventory (BMSFI) found that pelvic fractures of all types had a significantly profound negative effect on the sexual function of male patients, persisting for at least two years and possibly longer (101). Erectile dysfunction after blunt trauma and pelvic fracture has been documented to be between 20% and 80% (102).

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