Sexual Functioning

Pelvic fractures have also been shown to affect genitourinary and sexual functioning in both males and females. These effects have been found to be both physiological and psychological in nature. All studies have reported that pelvic fractures create a risk for genitourinary and sexual dysfunction, and that multifactorial, genitourinary, and sexual dysfunction have been shown to have a profound impact on a person's life.

In males, sexual function following pelvic fracture has been studied in relation to sexual drive and erectile function. Sexual drive focuses on overall satisfaction with sexual life as well as whether the man finds his sexual functioning personally problematic. Erectile function includes the quality, or firmness, of an erection, and the ability to attain an erection, maintain an erection, and ejaculate.

Several studies have focused on erectile function following a pelvic fracture. A detailed description of all of these investigations is beyond the scope of this chapter; however, a review article summarizing articles concerning erectile dysfunction after pelvic fracture estimated postinjury male sexual dysfunction to be as high as 30% (25). This percentage was even higher in males who incurred a concomitant urethral injury. Harwood et al. (25) state that studies as a whole have indicated that for these males the incidence of erectile dysfunction (ED) following pelvic injury was 42%.

Harwood et al. (25) describe the pathogenesis of ED as a combination of neurogenic, vascular, corporal, and psychogenic injury. Thus, ED is a complex condition that likely involves multiple systems. What remains to be determined is whether these injuries contributing to ED result from the initial insult, treatment, or both. Fracture management, pelvic arteriography and embolization, and timing of urological interventions have all been indicated as having the potential to prevent or create further physical injury that may result in ED. Additionally, the patient's psychological experience of invasive procedures and prolonged hospitalization may mitigate or exacerbate psychological responses. It is remarkable that sexual dysfunction in persons with PTSD has been reported as high as 80%. Given the high percentage of persons reporting PTSD following trauma, this prevalence underscores the need for providers to address the patients' psychological needs.

While most studies of ED have used physiological evaluations, such as electro-myography (EMG), pharmacologic testing, and penile angiography, a notable exception is a study that evaluated male sexual function after bilateral internal iliac artery emboli-zation (BIIAE) for pelvic fracture (26). Ramirez et al. (26) conducted a telephone survey using a questionnaire consisting of 24 items that assessed medical history, urinary function, and male sexual function. Three groups were surveyed: those who had a pelvic fracture and received BIIAE (group 1), those who had a pelvic fracture and did not receive BIIAE (group 2), and a healthy control group (group 3). There were 16 subjects in each group. Items assessing male sexual function included subjective rankings of sexual drive, erection firmness, ejaculatory function, and overall sex life. Additionally, subjects were queried regarding how personally problematic they found their sex life.

No differences for any of these items were found between the fracture groups. However, both group 1 and group 2 reported significantly lower scores for erectile function, sexual drive, and overall satisfaction with sexual life than the health control group. Furthermore, sexual function was perceived as personally more problematic in a higher proportion of both fracture groups than it was by the healthy controls. Subjects in the fracture groups also gave lower scores for ejaculatory function. Overall, the incidence of ED in the fractures groups was 19% while no healthy controls reported ED. While the intent of the article was to demonstrate the safety of BIIAE, the study provided a unique window into male's perception of sexual functioning. These results indicate that pelvic fracture has a negative impact on physical and psychological aspects of male sexuality.

Ramirez et al. (26) also assessed urinary function. Items on the questionnaire queried participants regarding difficulty voiding and urinary continence. No differences for either of these items were found among the groups. However, studies have indicated that a significant number of men do experience urinary problems following pelvic fracture. Men who have suffered damage to the urethra are especially vulnerable (27,28).

Sexual and genitourinary functions following pelvic injury has not been as extensively studied in females as it has in males. However, studies suggest that pelvic injury does affect female sexuality and genitourinary function. A study of 223 women with pelvis fractures only (n = 84), a pelvis fracture and lower extremity fracture (n = 39), and a lower extremity fracture only (n = 110) indicated that pelvic fracture is significantly associated with negative changes in sexual functioning (29). In telephone surveys conducted by trained female interviewers, the patients were administered the SF-36, supplemented with questions concerning sexual functioning. Overall, women in all groups reported some effect of the injury on their sexuality. Forty-five percent reported feeling less attractive, 19% reported less frequent sexual activity, 39% experienced less sexual pleasure, and 24% reported dyspareunia and hip and lower back pain during intercourse. Women with a pelvic fracture, however, suffered more negative changes, which although not statistically significant, were likely clinically significant to them. Furthermore, severity of the pelvic injury was found to be significantly associated with dyspareunia, feeling less attractive, and experiencing less sexual pleasure. Interestingly, associated injuries, including facial, genitourinary, and abdominal injuries, were not associated with sexual function.

Another study examining the effect of trauma and pelvic fracture on female genitourinary, sexual, and reproductive function produced similar findings (30). This study also compared women with pelvic fractures (group 1, N = 123) to those with a lower extremity fracture (group 2, N = 110), and was composed of the same subjects in the study cited above. An outcomes questionnaire covering the following domains was administered over the telephone by professional female interviewers: demographics, urinary and gastrointestinal symptoms, reproduction, and sexual function.

With respect to sexual function, a small percentage reported problems with physiologic arousal. Seven percent of women in the pelvic fracture group and 12% of women in the lower extremity group indicated that they had problems reaching orgasm. In addition, only a small percentage of women indicated a higher threshold to orgasm (5% in group 1 vs. 7% in group 2), decreased intensity of orgasm (3% in group 1 vs. 4% in group 2), and decreased ability to lubricate (3% in group 1 vs. 6% in group 2). However, a larger percentage of women in both groups reported new onset of pain during sex following their injury (group 1, 31% and group 2, 24%). Coital musculoske-letal pain was similar between the groups, but gynecological pain during intercourse was significantly more in group 1 (19%) than group 2 (9.5%) (p = 0.045). For subjects in group 1, fracture displacement contributed to reports of musculoskeletal and gynecologic pain during intercourse. Significantly more subjects with fractures displaced >5 mm at follow-up reported musculoskeletal and gynecologic pain during intercourse than those with fractures displaced <5 mm (43% and 25%, respectively, p = 0.04). It is notable that the majority of women in group 1 (76%) and group 2 (87%) reported that they received no instructions or information from their health care providers regarding the resumption of sexual activity.

The study also revealed that subjects in group 1 were significantly more likely to have urinary complaints than those in group 2 (21% vs. 7%, p = 0.003), and the majority had more than one complaint. Among the urinary complaints were cystitis, nocturia, stress incontinence, frequency, incontinence, and retention. The most frequent complaints indicated by group 1 were stress incontinence (13%) and frequency of urination (13%), both of which were significantly higher than group 2 (p = 0.007 and p = 0.02, respectively). There was also a significantly higher incidence of nocturia in group 1 than in group 2 (p = 0.04). Urinary complaints, similar to sexual dysfunction, were also significantly associated with fracture displacement. Group 1 subjects with initial and residual fracture displacement > 5 mm were significantly more likely to report urinary tract complaints than subjects with fracture displacement < 5mm (p = 0.02 and p = 0.018, respectively).

Findings concerning the impact of trauma and pelvic fracture on reproduction were inconclusive. No significant differences were found between the groups for miscarriage rates, and 6% of both groups reported infertility after the injury. A significant difference was found in the number of Cesarean sections performed for group 1 subjects before and after the injury (p < 0.001). However, it is not clear whether this was due to the pelvic fracture or other factors concerning parturition such as a prior Cesarean section. It is probable that reproductive function is of concern to young women who have experienced a pelvic injury and further research needs to be conducted to understand if and how pelvic fracture affects reproduction.

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