By Sheila M. Algan, MD
Incidences occur in women as well as men
Among the studies that report on sexual dysfunction after pelvic fracture, many address problems specific only to male patients, particularly impotence. Although sexual dysfunction after pelvic fracture also occurs in female patients, many of the research tools used to assess outcomes do not address their symptoms. In addition, women may not feel comfortable reporting symptoms related to sexual function. As a result, prevalence of the problem in women may be under-reported.
Orthopaedic surgeons commonly counsel patients about having sexual activity following total hip arthroplasty, but may not realize that a similar discussion may be helpful for pelvic fracture patients. Traumatic injury involving fracture is known to be disruptive to participation in activities of daily living, and pelvic fracture, in particular, results in a higher incidence of sexual dysfunction for both men and women.
Sexual dysfunction can be due to urethral, vascular, neurologic, and psychogenic injuries. In men, disruption of the posterior urethra in association with pelvic fracture has been shown to result in impotence, with incidence rates as high as 50 percent. In women, urethral disruption associated with pelvic fracture is less common, but the incidence of vaginal injury is high in pelvic fracture associated with urethral injury and should raise concern for subsequent sexual dysfunction.
From the literature
A study of 25 female patients with urethral and bladder neck injury associated with pelvic fracture found a 38 percent incidence of sexual dysfunction, and 43 percent of patients reported moderate or severe urinary tract symptoms at average follow-up of 7.3 years.
The Denis classification is commonly used with fractures of the sacrum; those fractures that involve the spinal canal (zone 3) have a high association with sexual dysfunction due to neurologic injury. A 2006 study found that 38 percent of patients who were treated surgically for unstable sacral fractures reported sexual impairment at 1 year. Men were more commonly affected than women (46 percent versus 14 percent) and the development of complete saddle anesthesia was associated with 100 percent impairment.
A study of sexual and excretory dysfunction in 1,160 patients (men and women) who had sustained blunt pelvic trauma found that 21 percent of patients with pelvic fracture reported sexual dysfunction, compared to 14 percent of those without pelvic fracture. In men, sacroiliac fractures were associated with sexual and excretory dysfunction. In women, symphyseal diastasis was associated with sexual and excretory dysfunction.
In a study of pelvic floor dysfunction after pelvic fracture specifically in women, 16 of the 24 patients reported some symptoms of pelvic floor dysfunction (urinary, bowel, or sexual); most reported more than one symptom. Of the 17 women who were sexually active 1 year after the injury, seven reported sexual dysfunction. None of the patients had sustained a direct injury to the bladder, vagina, or rectum.
A study on the impact of trauma and pelvic fracture on female genitourinary, sexual, and reproductive functions found no difference in miscarriage rates between multi-trauma patients with pelvic fracture and those without pelvic fracture. A statistically significant increase in the rate of Cesarean sections was noted among patients after injury compared to controls, particularly among those who had initial fracture displacement greater than or equal to 5mm. Dyspareunia also occurred more frequently in patients with displaced fractures compared to those with nondisplaced fractures.
Trauma and sexual functioning
Lisa K. Cannada, MD, used questions specific to female sexual function to survey women of childbearing age who had a pelvic fracture. Of the 71 patients surveyed, 49 percent reported genitourinary complaints and 38 percent noted pain with intercourse. In addition, 45 percent answered affirmatively to decreased interest in intercourse and decreased orgasm frequency after the injury. Of the 26 patients who delivered children after their pelvic fracture, 10 (38 percent) had a vaginal delivery. Four of the 10 women who delivered vaginally had undergone surgical fixation (symphyseal sparing).
Major trauma of any kind has a high association of sexual dysfunction. Results from the National Study on Costs and Outcomes of Trauma indicate that 30.5 percent of the respondents reported some degree of sexual dysfunction at 1 year post-injury, with the majority reporting severe dysfunction. Independent predictors specifically related to the trauma included increasing injury severity score, pelvic fracture, lower extremity fracture, and spinal cord injury. In this patient cohort, the risk of sexual dysfunction was equal in both women and men.
Sexual dysfunction is a common complication of pelvic fracture and lower extremity fracture. Men and women are affected differently by various injury patterns, with anterior pelvic ring injuries posing a greater risk for sexual dysfunction in women.
Treating orthopaedic surgeons should educate patients on appropriate timing to return to sexual activity. Once released to full activity, both men and women should be followed to ensure full recovery of sexual as well as musculoskeletal function. Female trauma patients should be asked about sexual function to ensure their return to the fullest function possible.
Sexual dysfunction in women sustaining severe trauma may be under-reported due to the outcome measures currently used. The Female Sexual Function Index is a detailed questionnaire that can be self administered or administered with the assistance of a nurse, with referral to a specialist as needed. The index is available at http://www.fsfiquestionnaire.com
References for the studies cited in this article can be found in the online version, available at www.aaosnow.org
Sheila M. Algan, MD, is a clinical assistant professor in the department of orthopaedic surgery and rehabilitation at the University of Oklahoma College of Medicine, and is a member of the AAOS Women’s Health Issues Advisory Board. Laura L. Tosi, MD, and Elizabeth A. Arendt, MD, provided editorial review.
Putting sex in your orthopaedic practice
This quarterly column from the AAOS Women’s Health Issues Advisory Board and the Ruth Jackson Orthopaedic Society provides important information for your practice about issues related to sex (determined by our chromosomes) and gender (how we present ourselves as male or female, which can be influenced by environment, families and peers, and social institutions). It is our mission to promote the philosophy that male and female patients experience and react to musculoskeletal conditions differently; when it comes to patient care, surgeons should not have a one-size-fits-all mentality.
- Black PC, Miller, EA, Porter, JR, Wessells H: Urethral and bladder neck injury associated with pelvic fracture in 25 female patients. J Urology 2006; 175:2140–2145.
- Denis F, Davis S, Comfort T: Sacral fractures: An important problem. Retrospective analysis of 236 cases. Clin Orthop Rel Res 1988;227:67–81.
- Totterman A, Glott, T, Madsen JE: Unstable sacral fractures: Associated injuries and morbidity at 1 year. Spine 2006;31(18):628–635.
- Wright JL, Nathens, AB, Rivara FP, MacKenzie EJ, Wessells H: Specific fracture configurations predict sexual and excretory dysfunction in men and women 1 year after pelvic fracture. J Urology 2006;176:1540–1545.
- Baessler K, Bircher MD, Stanton SL: Pelvic floor dysfunction in women after pelvic trauma. Br J Obstet Gynaecol 2004;111:499–502.
- Copeland CE, Bosse MJ, McCarthy ML, MacKenzie EJ, Guzinski GM, Hash CS, Burgess AR: Effect of trauma and pelvic fracture on female genitourinary, sexual, and reproductive function. J Orthop Trauma 1997;11(2):73–81.
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