2.1 Incidence of associated genitourinary trauma

Genitourinary injury can have significant short- and long-term effects on morbidity. Genitourinary injury in association with pelvic fracture has not been found to be an independent predictor of mortality; however, patients who sustain a pelvic fracture with genitourinary injury have more concomitant injuries, resulting in an increased overall mortality rate [5–7]. Early recognition of trauma to the female genitourinary tract is imperative; sepsis and necrotizing fasciitis occur primarily after unrecognized injuries [8, 9]. Late sequelae include incontinence, dyspareunia, dysmenorrhea and menstrual irregularities, labial swelling during voiding, fistulae, vaginal or urethral stricture, amenorrhea and infertility [5, 9–16].

The incidence of injuries to the female genitourinary tract associated with pelvic fracture is reported between 0.7% and 14.5% [2, 5–7, 12, 17]. Bladder injuries occur in 2–6% of women with pelvic fractures [3, 7, 18]. Injury to the lower urinary tract is known to occur with other intraabdominal injuries and with injuries to the female reproductive system [3, 7]. Urethral injuries in women, once thought to be extremely rare are now recognized in up to 6% of women with pelvic fractures [7, 9, 19]. Most urethral injuries (75–100%) are found in combination with vaginal injuries [7, 8, 11, 13, 20–23]. Vaginal lacerations occur in up to 7% of women with pelvic fractures [3, 5–8].

Recognizing these injuries depends on obtaining a thorough history and physical examination. Pain on attempting to void, abdominal distention in an alert patient, blood at the vaginal introitus, labial swelling, and inability to void, should trigger further investigation. However, their absence does not rule out lower genitourinary injury [7, 9, 18]. Inability to insert a urinary catheter, or persistent reports about needing to void also should raise suspicion for urethral injury [23].

Gross hematuria is present in 7–38% of patients with pelvic fractures. Of those with gross hematuria and pelvic fracture, 45–54% also have a ruptured bladder [18, 24, 25]. The positive predictive value of gross hematuria for bladder rupture is low, but the negative predictive value approaches 100% [17, 25, 26]. A visible perineal hematoma has a positive predictive value of only 16% but a negative predictive value of 98.6% [17, 26]. Pubic arch fractures are found in 80% of patients with pelvic fractures and bladder rupture (both sexes) [25].

Retrograde urethrography, important in men, is difficult to perform in women [23]. Computed tomography (CT) cystography has largely replaced cystography as the diagnostic study of choice for lower urinary tract injuries in women. Accuracy of CT cystography approaches 100% sensitivity and specificity in diagnosing bladder rupture [18, 27]. The study is easily obtained; however, timing may vary based on patient stability.

Patients with known bladder neck or urethral injuries require careful examination for vaginal injury. Conversely, vaginal laceration in the presence of pelvic fracture should also trigger a search for urethral or bladder neck injury if hematuria, vulvar swelling, or inability to void are present [9, 16].

Urethral lacerations are often missed, with potentially disastrous consequences [11]. Perry and Husmann [9] reported on six patients with urethral injuries and pelvic fractures. Blood at the vaginal introitus was present in 80% of their patients; however, only half received a vaginal inspection on presentation. The three patients who did not undergo careful vaginal inspection at presentation had urethral injuries that were missed initially. In two of these three patients, life-threatening sepsis developed secondary to necrotizing fasciitis. Missed injuries also can be associated with late development of urethrovaginal fistulae and incontinence [11]. Heterotopic ossification, scarring, and strictures also may follow untreated vaginal lacerations [28].

Surgeons should ensure that a vaginal examination is performed during the acute treatment phase of the pelvic fracture. Because abduction of the lower extremities causes severe pain in the fractured pelvis, adequate speculum examination is best performed under anesthesia. To minimize the risk of fracture displacement or exacerbation of hemorrhage, vaginal examination in the hemodynamically unstable patient may be deferred until provisional stabilization is obtained with external fixation, application of a pelvic binder, or other methods.

Although severe gynecological injury is uncommon, the literature describes case reports of injuries to the uterus, ovaries, and fallopian tubes in association with pelvic fracture [12, 29, 30]. Ovarian injury may occur in up to 2% of pelvic fractures [6] and in up to 11% of pelvic fractures associated with large retroperitoneal hematoma [31]. The incidence of infertility after blunt ovarian injury has not been reported.

2.2 Treatment

The principles of open fracture management used for extremity fractures also apply to the pelvis. Open fractures, whether through the vagina or the perineum, should be debrided meticulously. Open vaginal wound debridement may be performed through either the vaginal wound with assistance from a gynecologist if needed or through a Pfannenstiel approach. The determining factors are related to the surgeon′s comfort in achieving adequate visualization of the wound, bone fragments, and fracture. Early stabilization should be followed by frequent reexamination and repeated debridement of the wounds as necessary. After excision, debridement, and irrigation, vaginal wounds may be packed open or closed primarily over a drain. In patients with lateral compression injuries, anterior distraction external fixation can be used to protect a vaginal or bladder laceration by preventing recurrent pubic ramus fracture displacement (see Chapter 1.7).

A team approach is helpful in determining timing and method of repair of the pelvic fracture with associated genitourinary injuries. Most extraperitoneal bladder ruptures are treated with urinary catheter drainage and will heal. Intraperitoneal bladder ruptures require open repair ( Fig 1.12-1 ). Simultaneous repair of pelvic fractures and associated urological injuries has resulted in a low infection rate [32, 33]. Of five women treated with anterior internal fixation (five bladder injuries, one vaginal laceration, and one associated urethral injury) in a study by Routt [33], there was one fixation failure, thought to be due to spasticity from cerebral injury. One patient later required bladder suspension for urinary incontinence [33].

External fixation results in less precise reduction and stability than open reduction. Open reduction of the anterior pelvic ring may prevent problems such as herniation of the bladder through a symphyseal disruption, or scarring of the bladder to the anterior abdominal wall that may occur with external fixation (see Chapters 1.8.4 and 1.8.6) [34–36]. Simultaneous internal fixation with genitourinary repair appears to be safe; however, timing remains somewhat controversial.

2.3 Genitourinary outcomes

Copeland et al [3] performed a retrospective review of 255 female trauma patients, comparing women who sustained pelvic fractures (subjects, N = 123) with those who sustained upper or lower extremity fractures (controls, N = 118). Urinary complaints occurred significantly more often in patients with pelvic fractures than in controls (21% versus 7%; P = .003). Most women reported more than one problem. In particular, nocturia (P = .04), stress incontinence (P = .007), and urinary frequency (P = .02) were reported significantly more often in the subjects than in controls. Only one of the 26 subjects with urinary tract complaints sustained acute trauma to the genitourinary tract (ie, a vaginal laceration requiring repair); she reported urinary frequency and recurrent urinary tract infections. Patients with moderate and severe pelvic fractures (Tile types B and C) were significantly more likely to have urinary complaints (36% and 14%, respectively; P = .037) than patients with minor fractures (Tile type A) [3]. Patients with externally rotated fractures (anteroposterior compression [APC] or AO/OTA type B1, B3), vertically displaced (vertical shear [VS] or AO/OTA type C), or with combined APC and VS injuries were much more likely to have late urinary tract complaints than patients with internally rotated displaced fractures (LC) or AO/OTA type B2, (60%, 67%, and 21%, respectively, P = .04).

Other authors have investigated this population, reporting frequent new-onset urinary tract complaints despite a low incidence of frank urinary tract injuries. Baessler et al [4] reported bladder complaints in 50% of women with Tile types B (Young-Burgess LC II–III) and C (Young-Burgess APC, VS, combined) injuries. They reported on a consecutive cohort using a newly developed questionnaire that included a comparison of symptoms before and after the accident. The response rate was 80%. Of 24 women, four were treated with external fixation and 14 with internal fixation. Lacerations to the bladder (one), vagina (one), urethra and vagina (one), and perineum were treated at the time of fixation. Pelvic floor dysfunction occurred in 67% of these patients. In addition to bladder complaints, bowel problems (eg, urgency or incontinence) occurred in 45% of the patients. Only one third of symptomatic patients sought medical help.

Wright et al [37] reported on a large multicenter series of prospectively collected trauma patients. Patients with overt urinary tract injuries were excluded, allowing comparison of outcomes in patients with and without pelvic fractures 1 year after injury. Women with symphyseal disruption had a twelvefold increased risk of bowel dysfunction compared with women without pelvic fractures. These data should be interpreted with caution, however, because the diagnostic codes used to track the patients are not all anatomically specific, nor mutually exclusive. No radiographic investigation was performed, and no information regarding the type of fracture treatment is available. Despite these issues, bowel dysfunction correlated with worse scores on the Short Form 36, underscoring the important effect of these issues on patient outcome and quality of life [37].

Symphyseal disruption and lateral or vertical displacement of the hemipelvis appear to correlate with urinary dysfunction [3, 37]. Injury to the pudendal nerve and the pelvic floor is known to contribute to incontinence [38, 39]. Tearing of the pelvic floor musculature under tension is also believed to contribute to the urinary tract complaints in APC injuries (external rotation Tile type B1) and VS injuries (completely unstable Tile type C) ( Fig 1.12-2 ). In contrast, the pelvic floor becomes redundant and is less likely to tear in lateral compression injuries. Direct lumbosacral plexus injury can occur; of eight women with unstable sacral fractures requiring surgical intervention, three reported bladder dysfunction and one reported bowel dysfunction [40]. Results of urodynamic studies were abnormal in 75% of patients tested, even in asymptomatic patients. The authors recommended careful examination and early urodynamic investigation after a displaced sacral fracture, as delayed bladder emptying can lead to distention and infection [40].

Bladder suspension may be indicated for some patients with incontinence after pelvic injury [4, 33, 35], whereas others may respond to anticholinergic agents [4]. Pelvic floor (Kegel) exercises have been shown to reduce stress incontinence [41–43] and protect against perineal tears during childbirth [44]. Based on these data, many clinicians now include instruction in pelvic floor exercises as a component of physiotherapy for women at risk for adverse urinary outcomes (displaced APC or VS injuries) after pelvic fracture [4]. In addition to isometric exercises, progressively increased weighted vaginal cones may be used for muscular training. Many women are reluctant to complain about issues such as incontinence [3, 4], or they may be unaware of a disturbance in bladder function [40]; therefore, the surgeon should ask about urological symptoms because early referral to a urologist may mitigate these issues.

2.4 Sexual function

Sexual dysfunction warrants discussion as it negatively affects quality of life, social reintegration, and functional outcome [4, 37, 40, 45–47]. Sexual function can be affected generally by trauma injury and specifically by pelvic fracture. Miranda et al [48] reported that only 60 (75%; both genders) of 80 patients returned to their preinjury level of sexual function after pelvic fracture. McCarthy et al [2] reported a negative impact on sexual function after pelvic fracture, specifically with respect to body image and frequency of and pleasure derived from sexual activity. Kabak et al [46] reported moderate to major depression in patients with sexual dysfunction after completely unstable pelvic fractures (Tile type C or Young-Burgess APC II, VS; both genders). Wright et al [37] reported that women with symphyseal disruption were more likely to report limited physical ability to have sexual relations, which also correlated negatively with Short Form 36 outcomes.

Sexual problems may be related to the severity of fracture [2]. Tornetta and Matta [49] reported unspecified sexual problems in six (13%; both genders) of 46 patients with unstable posterior pelvic ring injuries (Tile type C or B Young-Burgess APC III, VS). Rotationally unstable injuries (Tile type B) treated at the same center were not associated with sexual problems [50]. Cole et al [51] reported sexual difficulties in 15 (29%; both genders) of 64 patients with unstable posterior pelvic ring injuries (Tile type C). Pohlemann et al [52] found no instances of sexual problems in women with stable (Tile type A) or rotationally unstable (Tile type B or Young-Burgess APC I–III or LC I–III) injuries; sexual problems were reported in only one of eleven women with completely unstable injuries (Tile type C or Young-Burgess APC III, VS).

Specific problems with sexual function are more difficult to identify, perhaps in part because of how patients are questioned and because patients are reluctant to share information [3, 4, 46, 53, 54]. Physiological components of normal sexual function in women include arousal (eg, lubrication or lengthening of the vagina) and orgasm. Copeland et al [3] reported that physiological problems with sexual function were uncommon (3–6%). No significant differences between subjects and controls were found with respect to arousal and orgasm.

Vallier et al [47] reported that women with pelvic fractures were less interested in sex and had relations less frequently. Cannada and Barr [53] reported that 45% of their female patients were less interested in sex and less able to achieve orgasm after pelvic fracture; however, their response rate was only 13%, making interpretation difficult. Anorgasmia as a specific complaint rarely has been reported. Bellabarba et al [55] reported anorgasmia in two of four women with displaced vertical Denis type III sacral fractures.

2.5 Dyspareunia

Dyspareunia is defined as pain in the labia, vagina, or pelvic area during or immediately after sexual intercourse. In the general population, 61% of individuals experience dyspareunia at some point in their lives; a total of 23.8% have dyspareunia almost constantly. A total of 41% sought medical advice about the problem, whereas only 39% had been asked about the issue by a health care practitioner [56].

Dyspareunia after pelvic fracture has been frequently described [2, 3, 5, 6, 51, 57]. Reported incidence ranges from 14% to 63% [4, 46, 47, 53, 54]. Bony spicules from, or displacement of, the pubis can cause dyspareunia [5, 6, 52]. Vaginal stricture also may contribute to dyspareunia [5]. Fallat et al [57] reported dyspareunia in two of five women with pelvic fractures associated with reproductive tract injuries. Both had open fractures with vaginal lacerations. Cole et al [51] reported dyspareunia in 4 (19%) of 28 women treated operatively for unstable posterior pelvic ring injuries. Two of the four patients underwent an open anterior approach to the pelvis. Pohlemann et al [52] reported dyspareunia in one of eleven women with completely unstable injuries (Tile type C or Young-Burgess APC III, VS). This patient had residual posterior displacement of the symphysis after treatment with external fixation.

Copeland et al [3] reported that subjects (ie, patients with pelvic fractures) reported dyspareunia specified as pain in the reproductive tract significantly more often than controls (ie, general trauma patients) (19% and 9.5% respectively; P = .045). Of the subjects with residual displacement of more than 5 mm, 43% reported discomfort during intercourse, which was significantly more than subjects with nondisplaced pelvic fractures (25%; P = .04). Thirteen of the 123 subjects had severe residual anterior pathology (eg, displaced ramus fractures, overriding rami, exuberant callus, or heterotopic ossification) but did not have an increased risk of dyspareunia. Fracture type and severity did not correlate with dyspareunia in this series ( Fig 1.12-3 ).

In a prospective investigation, Vallier et al [47] found that women with pelvic fractures were more likely than trauma patients without pelvic fractures to report dyspareunia (56% versus 37%; P<.05). Rotationally unstable (Tile type B or Young-Burgess APC I–II, LC I–II) and completely unstable (Tile type C or Young-Burgess APC III, VS) fractures correlated with dyspareunia (78% and 43% respectively). AO/OTA type B1, B3.1, C or Young-Burgess APC injuries (rotationally or completely unstable) were associated with the highest incidence of dyspareunia (91%). All five patients with bladder rupture reported dyspareunia. Residual symphyseal displacement of more than 5 mm also correlated with dyspareunia. In the subgroup of 28 patients with symphyseal disruption, 19 (79%) of 24 patients treated with plating had dyspareunia, whereas those treated without plating did not report dyspareunia (P = .005) [47]. Other authors have not found the same correlation with symphyseal plating and dyspareunia, although numbers remain small [58, 59]. It could be concluded that dyspareunia is associated with pelvic ring injuries but that the etiology is uncertain, and operative care of the pelvic injury does not influence its incidence.

2.6 Fertility

Infertility—defined as the inability to conceive after 1 year of unprotected intercourse—is uncommon after pelvic fracture, and its incidence has been reported to be similar in both subjects and controls (6% in both) [3]. Massive trauma to the genitourinary tract in association with pelvic fracture can result in infertility. Donner et al [12] reported a case of primary amenorrhea related to pelvic fracture. A 12-year-old girl who was crushed under a boat-style swing sustained an APC injury (AO/OTA type B3.1) with bilateral sacroiliac joint and rami fractures. Traumatic separation and scarring between the uterine corpus and cervix resulted in primary amenorrhea, requiring reconstruction at age 18 years. At age 32 years, the patient presented with primary infertility from scarring at this region and the adnexae; she was treated successfully with in vitro fertilization and cesarean delivery.

2.7 Delivery after pelvic fracture

Dystocia due to pelvic deformity has been reported [6, 60–63]. The earliest report appears to be by Malaigne [64], describing a woman kicked by a horse. The patient sustained anterior and posterior vertical fractures, healing with displacement and narrowing of the transverse diameter of the pelvic outlet. Two years later, she died after a complicated delivery requiring forceps extraction that resulted in an ischial fracture [64]. Many authors have stressed the importance of restoring the anatomy of the pelvis in women of childbearing age [61, 62]. Vaginal delivery is possible even after displaced pelvic ring disruption [1, 61–63, 65]. The numbers are small, and the true incidence and risk factors for cephalopelvic disproportion remain unknown. ( Fig 1.12-4 ).

Speer and Peltier [63] summarized 20 reported cases of women who became pregnant after pelvic fractures; they also reported on five patients of their own. Fetal death occurred in 10%. Vaginal delivery was successful in 53.5%, and cesarean delivery was necessary in 36.5%. Zhou [6] reported that of 75 women who sustained displaced fracture dislocations of the pelvis, 45 (60%) experienced dystocia and 30 (40%) required cesarean delivery. This population appears to have sustained high-energy trauma, as evidenced by the high incidence (14.5%) of urogenital trauma. Madsen et al [1] reported on 17 women who gave birth after displaced fractures of the pelvis; only one required cesarean delivery because of a suspected cephalopelvic disproportion. This patient had a lateral compression type II (Tile type B2) injury, with a decrease in the diameter of the hemipelvis and superior displacement of the right superior pubic ramus. Three of the patients in that series delivered vaginally after having had both pelvic ring fractures and cesarean delivery for complicated pregnancies (ie, uterine inertia requiring vacuum extraction in two patients, symphysiolysis in one patient) [1].

The study by Copeland et al [3] of young women sustaining pelvic fractures showed that the rate of cesarean delivery per term pregnancy was significantly higher (P <.0001) postinjury than preinjury. In the subject group (pelvic fracture), cesarean delivery was performed in 11 (48%) of 23 initial pregnancies after trauma. In 1995, the rate of cesarean delivery in the general population was 21% in the United States and 16% in Great Britain [66]. A follow-up study was conducted to identify the reasons for this high rate [67]. Of the 23 women who gave birth after pelvic fracture, eleven underwent cesarean delivery; of these, seven of eleven had no trial of labor. Five of the seven had no history of cesarean delivery, but their obstetricians selected it because of their history of pelvic fracture; two underwent elective cesarean section because of their history of cesarean delivery. Four patients underwent cesarean delivery after unsuccessful trials of labor: two experienced inefficient uterine action, similar to preinjury pregnancies in which cesarean delivery was required, and two possibly had dystocia secondary to the injury. In one patient, the decision for cesarean delivery was made immediately after a change in physician coverage. Both patients had minimally displaced lateral compression fractures with a mildly decreased radius of the affected hemipelvis ( Fig 1.12-5 ). The authors concluded that physician bias and a desire to avoid childbirth complications, as opposed to dystocia due to the pelvic fracture, likely contributed to the high rate of cesarean delivery. The decision for elective cesarean delivery may have been inappropriate because subsequently four patients delivered vaginally despite their history of both pelvic fractures and cesarean delivery.

Cannada and Barr [53] also studied pelvic fractures in women of childbearing age. Follow-up information was available on 26 women who delivered after pelvic fracture and for whom obstetrical records were available. A total of 16 (62%) of the 26 women had cesarean deliveries. Ten women delivered vaginally; of these, three had retained iliosacral screws, and one had retained ramus screws. Review of the obstetrical records revealed that in seven of 16 women who had cesarean delivery, pelvic fracture was cited as the reason. One patient had a trial of labor and required a cesarean delivery for concern of cephalopelvic disproportion. Obstetricians in this study also answered a questionnaire, with most (20 of 26) indicating that they believed cesarean delivery was required after pelvic fracture [53].

Vallier et al [68] reviewed 51 deliveries in 31 women after pelvic fracture. Cesarean deliveries accounted for 51% of all deliveries, which was significantly higher than the rate for the hospital during that same period (27%). Thirteen of the women had 26 cesarean deliveries. Three others were offered a trial of labor but declined due to personal concerns about delivery after pelvic fracture. Four were advised to avoid vaginal delivery by their obstetrician on the basis of the pelvic fracture; two had retained symphyseal plates, one had narrowing of the pelvis from a lateral compression injury that was treated nonoperatively.

None of the patients in the original series of Clasper et al [67] had fixation crossing either the symphysis or the sacroiliac joint. External fixation of the pelvis and open reduction of the iliac wing have been found to be compatible with subsequent vaginal delivery [1, 67, 69]. Multiple reports now exist of successful vaginal delivery after symphyseal stabilization. Vallier et al [68] report on a cohort of women who had successful vaginal deliveries after pelvic fracture, including three with symphyseal plates, one with retained ramus screws, and four with retained iliosacral screws. Other authors have reported successful vaginal delivery with in situ symphyseal plating [58, 59], internal anterior fixation with posterior fixation [70], after symphyseal wiring [71], or in the presence of ankylosis of the symphysis ( Fig 1.12-6 ).

The role of hardware removal remains unclear [58, 59]. On the assumption that removal would facilitate vaginal delivery, Madsen et al [1] performed elective removal of symphyseal plates before planned conception in two patients; resymphysiolysis was a complication in both. One woman delivered vaginally despite the resymphysiolysis; the other delivered by elective cesarean and subsequently had a successful vaginal delivery. Resymphysiolysis also can occur after pelvic fractures that are treated nonoperatively [72]. Hardware removal before pregnancy does not always lead to symphysiolysis [58]. Resymphysiolysis does not preclude uncomplicated vaginal delivery in subsequent pregnancies [1, 72].

Risk factors for dystocia remain unclear and warrant further investigation. Both the patient and obstetrician should be advised about the anatomical location and displacement of fractures, the presence of hardware, and the perceived ability of the symphysis and sacroiliac joints to relax. The distinction between acetabular and pelvic fracture also should be made clear to both the patient and the obstetrician. Acetabular fractures, even when fixed operatively, do not preclude vaginal delivery [63, 67]. Acetabular fractures that result in limited hip range of motion may preclude the lithotomy position, which can be determined by physical examination. Gross deformity (ie, narrowing of the true pelvis), extensive internal heterotopic ossification, bridging callus formation, or autofusion may preclude vaginal delivery. Transsymphyseal fixation does not necessarily preclude vaginal delivery.

Medicolegal concerns have long been a concern for obstetricians [65]. Elective cesarean delivery, while perhaps safer than attempted vaginal delivery through a grossly scarred and deformed outlet, is not without risks [66]. The surgeon′s role is to counsel the patient regarding the specifics of her injury. Supplying patients with diagrams of their injury and fixation, postoperative x-rays, or follow-up CT scans for pelvimetry might decrease the rate of unnecessary cesarean delivery after pelvic fracture.