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Schmid FA, Held U, Eberli D, Pape HC, Halvachizadeh S. Erectile dysfunction and penile rehabilitation after pelvic fracture: a systematic review and meta-analysis. BMJ Open 2021; 11:e045117. [PMID: 34049910 PMCID: PMC8166614 DOI: 10.1136/bmjopen-2020-045117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 05/11/2021] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE To investigate the rate of erectile dysfunction (ED) after pelvic ring fracture (PRF). DESIGN Systematic review and meta-analysis. METHODS A systematic literature search of the Cochrane, EMBASE, MEDLINE, Scopus and Web of Science Library databases was conducted in January 2020. Included were original studies performed on humans assessing ED after PRF according to the 5-item International Index of Erectile Function (IIEF-5) questionnaire and fracture classification following Young and Burgess, Tile or Arbeitsgemeinschaft für Osteosynthesefragen/Orthopedic Trauma Association. Furthermore, interventional cohort studies assessing the effect of penile rehabilitation therapy with phosphodiesterase-5-inhibitors (PDE-5-I) on IIEF-5 scores compared before and after treatment were included. Results were presented as forest plots of proportions of patients with ED after PRF or mean changes on IIEF-5 questionnaires before and after penile rehabilitation. Studies not included in the quantitative analysis were narratively summarised. Risk of bias assessment was conducted using the revised tool for the Quality Assessment on Diagnostic Accuracy Studies. RESULTS The systematic literature search retrieved 617 articles. Seven articles were included in the qualitative analysis and the meta-analysis. Pooled proportions revealed 37% of patients with ED after suffering any form of PRF (result on probability scale pr=0.37, 95% CI: 0.26 to 0.50). Patients after 3 months of penile rehabilitation therapy reported a higher IIEF-5 score than before (change score=6.5 points, 95% CI: 2.54 to 10.46, p value=0.0013). CONCLUSION Despite some heterogeneity and limited high-quality research, this study concludes that patients suffering from any type of PRF have an increased risk of developing ED. Oral intake of PDE-5-I for the purpose of penile rehabilitation therapy increases IIEF-5 scores and may relevantly influence quality-of-life in these patients. PROSPERO REGISTRATION NUMBER CRD42020169699.
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Affiliation(s)
- Florian A Schmid
- Department of Urology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Ulrike Held
- Department of Epidemiology, Biostatistics and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Daniel Eberli
- Department of Urology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Hans-Christoph Pape
- Department of Trauma, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Sascha Halvachizadeh
- Department of Trauma, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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Nieto-Esquivel A, Delgado-Balderas R, Robles-Torres JI, Gómez-Guerra LS. [Use of tadalafil in the rehabilitation of patients with a history of posterior urethral injury in the context of pelvic fracture]. Rev Int Androl 2017; 16:15-19. [PMID: 30063018 DOI: 10.1016/j.androl.2017.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 01/18/2017] [Accepted: 02/24/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the tadalafil effect in the treatment of erectile dysfunction as a consequence of posterior urethral injury. MATERIAL AND METHODS This is a retrospective study that included patients with posterior urethral injury caused by previous pelvic fracture; our patients received emergency urethral alignment and urethroplasty between 8 to 10weeks after trauma. To assess the degree of erectile dysfunction pre- and post-treatment, we applied the questionnaire of International Index of Erectile Function (IIEF-5). Statistics Wilcoxon test and descriptive statistics were performed. RESULTS Eight patients were included in this study, with an average age of 32.5years; the IIEF scale prior to treatment was on average 8.5 points and increased to 12.36 points with a value of P=.011. DISCUSSION These eight patients showed erectile dysfunction at the time of IIEF assessment, this due to emergency urethral realignment arising from the trauma caused by pelvic fracture. Treatment with inhibitors of 5-phosphodiesterase (iPDE5) is the first-line treatment in patients with erectile dysfunction because it is efficient, non-invasive and well tolerated. In this study we found results indicating good response to this treatment in 7 out of the 8 patients (87.5%). Only one patient showed no improvement after treatment, due to the presence of risk factors such as age (65years), tobacco use, and high blood pressure. CONCLUSION The 87.5% of patients with urethral injury medicated with tadalafil were rehabilitated.
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Affiliation(s)
| | | | - J Iván Robles-Torres
- Servicio de Urología, Hospital Universitario Dr. José Eleuterio González, Monterrey, México
| | - Lauro S Gómez-Guerra
- Servicio de Urología, Hospital Universitario Dr. José Eleuterio González, Monterrey, México.
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Pansard RB, Morais EN, Alves ADS, Ramos Neto EJ, Copetti H, Lazzari B, Ribeiro TA. Traumatic Hemipelvectomy: A Rare and Catastrophic Injury: A Case Report. JBJS Case Connect 2014; 4:e44. [PMID: 29252348 DOI: 10.2106/jbjs.cc.m.00252] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Rafael Boeira Pansard
- Serviço de Cirurgia (R.B.P., E.N.M., and H.C.) and Serviço de Ortopedia e Traumatologia (A.S.A., E.J.R.N., B.L., and T.A.R.) do Hospital Universitário de Santa Maria, and Federal University of Santa Maria, Roraima Avenue n° 1000, University Campus, Santa Maria, Rio Grande do Sul, 97105-900, Brazil.
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Jones CB, Sietsema DL, Hoffmann MF. Can lumbopelvic fixation salvage unstable complex sacral fractures? Clin Orthop Relat Res 2012; 470:2132-41. [PMID: 22318668 PMCID: PMC3392374 DOI: 10.1007/s11999-012-2273-z] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Traditional screw or plate fixation options can be used to fix the majority of sacral fractures. However, these techniques are unreliable with dysmorphic upper sacral segments, U-fractures, osseous compression of neural elements, and previously failed fixation. Lumbopelvic fixation can potentially address these injuries but is a technically demanding procedure requiring spinal and pelvic fixation and it is unclear whether it reliably corrects the deformity and restores function. QUESTIONS/PURPOSES We therefore assessed reduction quality and loss of fixation, pain related to prominent hardware, subjective dysfunction measured by the Short Musculoskeletal Function Assessment (SMFA), and complications. METHODS We retrospectively reviewed 15 patients with unstable sacral fractures treated with lumbopelvic fixation between 2002 and 2010. Patients had radiographic monitoring regarding reduction quality and loss of fixation and clinical followup using the SMFA. The minimum followup was 12 months (mean, 23 months; range, 12-41 months). RESULTS Posterior reduction quality was 11 of 15 with less than 5 mm persistent displacement and four of 15 with 5 to 10 mm displacement. Loss of fixation was observed in one patient as a result of a technical error. Prominent hardware resulted in greater pain. Despite daily activity and bother subscores improving over time, we found long-term dysfunction in the SMFA. Eleven of the 15 patients were able to return to previous work or activities. CONCLUSION Complex posterior pelvic ring injuries of the sacrum not amenable to traditional fixation options can be salvaged with adherence to the technical details of lumbopelvic fixation. Hardware prominence and pain are markedly reduced with screw head recession. Long-term impairment is noted in patients with complex pelvic ring injuries requiring lumbopelvic fixation compared with normative data. LEVEL OF EVIDENCE Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Clifford B. Jones
- Orthopaedic Associates of Michigan, Grand Rapids, MI USA ,Michigan State University, 230 Michigan Street NE, Suite 300, Grand Rapids, MI 49503 USA
| | - Debra L. Sietsema
- Orthopaedic Associates of Michigan, Grand Rapids, MI USA ,Michigan State University, 230 Michigan Street NE, Suite 300, Grand Rapids, MI 49503 USA
| | - Martin F. Hoffmann
- Grand Rapids Medical Educational Partners, Grand Rapids, MI USA ,Asklepios Klinik St Georg, Hamburg, Germany
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5
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Lasurt S, Combalia-Aleu A. Complete traumatic hemipelvectomy: Report of a case after 19 years of follow-up. Injury 2010; 41:874-82. [PMID: 20478558 DOI: 10.1016/j.injury.2010.04.009] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2010] [Accepted: 04/07/2010] [Indexed: 02/02/2023]
Affiliation(s)
- Sandra Lasurt
- Hospital Clínic, University of Barcelona, Department of Orthopaedic Surgery and Trauma, Barcelona, Spain
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Harwood PJ, Grotz M, Eardley I, Giannoudis PV. Erectile dysfunction after fracture of the pelvis. ACTA ACUST UNITED AC 2005; 87:281-90. [PMID: 15773631 DOI: 10.1302/0301-620x.87b3.15662] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- P J Harwood
- St. James's University Hospital, University of Leeds, West Yorkshire, England, UK
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Ramirez JI, Velmahos GC, Best CR, Chan LS, Demetriades D. Male sexual function after bilateral internal iliac artery embolization for pelvic fracture. ACTA ACUST UNITED AC 2004; 56:734-9; discussion 739-41. [PMID: 15187735 DOI: 10.1097/01.ta.0000120287.04574.78] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Bilateral internal iliac artery embolization (BIIAE) effectively controls unlocalized bleeding from pelvic fractures. Its short-term safety has been documented, but its long-term effect on urogenital function has not been evaluated. METHODS Patients having temporary BIIAE with gelatin sponge slurry for pelvic fractures were prospectively identified. Two control groups were created--one with similar pelvic fractures but no embolization, and the other with nonpelvic injuries. The groups were matched for risks of urogenital dysfunction: age, time elapsed since injury, Injury Severity Score, pelvic Abbreviated Injury Scale score, and presence of urethral or bladder injuries. Urogenital function was assessed at least 1 year after injury using a validated questionnaire. RESULTS Sexual function was significantly compromised in patients having pelvic fractures compared with those not having fractures. There was no difference in sexual function between patients having pelvic fractures treated with BIIAE and those having pelvic fractures alone. CONCLUSION BIIAE does not produce lasting adverse effects on urogenital function. Sexual dysfunction frequently occurs after traumatic pelvic fracture and is produced by the injury itself.
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Affiliation(s)
- Jesus I Ramirez
- Department of Surgery, Division of Trauma and Critical Care, University of Southern California, Los Angeles County and University of Southern California Medical Center, Los Angeles, California 90033, USA
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9
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Abstract
Fifty-one male patients with prior pelvic fracture completed a Brief Sexual Function Inventory questionnaire (BSFI) 2 years postinjury. Responses were compared to those of 53 men with ankle fractures. Patients with pelvic fracture scored significantly worse than patients with ankle fracture. Patients with pelvic fracture scored poorly on sex drive, erection, ejaculation, and satisfaction with sex life. Older patients had significantly worse sex function scores than younger patients. Sexual dysfunction is common after pelvic fracture, and many facets of sex life are affected. The BSFI was well accepted, and is a useful screening tool for identifying patients with sexual dysfunction.
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Affiliation(s)
- Donald Ozumba
- Department of Orthopedic Surgery, University of Texas Southwestern Medical Center, Dallas, Tex 75390-8883, USA
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Abstract
Pelvic fractures are associated with a high morbidity and mortality rate. This article reviews the anatomy of the pelvis, discusses fracture patterns commonly seen in patients with an injured pelvis, and proposes a new method of classifying pelvic fractures based on potential associated injuries. Finally, algorithms for the management of hemodynamically stable and unstable patients with pelvic fractures are presented.
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Affiliation(s)
- P T Coppola
- Brookhaven Memorial Hospital, East Pathogue, New York, USA
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11
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Schildhauer TA, Wilber JH, Patterson BM. Posterior locked lateral compression injury of the pelvis: report of three cases. J Orthop Trauma 2000; 14:107-11. [PMID: 10716382 DOI: 10.1097/00005131-200002000-00007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Lateral compression injuries to the pelvis typically result in a rotationally unstable and vertically stable condition including an impaction and compression fracture of the posterior pelvic ring. The operative and postoperative management, as well as the morbidity and mortality, of these fractures differs significantly from vertical shear injuries to the pelvis, which are characterized by vertical and rotational instability. We report on three unusual lateral compression injuries to the pelvis, resulting in a complete disruption of the pelvic ring with vertical and rotational instability, by definition. Nevertheless, in these patients, locking of the posterior pelvic ring with medial translation of the iliac wing anterior to the sacrum resulted in a pseudostable condition. Their high rate of fracture-related associated injuries and possible complications, as well as the malalignment of the pelvis, required surgical restoration of the pelvic ring. Fracture reduction was successfully performed through an anterior approach in one patient and a posterior approach in two patients; the posterior approach was preferred. Open reduction and internal fixation of these pelvic ring fractures can result in a satisfactory outcome if the associated injuries are successfully dealt with.
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Affiliation(s)
- T A Schildhauer
- Department of Orthopaedic Surgery, Case Western Reserve University School of Medicine, Cleveland, Ohio 44106, USA
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Abstract
Controversy exists regarding the management of pelvic fractures with concomitant injuries to the lower urologic tract. This can be seen in both the urologic and orthopedic literature as it pertains to the ideal form of treatment for either problem and the timing of surgical intervention, if it is needed. This article reviews the anatomy, mechanism of injury, diagnostic approach, and treatment.
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Affiliation(s)
- R Taffet
- Department of Orthopaedic Surgery, Cooper Hospital/University Medical Center, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, Camden, New Jersey 08103, USA
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13
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Lawless MW, Laughlin RT, Wright DG, Lemmon GW, Rigano WC. Massive pelvis injuries treated with amputations: case reports and literature review. THE JOURNAL OF TRAUMA 1997; 42:1169-75. [PMID: 9210563 DOI: 10.1097/00005373-199706000-00034] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- M W Lawless
- Wright State University School of Medicine, Dayton, Ohio 45409, USA
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Mark SD, Keane TE, Vandemark RM, Webster GD. Impotence following pelvic fracture urethral injury: incidence, aetiology and management. BRITISH JOURNAL OF UROLOGY 1995; 75:62-4. [PMID: 7850299 DOI: 10.1111/j.1464-410x.1995.tb07234.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
OBJECTIVE To evaluate the potency status of patients undergoing delayed perineal repair following a pelvic fracture urethral injury to determine the incidence and aetiology of impotence. PATIENTS AND METHODS Long-term potency (> 6 months post-operatively) was subjectively evaluated in 92 patients and correlated with their pre-operative and intra-operative findings. The management of their impotence was aso reviewed. Thirty original pelvic radiographs were assessed independently to determine if the pattern of bony injury was associated with the development of impotence. RESULTS Fifty-seven patients (62%) remained impotent in the long term with a median follow-up of 48 months (range 12-128) and the operation did not render any potent patient impotent. Self-injection with vasoactive agents was successful in 24 of 27 (89%), suggesting a neurogenic aetiology in the majority. Bilateral pubic rami fracture was also associated with a high incidence of impotence. CONCLUSION Disruption of the cavernosal nerves lateral to the prostatomembranous urethra behind the symphysis pubis is the most likely cause of impotence in this injury.
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Affiliation(s)
- S D Mark
- Department of Surgery, Duke University Medical Center, Durham, North Carolina
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Dhabuwala CB, Hamid S, Katsikas DM, Pierce JM. Impotence following delayed repair of prostatomembranous urethral disruption. J Urol 1990; 144:677-8. [PMID: 2388326 DOI: 10.1016/s0022-5347(17)39552-6] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
A group of 26 patients with pelvic fracture and disruption of the prostatomembranous urethra were evaluated for impotence. Impotence was defined as inability to achieve an erection firm enough for vaginal penetration. Of the patients 25 were potent before the injury, whereas 1 was only 7 years old at injury. Seven patients admitted to being potent after the injury but before the final urethral anastomosis. Four patients became potent after urethroplasty. The definitive operation to the urethra was done approximately 6 months after the injury. Only 11 of the 26 patients (46%) reported erections adequate for vaginal penetration. No patient who had adequate erections before urethroplasty became impotent postoperatively. We believe that the impotence was caused by damage to the neurovascular supply to the penis at injury.
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Affiliation(s)
- C B Dhabuwala
- Wayne State University, Detroit Medical Center Hospitals, Michigan
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Abstract
Many problems may complicate the treatment of pelvic fractures. Thorough evaluation of the whole patient, all local structures, and the skeletal injury itself is essential. Continued bleeding due to unstable pelvic ring injuries is most effectively controlled by prompt anterior external fixation. Posterior shearing injuries are poorly stabilized by external fixation, and require additional treatment. Especially when significant deformity exists, or when the posterior injury is primarily ligamentous, open reduction and internal fixation are likely to be beneficial.
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