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REVIEW ARTICLE
Epidemiology and aetiology of male and female sexual dysfunctions
related to pelvic ring injuries: a systematic review
Giuseppe Rovere
1
&Andrea Perna
1
&Luigi Meccariello
2
&Domenico De Mauro
1
&Alessandro Smimmo
1
&
Luca Proietti
1
&Francesco Falez
3
&Giulio Maccauro
1
&Francesco Liuzza
1
Received: 23 February 2021 /Accepted: 17 July 2021
#The Author(s) 2021
Abstract
Introduction Pelvic ring injuries, frequently caused by high energy trauma, are associated with high rates of morbidity and
mortality (5–33%), often due to significant blood loss and disruption of the lumbosacral plexus, genitourinary system, and
gastrointestinal system. The aim of the present study is to perform a systematic literature review on male and female sexual
dysfunctions related to traumatic lesions of the pelvic ring.
Methods Scopus, Cochrane Library MEDLINE via PubMed, and Embase were searched using the keywords: “Pelvic fracture,”
“Pelvic Ring Fracture,”“Pelvic Ring Trauma,”“Pelvic Ring injury,”“Sexual dysfunction,”“Erectile dysfunction,”
“dyspareunia,”and their MeSH terms in any possible combination. The following questions were formulated according to the
PICO (population (P), intervention (I), comparison (C), and outcome (O)) scheme: Do patients suffering from pelvic fracture (P)
report worse clinical outcomes (C), in terms of sexual function (O), when urological injury occurs (I)? Is the sexual function (O)
influenced by the type of fracture (I)?
Results After screening 268 articles by title and abstract, 77 were considered eligible for the full-text analysis. Finally 17 studies
that met inclusion criteria were included in the review. Overall, 1364 patients (902 males and 462 females, M/F ratio: 1.9)
suffering from pelvic fractures were collected.
Discussion Pelvic fractures represent challenging entities, often concomitant with systemic injuries and subsequent morbidity.
Anatomical consideration, etiology, correlation between sexual dysfunction and genitourinary lesions, or pelvic fracture type
were investigated.
Conclusion There are evidences in the literature that the gravity and frequency of SDare related with the pelvic ring fracture type.
In fact, patients with APC, VS (according Young-Burgess), or C (according Tile) fracture pattern reported higher incidence and
gravity of SD. Only a week association could be found between GUI and incidence and gravity of SD, and relationship between
surgical treatment and SD. Electrophysiological tests should be routinely used in patient suffering from SD after pelvic ring
injuries.
Keywords Sexual disfunction .Pelvic ring injuries .Penile erection .Dyspareunia .Lumbosacral plexus
Introduction
Pelvic ring injuries, frequently caused by high-energy trauma,
are associated with high rates of morbidity and mortality (5–
33%), often due to significant blood loss and disruption of the
lumbosacral plexus, genitourinary system, and gastrointesti-
nal system [1–4].
Genitourinary injuries (GUI) and sexual dysfunctions (SD)
associated to pelvic ring disruption are the result of direct or
indirect trauma [5,6]. Urogenital system structural and func-
tional damages could be related to the anatomical relationship
between the abdominal organs, neuro-vascular structures, and
Giuseppe Rovere and Andrea Perna contributed equally to this work.
*Francesco Liuzza
francesco.liuzza@policlinicogemelli.it
1
Department of Orthopaedics and Traumatology, Fondazione
Policlinico Universitario A. Gemelli IRCCS - Università Cattolica
del Sacro Cuore, Largo Agostino Gemelli, 8, 00168 Rome, Italy
2
Department of Orthopaedics and Traumatology, AORN San Pio,
Benevento, Italy
3
Santo Spirito in Sassia Hospital, 00193 Rome, Italy
International Orthopaedics
https://doi.org/10.1007/s00264-021-05153-8
thepelvicring[3]. Sexual dysfunctions represent an
underestimated consequence of pelvic injuries mostly in
young and sexually active patients, often cause of depression
and quality of life reduction [2,3].
Some authors observed a direct correlation between the
Injury Severity Score (ISS) increase and the sexual distur-
bance incidence [7]. Some factor such as age, pelvic fracture
complexity, and pubic symphysis alterations could represent
erectile dysfunction risk factors after major pelvic injuries.
Moreover elderly patients seem to be prone to experience
impotence and SD after a pelvic ring trauma respect to youn-
ger patients [8,9]. On the other hand, urethral trauma, pelvic
organ prolapse, and urinary impairment are most frequent in
women, as a consequence of posterior pelvic fractures [3,5].
A direct trauma on the pelvic floor or pelvic soft tissue damage
(such as connective tissue, neuro-vascular structures) could
lead to pelvic floor dysfunction, urogenital and neurogenic
pain, and dyspareunia [10].
Some literature review were performed on this topic, how-
ever, reported data were fragmentary and non-conclusive; fur-
thermore, there is no consensus in the literature about the
relationship between the type of pelvic fracture, the treatment
received, and the urological/gynecological lesions and sexual
dysfunctions in male and female patients. The aim of the pres-
ent study was to perform a systematic literature review on
male and female sexual dysfunctions related to traumatic le-
sions of the pelvic ring and to verify the possible association
between the type of pelvic ring injury, the received treatment,
and the gravity of sexual dysfunction.
Material and methods
Study setting and design
The present investigation represents a systematic literature
review reported according to the Preferred Reporting Items
for Systematic Reviews and Meta-Analyses (PRISMA) guide-
lines (Figure 1)[11].
Review questions
The review questions were formulated following the PICO
scheme (population (P), intervention (I), comparison (C),
and outcome (O)) as follows:
&Do patients suffering from pelvic fracture (P) report worse
clinical outcomes (C), in terms of sexual function (O),
when urological injury occurs (I)?
&Is the sexual function (O) influenced by the type of frac-
ture (I)?
Inclusion and exclusion criteria
In this review, we considered the studies published as full-text
articles in indexed journals, which investigated the association
between pelvic ring injuries and sexual dysfunction. Only
articles written in English with available abstract were includ-
ed. No publication date limits were set. Surgical technique
reports, expert opinions, case report, letter tothe editor, studies
on animals, unpublished reports, cadaver or in vitro investiga-
tions, review of the literature, abstracts from scientific meet-
ings, and book chapters were excluded from the present
review.
Search strategy and study selection
Scopus, Cochrane Library MEDLINE via PubMed, and
Embase were searched using the keywords: “Pelvic fracture,”
“Pelvic Ring Fracture,”“Pelvic Ring Trauma,”“Pelvic Ring
injury,”“Sexual dysfunction,”“Erectile dysfunction,”
“dyspareunia,”and their MeSH terms in any possible combi-
nation. The reference lists of relevant studies were screened to
identify other studies of interest. The search was reiterated
until December 15, 2020.
Data extraction
Two independent reviewers (A.P. and G.R.) collected the data
from the included studies. Any discordances were solved by
consensus with a third author (F.L.). For each study included
in the present analysis, the following data were extracted:
demographic features, type of fracture, traumatic mechanism,
presence of risks factors, presence of associated urethral or
bladder injuries, presence of other associated injuries, pres-
ence of dyspareunia (in females patients) or erectile dysfunc-
tion, treatment performed, possible complications and out-
comes, hospital stay, and follow-up.
Primary and secondary outcome measures
The primary outcome was the correlation between the type of
fracture and the incidence of SD. The secondary outcomes
were represented by the correlation between the treatment
received and the incidence of SD.
Statistical analysis
Risk of bias assessments and quality assessment of included
studies was checked using Cochrane risk of bias tool
(Figure 2). Numbers software (Apple Inc., Cupertino, CA)
was used to tabulate the obtained data. Categorical variables
are presented as frequency and percentages. Continuous var-
iables are presented as means and standard deviation. Only
one decimal digit was reported and was rounded up.
International Orthopaedics (SICOT)
Results
Study selection
After screening 268 articles by title and abstract, 77 were
considered eligible for the full-text analysis. Sixty studies
were excluded because they did not fulfill inclusion criteria.
Finally, 17 studies that met inclusion criteria were included in
the review [5,10,12–26](Figure1). Among them, one had a
level of evidence II, four had a level of evidence III, while 11
had a level of evidence IV [27].
Patient characteristics
Overall, 1364 patients (902 males and 462 females, M/F ratio:
1.9) suffering from pelvic fractures were collected. The mean
age ± standard error was 35.6 ±1.71 years. The mechanisms of
injury were reported in 1005 of 1364 patients (73.6%); the
most common was high energy traffic accident in 876 cases
(87.2%), high falling injury in 87 cases (8.6%) and other
causes in 42 patients (4.2%). Mean follow-up was reported
in 14 out of 17 studies (82.3%), and it was about 32.9 months.
Five hundred seventy six (42.2%) of all patients were
polytraumas with associated lesions. The most common asso-
ciated injuries were as follows: urogenital (336 cases), mus-
culoskeletal (277 cases), visceral (124), and head (72 cases)
injuries. In 13 studies, for a total of 740 patients (54.2%), the
pelvic fractures were classified according to the Tile classifi-
cation (type A: 260 pt, type B: 266 pt, type C: 214 pt), while in
three studies, for a total of 326 patients (23.7%), the Young-
Burgess classification was used (Anterior and Posterior
Compression type, APC: 94 pt; Lateral Compression type,
LC: 133 pt; Vertical Shear type, VS: 89 pt; Composite
Stress type: 10 pt). In one study, for a total of 298 patients
(21.8%), the pelvic fracture classification was not reported.
Demographic characteristics of the included studies are re-
ported in Table 1.
Sexual dysfunction
Sexual dysfunctions (SD) represent a common complication
of pelvic injuries. Among the analyzed patients, 525 (39.8%)
reported SD. The most common conditions described were as
follows: erectile dysfunction (ED) in 366 cases, male orgas-
mic dysfunction (MOD) in 39 cases, and dyspareunia (DYS)
in 120 cases. ED represents a condition of inability to obtain
or maintain a penile erection sufficient to perform a satisfying
sexual intercourse [28]. MOD includes many disorders rang-
ing from premature ejaculation to complete inability to ejacu-
late including retrograde ejaculation [28]. DYS in woman rep-
resents painful sexual intercourse [29]. In nine studies, the
authors used the International Index of Erectile Function
Fig. 1 PRISMA flowchart
International Orthopaedics (SICOT)
(IIEF) questionnaire for the evaluation of sexual dysfunction
[13,16,20–22,24–26]. Ad hoc questionnaire, Arizona Sexual
Experiences Scale (ASEX) [25], Female Sexual Function
Index (FSFI) [25], and Majeed and Hannover questionnaire
were also used in other studies [23]. In eight studies for a total
of 291 patients, the gravity of SD was reported. In 78 patients,
SD was classified as severe, in 61 as moderate, in 116 as mild
to moderate, and in 36 as mild (Table 2).
Discussion
Pelvic fractures represent challenging entities, often concom-
itant with systemic injuries and subsequent morbidity [30].
They are relatively uncommon (3–9% of all fractures), but
their incidence increases up to 20% in polytraumatized pa-
tients [30]. Sexual dysfunctions after pelvic injuries are com-
mon but underestimated complications and are generally
caused by high-energy trauma in young and usually sexually
active subjects [1–6]. In fact, it has been shown that for a 1-
point increase in Injury Severity Score, there is a 2% increase
of sexual dysfunction [7]. The aim of this research is to pro-
vide a detailed analysis of the SD etiology after a pelvic injury
and to examine possible factors that may increase the inci-
dence and risk of SD in these patients.
Anatomical consideration and classification systems
The pelvis is anosteo-ligamentous ring thatconnects the spine
to the lower limbs allowing the weight-bearing force transmis-
sion [31]. Its stability depends on strong ligamentous struc-
tures such as the anterior symphyseal and the sacrospinous
ligaments that oppose external rotation, the sacral-tuberous
ligaments which resist shear and flexion, and the sacro-iliac
ligament that confers stability on vertical plane [32]. The ure-
thra crosses the urogenital diaphragm and the perineal mem-
brane and is very close to the anterior arch of the pelvis. In
particular, in males, the membranous urethra pierces the per-
ineal membrane and is stabilized by the pubo-prostatic liga-
ments [31]. For this reason, especially pubic bone fractures or
diastasis may cause urethral injuries. Considering this com-
plex anatomy, high energy trauma of the pelvic ring could
create mechanical and hemodynamic instability with loss of
blood and disruption of the genitourinary system, the gastro-
intestinal system, and the lumbosacral plexus [1–6]. Different
classification systems for pelvic injuries have been developed
to identify different types of fractures based on the traumatic
mechanism and associated injuries (Young and Burgess
Classification) [33] or on the stability of the pelvic ring (Tile
classification) [34]. A comprehensive modern classification is
the AO/OTA [35].
Neurogenic etiology
Most of the previous papers that studied the etiology of SD
after pelvic injuries did not differentiate the neurogenic factors
from the vascular ones [18–21]. The nervous supply damage
to the penis or clitoris seems to be one of the most important
factors. Erection depends on a combination of psychophysical
stimuli, and it is controlled by parasympathetic system whose
fibers originate from S2 to S4 nervous roots [21]. These
nerves in fact, as part of the somatic nervous system, partici-
pate to the erectile mechanism by providing sensation to the
Fig. 2 Risk of bias assessments of included studies using Cochrane risk
of bias tool. Risk of bias is judged in each domain of selection bias,
performance bias, detection bias, attrition bias, reporting bias, and other
bias. Green: domain judged to be at low risk of bias; yellow: domain
judged to be at unclear risk of bias; red: domain judged to be at high
risk of bias
International Orthopaedics (SICOT)
Table 1 Clinical characteristic, fracture classification, treatment received (orthopedics and urologic), and associated complications of included patients
Studies Number of
patients
Sex Age (year) Traumatic mechanism Classification AO/
Tile
Classification Y/B Polytrauma (nof
patients)
Associated
lesions
MF Traffic
accident
Fall from
height
Other Tile
A
Tile
B
Tile
C
APC LC VS CM Visceral
Pohlemann 1996 58 40 18 _ 58 _ _ _ 28 30 _ _ _ _ _ _
Malavaud 2000 46 46 _ 39.6
(±15.9)
_ _ _ 27 5 14 _ _ _ _ 33 _
Bellabarba 2003 10 7 3 36 (23–64) 10 _ _ _ 10 _ _ _ _ _ 7 2
Baessler 2004 24 _ 24 24 (11–92) 16 6 _ _ 16 8 _ _ _ _ 4 _
Wright 2006 298 192 106 33.1
(18–59)
298 _ _ ________ _
Metze 2007 77 77 _ 35 (22–48) 44 33 _ 27 22 28 _ _ _ _ 61 43
Feng 2008 40 40 _ 35.4
(18–54)
__ _2713______ _
Odutola 2012 151 111 40 40 (16–76) _ _ _ _ _ _ 46 56 49 _ 32 _
Vallier 2012 187 187 33 (16–55) 162 16 9 _ 101 86 _ _ _ _ 28 23
Harvey-Kelly 2014 80 48 32 44.1
(19–65)
50 18 12 _ _ _ 23 40 5 _ 66 34
Ceylan 2015 26 26 _ 42.6
(20–68)
26 _ _ 16 5 5 _ _ _ _ 11 2
Guan 2015 120 120 _ 37.6 (±6.3) _ _ _ 73 35 12 _ _ _ _ _ _
El-Assmy 2016 58 58 _ 31.6
(±12.2)
58 _ _ 45 5 8 _ _ _ _ _ _
Ismail 2016 26 17 9 30.54
(±10.8)
26 _ _ _ 15 11 _ _ _ _ 9 3
Pandian 2017 20 20 _ 34 (17–61) 18 _ 2 11 2 7 _ _ _ _ _ _
Duramaz 2019 95 52 43 34(18–50) 71 14 10 _ _ _ 25 35 35 10 26 7
Fanjalalaina Ralahy
2019
48 48 _ 39 (18–82) 39 _ 9 34 9 5 _ _ _ _ 11 10
Total 1364 902 462 35.6 (± 4.9) 876 87 42 260 266 214 94 131 89 10 288 124
Studies Associated lesions Orthopaedic treatment Urologic treatment Complication
Muscoloskeletal Head Urogenital Conservative External
fixation
ORIF/
CRIF
Chronic
catheter
Reparation of bladder
or urethral tear
Urethral
realignment
Infection Pain Non-union/
malunion
TVP/
TEP
Neurological
Pohlemann
1996
_ _6 _ 355_ _ _ 2136 10 21
Malavaud
2000
29 _ 4 _ _ _ _ _ - _ _ _ _ _
Bellabarba
2003
821 11816 ______
Baessler 2004 _ _4 6 414_ _ _ _13_ _ _
Wright 2006 ___ _____ ______
International Orthopaedics (SICOT)
Table 1 (continued)
Studies Associated lesions Orthopaedic treatment Urologic treatment Complication
Muscoloskeletal Head Urogenital Conservative External
fixation
ORIF/
CRIF
Chronic
catheter
Reparation of bladder
or urethral tear
Urethral
realignment
Infection Pain Non-union/
malunion
TVP/
TEP
Neurological
Metze 2007 75 361 _ _27_ 1 _ 19_ _ _
Feng 2008 __40_____ 11_____
Odutola 2012 32 _ 29 _ 21 130 _ _ _ _ _ _ _
Vallier 2012 28 _ 18 107 16 58 _ 15 _ 3 31 1 _
Harvey-Kelly
2014
73 23 11 42 _ 38 _ _ _ _ 2 12 _ _
Ceylan 2015 9__2231__ ______
Guan 2015 __115_____115_____
El-Assmy 2016 __50_____ 58_____
Ismail 2016 4 3 18 _ _ 26 _ _ _ 5 9 _ _ 3
Pandian 2017 _ _ 20 19 1 _ _ _ 20 _ _ _ _ _
Duramaz 2019 14 512 - _95_ _ _ 6_ 4 _ 4
Fanjalalaina
Ralahy 2019
537462___ _____
Total 277 72 336 243 51 452 1 22 204 16 87 23 10 28
International Orthopaedics (SICOT)
Table 2 Epidemiology and evaluation of sexual dysfunction after pelvic ring injury
Studies Number of
patients
Sexual dysfunction Evaluation scale Dysfunction quantification
Erectile
dysfunction
Ejaculation
disturbances
Dyspareunia Percentage IIEF ASEX Other Mild Mild to
moderate
Moderate Severe
Pohlemann 1996 58 5 1 10.3% _ _ Ad hoc questionnaire
Malavaud 2000 46 11 _ 23.9% X _ _ 4 5 1 1
Bellabarba 2003 10 1 _ 2 30.0% _ _ Ad hoc questionnaire _ _ _ _
Baessler 2004 24 _ _ 8 30.0% _ _ Golombok Rust Inventory of Sexual
Satisfaction
__ _ _
Wright 2006 298 39 23 20.8% _ _ FCI questionnaire 55 7
Metze 2007 77 16 _ _ 19.5% X _ _ 4 2 1 8
Feng 2008 40 11 _ _ 27.5% _ _ Nocturnal penile tumescence, Doppler
ultrasonography
__ _ _
Odutola 2012 151 21 30 1 34.4% _ _ Sexual functioning questionnaire _ _ _ _
Vallier 2012 187 _ _ 48 25.7% _ _ _ _ _ _ _
Harvey-Kelly 2014 80 25 _ 14 48.7% X _ FSFI, EQ5D _ _ _ _
Ceylan 2015 26 26 _ 100% X 14 12
Guan 2015 120 115 _ _ 95.8% X _ _ 16 34 47 18
El-Assmy 2016 58 42 _ _ 72% X _ _ 6 6 19
Ismail 2016 26 10 _ _ 38% _ _ Majeed, Hannover _
Pandian 2017 20 15 _ _ 75% X _ _ _ _ 8 7
Duramaz 2019 95 13 9 23 47.4% X X FSFI _ _ _ _
Fanjalalaina
Ralahy 2019
48 16 _ _ 33.3% X _ _ 6 4 6
Total 1364 366 39 120 39.3
(±24.6)%
9 1 9 36 116 61 78
International Orthopaedics (SICOT)
skin of the penis [36]. A similar mechanism was involved in
women and causes clitoris swelling and engorgement as well
as vagina lubrication [37].
Differently to the erection, the predominant input for
ejaculation was provided by sympathetic nervous system
(T12–L2) which runs from the hypogastric plexus to the
genital structure through the hypogastric nerve [37].
However, while the parasympathetic system is involved
during reflexogenic penile erection (physical stimulation),
sympathetic system could cause psychogenic penile erec-
tion [37]. Damage to the S2–4 nervous roots after ilium
fractures and sacro-iliac diastasis could cause sexual or
urination dysfunction by stretching the S2–4nerveroots
and their branches (pudendal nerve and dorsal nerve of
the penis) with interruption of the local reflex arc [12,
36]. This occurrence causes the well-known lower motor
neuron syndrome (LMNS) [37]. Patient with LMNS le-
sions after pelvic trauma usually fail to have penile erec-
tions in response to tactile stimulation. Nevertheless in
these patients, a psychogenic erection (mediated by sym-
pathetic pathways T10–T12) could occur [37]. As for
women, few studies are available in literature. It appears
that clitoral enlargement and vaginal lubrication may oc-
cur in response to direct stimulation when the sacral reflex
is intact and after psychogenic stimulation in the case of
LMNS [38].
Although neurological etiology is one of the most frequent-
ly described [21], sensitive and direct neurophysiologic tools
for neurological assessment are still missing.
Electrophysiological tests used to diagnose neurogenic SD
are as follows: posterior tibial somatosensory nerve evoked
potentials (PTSSEPs), pudendal nerve evoked potentials
(PDEPs), and the bulbocavernosus reflex (BCR). However,
these tests are often neglected or not routinely performed in
patients with pelvic trauma. [21]
Vascular aetiology
A deficit of penis blood supply seems to be one of the most
probable vascular causes of erectile dysfunction. The internal
pudendal artery represents the only vascular supply to the
corpus cavernosum. This artery had two branches. The first,
so-called internal pudendal artery across the Alcock’scanal.
At this level, pelvic injuries could damage the internal puden-
dal artery [36].
Veno-occlusive etiology as results of mechanic damage is
not clear; however, it is well known that the veno-occlusion
that occurs during erection in the corpus cavernosum is caused
by increased arterial blood flow and smooth penile muscle
relaxation. Some authors in fact hypothesized that traumatic
injuries could cause smooth muscle structural changes which
leads to SD [32].
Correlation between sexual dysfunction and
genitourinary lesions
The incidence of associated genitourinary injury (GUI), in-
cluding bladder disruptions, injury to the bladder neck, and
urethral injuries with associated sexual dysfunctions, ranges
from 6.5 to 30% [39–41]. Only 14 of 17 studies evaluated the
association between SD and concomitant genitourinary le-
sions after a pelvic ring fracture. Among these, 8 studies
(47%) [10,13,14,18,20,22–24] reported that genitourinary
injuries represent an additional risk factor for the development
of SD, both in man and women. However, the correlation
seems to be moderate and mostly not statistically significant.
In 6 studies (35.3%), the authors assumed that the presence of
a genitourinary lesion did not represent a risk factor for the
development of SD after a fracture of the pelvic ring. In three
studies (17.7%), the correlation between SD and genitourinary
injuries was not analyzed.
Correlation between sexual dysfunction and pelvic
fracture type
The pelvic lesions most frequently associated with sexual dys-
functions are the ones that involve bilateral pubic rami, the
symphysis diastasis, and fractures or dislocations of the sacro-
iliac joints. [9]. Many authors have described an association
between sacro-iliac and pubic symphysis injuries and urogen-
ital impairment in both sexes [10,20,25].
Sixteen of 17 studies evaluated the association between SD
and the type of pelvic fracture. Regarding the Tile classifica-
tion, the authors of five studies (29.4%) sustained that a pelvic
fracture represents an independent risk factor for the develop-
ment of SD; besides, there is not any statistically significant
correlation between the Tile classification and the gravity or
the frequency of SD. In another seven studies (41.2%), a sta-
tistically significant correlation was found between the com-
plexity of the fracture and the frequency of SD. In these stud-
ies, Tile B and C fractures were associated with a higher inci-
dence of SD in both males and females. For the Young-
Burgess classification, a statistically significant correlation
was found in all studies (4, 23.5%) between the presence of
APC or VS fractures and the gravity and frequency of SD.
Other factors that may influence the gravity and the incidence
of SD after pelvic fracture with statistically significant results
seem to be sacroiliac fractures, lumbar transverse process frac-
tures, symphyseal diastasis (> 25 mm), and pubic rami
fractures.
Other correlations
A noteworthy correlation concerns the association between
SD and surgical treatment in patients with pelvic fractures.
The authors of two studies [10,25] sustained that symphyseal
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plating was associated with higher incidence of DYS in their
series. Harvey-Kelly et al. [20], instead, sustained that an
ORIF of the pelvic fracture represents a higher risk for SD
compared with CRIF techniques and/or conservative
treatment.
Treatment and complications of pelvic ring injuries
Pelvic ring fracture management is closely related to the pel-
vic ring stability, defined as the capacity to support physio-
logic load when the patient is in sit, lie, or stand position [42].
Isolated anterior pelvic ring fractures (type A) are usually
stable and treated conservatively, while, injuries with posteri-
or ring or combined anterior and posterior pelvic ring involve-
ment (types B and C) are usually considered unstable and
surgical stabilization should be considered [42]. Non-
operative patients should be followed for at least one year to
determine the outcome and maintenance of the reduction.
Weight bearing is usually gradually allowed using crutches
or a walker after a variable period of bed rest [42]
Surgical treatment is needed in all cases of instability and/
or deformity of the pelvic ring and many techniques exist for
both open and closed reductions, but the main issue remains
achieving anatomic restoration of the pelvis [43].
Owing to the important wound complications following
open surgery, less invasive techniques, such as percutaneous
screw fixation, have been largely used over the last few years
to stabilize the posterior pelvic ring and lumbo-sacral junction
while reducing complications [44–50].
Among the analyzed studies, only 12 reported the ortho-
paedic treatment performed in 746 patients. In 452 of 746
cases (60.6%), open reduction internal fixation (ORIF) or
closed reduction internal fixation (CRIF) was performed, 51
patients (6.8%) were treated with external fixation whereas
243 (32.6%) were treated conservatively with bed rest and
physiotherapy (Table 1).
Anastomotic urethroplasty remains the gold standard for
the treatment of pelvic fractures urethral injuries (PFUI) and
the aim of this surgery is to allow a tension free bulbo-
membranous anastomosis [51]. In seven studies for a total of
227 patients, an urological treatment was performed. In 204 of
227, a urethral realignment was performed while in 22 cases, a
bladder or urethral reparation was performed.
Regarding neurosurgical repair of sacral plexus and periph-
eral genital nerves, or sacral electrical stimulation, some sur-
gical procedures were proposed principally for patients with
spinal cord injuries (SCI) [52]. The peripheral nerve transfer
into the nerves/roots below the injury seems to be a promising
approach. Itcould permit urinary and sexualfunction recovery
in patients with complete or incomplete S2–S4 lesions; how-
ever, only a few cases were described [52]. Sacral anterior root
stimulation (SARS) and later sacral deafferentation (SDAF)
introduced by Brindley [53] primarily for neurogenic bladder
dysfunction in SCI individuals could be an option for neuro-
genic sexual dysfunction management [54]. Zaer et al. in a
recent study with 287 patients [54] described a compensation
of erection reflex due to electrostimulation reflex erection in
30% of male patients after SARS-SDAF procedures. On the
other hand, no significant differences were observed in female
patients corroborating the theory that the women’ssexualcy-
cle is more controlled by mental excitements than physical
symptoms [54].
Excluding sexual dysfunction, seven of the 17 studies an-
alyzed reported the complications related to the fracture or to
the received treatment. In 87 patients, a persistent pain at the
last follow-up was observed. In 28 cases, neurological com-
plications were found. In 23 patients, a non-union or malunion
was detected. In 16 patients, a superficial or deep wound in-
fection was observed. Thromboembolic complications were
described in ten patients (Table 1).
Limitations
This study has some limitations. First, most of the studies
included in the analysis were retrospective case series with
no comparative group; unfortunately, no higher quality stud-
ies have been performed on the subject due to its high com-
plexity; in fact, it is not possible to perform randomized clin-
ical trials or double-blind controlled studies. Second, there is
variability in age groups and also follow-up. Third, there is a
lack of homogeneity in reporting fracture classification, eval-
uation scales, treatment, and outcomes.
Conclusions
SD after pelvic ring injuries, in both male and female patients,
represent a common consequence, with important influence
on quality of life, especially in young patients.
There is evidence in the literature that the gravity and fre-
quency of SD are related with the pelvic ring fracture type. In
fact, patients with APC, VS (according Young-Burgess), or C
(according Tile) fracture pattern reported higher incidence and
gravity of SD. Only a week association could be found be-
tween GUI and incidence and gravity of SD, and relationship
between surgical treatment and SD. Electrophysiological tests
should be routinely used in patients suffering from SD after
pelvic ring injuries. A multidisciplinary approach involving
orthopedist, urologist, neurologist, and neurosurgeon should
be recommended in the treatment of sexual dysfunction fol-
lowing pelvic injuries.
Author contribution The authors contributed equally.
International Orthopaedics (SICOT)
Funding Open access funding provided by Università Cattolica del Sacro
Cuore within the CRUI-CARE Agreement.
Data availability Not applicable
Declarations All patients provided the informed consentfor the pub-
lication of the clinical history. The study was authorized by the local
ethical committee and was performed in accordance with the Ethical
standards of the 1964 Declaration of Helsinki as revised in 2000.
Consent for publication Not applicable
Ethics approval and consent to participate Not applicable
Competing interests The authors declare no competing interests.
Open Access This article is licensed under a Creative Commons
Attribution 4.0 International License, which permits use, sharing, adap-
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