Each year in the United States, over 100,000 patients are treated for pelvic fractures with a mortality rate of 7 to 25% [5
]. The pelvis is a stabilizing structure of the lower extremity and trunk with major structures passing through, including genitourinary, vascular, neurologic, and gastrointestinal structures. There can be major problems in terms of functional recovery. Female patients may be concerned about participation in sexual activity and possibly future ability to bear children. In a retrospective review of women of childbearing age with pelvic fractures, we asked whether (1) genitourinary and sexual dysfunction can be expected even with stable pelvic fractures treated nonoperatively; (2) functional outcomes are related to fracture pattern and surgery; and (3) women treated nonoperatively and those treated surgically with fixation sparing the symphysis can deliver children vaginally.
We note several limitations. First, this was a retrospective study. However, this sort of study must necessarily be retrospective as it would not be feasible to follow women of childbearing age who had a pelvic fracture in anticipation of possible childbirth. Second is the low response rate of 13%. Trauma patients may be more transient in nature and loss of followup is common. On the other hand, questions regarding sexual relations, such as frequency, orgasm and pain are sensitive issues. It is possible women who received the survey chose not to respond after reading the questions and they did not want to share details of intimate relations. More than 50% of the women who responded in our study did have children after their pelvic fracture. This may lead to a selection bias in reporting the outcomes. We believe the women who did have children after pelvic fracture selectively responded to the survey, and while this does provide some desired information, there may be women who had difficulty getting pregnant who chose not to respond, and they may have a poorer functional result. Third, pelvic fractures range from nondisplaced so called “minor” fractures to vertically and rotationally unstable injuries. One wonders whether the severity and/or treatment of the fracture may affect the postinjury nature of genitourinary and sexual complaints. In a study of 233 women with pelvic fractures and major lower extremity trauma, 45% of women reported feeling less sexually attractive and 39% reported a decrease in sexual pleasure [11
]. In our study, 45% of the women reported less interest in sexual intercourse and reaching orgasm less than before their fracture.
Pelvic fractures are known to affect genitourinary function. Urinary complaints were more common, especially in women with residual pelvic fracture displacement [2
]. In our study, we evaluated the fracture patterns but did not record residual displacement. We found close to half (49%) of women with pelvic fractures had one or more genitourinary complaints, and this was not related to fracture pattern/stability. This topic is not well covered in the literature with only one article addressing specifically female genitourinary complaints after pelvic trauma. Copeland et al. found women were more likely to have more than one urinary complaint, finding 57 complaints in 26 subjects [2
]. The overall rate of urinary complaints compared to controls in her study was 21% [2
]. There were few genitourinary injuries recorded in that population and perhaps subclinical soft tissue injuries or prolonged urinary catheterization could have been the contributing factors [2
]. We did not evaluate the associated soft tissue injuries or length of urinary catheter use in our patients. Overall, without direct genitourinary injuries such as bladder rupture or vaginal laceration, one would not expect a 49% rate of urinary complaints, but perhaps this is not fully evaluated or asked in the post injury followup.
There is increasing interest in the effect of trauma on functional outcomes. There are validated outcome measures used. In a study of women with major lower extremity trauma and women with pelvic fractures, the SF-36 was used and compared to age standardized norms. The patients as a group scored considerably worse in all dimensions [11
]. In our study, we looked for differences in outcome related to fracture type and treatment. We did not find differences in overall scores. However, the overall SF-12 scores were higher in women who had children after a pelvic fracture. Considering that women have a higher rate of posttraumatic stress disorder and postpartum depression can occur [4
], this result was not anticipated. There was an average of 6 years from the trauma until the patients completed the forms. Perhaps this length of time after trauma and having a child both contributed to the better overall functional outcome score.
The treatment for pelvic fractures ranges from nonoperative with full weight bearing to limited weight bearing and percutanous fixation to open reduction and internal fixation. Even the so-called stable lateral compression pelvic fracture may be considered unstable and treated operatively [7
]. Thus, it is difficult to predict the type of delivery a woman may have should she get pregnant after a pelvic fracture. In one paper directly evaluating cesarean section rates of women with pelvic fractures who had children before and after their fracture, the cesarean section rate was substantially increased postinjury (14.5% preinjury versus 48% postinjury) [2
]. Other authors have reported variable rates of cesarean section after pelvic fractures, ranging from 8% to 66% [10
]. Currently, the American College of Obstetrics and Gynecology reports the cesarean section rate to be 31% [9
]. Our rate of cesarean sections in women after pelvic fracture was double the rate in the United States. The history of pelvic fracture contributed to 44% (seven of 16) cesarean sections and history of cesarean section was responsible for 25% of the cesarean sections. A trial of labor was only given in one of 11 cesarean sections. Cesarean sections expose the patient and fetus to anesthetic and surgical risk. The decision may not be based on any factor other than lack of knowledge regarding the ability to deliver vaginally after a pelvic fracture because 77% of obstetricians who completed the patient’s records indicated they had not treated patients with pelvic fractures. There may be a concern for litigation. Other factors that may contribute to increased cesarean section rates after a pelvic fracture include the question of whether pelvic disproportion exists, obstetrician training and experience, and previous results [3
Overall, there is a paucity of data and a variety of published opinions regarding childbirth after pelvic fractures [2
]. Our data suggest the cesarean section rate is more than double standard norms, but vaginal delivery after pelvic fracture, even in those treated with surgical fixation sparing the pubic symphysis, is possible. In addition, women who had children after pelvic fractures had considerably higher SF-12 overall scores. That was an unexpected, yet encouraging result. Pelvic fractures represent a serious injury for women of childbearing age. The possible genitourinary, sexual and functional outcomes along with ability to have a vaginal delivery after surgical fixation of a pelvic fracture should be discussed with patients.