There is an established association between ED and pelvic fracture urethral injuries (PFUIs). However, ED can occur after the injury and/or the urethral repair. To our knowledge, only one study of erectile function (EF) after urethroplasty for PFUIs used a validated questionnaire. This study was carried out to determine the impact of anastomotic posterior urethroplasty for PFUIs on EF. We retrospectively reviewed the computerized surgical records to identify patients who underwent anastomotic urethroplasty for PFUIs from 1998 to 2014. Those patients were contacted by phone or mail and were re-evaluated in the outpatient clinic by International Index of Erectile Function questionnaire; in unmarried men, the single-question self-report of ED was used for evaluation of EF, clinical examination and penile color Doppler ultrasonography (CDU) for men with ED. Overall, 58 patients were included in the study among whom 36 (62%) men were sexually active and the remaining 22 (38%) were single. The incidence of ED among our group is 72%. All patients developed ED after initial pelvic trauma and none of our patients had impaired EF after urethroplasty. The incidence of ED increased proportionally with severity of pelvic trauma. All patients with type-C pelvic fracture, associated symphysis pubis diastasis, sacroiliac joints diastasis and bilateral pubic ramus fractures had ED. Men with PFUIs had worse EF than men in other series with pelvic fractures without urethral injury. The majority (88%) of men with ED showed veno-occlusive dysfunction on penile CDU. So we concluded that men with PFUIs had a high incidence of ED up to 72%. Anastomotic posterior urethroplasty had no negative impact on EF and the development of ED after PFUIs was related to the severity of the original pelvic trauma. Veno-occlusive dysfunction is the commonest etiology of ED on penile CDU.
Pelvic fracture urethral injuries (PFUIs) often result from high-velocity injuries that are associated with disruption of the pelvic ring.1 Urethral injuries associated with PFUIs were initially termed pelvic fracture urethral distraction defects by Turner–Warwick based on the assumption that they were usually complete injuries. However, the International Consultation on Urological Diseases recommended replacing pelvic fracture urethral distraction defect with PFUI, because these injuries are not complete disruptions in most cases and that, even when they are complete, they are not necessarily distracted.1
Pelvic fracture with or without urethral injury have been linked to ED with an incidence varying from 18% to 72%.2, 3, 4, 5, 6, 7, 8, 9, 10 ED is thought to be vasculogenic, neurogenic, corporal and psychogenic in etiology.11
A variety of treatment approaches exist for urethral strictures, including urethral dilation, internal urethrotomy and urethral stenting. Open urethroplasty is a highly effective and durable approach for treating stricture disease. One of the more concerning complications of urethroplasty is postoperative ED. The theoretical risk of ED comes from the close relationship of the cavernous nerves with the proximal urethra when they emerge from the pelvic floor12 and this risk is supported by reports of ED after anterior and posterior urethroplasty.10, 13
On the other hand, some authors believe that neurovascular damage to the cavernous nerves that occurs at the time of pelvic injury rather than the corrective urethroplasty is the primary cause of ED in men with PFUIs. Dhabuwala et al.5 found that none of the patients who had adequate erections for intercourse before urethroplasty developed ED after surgery. A similar conclusion was also reported by Mark et al.8
To the best of our knowledge, only one study of erectile function (EF) after posterior urethroplasty repair of PFUIs2 used validated questionnaire such as International Index of Erectile Function (IIEF).14 That study included a small number of patients and also no detailed information on the nature of pelvic fracture and associated injuries were available. In the present study, we used a validated questionnaire after posterior anastomotic urethroplasty to determine the relation between EF and PFUIs and urethroplasty. Furthermore, we compared our results with previously published results assessed with the same tool.
Materials and methods
After institutional review board approval, the computerized surgical records were retrospectively reviewed to identify patients who underwent perineal anastomotic posterior urethroplasty for PFUIs from June 1998 to January 2014. Clinical presentation, investigations, operative and postoperative details were reviewed from the patient charts. The imaging studies were reviewed, and according to Tile’s classification,15 pelvic fractures were categorized as type-A fracture, which is a minimally displaced stable fracture. Type B is a rotationally unstable fracture that is vertically stable. Type C is both rotationally and vertically unstable.
All surgical repairs were approached through inverted U-shaped or midline perineal incisions with the patient in an exaggerated lithotomy position. The bulbar urethra was dissected down to the distal end of the strictured segment, which led to the apex of the prostate. After excising all scarred tissue, the distal urethral end was spatulated after mobilizing the anterior urethra and a tension-free mucosa-to-mucosa anastomosis was made with four to six sutures of 4/0 polyglycolic acid over a silicon Foley catheter. The operation was completed by inserting a suprapubic tube and closing the perineal wound with a drain. None of our patients required supra-crural re-routing or symphysiotomy to complete the anastomosis.
The silicon catheter and suprapubic cystostomy drainage were maintained for 21–28 days after surgery. After removing the urethral catheter, a gravity voiding film, with contrast medium infused through the suprapubic cystostomy tube, was taken to confirm the integrity of the repair, and if satisfactory the suprapubic cystostomy catheter was removed 1 day later.
Patients were contacted by mail or phone and were re-evaluated in the follow-up outpatient clinic after informed consent was obtained. Assessment of the complaints of ED was achieved using the IIEF questionnaire,14 which consists of 15 questions evaluating EF, orgasmic function, sexual desire, intercourse satisfaction and overall satisfaction domains. The degree of erection was assessed on the basis of the score of the six questions from the EF domain of the IIEF and classified as mild ED (score 17–25), moderate (score 11–16) and severe dysfunction (score <10). Patients with erection score between 26 and 30 did not suffer from ED. In unmarried men the single-question self-report of ED was used for evaluation of EF.16
All the patients were interviewed during which a complete medical and sexual history was taken to detect any possible risk factors for ED, such as cigarette smoking, hypertension, the use of antihypertensive drugs and diabetes mellitus. Particular attention was given to the patient’s ability to obtain an erection before pelvic fracture, immediately after trauma and after urethroplasty. Patients with ED were evaluated by penile color Doppler ultrasonography (CDU) (Acuson, Mountain view, CA, USA).
The type of pelvic fracture was correlated with ED using the Fisher's exact test. The results of this study were further compared with previous studies who had used the same assessment tool for evaluation of EF after pelvic fracture7, 17 and after urethroplasty2 using Student's one-sample t-test. Data were processed using SPSS-16 for Windows (SPSS, Chicago, IL, USA). A P-value of <0.05 was considered significant.
Overall, 58 patients were included in the study. The mean±s.d. (range) age of the patients at the time of interview was 31.6±12.2 (16–73) years and the mean±s.d. (range) time from the urethroplasty to the interview was 61.3±46.7 (6–165) months. No patient had complained of impaired EF before pelvic trauma. None of the patients had major medical illness, diabetes mellitus, neurological abnormalities or psychological disorders at the time of interview. The cause of trauma was road traffic accident in all patients.
Among the 58 patients, 36 (62%) men were married (sexually active) and the remaining 22 (38%) were single (sexually inactive). The incidence of ED was 72% (42 patients) (Figure 1). Among the sexually active men, 86.1% complained of ED and 2/3 of them had severe ED and the mean EF domain score was 13.7±8.3. The development of ED in all of our patients started after the initial pelvic trauma with no relation at all to urethroplasty.
The mean±s.d. stricture length of patients with good EF was 3.6±1.2 cm and that of patients with ED was 4.1±1.3 cm with no statistical significant difference (P=0.29). We found that the incidence of ED increased proportionally with severity of pelvic trauma. All patients (100%) with type-C pelvic fracture had ED compared with 68% and 80% of type A and B, respectively, with statistically significant difference (P=0.049). Also, we found that all patients with symphysis pubis diastasis, sacroiliac joints diastasis and bilateral pubic ramus fractures had ED, and these differences were statistically significant; Table 1.
We reviewed Medline and identified two studies that previously used the IIEF to evaluate EF in men who sustained pelvic fractures, namely, Malavaud et al.7 and Metze et al.17 In addition, we identified one study that used the IIEF questionnaire to evaluate EF after posterior urethroplasty for PFUIs, namely, Anger et al.2 The EF domain scores among men with PFUIs in our study were lower than those found in the previous three studies; results are demonstrated in Table 2.
Among the 42 patients with ED, penile CDU showed veno-occlusive dysfunction in 37 (88%) patients, arterial insufficiency in 2 (4.7%) and mixed etiology in 3 (7.3%) patients.
ED is a well-known complication of pelvic fractures, particularly those associated with posterior urethral injuries. Recent studies in the urological literature indicate the incidence of ED to be between 18% and 72%.2, 3, 4, 5, 6, 7, 8, 9, 10 This difference is most likely due to the variability in the criteria used to define ED. The main definition of ED was an inability to obtain an erection firm enough for vaginal penetration, used in nearly half of the studies.3, 4, 5, 8
Although Anger et al.2 defined ED using the IIEF questionnaire,14 the BSFI (Brief Male Sexual Function Inventory)18 scoring system was used to define sexual dysfunction in another study.9 In a single study, the presence of abnormal nocturnal EF and RigiScan were used for objective evaluation of ED.10 Of the questionnaire-based studies, three used the validated sexual function questionnaire of the IIEF.14 Two of these studies included patients with pelvic fracture7, 17 and the remaining study included cases of urethroplasty after PFUIs.2 The questionnaire-based assessment provides a reproducible method of gathering relevant information.
In our study, we found significant compromise of EF among men with PFUIs; ED was identified in 72% (42 patients). Among the sexually active men, 86.1% complained of ED and 2/3 of them had severe ED and the mean EF domain score was 13.7±8.3. The severity of ED in this patient cohort was worse than that found in two separate series of men with pelvic fractures.7, 17 This observation indicates that men who sustain PFUIs are at greater risk of ED than other men with pelvic fracture. Also, the mean EF domain in our study was lower than that reported by Anger et al.2 This could be explained by the fact that our patients were evaluated with a minimum of 6 months follow-up compared with 1 year in the study by Anger et al.2 and we therefore might have overestimated ED in some patients.
Several risk factors for ED after PFUIs have been identified. Ozumba et al.9 previously used BSFI questionnaire and found that older patients had significantly worse EF than younger men. Malavaud et al.7 found that pubic diastasis to be the only factor that was significantly associated with ED. In a series of 77 men by Metz et al.,17 ED was significantly associated with both distraction type-B injuries and posterior pelvic ring disruptions. Recently, in a study of 90 men with PFUIs, Koraitim6 found that the development of ED after PFUI can be predicted by three factors, namely, diastasis of pubic symphysis, lateral prostatic displacement and long urethral gap.
In this study, we found that the development of ED was significantly associated with the severity of initial pelvic trauma. All patients (100%) with type-C pelvic fracture had ED compared with 68% and 80% of type A and B, respectively, with statistically significant difference. Also we found that all patients with symphysis pubis and sacroiliac joints diastases and bilateral pubic ramus fractures had ED and that these differences were statistically significant.
The preferable timing of assessing sexual function following pelvic fracture is another area of discrepancy among the authors in the existing literature. Dhabuwala et al.,5 Mark et al.8 and Metze et al.17 showed that recovery in male EF could occur up to a maximum of 18 months after injury. However, men had been shown to have an improvement of EF even up to 2 years after surgery.2 Our patients were evaluated with a minimum of 6 months postoperatively and we therefore might have overestimated ED in a few of the patients.
The etiology of ED is thought to be vasculogenic, neurogenic, corporal and psychogenic.11 Shenfeld et al.,10 using penile duplex ultrasonography, arteriogram and response to intracavernous vasoactive injection, showed that 72% of patients had a neurogenic cause of ED, whereas vasculogenic etiology was implicated in the other 28%. In addition, Asci et al.3 reported penile vascular insufficiency as the major etiological factor causing ED in patients with pelvic fracture. Mark et al.8 suggested a neurogenic etiology owing to the frequent association of ED with pubic rami fractures and the relation of this fracture pattern to cavernous nerve damage.
In our study, we found that veno-occlusive dysfunction is the commonest finding in CDU (88% of patients). This high incidence could be explained by the fact that nerve trauma which occurred during pelvic fracture (known as neuropraxia) results in loss of daily and nocturnal erections leading to persistent cavernous hypoxia. Such penile hypoxia results in collagen accumulation, smooth-muscle apoptosis and fibrosis caused by transforming growth factor beta 1 production.19, 20 These changes lead to ED because of veno-occlusion of the corpus cavernosum and to permanent ED. As most of our patients were evaluated long time after repair of PFUIs (mean=61 months), this long period mostly lead to irreversible morphological and functional changes to the erectile tissue and veno-occlusive mechanism. So these men represent a target group for early penile rehabilitation programs as previously recommended by Anger et al.2 to avoid such hypoxic irreversible changes of corpora cavernosum.
We acknowledge some limitations in our study; first, the time from injury to IIEF assessment was on average 61 months. There is an obvious temporal bias and recall bias. An adverse change in EF could occur over that 5-year period from treatment to survey. It may also be difficult to recall EF preinjury as the patient age range was 16–73 years and some patients may have had ED preaccident. Second, the role of neurological injury in the pathogenesis of ED after PFUIs cannot be proved as these minute structures cannot be confirmed by imaging. In addition, our study did not contain data about the response to medical treatment of ED in such critical group of patients. Furthermore, the limited number of patients necessitates confirming the results on a larger scale of patients. Finally, as ED was evaluated by self-reporting questionnaires carried only once at the time of postoperative interview, future studies are encouraged to study the effect of time on EF.
Men with PFUIs have a high incidence of ED occurring in up to 72% in such patients. Anastomotic posterior urethroplasty has minimal impact on EF as none of the patients with adequate erection before urethroplasty developed ED after surgery. The development of ED after PFUIs is related to the severity of the original pelvic trauma. The highest incidence of ED is associated with type-C pelvic fracture and patients with symphysis pubis diastasis, sacroiliac joints diastasis and bilateral pubic ramus fractures. Veno-occlusive dysfunction is the commonest finding in penile duplex ultrasonography in men with ED after PFUIs, so these men represent a target group for early penile rehabilitation programs.
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The authors declare no conflict of interest.
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El-Assmy, A., Harraz, A., Benhassan, M. et al. Erectile function after anastomotic urethroplasty for pelvic fracture urethral injuries. Int J Impot Res 28, 139–142 (2016). https://doi.org/10.1038/ijir.2016.18
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