Comparison of sexual function and quality of life after pelvic trauma with and without Angioembolization

Sexual dysfunction after major trauma is a significant long term problem in those
patients that survive their injuries. The causes for this are multifactorial 14]. Magnetic resonance imaging and duplex ultrasound results show that there is an underlying
vascular cause to impotence after pelvic trauma in up to 80 % of affected men 15]. Conversely, Mark et al. suggested a neurogenic cause for impotence; this was evident
by a successful response to self injection of vasoactive agents. They concluded that
bilateral pubic rami fractures carry a high risk for impotence due to disruption of
the cavernosal nerves 16]. Decreased blood flow to the penis has been observed in renal transplant patients
where the donor’s renal artery has been anastomosed in an end to end fashion to the
recipient’s internal iliac artery, but in the absence of atherosclerosis no negative
effects on erectile function has been observed 17]. In females, damage of the soft tissue in the perineum with resultant scar tissue
formation and the residual deformity of the posterior pelvic ring and its associated
posttraumatic arthritis of the sacroiliac joints among other have been considered
as plausible causes for dyspareunia 18], 19]. Psychogenic factors manifested by anxiety, depression and post traumatic stress
also have an adverse effect on sexual life 20].

The use of AE in hemorrhaging vessels is an essential modality for localizing and
treating arterial bleeding in patients presenting with pelvic fractures and hemodynamic
compromise. This modality has been associated with a lower blood product transfusion
requirement and is generally considered an appropriate replacement to operative management
21]. The relative safety of AE in the short term has been demonstrated. In a prospective
study, Velmahos et al. stated that AE should be used “liberally” in the setting of
pelvic fractures complicated by hemorrhage 22]. There are reports, however, of short and long term complications such as perineal
necrosis as well as buttock, thigh and perineal paresthesia, particularly after undergoing
bilateral internal iliac artery AE 7]. There is limited data, however, on the effect that these complications have on long
term sexual function, particularly in women.

The FSFI and the IIEF are validated questionnaires that provide quantitative measures
assessing various aspects of male and female sexual function. Using the IIEF questionnaire
for men, Malavaud et al. found a 30 % incidence of erectile dysfunction in patients
sustaining pelvic fractures. Their patient group scored significantly lower in the
overall satisfaction domain than controls 23]. Metze et al. reported short term sexual impairment as high as 61 % in men after
pelvic injury. Over half of their cohort had erectile dysfunction post injury with
the majority recovered within 12 months 10]. In women, many reports found that pelvic fractures had been associated with sexual
impairment, dyspareunia and difficulty with vaginal delivery 24]. In a study by McCarthey et al. studying sexual function and QOL in female patients
post pelvic fractures, they found that 51 % of the patients reported feeling less
sexual pleasure and 19 % reported dyspareunia. The QOL of their cohort was significantly
lower than normal controls as evidenced by the low scores in almost all the domains
of the SF36 questionnaire 25]. Black et al. reported a 61 % incidence of sexual dysfunction in 13 female patients
following pelvic fracture associated with urethral and bladder neck injury 26]. In the only study studying sexual function after AE, Ramirez et al. considered the
effect that bilateral internal iliac AE had on male sexual function after pelvic fractures.
In their report, they compared patients who had AE to two matched groups; 1) patients
with pelvic fractures that did not require AE and 2) a control group of trauma patients
without pelvic injury. Both pelvic fracture groups showed significantly compromised
sexual function compared to the group without pelvic fractures and concluded that
male sexual dysfunction was due to the pelvic fracture, not AE 9]. Non-validated questions were used, however, to reach these conclusions.

Our results confirm these findings; AE does not contribute to poor long term sexual
function over and above the dysfunction suffered from pelvic injuries. Within our
total population, there were equivalent rates of sexual dysfunction, as based on the
IIEF and the FSFI results, regardless of whether or not AE was performed.

Disappointingly, only 1 woman that underwent AE completed the survey. After combining
all female subjects (i.e. with and without AE) completing the FSFI, we demonstrated
poorer overall long term sexual function compared to the normal control population.
For men, while there was a significant reduction in long term sexual function compared
to normal controls, AE did not play a role in this decline. The possibility for type
II error exists in the erectile function domain, however. Those patients that underwent
AE had a score less than half of those subjects that did not undergo AE. This p value was close to the 0.05 considered significant. A possible cause for this result
may lie within the age of our cohort. Our overall group was older than other reported
populations. There is a possibility that the reduction in blood flow that results
in AE impacts elderly men more significantly than younger patients.

QOL results, as judged by the SF36, demonstrated similar findings to long term sexual
function; AE itself is not the cause poor QOL, but rather, pelvic trauma is. Those
patients with pelvic trauma had similar scores regardless of the need for AE. When
comparing all pelvic fracture patients to normal controls, there were significantly
lower scores in 4 of the 8 domains.

Our study has some limitations. First, despite that the response rate for our survey
is on par with other questionnaire studies, a 39 % survey completion rate limited
our conclusion. Not only are trauma patients notorious for poor follow-up rates, we
believe that the topic of the questionnaire significantly impacted the return rate.
Due to the design of our study, we were able to call potential subjects. A significant
number of patients, particularly women, refused to complete the survey due to the
nature of the questions asked. Sexual function is a difficult topic for any person
to consider, particularly after the severe body image perceptions that can result
from trauma. Both sexual function surveys ask graphic questions related to lubrication,
dyspareunia and orgasm, information some potential subjects were unwilling to share.
As a result, we were unable to complete one of our aims; that of evaluating long term
sexual function in women after AE. In addition to preventing us from performing one
of our stated aims, the lack of data from 61 % of potential subjects biased the results
and may have resulted in further type II error given the small number of responders.
Second, there is an average of 6 years delay between the onset of injury and the time
of survey enrolment, this could have added an age related decline in sexual function.
Third, this is a retrospective study, making it hard to draw a cause and effect relationship.