Every year in the United States, over 100,000 traumatic injuries to the pelvis occur, with the majority of these occurring in men under the age of 45 years.^1-3 While the mortality rate from such injuries was previously as high as 35%–40%, improvements in multidisciplinary trauma care and motor vehicle safety have led to significant improvements in overall survival and, thus, a growing population of patients who are now living past these traumas, albeit with the long-term adverse side effects that often accompany such injuries. Sexual dysfunction resulting from pelvic fracture has been well-established in the urological literature for some time, but much of the supporting data come from studies focused on patients with coexistent lower urinary tract injuries. However, while patients with pelvic-fracture urethral injuries likely have the highest rates of associated sexual dysfunction following injury, focusing on this group alone misses the approximately 98% of pelvic fracture patients without urethral injury but who are still at high risk for development of sexual health complications.

Data from an online survey sent to men treated for traumatic pelvic fractures at a single, large Level I trauma center who did not have associated lower urinary tract injuries found that 46.3% of respondents reported de novo sexual dysfunction following injury.⁴ Interestingly, while most of the prior literature has focused on erectile dysfunction (ED) alone as a marker for sexual dysfunction in this population, only 27.9% of responders reported ED as their primary sexual health complaint. Difficulty with orgasm and/or ejaculation, decreased libido, pain with intercourse, genital numbness and genital pain were frequently noted and found to have a significant negative impact on patients’ overall quality of life (fig. 1). Furthermore, of those with reported sexual health issues following injury, only 16.6% reported spontaneous resolution of their symptoms over time and, notably, if this resolution did not occur within 1 year of injury, it was exceedingly unlikely to occur afterward.

Figure 1. Characterization of sexual health complaints in men reporting sexual dysfunction following pelvic fracture.⁴

Further evaluation of this cohort of men found that after adjustment for injury characteristics, age and relationship status, men with untreated sexual dysfunction reported significantly decreased overall health-related quality of life (HrQOL) as measured by the EQ-5D (EuroQol Group 5 dimension questionnaire) generic health-related quality of life instrument.⁵ Interestingly, a decline in any individual domain (erectile function, orgasmic function, intercourse satisfaction or overall satisfaction) of the International Index of Erectile Function questionnaire led to a significant decline in overall HrQOL. The presence of ED in particular following injury was associated with an approximately 1.6 quality-adjusted life year loss per 10 years relative to men without ED (fig. 2). As such, it was not surprising to find that 67% of subjects reported that sexual health was important to very important in determining their overall quality of life.⁴ Taken together, these data suggest that although there may be many factors that affect HrQOL following traumatic pelvic fracture, untreated and persistent sexual dysfunction appears to have a measurable and independent impact on the livelihoods of these men after injury.

Figure 2. Impact of ED on EQ-5D visual analog scale scores for HrQOL.⁵

Despite these findings, men are exceedingly unlikely to raise the topic of sexual health in conversation with health care providers after injury. Of men who reported difficulties with sexual health, only 28.6% reported having discussions with health care providers about this topic, and of those who did, 74.3% of these discussions were patient-initiated.⁴ There were multiple reasons patients reported they avoided raising the topic: assuming their issues would resolve, lack of knowledge that their sexual health concerns were related to injury, embarrassment, feeling they did not have appropriate providers to discuss the topic with and lack of confidence in raising the topic, to name a few. However, an in-depth qualitative study involving multiple subject interviews revealed that patients are often desperate to have these issues discussed at their followup appointments and to have appropriate expectations for treatment and recovery set.⁶ Patients reported that the lack of communication and predetermined care pathways related to sexual health after injury resulted in significant distress and feelings of helplessness, such that they felt that their concerns related to their sexual health were often marginalized and delegitimized.

Taken as whole, these data suggest that there is ample room for improvement when it comes to establishing patient-centered trauma survivorship programs with a focus on sexual health. Nonetheless, there are a number of inherent difficulties in the establishment of such programs. How to communicate information and expectations regarding sexual health most effectively to patients, at what time and through what means remains unknown. Care of trauma patients is often fragmented and inconsistent, and long-term care is often left to primary care physicians who may not feel appropriately equipped to handle such a task. Lastly, appropriate screening for sexual health issues often takes a back seat to other patient and provider priorities in the immediate post-injury period and may be ignored until such a time that a patient has already begrudgingly accepted that this is now part of their new normal.

But there is room for optimism. By establishing the prevalence and burden of these issues in survivors and recognizing the impact that they have on patient experiences and quality of life, we can take the first steps in improving the care we provide. Establishment of close working relationships with orthopedic surgeons, trauma surgeons and physical therapists may help raise awareness of sexual health as a component of survivorship and help to begin the process of bringing screening for sexual health issues into normal post-injury care pathways. Just as care for prostate cancer survivors does not end once the cancer is cured, care for pelvic trauma survivors should not end once the bones are healed.