Abstract
Background/Aim: This study aimed to describe the voiding patterns of patients after surgical treatment of pelvic fractures and determine the predictive factors of lower urinary tract injuries (LUTIs) and spontaneous voiding failure among patients with surgically treated pelvic fractures at a tertiary trauma center in Japan. Patients and Methods: We retrospectively assessed patients with surgically treated pelvic fractures in our tertiary trauma center during May 2009–April 2021. We excluded patients who died during hospitalization and who had indwelling catheter prior to the injury. Patients’ LUTIs and spontaneous voiding failure at discharge were recorded. Multivariate analysis was performed to assess the predictive factors of LUTIs and spontaneous voiding failure at discharge. Results: In total, 334 eligible patients were identified. Among them, 301 patients (90%) voided spontaneously with or without diapers at discharge. Thirty-three patients required some form of catheterization for bladder drainage. LUTIs were found to be associated with chronological age [odds ratio (OR)=0.96; 95% confidence interval (CI)=0.92-0.99; p=0.024] and pelvic ring fracture (OR=12.0; 95%CI=1.39-255.2; p=0.024). Spontaneous voiding failure was associated with intensive care unit admission (OR=7.17; 95%CI=1.49-34.4; p=0.004). Conclusion: Overall, 10% of patients with surgically treated pelvic fractures were not able to void spontaneously at discharge. Spontaneous voiding failure after pelvic fractures was related to injury severity.
Overall, 2%-8% of all fractures are pelvic fractures, and motor vehicle accidents, falls, and industrial injuries are the most common causes of these fractures (1, 2). Pelvic fractures that require surgical stabilization are usually caused by high-energy trauma and are related to significant morbidity, mortality, and high cost (2, 3). Approximately 2%-25% of patients with pelvic fractures present with associated lower urinary tract injuries (LUTIs), such as bladder and urethral injuries, and these injuries cause long-term complications and a decrease in quality of life (1, 4-6). Erectile dysfunction, incontinence, and urethral strictures have been reported as long-term complications of LUTIs associated with pelvic fractures (7, 8). Additionally, patients with pelvic fractures have been reported to have urinary dysfunction in the absence of LUTIs. Notably, there are several studies investigating the incidence and epidemiology of urinary dysfunction in patients with pelvic fractures (9-12). However, these studies used various questionnaires, and detailed information regarding voiding patterns in patients with pelvic fractures has not been reported.
The present study aimed to describe the voiding patterns of patients after surgical treatment of pelvic fractures and determine the predictive factors of LUTIs and spontaneous voiding failure in patients with surgically treated pelvic fractures at a tertiary trauma center in Japan.
Patients and Methods
In this retrospective observational study, patients with pelvic fractures who presented at Teikyo University Hospital, Tokyo, Japan between May 2009, and April 2021 were included. Notably, all patients who underwent surgery for pelvic fractures in our institutional trauma registry were included. Those who died during hospitalization and those who had an indwelling urethral catheter prior to injury were excluded. This study was approved by the hospital’s institutional review board. All patients’ medical records were reviewed, and demographic information and lengths of stay were documented for each patient. Pelvic fractures were classified into two groups: acetabular and pelvic ring fractures. LUTIs were classified into bladder and urethral injuries; further, bladder injuries were classified into extraperitoneal or intraperitoneal injuries, and urethral injuries were classified in accordance with the American Association for the Surgery of Trauma classification system (13). Only injuries confirmed by imaging studies or operative procedures were considered in the present study. Primary in-hospital complications—pneumonia, septic shock, and deep vein thrombosis—were assessed according to the modified Clavien grading system (14). Voiding patterns at discharge were reviewed and classified according to the ability to void spontaneously, diaper use, and catheter requirements.
Continuous variables were expressed as a median and interquartile range, whereas categorical variables were expressed as frequency and percentage. Moreover, the Kruskal-Wallis test was used to compare continuous variables, and the chi-square or Fisher’s exact test was used to compare categorical variables. Binary logistic regression was used to evaluate the multivariate relationship between LUTIs and spontaneous voiding failure with all potential predictors and confounders. A p-value of <0.05 was considered statistically significant. All statistical analyses were performed using JMP® Pro statistical software version 16.1.0 (SAS Institute Inc., Cary, NC, USA).
Results
The trauma registry of our institution revealed 342 patients with surgically treated pelvic fractures during the 12-year study period. Seven patients who died during hospitalization and one patient with urethral catheter before injury were excluded; hence, the final cohort comprised 334 patients. Table I lists the demographic and clinical characteristics of all patients. The most common injury mechanism for all pelvic fractures was falls, which accounted for 54% of all cases. Moreover, the incidence of LUTIs was 3.3%. Of the eight bladder injuries, four were intraperitoneal injuries, and the remaining four were extraperitoneal injuries. Emergency bladder repair was performed for three intraperitoneal injuries; the remaining case combined with complete urethral disruption was treated with an open cystostomy. All extraperitoneal bladder injuries were managed using urethral catheter drainage. Regarding urethral injuries, one grade 5 injury and one grade 4 injury were treated using suprapubic catheterization. Moreover, two grade 3 injuries were conservatively treated using urethral catheterization. Regarding voiding patterns at discharge, 301 patients (90%) voided spontaneously; of these, 14 patients wore diapers. Twenty-five patients required urethral catheterization, six required clean intermittent catheterization, and two required suprapubic catheterization for bladder drainage.
Demographic and clinical characteristics of all patients.
A comparison of demographics and clinical indicators between pelvic fractures with and without spontaneous voiding at discharge is presented in Table II. Patients without spontaneous voiding were commonly female (52% vs. 32%; p=0.033) and had significantly higher rates of pelvic ring fractures (91% vs. 56%; p<0.001), transarterial embolization (70% vs. 30%; p<0.001), and intensive care unit (ICU) admission (94% vs. 55%; p<0.001). Logistic regression analysis including age, sex, mechanisms of injury, and pelvic fracture type identified age and pelvic ring fracture as significant predictive factors associated with LUTIs (Table III). Logistic regression analysis, including age, sex, mechanisms of injury, pelvic fracture type, LUTIs, ICU admission, and length of ICU stay, identified ICU admission as a significant predictive factor associated with spontaneous voiding failure (Table IV).
Comparison of patient demographics with and without spontaneous voiding.
Logistic regression analysis of potential predictors of lower urinary tract injuries.
Logistic regression analysis of potential predictors of spontaneous-voiding failure.
Discussion
This study investigated the voiding patterns of patients after surgical treatment of pelvic fractures as well as the predictive factors of LUTIs and spontaneous voiding failure in patients with surgically treated pelvic fractures at a tertiary trauma center in Japan. In our cohort of 334 patients, 90% of patients could void spontaneously at discharge. The remainder required some form of bladder drainage including clean intermittent catheterization and cystostomy. Compared with patients who could void spontaneously at discharge, those who could not were commonly female and had significantly higher rates of pelvic ring fractures and ICU admission. ICU admission was found as a predictive factor of spontaneous voiding failure at discharge, and chronological age and pelvic ring fractures were found as predictive factors of LUTIs.
Several investigators have evaluated the incidence and clinical characteristics of urinary dysfunction associated with pelvic fractures (9-12). However, the studies by these investigators were based on various questionnaires, and the definition of urinary dysfunction varied from study to study. In a multicenter cohort study of 1,160 patients at 12 trauma centers, 292 patients had pelvic fractures; moreover, excretory dysfunction (bladder or bowel incontinence) based on the Functional Capacity Index (15) was reported in 8% of patients with pelvic fractures after 1 year of injuries. In addition, sacroiliac fractures and symphyseal diastasis in men and women, respectively, were associated with excretory dysfunction (10). In a single-center retrospective observational study of 151 patients with surgically treated pelvic ring injuries, the incidence of new urinary dysfunction defined by the original questionnaire was 41%, and urinary dysfunction was associated with pelvic fracture type but not with age, sex, or LUTIs (11). In another single-center retrospective observational study of 113 patients with surgically treated pelvic fractures, male urinary dysfunction based on the International Consultation on Incontinence Questionnaire (16, 17) was predicted by the Injury Severity Score (18) and pelvic fracture type, whereas female urinary dysfunction was predicted according to urinary tract injury at admission (12).
To the best of our knowledge, this is the first study to reveal the specific voiding patterns of patients with pelvic fractures. In our study, 10% of patients with pelvic fractures were unable to void spontaneously at discharge. Although the results of our study are short-term results, there have been no previous studies on the specific voiding status after pelvic fractures, and we believe that our study is valuable in that regard. Furthermore, the predictive factor of spontaneous voiding failure in our study was ICU admission. Owing to the fact that ICU admission was associated with spontaneous voiding failure, the severity of the injury itself probably had a major effect on short-term voiding dysfunction after pelvic fractures. In contrast, LUTIs were associated with chronological age and pelvic ring fractures in our study. In a single-center retrospective observational study of 362 patients with blunt pelvic fractures, the widened symphysis and sacroiliac joints were associated with bladder injuries, whereas the widened symphysis and fractures of the inferior pubic ramus were associated with urethral injuries (4). In a single-center retrospective nested case-control study of 119 male patients with pelvic fractures, displaced inferomedial pubic fractures and symphysis pubis diastasis were independently associated with urethral injury (5). The results of our study were similar to those of previous studies, except for chronological age. The association with chronological age may be because pelvic fractures in the elderly include fragility fractures that are less likely to lead to other organ injuries, including LUTIs (19).
This study had several limitations. The first limitation is the single-institutional, retrospective, and observational design of the study. The second limitation is the lack of long-term follow-up of patients with pelvic fracture. Based on the findings of the present study, a long-term trend of deterioration in urinary function over time and a longitudinal follow-up of voiding patterns will be the subject of future research. The third limitation is related to the assessment of voiding dysfunction. Using spontaneous micturition at discharge as an endpoint to assess voiding dysfunction can be controversial. Furthermore, the lack of urodynamic study data is a major limitation. However, we believe that the percentage of patients who were able to void spontaneously at discharge is valuable information for counseling patients with pelvic fractures.
In conclusion, this retrospective observational study evaluated patients with surgically treated pelvic fractures at a tertiary trauma center in Japan. Overall, 10% of patients with pelvic fracture were not able to void spontaneously at discharge, and spontaneous voiding failure after pelvic fractures was associated with ICU admission.
Acknowledgements
The Authors would like to thank Enago (www.enago.jp) for the English language review.
Footnotes
Authors’ Contributions
Tomoyuki Kaneko: Conceptualization (lead); data curation (lead); writing – original draft (lead); writing – review and editing (lead). Kazuki Yanagida and Kentaro Matsui: Data curation (lead); writing – review and editing (supporting). Taketo Kawai, Yukio Yamada, Takashi Suzuki, Taketo Kurozumi, and Keisuke Ishii: Data curation (supporting); writing – review and editing (supporting). Yoshinobu Watanabe, Tetsuya Sakamoto, and Hirotaka Kawano: Writing – review and editing (supporting); supervision (supporting). Tohru Nakagawa: Writing – review and editing (supporting); supervision (lead).
Conflicts of Interest
The Authors declare no conflicts of interest in relation to this study.
- Received March 21, 2023.
- Revision received March 31, 2023.
- Accepted April 3, 2023.
- Copyright © 2023, International Institute of Anticancer Research (Dr. George J. Delinasios), All rights reserved
This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY-NC-ND) 4.0 international license (https://creativecommons.org/licenses/by-nc-nd/4.0).
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