Our disclosures are as listed. Pelvic trauma is a known risk factor for stress urinary incontinence. In fact, in a retrospective cohort study, the absolute risk of stress urinary incontinence immediately following pelvic fracture was 3.3% versus 1% in a matched general population. The hazard ratio for stress incontinence surgery following fracture was 5.8. Moreover, traumatic pelvic ring disruption has been shown to increase the likelihood of developing de novo genital urinary and GI tract disorders, including urinary and fecal urgency, dyspareunia, and incomplete emptying. We present a case of pelvic trauma. Our patient is a 75-year-old female with worsening urinary incontinence following pelvic trauma. Her history is notable for osteoporosis and a history of mild, urge-predominant mixed urinary incontinence. She has a history of uterovaginal prolapse, which was surgically managed with a vaginal hysterectomy and native tissue repairs seven years prior. The patient and her husband own a tree removal service. In April 2018, she suffered several injuries when a tree fell on her. Her injuries included several broken ribs, a pneumothorax, a fracture of her T12 vertebrae, as well as six pelvic fractures. Here's a radiograph from the hospital, which initially managed her. Fracture sites are highlighted with arrows. The patient sustained ununited fractures to the bilateral superior and inferior pubic rami. Her fractures on the right were impinging on, though not perforating, her bladder. She also sustained bilateral fractures in her sacrum. She was evaluated by orthopedics, who repaired her spine and rib fractures, though they ultimately decided her pelvis was stable enough to not require fixation. Three months following her accident, the patient presented to our clinic for evaluation of severe stress urinary incontinence. At this time, she reported large-volume urinary leakages, with changes in position, sneezing, and coughing. This severely limited her quality of life. Her urgency incontinence was minimal. At the time of consultation, her urodynamic study confirmed stress urinary incontinence. Her post-void residual was 60 milliliters. After discussion of options, the patient preferred surgical management. Thus, we made the plan to repeat her imaging and consult with orthopedics regarding our timing and approach to surgery. Their initial recommendation was to allow for three more months of healing. During this period, the patient used a knob pestery with minimal improvement in her symptoms. Three months following her consultation and six months after her injury, she had a repeat pelvic CT scan. The findings from the study include the following. She had displaced, ununited fractures of the right superior and inferior pubic rami, with displaced superior pubic ramus being in close proximity to the urinary bladder, as well as mildly displaced, ununited fractures of the left superior and inferior pubic rami, with moderate surrounding callus formation. Given there was no significant healing across the pubic rami fractures, orthopedics recommended continued healing. In March 2019, a year following her injury, she had a repeat CT scan, which showed adequate interval ossification of her fractures, though they continued to be severely displaced. Here is her CT with 3D reconstruction. Note the ossified bone bridges between the fracture planes. This is the same reformatted study in another orientation. We again had a discussion with orthopedics, who recognized her interval but slow improvement. Given the patient's severe symptoms and impact on her quality of life, we decided to proceed with surgery. Given her anatomy was so complex, her case was discussed within our division. Though an available treatment option, urethral bulking was not likely to adequately improve her symptoms. Birch urethrapexy was an option, but the distortion of her pelvic ring would preclude supporting her urethra symmetrically and could lead to urethral stricture should her fractures displace more over time. A trans-obturator sling was considered, but the distortion of her upper and lower right pubic rami severely distorted her obturator foramen anatomy. An autologous pubovaginal sling was also considered. A retropubic sling, like the trans-obturator sling, relies on bony landmarks for placement, though her fractures on the right were more lateral, and we felt confident we could safely pass a trocar medial to these fractures. Ultimately, we decided to proceed with a retropubic mesh-med urethral sling. Her surgery began with a diagnostic rigid cystoscopy. Here you see the bilateral ureteral orifices on the patient's left and on the right. Note that the urinary bladder is distorted by the right superior pubic rami bone fragment. Despite several attempts, the rigid cystoscope provided a limited view over this bony protrusion. The left pubic ramus only mildly distorts the bladder. Next, the midurethral sling was placed. The bladder neck was palpated and marked in the usual fashion. In planning the exit sites of the sling trocars, we marked the patient's left side per our usual placement. On the right, the exit site was marked more medial to our typical placement. The bladder neck was then incised and tunnels created in the usual fashion. The left trocar was then passed with ease. The right trocar was passed, taking care to avoid the urethra, but also stay medial to the displaced bony fracture. Cystoscopy was then repeated. Rigid cystoscopy was again performed. The left trocar placement was deemed to be adequate and without perforation. Visualization over the right bony protrusion prevented optimal visualization to assess for bladder perforation. Given this, we then decided to proceed with flexible cystoscopy. The flexible cystoscope was navigated over the bony protrusion and the bladder mucosa was noted to be intact with no evidence of perforation. Urethroscopy was then performed and no injury was noted. The sling was then tensioned, trimmed, and the bladder mucosa closed in the usual fashion. The patient had an uncomplicated postoperative course. She excitedly completed transfers and ambulated without leakage for the first time since her accident. She passed her void trial prior to discharge on postoperative day 1 and has maintained resolution of her stress urinary incontinence. This case demonstrates the multidisciplinary nature of managing female stress urinary incontinence following pelvic trauma. Following trauma, the pelvis should, first and foremost, be evaluated for stability. Orthopedics may decide to proceed with fixation versus interval healing. Additionally, the bladder and urethra should be evaluated for acute trauma, such as urethral convulsion. Upon urogynecology consultation, the patient should receive abdominal imaging to evaluate bony landmarks in their proximity to the genitourinary organs. Cystoscopy should be performed to assess for urethral or bladder injury. A flexible cystoscope is recommended if there is encroachment of other pelvic structures into the urinary bladder. Urodynamic testing can provide clarity as to the nature and severity of the patient's incontinence symptoms. Finally, during operative management, consider the fact that anatomical landmarks will not be reliable, and surgeons should individualize their approach based on the patient's injury.

urinary incontinence

pelvic trauma

stress urinary incontinence

genitourinary disorders

pelvic fractures